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The aim of this study was to evaluate feasibility and impact of an intraoperative surgical site infection prevention bundle for emergency appendectomy. Consecutive adult patients undergoing emergency appendectomy were prospectively included during a 10-year study period (2011-2020). The care bundle was implemented as of November 1, 2018, and focused on 4 intraoperative items (disinfection, antibiotic prophylaxis, induction temperature control >36.5°C, and intracavity lavage). The primary outcome was the compliance to bundle items. Thirty-day surgical site infections were assessed by the independent Swiss National SSI Surveillance Program (2011 to October 2018) and by an institutional audit (November 2018-2020). Independent risk factors for surgical site infection were identified through multinominal logistic regression analysis. Of 1,901 patients, 449 (23.6%) were included after bundle implementation. Overall surgical site infection rate was 111 (5.8%). In 42 patients with surgical site infection (37.8%), antibiotic treatment alone was done, and additional surgical management was necessary in 31 patients (27.9%), computed tomography-guided drainage in 30 patients (27%), and bedside wound opening in 9 cases (8.1%). Overall compliance to the bundle was 79.9%. Overall surgical site infection rates were decreased after bundle implementation (17/449 [3.8%] vs 94/1,452 [6.5%], P = .038), mainly due to a decrease in superficial incisional infections (P = .014). Independent risk factors for surgical site infection were surgical duration ≥60 minutes (odds ratio: 1.66, P = .018), contamination class IV (odds ratio: 2.64, P < .001), and open or converted approach (odds ratio: 4.0, P < .001), and the bundle was an independent protective factor (odds ratio: 0.58, P = .048). Implementation of an intraoperative surgical site infection prevention bundle was feasible and might have a beneficial impact on surgical site infection rates after emergency appendectomy.

IntroductionEnhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes.MethodsRetrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification.ResultsA total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I–V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001).ConclusionsCompliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

Objective Surgical site infections (SSI) are the most frequent complications after colorectal surgery. The aim of the present study was to evaluate the impact of a standardized SSI prevention bundle. Methods The multimodal, evidence-based care bundle included 9 intraoperative items (antibiotic type, timing and re-dosing, desinfection, induction temperature control >36.5°, glove change, intracavity lavage, wound protection and closure strategy). The bundle was implemented in November 2018 and applied to all consecutive patients undergoing colonic resections. Demographics, surgical specifics and overall compliance to the care bundle were prospectively assessed until October 2020. The primary outcome SSI was defined according to the definition of the Center for Disease Control (CDC) and independently assessed by the National Infection Surveillance Committee (Swissnoso) up to 30 postoperative days. A historical, institutional pre-implementation control group (2012-2017, DOI: 10.1016/j.jhin.2018.09.011) with identical methodology was used for comparison. Results In total, 243 patients were included. The control group included 1’263 patients. Both groups were comparable regarding main demographics (age, sex, body mass index, American Society of Anaesthesiologists class) and surgical characteristics (type and duration of surgery). Overall compliance to the care bundle was 77% (IQR 77-88). Lowest compliance was observed for temperature control (48%), intracavity lavage (59%) and predefined wound closure strategy (74%). Surgical site infections were reported in 54 patients (22.2%) vs. 21.4% in the control group, p = 0.79. Infection rates were comparable throughout the CDC categories: superficial: 11 patients (4.5%) vs. 4.2%, p = 0.82, deep incisional: 9 patients (3.7%) vs. 5.1%, p = 0.34, organ space: 34 (14%) vs. 12.4%, p = 0.48. Conclusion Implementation of a standardized surgical care bundle had no impact on SSI rates according to these preliminary results. Improved compliance to individual measures may help to achieve a clinical benefit.

The prevention of post-operative pulmonary complications (PPC) is targeted by several enhanced recovery (ERAS) items including early mobilisation, prevention of fluid overload and omission of routine nasogastric tubes. The aim of the present study was to assess the impact of ERAS on PPC. This was a retrospective analysis of an institutional database including consecutive colorectal ERAS procedures from May 2011 until May 2017. Multiple logistic regressions were performed to identify risk factors for PPC among demographic, surgical characteristics and items related to the ERAS protocol. In total, 1298 patients were included; among them 120 (9.2%) had one or more PPC. Multivariable analysis retained minimally invasive surgery [odds ratio (OR) 0.26; 95% confidence interval (CI) 0.15–0.46] and compliance to the ERAS protocol of ≥ 70% (OR 0.53; CI 0.30–0.94) as protective factors. Emergency surgery (OR 2.70; CI 1.20–6.01), blood loss of ≥ 200 mL (OR 2.06; CI 1.20–3.53) and ASA score of ≥ 3 (OR 2.00; CI 1.12–3.57) were independent risk factors. Median length of hospital stay was significantly longer in patients who experienced respiratory complications (21 [4–183] vs. 6 [1–95] days, p ≤ 0.001). Minimally invasive surgery and high compliance with the ERAS protocol can help to prevent PPC.

Enhanced recovery after surgery (ERAS) and minimally invasive surgery are both in the limelight due to their potential positive effects on surgical outcome. Large randomized trials and meta-analyses validated the use of both, laparoscopy and ERAS protocol, as individual measures. A synergistic effect of both entities might contribute to even better outcomes. This review hence assessed the literature upon up-to-date studies combining both methods.

The success of enhanced recovery (ERAS) pathways depends on the actual application of the intended protocol (adherence), but its full implementation remains challenging. In order to potentially streamline the pathway, it is indispensable to know the impact of individual items and the entire protocol on clinical outcomes. Retrospective analysis including all consecutive colorectal ERAS patients since implementation (May 2011) until February 2014; demographics, adherence and outcomes were retrieved from a prospectively maintained database. Primary outcome was the impact of individual item and of the entire protocol on complications (overall and major) and length of hospital stay. Statistical analysis included logistic multivariate regression and adjustment for confounding factors. There were 328 patients with complete data sets analyzed. A minimally invasive approach [odd ratio (OR) 0.62; confidence interval (CI) 0.4-0.9] was significantly associated with less overall complications. In contrast, the use of prophylactic nasogastric tubes (OR 3.18; CI 1.4-7.4), prophylactic abdominal and pelvic drains (OR 1.96; 1.2-3.2) and intraoperative thoracic epidural analgesia (OR 1.76; CI 1.3-2.4) were associated with more overall complications. Minimal invasive approach was further associated with reduced hospital stay (OR 0.5; CI 0.4-0.7) and less major complications (OR 0.58; CI 0.4-0.8). Higher adherence to the entire ERAS protocol was associated with significantly less complications (P < 0.001) and shorter hospital stay (P < 0.001). Minimally invasive surgery was the single most important component of the ERAS pathway while nasogastric tubes, drains and epidurals should be avoided. Overall, increasing adherence with the protocol was associated with better outcomes and should be the goal.

Enhanced recovery after surgery (ERAS) pathway includes recovery goals requiring active participation of the patients; this may be perceived as "aggressive" care in older patients. The aim of the present study was to assess whether ERAS was feasible and beneficial in older patients. Since June 2011, all consecutive colorectal patients were included in an ERAS pathway and documented in a dedicated prospective database. This retrospective analysis included 513 patients, 311 younger patients (