Effect of a decision aid on the choice of pregnant women whether to have epidural anesthesia or not during labor.

OBJECTIVE: Decision aids (DAs) are useful in providing information for decision-making on using epidural anesthesia during birth. To date, there has been little development of DAs for Japanese pregnant women. Herein, we investigated the effect of a DA on the decision of pregnant women whether to have epidural anesthesia or not for labor during vaginal delivery. The primary outcome was changes in mean decision conflict score. METHODS: In this non-randomized controlled trial, 300 low-risk pregnant women in an urban hospital were recruited by purposive sampling and assigned to 2 groups: DA (intervention) and pamphlet (control) groups. Control enrollment was started first (until 150 women), followed by intervention enrollment (150 women). Pre-test and post-test scores were evaluated using the Decision Conflict Scale (DCS) for primary outcome, knowledge of epidural anesthesia and satisfaction with decision making for secondary outcomes, and decision of anesthesia usage (i.e., with epidural anesthesia, without epidural anesthesia, or undecided). RESULTS: Women in the DA group (n = 149: 1 excluded because she did not return post-test questionnaire) had significantly lower DCS score than those in the pamphlet group (n = 150) (DA: -8.41 [SD 8.79] vs. pamphlet: -1.69 [SD 5.91], p < .001). Knowledge of epidural anesthesia and satisfaction with decision-making scores of women who used the DA were significantly higher than those of women who used the pamphlet (p < .001). Women in the DA group showed a significantly lower undecided rate than those in the pamphlet group. The number of undecided women in the DA group significantly decreased from 30.2% to 6.1% (p < .001), whereas that in the pamphlet group remained largely unchanged from 40.7% to 38.9%. CONCLUSION: This study indicates that a DA can be useful in helping women make a decision whether to have epidural anesthesia or not for labor during vaginal delivery.

Multisite Randomized Controlled Trial of Bladder Management in Labor With Epidural Analgesia/Anesthesia.

OBJECTIVE: To compare the effects of continuous indwelling catheterization with those of intermittent catheterization during labor with epidural analgesia/anesthesia on mode of birth and incidence of urinary tract infection (UTI) symptoms in the postpartum period. DESIGN: Randomized clinical trial. SETTING: Labor and delivery units at three metropolitan hospitals in the Western United States. PARTICIPANTS: Women (N = 252) who were nulliparous with term, singleton pregnancies in labor with epidural analgesia/anesthesia. METHODS: Participants were randomized to indwelling or intermittent (every 2 hours) catheterization groups after the administration of epidural analgesia/anesthesia during labor. One to 2 weeks after discharge, participants were contacted and questioned about symptoms of UTI. RESULTS: A total of 252 participants were enrolled in the study: 81% (n = 202) gave birth vaginally, and 19% (n = 50) gave birth via cesarean. Between the indwelling and intermittent catheterization groups, demographic characteristics were similar. We found no significant difference in the incidence of cesarean birth between groups (15.6% vs. 22.5%, p = .172). Overall, 3% of participants reported and sought treatment for symptoms of UTI within 2 weeks with no significant difference between groups (p = .929). CONCLUSION: We found no differences in mode of birth or symptoms of UTI in women who received indwelling or intermittent catheterization during epidural analgesia/anesthesia. We recommend additional research with objective data for UTI diagnosis and larger samples to study the multiple potential confounding variables associated with cesarean birth after catheterization during epidural analgesia/anesthesia.

An Updated Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population from 2000 to 2018.

BACKGROUND: With increasing costs of health care in the United States, attention is focused on expensive conditions. Musculoskeletal disorders with low back and neck pain account for the third highest amount of various disease categories. Minimally invasive interventional techniques for managing spinal pain, including epidural injections, have been considered to be growing rapidly. However, recent analyses of utilization of interventional techniques from 2000 to 2018 has shown a decline of 2.6% and a decline of 21% from 2009 to 2018 for epidural and adhesiolysis procedures. OBJECTIVES: The objectives of this analysis of epidural procedures from 2000 to 2018 are to provide an update on utilization of epidural injections in managing chronic pain in the fee-for-service (FFS) Medicare population, with a comparative analysis of 2000 to 2009 and 2009 to 2018. STUDY DESIGN: Utilization patterns and variables of epidural injections in managing chronic spinal pain from 2000 to 2009 and from 2009 to 2018 in the FFS Medicare population in the United States. METHODS: This analysis was performed by utilizing master data from CMS, physician/supplier procedure summary from 2000 to 2018. The analysis was performed by the assessment of utilization patterns using guidance from Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). RESULTS: Overall, epidural procedures declined at a rate of 20.7% per 100,000 Medicare enrollees in FFS Medicare in the United States from 2009 to 2018, with an annual decline of 2.5%. However, from 2000 to 2009, there was an increase of 89.2%, with an annual increase of 7.3%. This analysis showed a decline in all categories, with an annual decrease of 4.7% for lumbar interlaminar and caudal epidural injections, 4.7% decline for cervical/thoracic transforaminal epidural injections, 1.1% decline for lumbar/sacral transforaminal epidural injections, and finally 0.4% decline for cervical/thoracic interlaminar epidural injections. Overall declines from 2009 to 2018 were highest for cervical and thoracic transforaminal injections with 35.1%, followed by lumbar interlaminar and caudal epidural injections of 34.9%, followed by 9.4% for lumbar/sacral transforaminal epidurals, and 3.5% for cervical and thoracic interlaminar epidurals. LIMITATIONS: This analysis was limited by noninclusion of Medicare Advantage plans, which constitutes almost 30% of the Medicare population. In addition, utilization data for individual states continues to be sparse and may not be accurate or representative of the population. CONCLUSIONS: The declining utilization of epidural injections in all categories with an annual of 2.5% and overall decrease of 20.7% from 2009 to 2018 compared with annual increases of 7.3% and overall increase of 89.2% from 2000 to 2009 shows a slow decline of utilization of all epidural injections. KEY WORDS: Chronic spinal pain, interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, utilization patterns.

Risk of Postdural Puncture Headache in Adolescents and Adults.

BACKGROUND: Spinal anesthesia is known to have numerous benefits, including reductions in nausea and opioid consumption; however, postdural puncture headache (PDPH) remains a significant risk associated with this technique. The literature specifically examining this complication in adolescents is scarce. Our primary objective was therefore (1) to estimate the incidence of PDPH with a 27G pencil-point needle in patients between the ages of 12 and 19 undergoing ambulatory lower extremity procedures and (2) to compare it to the incidence in adults aged 20-45 years. METHODS: After institutional review board (IRB) approval, patients aged 12-45 years undergoing ambulatory lower extremity surgery were approached. Patients undergoing the procedure under combined spinal-epidural (CSE) or spinal anesthesia with a 27G pencil-point needle were eligible for enrollment. Patients were consented before surgery and received a survey via e-mail on postoperative day (POD) 4 inquiring about the presence of a headache. Each headache was described by the participant and assessed for severity, time of onset, duration, location, and whether it was of a postural nature. All patients reporting a postural headache were contacted by a physician author to confirm a diagnosis of PDPH using the International Headache Society diagnostic criteria. RESULTS: A total of 656 patients were included in the analysis. Overall, 3.4% of patients developed PDPH. The percentage developing PDPH was 4.9% (3.0-7.8) among those aged 12-19 years and 1.8% (0.8-3.9) in the 20- to 45-year-old group. After adjusting for covariates, the age group between 12 and 19 years was associated with an almost 3-fold increase in the odds (2.8 [95% confidence interval {CI}, 1.1-7.3]) for the development of PDPH compared to that in the 20-45 age group. One patient in the adult group required an epidural blood patch. CONCLUSIONS: The overall incidence for the development of PDPH in ambulatory patients <45 years of age is low. However, the odds for developing PDPH is significantly higher in teenagers compared to those aged 20-45 years. This increase was not associated with an increase in the need for an epidural blood patch. Providers may incorporate these data in their consent process and have a higher index of suspicion for PDPH in teenagers who report headaches after neuraxial anesthesia.

Case report: difficulty in diagnosis of delayed spinal epidural hematoma in puerperal women after combined spinal epidural anaesthesia.

BACKGROUND: Spinal epidural hematoma is a rare but serious complication of epidural anaesthesia and neurological impairment. Epidural hematoma usually becomes evident within a few hours of the procedure. Delayed clinical presentation of spinal epidural hematoma is even rarer and insidious. CASE PRESENTATION: We reported a case of a 44-year-old woman who underwent a caesarean section for a twin pregnancy during which a delayed dorsal spinal epidural hematoma occurred. Symptoms were reported 5 days after surgery and 72 h after removal of the epidural catheter. An MRI scan showed a dorsal epidural hematoma. The patient was moved to the Neurosurgical Department and underwent decompression surgery. CONCLUSION: The possibility of the delayed onset of a spinal epidural hematoma in a pregnant woman who undergoes epidural anaesthesia in labour must always be taken into consideration. In order to achieve the best clinical result, we stress the importance of a timely diagnosis and prompt surgical treatment.

Effects of Thoracic Epidural Anesthesia on Neuronal Cardiac Regulation and Cardiac Function.

Cardiac sympathetic blockade with high-thoracic epidural anesthesia is considered beneficial in patients undergoing major surgery because it offers protection in ischemic heart disease. Major outcome studies have failed to confirm such a benefit, however. In fact, there is growing concern about potential harm associated with the use of thoracic epidural anesthesia in high-risk patients, although underlying mechanisms have not been identified. Since the latest review on this subject, a number of clinical and experimental studies have provided new information on the complex interaction between thoracic epidural anesthesia-induced sympatholysis and cardiovascular control mechanisms. Perhaps these new insights may help identify conditions in which benefits of thoracic epidural anesthesia may not outweigh potential risks. For example, cardiac sympathectomy with high-thoracic epidural anesthesia decreases right ventricular function and attenuates its capacity to cope with increased right ventricular afterload. Although the clinical significance of this pathophysiologic interaction is unknown at present, it identifies a subgroup of patients with established or pending pulmonary hypertension for whom outcome studies are needed. Other new areas of interest include the impact of thoracic epidural anesthesia-induced sympatholysis on cardiovascular control in conditions associated with increased sympathetic tone, surgical stress, and hemodynamic disruption. It was considered appropriate to collect and analyze all recent scientific information on this subject to provide a comprehensive update on the cardiovascular effects of high-thoracic epidural anesthesia and cardiac sympathectomy in healthy and diseased patients.This review provides a comprehensive update on the cardiovascular effects of high-thoracic epidural anesthesia and cardiac sympathectomy in healthy and diseased patients.

Association of Neuraxial Anesthesia With Postoperative Venous Thromboembolism After Noncardiac Surgery: A Propensity-Matched Analysis of ACS-NSQIP Database.

BACKGROUND: Neuraxial anesthesia improves components of the Virchow's triad (hypercoagulability, venous stasis, and endothelial injury) which are key pathogenic contributors to venous thrombosis in surgical patients. However, whether neuraxial anesthesia reduces the incidence of venous thromboembolism (VTE) remain unclear. We therefore tested the primary hypothesis that neuraxial anesthesia reduces the incidence of 30-day VTE in adults recovering from orthopedic surgery. Secondarily, we tested the hypotheses that neuraxial anesthesia reduces 30-day readmission, 30-day mortality, and the duration of postoperative hospitalization. METHODS: Inpatient orthopedic surgeries from American College of Surgeons National Surgical Quality Improvement Program database (2011-2015) in adults lasting more than 1 hour with either neuraxial or general anesthesia were included. Groups were matched 1:1 by propensity score matching for appropriate confounders. Logistic regression model was used to assess the effect of neuraxial anesthesia on 30-day VTE, 30-day mortality, and readmission, while Cox proportional hazard regression model was used to assess its effect on length of stay. RESULTS: Neuraxial anesthesia decreased odds of 30-day VTE (odds ratio 0.85, 95% confidence interval, 0.78-0.95; P = .002) corresponding to number-needed-to-treat of 500. Although there was no difference in 30-day mortality, neuraxial anesthesia reduced 30-day readmission (odds ratio 0.90, 98.3% confidence interval, 0.85-0.95; P < .001) corresponding to number-needed-to-treat of 250 and had a shortened hospitalization (2.87 vs 3.11; P < .001). CONCLUSIONS: Neuraxial anesthesia appears to provide only weak VTE prophylaxis, but can be offered as an adjuvant to current thromboprophylaxis in high-risk patients.

Antenatal education for childbirth-epidural analgesia.

The language structures used by antenatal educators have not been previously researched in the context of antenatal childbirth classes. Epidural analgesia for labour is a common, and a frequently asked about, component of antenatal education for parents in hospitals providing maternity care. AIM OF THE STUDY: We aimed to identify the way information is described and presented by childbirth educators to assess content and determine which language structures such as metaphor, suggestion, information and storytelling are utilized. DESIGN: This observational study of antenatal education was conducted at a single tertiary referral center for maternity care in Western Sydney, Australia. All three childbirth educators agreed to be video recorded whilst providing information to parents during antenatal classes. Audio data was subsequently transcribed and then analysed by two researchers, independently categorising the various language structures and types of information provided. For the purposes of the current study, data concerning a single topic was used for the analysis-'epidural analgesia for labour'. FINDINGS: Language structures used were highly variable between educators, as was the content and time taken for the information being provided. CONCLUSION AND RECOMMENDATIONS: Our findings represent a first attempt to identify baseline information used in the clinical setting of antenatal education in order to categories communication structures used. This study has identified areas for further improvements and consistency in the way educators provide information to parents and has important implications for future midwifery practice, education and research.

Trends in perinatal health in metropolitan France from 1995 to 2016: Results from the French National Perinatal Surveys.

OBJECTIVE: To study trends in the main indicators of perinatal health, medical practices and risk factors in France since 1995. POPULATION AND METHOD: All live births during one week in 1995 (n=13,318), 2003 (n=14,737), 2010 (n=14,903) and 2016 (n=13,384). Data were from interviews of women in postpartum wards and from medical records and were compared between years. RESULTS: Between 1995 and 2016, maternal age and body mass index increased steadily. Pregnancies that occurred with use of contraception increased from 7.4% in 2010 to 9.3% in 2016. Smoking during pregnancy (16.6%) did not decrease since 2010. The frequency of more than three ultrasounds during pregnancy was 48.5% in 1995 and 74.7% in 2016. Deliveries in large public hospitals increased steadily. The caesarean section rate has been relatively stable since 2003 (20.4% in 2003, 21.1% in 2010 and 20.4% in 2016). The rate of induction of labour was 22% in 2010 and 2016. Overall, 83.8% of women had epidural analgesia/anaesthesia in 2016. Rates of pre-term birth in 2016 ranged from 7.5% among all live births to 6.0% among live born singletons; for singletons, this rate increased steadily from 1995 to 2016, whereas there was no clear trend for low birth weight. Exclusive breastfeeding decreased from 60.3% in 2010 to 52.2% in 2016. CONCLUSION: Routine national perinatal surveys highlight successful policies and recommendations but also point out some health indicators, practices, preventive behaviours and risk factors that need special attention.

Thoracic Epidural Anesthesia Reversed Myocardial Fibrosis in Patients With Heart Failure Caused by Dilated Cardiomyopathy.

OBJECTIVE: To verify that high thoracic epidural anesthesia (TEA) could reverse myocardial fibrosis in heart failure caused by dilated cardiomyopathy (DCM). DESIGN: Hospitalized patients with DCM and heart failure. SETTING: Harbin Medical University, Harbin, Heilongjiang, China. PARTICIPANTS: Eight patients. INTERVENTIONS: 0.5% lidocaine was administered epidurally at the T4-T5 interspace for 4 weeks. MEASUREMENTS AND MAIN RESULTS: Eight hospitalized patients with DCM and heart failure were enrolled into the present study. All patients received TEA plus optimal medical therapy (OMT) for 4 weeks. Echocardiograms and cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) technique were used to evaluate cardiac function and detect myocardial fibrosis before and after treatment. The 6-minute walking distance and the level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) also were measured. The authors used before-after study to verify whether thoracic epidural anesthesia could reverse myocardial fibrosis. The left ventricular end-diastolic diameter was reduced significantly and the left ventricular ejection fraction (LVEF) was increased significantly after a 4-week treatment. Meanwhile, the 6-minute walking distance was increased dramatically. Furthermore, the level of NT-proBNP was reduced significantly after TEA plus OMT treatment. Consistent with echocardiography parameters, the LVEF measured by CMR also was increased markedly. Both total LGE volume and average LGE volume were reduced significantly after 4 weeks of TEA plus OMT treatment. CONCLUSIONS: TEA plus OMT could reverse myocardial fibrosis and improve cardiac function in patients with heart failure caused by DCM.

Commonly-used versus less commonly-used methods in the loss of resistance technique for identification of the epidural space: A systematic review and meta-analysis of randomized controlled trials.

STUDY OBJECTIVE: To summarize the efficacy of less-commonly used modern methods (e.g. epidrum, lidocaine, acoustic device, Macintosh balloon) compared to more commonly-used methods (i.e. air, saline, both) in the loss of resistance technique for identification of the epidural space. DESIGN: A systematic review. SETTING: A hospital-affiliated university. MEASUREMENTS: The following databases were searched: PubMed, CENTRAL, EMBASE, and LILACS. We used the GRADE approach to rate overall certainty of the evidence. RESULTS: Eight randomized trials including 1583 participants proved eligible. Results suggested a statistically significantly reduction in inability to locate the epidural space (RR 0.29, 95% CI 0.11, 0.77; P=0.01; I2=60%, risk difference (RD) 104/1000, moderate quality evidence), accidental intravascular catheter placement and accidental subarachnoid catheter placement (RR 0.35, 95% CI 0.21, 0.59; P<0.0001; I2=0%, risk difference (RD) 108/1000, moderate quality evidence), and unblocked segments (RR 0.37, 95% CI 0.18, 0.77; P=0.008; I2=0%, risk difference (RD) 56/1000, moderate quality evidence) with the use of epidrum, lidocaine, acoustic device, or modified Macintosh epidural balloon methods in comparison to air. Compared to saline, lidocaine presented higher rates of reduction in the inability to locate the epidural space (RR 0.31, 95% CI 0.12, 0.82; P=0.02; I2=not applicable). CONCLUSIONS: Moderate-quality evidence shows that less commonly-used modern methods such as epidrum, lidocaine and acoustic devices, are more efficacious compared to more commonly-used methods (i.e. air, saline, both) in terms of the loss of resistance technique for identification of the epidural space. These findings should be explored further in the context of the clinical practice among anaesthesiologists.

What's trending now? An analysis of trends in internet searches for labor epidurals.

BACKGROUND: The study aim was to investigate internet use for obtaining information about epidurals for labor and delivery. METHODS: Google Trends for US data was queried from 2004 to 2015 to find the most common searches and determine temporal trends. The Google Trends query used the term [epidural] and evaluated changes in search trends over time. Search comparisons were made for each year from 2004 to 2015, and three equal time epochs during the study period (2004-07, 2008-11, 2012-15) were compared. We also compared searches for epidurals with commonly searched birth-related terms. RESULTS: Internet searches are increasing; there were 726000 searches for [epidural] in 2015. Search terms with the most significant growth in the past 4years (2012-15) were "birth with epidural," "pain after epidural," "labor without epidural," "epidural birth video," and "epidural vs natural". Searches for epidural side effects, risks, and pain on insertion were among the most common and were increasing most rapidly. Searches related to epidurals were more common than searches related to "natural births", "home births", and "labor pain", but were less common than searches for "midwives" or "doulas". CONCLUSION: The findings provide an insight into internet use by those seeking information about labor analgesic options. Identifying the most common and rapidly increasing online search queries may guide physician-parturient interactions and online content creation, to address labor analgesic topics that most interest users.

¿Es seguro someterse a cambios de presion atmosferica tras una tecnica epidural? / ¿Is it safe to changes in atmospheric pressure after epidural?

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Comparison of the type and severity of early attentional network decline after total intravenous or epidural anesthesia in middle-aged women after gynecological surgery.

Compared with regional anesthesia, general anesthesia may increase the risk of postoperative cognitive decline. This study aimed to investigate the type and severity of attentional network decline and the recovery of attentional networks in middle-aged women after gynecological surgery. A total of 140 consenting women undergoing elective gynecological surgery were enrolled in the study. Patients were assigned randomly to receive either total intravenous anesthesia or epidural anesthesia. To determine the efficacy of the attentional networks, patients were examined for alerting, orienting, and executive networks on the preoperative day and on the first and fifth postoperative days using the attentional network test. Significant differences were observed in the effect scores of the three attentional networks at all time points. These effect scores differed significantly between groups and between 1 and 5 days postoperation (DPO). Participants showed significantly lower effect scores for the alerting and orienting network tasks and had more difficulties in resolving conflict at 1 DPO compared with the baseline. On comparing effect scores between baseline and 5 DPO, no significant differences on the alerting and orienting network tasks were observed in the epidural anesthesia group, a significant difference on the orienting network task was observed in the general anesthesia group, and significant differences on the executive control network were observed in both the groups. Compared with epidural anesthesia, total intravenous anesthesia is more likely to impair and delay the recovery of attentional networks in middle-aged women undergoing elective hysterectomy. The executive control function showed marked damage and there were difficulties in recovery from either type of anesthesia.

Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study.

BACKGROUND: Transforaminal epidural steroid injections (TFESI) have demonstrated efficacy and effectiveness in treatment of radicular pain. Despite little evidence of efficacy/effectiveness, interlaminar epidural steroid injections (ILESI) are advocated by some as primary therapy for radicular pain due to purported greater safety. OBJECTIVE: To assess immediate and delayed adverse event rates of TFESI and ILESI injections at three academic medical centers utilizing International Spine Intervention Society practice guidelines. METHODS: Quality assurance databases from a Radiology and two physical medicine and rehabilitation (PM&R) practices were interrogated. Medical records were reviewed, verifying immediate and delayed adverse events. RESULTS: There were no immediate major adverse events of neurologic injury or hemorrhage in 16,638 consecutive procedures in all spine segments (14,956 TFESI; 1,682 ILESI). Vasovagal reactions occurred in 1.2% of procedures, more frequently (P = 0.004) in TFESI (1.3%) than ILESI (0.5%). Dural punctures occurred in 0.06% of procedures, more commonly after ILESI (0.2% vs 0.04%, P = 0.006). Delayed follow up on PM&R patients (92.5% and 78.5, next business day) and radiology patients (63.1%, 2 weeks) identified no major adverse events of neurologic injury, hemorrhage, or infection. There were no significant differences in delayed minor adverse event rates. Central steroid response (sleeplessness, flushing, nonpositional headache) was seen in 2.6% of both TFESI and ILESI patients. 2.1% of TFESI and 1.8% of ILESI patients reported increased pain. No long-term sequelae were seen from any immediate or delayed minor adverse event. CONCLUSIONS: Both transforaminal and ILESI are safely performed with low immediate and delayed adverse event rates when informed by evidence-based procedural guidelines. By demonstrating comparable safety, this study suggests that the choice between ILESI and TFESIs can be based on documented efficacy and effectiveness and not driven by safety concerns.

Current issues in postoperative pain management.

Postoperative pain has been poorly managed for decades. Recent surveys from USA and Europe do not show any major improvement. Persistent postoperative pain is common after most surgical procedures, and after thoracotomy and mastectomy, about 50% of patients may experience it. Opioids remain the mainstay of postoperative pain treatment in spite of strong evidence of their drawbacks. Multimodal analgesic techniques are widely used but new evidence is disappointing. Regional anaesthetic techniques are the most effective methods to treat postoperative pain. Current evidence suggests that epidural analgesia can no longer be considered the 'gold standard'. Perineural techniques are good alternatives for major orthopaedic surgery but remain underused. Infiltrative techniques with or without catheters are useful for almost all types of surgery. Simple surgeon-delivered local anaesthetic techniques such as wound infiltration, preperitoneal/intraperitoneal administration, transversus abdominis plane block and local infiltration analgesia can play a significant role in improvement of postoperative care, and the last of these has changed orthopaedic practice in many institutions. Current postoperative pain management guidelines are generally 'one size fits all'. It is well known that pain characteristics such as type, location, intensity and duration vary considerably after different surgical procedures. Procedure-specific postoperative pain management recommendations are evidence based, and also take into consideration the role of anaesthetic and surgical techniques, clinical routines and risk-benefit aspects. The role of acute pain services to improve pain management and outcome is well accepted but implementation seems challenging. The need for upgrading the role of surgical ward nurses and collaboration with surgeons to implement enhanced recovery after surgery protocols with regular audits to improve postoperative outcome cannot be overstated.