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The main aim of this paper is to explore and discuss the interesting juxtaposition of patient involvement within a standardised Enhanced Recovery After Surgery care programme (ERAS). We address our aim by examining the work and strategies of nursing staff caring for patients during postoperative recovery from surgery, exploring how these two potentially competing priorities might effectively co‐exist within a hospital ward. This was a qualitative exploratory study, with data generated through 42 semi‐structured interviews with patients and nurses who had taken part in an ERAS programme in one of three hospital wards in the United Kingdom, adopting a reflexive thematic approach to data analysis. We shine a light on the work undertaken by patients and nurses during the navigation of postoperative recovery, identifying strategies of collaboration and negotiation during this journey. Furthermore, we also identify and consider patients engaged in peer‐peer support during postoperative recovery. This paper adds to the existing literature and current ways of thinking in relation to the quest for standardised, clinically effective care balanced with the aspirations for individualised, patient‐centred care. This paper also helps inform thinking about the use of care pathways in relation to service delivery, considering how best to initiate and deploy best practice aimed at safe and effective postoperative recovery. [ABSTRACT FROM AUTHOR]

Since the late 1990s, perioperative care through the enhanced recovery after surgery (ERAS, European Society for Clinical Nutrition and Metabolism [ESPEN]) program has spread. ERAS protocols aim to reduce surgical complications, improving postoperative outcomes and thereby saving resources by addressing various clinical elements through a multidisciplinary approach or based on evidence. In the field of gastric cancer, the philosophy of ERAS has gradually become accepted and, in 2014, consensus guidelines for enhanced recovery after gastrectomy were published. These guidelines consist of "procedure‐specific" guidelines and "general (not procedure‐specific) enhanced recovery items." In this review, we focused on the procedure‐specific guidelines and tried to update the contents of every element of the procedure‐specific guidelines. The procedure‐specific guidelines consist of the following eight elements: "Preoperative nutrition," "Preoperative oral pharmaconutrition," "Access (of gastrectomy)," "Wound catheters and transversus abdominis plane block," "Nasogastric/Nasojejunal decompression," "Perianastomotic drains," "Early postoperative diet and artificial nutrition," and "Audit." On reviewing papers supporting these elements, it was reconfirmed that the recommendations of the guidelines are pertinent and valid. Four meta‐analyses concerning the evaluation of ERAS protocols for gastric cancer were included in this review. Every study showed that the ERAS protocol reduced the cost and duration of hospital stay without increasing surgical complication rates, suggesting that ERAS is effective for gastric cancer surgery. However, it cannot be said that ERAS has achieved full penetration in Japan because most evidence is established in Western countries. Future studies must focus on developing a new ERAS protocols appropriate to Japanese conditions of gastric cancer. [ABSTRACT FROM AUTHOR]

Aim: Ambulatory laparoscopic colectomy (ALC), meaning discharge within 24 h of surgical colonic resection, has recently been proposed in a few, selected patients. This systematic review was performed with the aim of reviewing protocols for ALC and assessing feasibility, safety and outcomes after ALC. Method: A PRISMA‐compliant systematic review and pooled analysis was performed searching all English studies published until October 2022 in PubMed, Cochrane Library, Web of Science (PROSPERO, CRD42022334463). Inclusion criteria were original articles including patients undergoing ALC, specifying at least one outcome of interest. Exclusion criteria were articles reporting a robotic‐assisted procedure; unable to retrieve patient data from articles; the same patient series included in different studies. Primary outcomes were success, overall complications and readmission rates. Secondary outcomes included mortality and specific complications such us surgical site infection, anastomotic leak, ileus, bleeding, rate of ALC acceptance, and unscheduled consultation and reoperation rate. Results: Among 1087 studies imported for screening, 11 were included (1296 patients). The success rate was 47% with an overall morbidity of 14%. Readmission and reoperation rates were 5% and 1%, respectively. No mortality was recorded. Protocols of ALC differ significantly among published studies. Conclusions: Overall, ALC appears to be safe and feasible in selected cases with an acceptable success rate and a low risk of readmission after hospital discharge. Future studies should evaluate patients' benefits and discharge criteria, as well as uniformity and standardization of eligibility criteria. This systematic review may help inform on ALC adoption in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence‐based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center. Methods: The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0–5 cumulative opioid use (morphine milligram equivalent [MME]). Results: A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre‐ERAS patients. Although the mean case durations were similar in the ERAS and pre‐ERAS cohorts (265 vs. 274 min; p =.22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p =.003), decreased postoperative day 0–5 cumulative mean opioid use (178 vs. 396 MME; p <.0001), earlier ambulation (mean, 34 vs. 57 h; p =.0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p <.001), and shorter LOS (5.4 vs. 7.5 days; p <.0001). Conclusions: The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption. Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. The implementation of a multidisciplinary enhanced recovery after surgery program designed for metastatic spine tumor surgery has led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption. [ABSTRACT FROM AUTHOR]

Objective: To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19. Data Sources: PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases. Review Methods: Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19–specific findings. Conclusions: Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients. Implications for Practice: SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients. [ABSTRACT FROM AUTHOR]

Background: There is some evidence in the literature to suggest that pre‐operative counselling improves pain scores postoperatively. However, it is unclear whether pre‐operative counselling of the donor improves immediate and short‐term outcomes after living liver donation. Objectives: This systematic review aimed to investigate the available quality of evidence (QOE) of pre‐operative counselling for living donors on short term outcomes, provide expert opinion, grade recommendations and identify relevant components for Enhanced Recovery after Surgery (ERAS) protocols. Data Sources: Ovid MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Central. Methods: Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Endpoints were defined by the WHOQOL‐BREF scale: physical health, psychological, social relationships, and environment. PROSPERO ID: CRD42021260677. Results: Screening of 452 records and full texts led to 12 articles matching inclusion criteria, of which one was a randomized controlled trial (RCT), and 11 were observational retrospective cohort studies. A total of 933 individuals undergoing donor hepatectomy were included, of whom only 90 received dedicated perioperative ERAS protocols. Donors that received pre‐operative counselling had fewer physical symptoms post donation, lower rates of fatigue, lower rates of pain, shorter recovery times and fewer unexpected medical problems, and less anxiety post donation. Female donors had higher affective and adverse effects scores, and 50% of donors reported adverse effects to analgesia that interfered with functional activity. Receiving information about analgesic options increased perception of care among donors. Conclusions: Providing comprehensive pre‐operative counselling to living liver donors is associated with improved short‐term outcomes after donation (QOE; moderate to low I Grade of Recommendation; Strong). [ABSTRACT FROM AUTHOR]

Purpose: Enhanced recovery after surgery (ERAS) pathways have been shown to reduce surgical morbidity and length of stay across various procedures. Our objective was to systematically evaluate the literature for best practices of ERAS elements in abdominal sacrocolpopexy (ASC), to determine if there is sufficient evidence to create best practice guidelines for this procedure. Materials and Methods: Following the preferred reporting items for systematic review and meta‐analysis (PRISMA) statement, we performed a review using Pubmed, Embase, and Cochrane Library. Eligible articles contained ERAS components and postoperative outcomes of ASC published in English since 1997. Thirty‐five full‐text articles were selected for final qualitative analysis. Results: Poor functional status before ASC was associated with a longer length of hospital stay. Laparoscopic ASC was associated with a shorter postoperative hospital stay, with no difference between laparoscopic and robotic approaches. Epidural analgesia in addition to spinal anesthesia lowered levels of pain throughout the postoperative stay in laparoscopic ASC. A multimodal bowel regimen shortened time to first bowel movement compared to a single agent regimen. Removing a Foley catheter may lead to sooner first spontaneous void but may result in higher rates of urinary retention and urinary tract infection. Studies investigating preoperative bowel preparation, preanesthesia medication, and multidose antimicrobial prophylaxis did not show significant benefit. Conclusions: Best practices for ASC can be developed based on current findings from the literature and extrapolation of evidence from other surgeries where ASC‐specific elements are missing, with the ability to modify the pathways as new data become available. [ABSTRACT FROM AUTHOR]

Aim: Enhanced recovery after surgery programmes in elective colorectal surgery have been developed and implemented widely, but a subgroup of patients may still require longer hospital stays than expected. The aim of this study was to identify and describe factors compromising early postoperative recovery by asking 'why is the patient still in hospital today?' after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery programme. Method: Patients undergoing elective laparoscopic colorectal cancer resection were evaluated postoperatively with predefined potential reasons for still being in hospital. The primary outcome was 'reason for still being in hospital' on postoperative day 0–4 and secondarily length of stay with a focus on differences between patients with and without a stoma. Results: Ninety‐six patients having colorectal cancer surgery were included. The median length of stay for the whole group was 3 days (range 1–14). The four dominant causes for patients without a stoma to be in hospital were lack of gastrointestinal function, lack of early mobilization, lack of normal micturition and nausea. Patients with a stoma stayed in hospital due to stoma training, lack of gastrointestinal function, lack of free micturition and a miscellaneous 'others' group. Conclusion: Delayed gastrointestinal function, insufficient mobilization, poor urinary function and stoma care training have been characterized as dominant compromising factors for postoperative recovery. Together with a focus on frailty, future studies should focus on improving early mobilization, prevention and treatment of postoperative urinary retention and improved stoma care training, in order to minimize delay in postoperative recovery and discharge. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to compare robotic and laparoscopic rectal surgery in terms of perioperative data, short‐term outcome and compliance to the Enhanced Recovery After Surgery (ERAS) protocol. Method: In this cohort study, 224 patients scheduled for rectal resection for cancer or adenoma between January 2011 and January 2017 were evaluated. In the first time period (12 January 2011 to 23 April 2014), 47 (46%) of 102 patients had laparoscopic surgery. In the second time period (24 April 2014 to 30 January 2017), 72 (59%) of 122 patients had robotic surgery. Perioperative data and short‐term outcome were collected from the ERAS database and patient charts. Data obtained from laparoscopic and robotic surgery in the two time periods studied were compared. Primary outcome was hospital length of stay (LOS) and secondary outcomes were compliance to the ERAS protocol, difference in postoperative complications and conversion to open surgery. Results: Compliance to the ERAS protocol was 81.1% in the robotic group and 83.4% in the laparoscopic group (P = 0.890). Robotic surgery was associated with shorter median LOS (3 days vs 7 days, P < 0.001), lower conversion rate (11.1% vs 34.0%, P = 0.002), lower rate of postoperative complications (25% vs 49%, P < 0.01) and longer duration of surgery (5.8 h vs 4.5 h, P < 0.001). The differences remained after multivariate analysis. Conclusion: Robotic surgery was associated with shorter LOS, lower conversion rates and fewer postoperative complications compared with laparoscopic surgery. Robotic surgery may add benefits to the ERAS protocol. [ABSTRACT FROM AUTHOR]

Aim: The present database study aimed to identify patients with a longer postoperative length of stay (LOS) or patients readmitted and to characterize both groups based on perioperative factors. Method: A retrospective review of the Danish Colorectal Cancer Group database and a local database was performed of all patients undergoing elective resection for colorectal cancer in a 25‐month period. The primary outcome was the number of patients with a prolonged hospital stay (LOS ≥ 10 days after the primary operation) and readmissions within 30 days after discharge. Results: A total of 372 patients with colon resection and 215 patients with rectal resection were included. Patients undergoing colonic resection had a rate of prolonged hospital stay of 10.6% and a readmission rate of 13.7%; prolonged hospital stay was significantly associated with age ≥ 76 years and those who underwent a conversion from a laparoscopic procedure. Patients undergoing rectal cancer resection had a rate of prolonged hospital stay of 17.7% and a readmission rate of 14.0%; Charlson comorbidity score (CCS) ≥ 2, total mesorectal excision (TME) and laparoscopic conversion were significantly associated with prolonged hospital stay, and American Society of Anesthesiologists (ASA) score ≥ 3, TME and a duration of surgery ≥ 300 min were significantly associated with readmission. Conclusion: In patients with colon cancer, older age and conversion to open surgery were associated with prolonged hospital stay. In patients with rectal cancer, CCS ≥ 2, TME and conversion were associated with prolonged hospital stay, and a preoperative ASA score ≥ 3, TME and a duration of surgery ≥ 300 min were associated with readmission. [ABSTRACT FROM AUTHOR]

Aim The aim of this randomized clinical trial was to compare patients treated using a multimodal approach [enhanced recovery after surgery ( ERAS)], with a special focus on counselling, to patients treated in a standard conventional care pathway, who underwent elective colorectal resection. Method In a single-centre trial, adult patients eligible for open or laparoscopic colorectal resection were randomized to an ERAS programme or standard care. The primary end-point was postoperative total hospital stay. Identical discharge criteria were defined for both treatment groups. Secondary end-points included postoperative complications, postoperative C-reactive protein levels, postoperative hospital stay, readmission rate and mortality. All parameters were recorded before operation, on the day of surgery and daily thereafter until discharge. Results Total hospital stay was significantly shorter among patients randomized to ERAS than among the standard group [median 5 days (range 2-50 days) vs median 8 days (range 2-48 days); P = 0.001]. The two treatment groups exhibited similar outcomes regarding overall major and minor morbidity, reoperation rate, readmission rate and 30-day mortality. There were also no differences in tolerance of enteral nutrition or in the inflammatory response, as reflected by postoperative C-reactive protein levels. Conclusion ERAS care was associated with a significantly shorter length of hospital stay. Without any difference in surgical or general complications, tolerance of enteral nutrition or postoperative C-reactive protein levels, peri-operative information and guidance for ensuring that patients comply with the ERAS approach appear to be important factors to reduce the length of hospital stay. [ABSTRACT FROM AUTHOR]

Aim The study compared the outcome of laparoscopic and open surgery in daily practice when performed in a strict Enhanced Recovery After Surgery ( ERAS) environment. Method Two-hundred and ninety-two consecutive patients who received elective surgery, in three Swedish ERAS centres, for cancer or adenoma in the right colon in the period 1 January 2011 to 31 December 2012, were prospectively registered in a Web-based ERAS database. Peri-operative data were collected from the database and patient charts. The primary end-points included postoperative recovery and morbidity. The secondary objective was to identify preoperative variables that influenced the selection of patients for laparoscopic or open surgery. Results One-hundred and twenty-three (42%) patients were selected for laparoscopic surgery. The overall preoperative ERAS-compliance rate was 87% and no significant difference was seen between the surgical techniques. In multivariate analysis, patients treated with laparoscopy had significantly earlier pain control (2.4 ± 3.2 days vs 4.2 ± 5.9 days; P = 0.016) and a shorter length of hospital stay ( LOS) (4 days vs 6 days; P = 0.002) compared with open surgery. There was no significant difference in the complication rate [18.7% vs 21.3%; OR = 1.0 (95% CI: 0.5-2.0)], the number of lymph nodes removed or the rate of R0 resection between laparoscopic and open surgery. Tumours selected for laparoscopy were generally smaller, had a lower T-stage and were predominantly situated in the caecum and the ascending colon compared with those of patients selected for open surgery. Conclusion The use of laparoscopy in routine right-sided colectomy in an ERAS environment, with data on outcome corrected for selection bias, may result in faster recovery compared with open surgery. [ABSTRACT FROM AUTHOR]

Aim Elderly patients may be at higher risk of postoperative complications, particularly infective, than younger patients. Method We prospectively followed 163 consecutive patients undergoing elective laparoscopic resection for cancer. We compared patients < 65, 65-80 and > 80 years of age at the time of surgery. Results Seventy (42.9%) patients had no complication; 93 (57.1%) had at least one complication following surgery and in 20 (12.3%) this was major. There was no difference in major complications between the groups (P = 0.47). Patients over 65 years of age were more likely to have a complication of any severity [< 65 years, 39.3%; 65-80 years, 69.3%; and > 80 years, 63.0% (P = 0.002)]. The frequency of gastrointestinal complications (30.1%) was similar in the groups (P= 0.29), as was wound infection (25.2%) (P= 0.65). There was an increase in the frequency of infectious complications, especially chest infection, with age, from 14.8% in patients < 65 years, to 22.7% in patients 65-80 years, to 44.4% in patients > 80 years (P = 0.01). Multivariate analysis showed no increase in overall complications in elderly patients, but Stage II or Stage III cancer (OR = 2.59, P= 0.04) and increasing body mass index (BMI) (OR = 1.07 for each unit increase in BMI, P = 0.04) were related to complications. Age remained the only predictor of an infective complication on multivariate analysis. Patients > 80 years of age had 4.21 times the OR of an infective complication (P = 0.03). Conclusion Older patients are more susceptible to infective complications postoperatively, particularly chest complications. Surgeons should alter their practice to reduce morbidity, such as adopting protocols requiring early physiotherapy. [ABSTRACT FROM AUTHOR]

Aim Hospital stays of 5 days or more are not uncommon following ileostomy closure, yet within an enhanced recovery programme ( ERP) it is possible for patients to be discharged on the first postoperative day following anterior resection. The aim of this study was to evaluate whether the introduction of an ERP for ileostomy closure reduced hospital stay without affecting morbidity or readmission rates. Method Consecutive patients undergoing elective ileostomy closure from October 2000 to March 2013 were included in this study. The data were collected prospectively into a database. Enhanced recovery was introduced for all elective ileostomy closures in June 2010. Demographic data, length of stay ( LOS), readmission, morbidity and mortality were compared between the two groups using the Mann-Whitney U-test and Fisher's exact test. Results One hundred and forty-five patients underwent elective ileostomy closure during the study period (37 ERP and 108 pre- ERP). There were no differences between the two groups with respect to demographics, American Society of Anesthesiologists grade, prior radiotherapy or chemotherapy, operative time, body mass index, antibiotic use or closure method. Readmission rates (5% vs 6.5%, P = 1.0), morbidity (8% vs 10%, P = 1.0) and mortality (0% vs 0%) were not significantly different. Median (2 vs 4 days, P < 0.0001) and mean (3.4 vs 5.6 days, P = 0.033) LOS were significantly shorter in the ERP group compared with the pre- ERP group. Conclusion An ERP for closure of ileostomy significantly reduces LOS without adverse effects for patients. [ABSTRACT FROM AUTHOR]

Objective To describe and assess the evolution of an enhanced recovery programme ( ERP) for open radical cystectomy. Patients and Methods We introduced a mentored ERP for radical cystectomy in January 2011. The programme underwent service evaluation and multiple changes in August 2012 that we define as marginal gains. We present a retrospective review of 133 consecutive patients undergoing open radical cystectomy, grouped according to the three stages of the ERP from October 2008 to April 2013: (1) non- ERP group ( October 2008 to December 2010): n = 69; (2) ERP-1 group ( January 2011 to July 2012): n = 37; and (3) ERP-2 group ( August 2012 to April 2013): n = 27. Primary outcomes were length of hospital stay ( LOS), readmission, morbidity at 90 days using the Clavien classification system and mortality. Secondary outcomes were time to flatus, ileus rates, re-operation rates and oncological outcomes. Results There were no differences in patient demographics among any of the groups for: age, gender, BMI, American Society of Anesthesiologists score and the use of neoadjuvant chemotherapy. There were no differences in readmission, morbidity and mortality rates. The overall 90-day mortality was six patients (4.5%). There were significant differences in ileus rates between the non- ERP, the ERP-1 and the ERP-2 groups: 44.9% (31 patients), 29.7% (11 patients) and 14.8% (four patients), respectively ( P = 0.017). There was a significant difference in the presence of pathological lymphadenopathy in the ERP-2 group: non- ERP group, 10.1%; ERP-1 group, 16.2%; and ERP-2 group, 44.4%; P = 0.002. There was also a difference in the mean ( sd) lymph node yield in ERP-2: non- ERP group, 8.4 (5.4) nodes; ERP-1, 8.2 (6.4) nodes; and ERP-2, 16.7 (5.4) nodes ( P < 0.001). The median (range) LOS was 14 (7-91) days, 10 (6-55) days and 7 (3-99) days in the non- ERP, ERP-1 and ERP-2 groups, respectively ( P < 0.001). Conclusions Auditing an already successful ERP and implementing a number of marginal gains has led to a significant decrease in the median LOS for radical cystectomy. The LOS for open radical cystectomy at University Hospital Southampton has halved. In the second phase of our ERP, our median LOS is 7 days. [ABSTRACT FROM AUTHOR]