Search

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

Access to nutritional care is frequently limited or denied to patients with disease-related malnutrition (DRM), to those with the inability to adequately feed themselves or to maintain their optimal healthy nutritional status which goes against the fundamental human right to food and health care. That is why the International Working Group for Patient's Right to nutritional care is committed to promote a human rights based approach (HRBA) in the field of clinical nutrition. Our group proposed to unite efforts by launching a global call to action against disease-related malnutrition through The International Declaration on the Human Right to Nutritional Care signed in the city of Vienna during the 44th ESPEN congress on September 5th 2022. The Vienna Declaration is a non-legally binding document that sets a shared vision and five principles for implementation of actions that would promote the access to nutritional care. Implementation programs of the Vienna Declaration should be promoted, based on international normative frameworks as The United Nations (UN) 2030 Agenda for Sustainable Development, the Rome Declaration of the Second International Conference on Nutrition and the Working Plan of the Decade of Action on Nutrition 2016–2025. In this paper, we present the general background of the Vienna Declaration, we set out an international normative framework for implementation programs, and shed a light on the progress made by some clinical nutrition societies. Through the Vienna Declaration, the global clinical nutrition network is highly motivated to appeal to public authorities, international governmental and non-governmental organizations and other scientific healthcare societies on the importance of optimal nutritional care for all patients. [ABSTRACT FROM AUTHOR]

The Society for Vascular Surgery and the Enhanced Recovery After Surgery Society formally collaborated and elected an international, multidisciplinary panel of experts to review the literature and provide evidence-based recommendations related to all the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites) for aortic aneurysm and aortoiliac occlusive disease. Structured around the Enhanced Recovery After Surgery core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations. [ABSTRACT FROM AUTHOR]

This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively. [ABSTRACT FROM AUTHOR]

Clinical outcome is negatively correlated to postoperative insulin resistance and hyperglycemia. The magnitude of insulin resistance can be modulated by glucose control, preoperative nutrition, adequate pain management and minimal invasive surgery. Effects of glucose control on perioperative glucose kinetics in liver surgery is less studied. 18 patients scheduled for open hepatectomy were studied per protocol in this prospective, randomized study. In the treatment group (n = 9), insulin was administered intravenously to keep arterial blood glucose between 6 and 8 mmol/l during surgery. The control group (n = 9) received insulin if blood glucose >11.5 mmol/l. Insulin sensitivity was measured by an insulin clamp on the day before surgery and immediately postoperatively. Glucose kinetics were assessed during the clamp and surgery. Mean intraoperative glucose was 7.0 mM (SD 0.7) vs 9.1 mM (SD 1.9) in the insulin and control group respectively (p < 0.001; ANOVA). Insulin sensitivity decreased in both groups but significantly (p = 0.03, ANOVA) more in the control group (M value: 4.6 (4.4–6.8) to 2.1 (1.2–2.6) and 4.6 (4.1–5.0) to 0.6 (0.1–1.8) mg/kg/min in the treatment and control group respectively). Endogenous glucose production (EGP) increased and glucose disposal (WGD) decreased significantly between the pre- and post-operative clamps in both groups, with no significant difference between the groups. Intraoperative kinetics demonstrated that glucose control decreased EGP (p = 0.02) while WGD remained unchanged (p = 0.67). Glucose control reduces postoperative insulin resistance in liver surgery. EGP increases and WGD is diminished immediately postoperatively. Insulin seems to modulate both reactions, but mostly the WGD is affected. Intraoperative EGP decreased while WGD remained unaltered. ANZCTR 12614000278639. [ABSTRACT FROM AUTHOR]

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function. [ABSTRACT FROM AUTHOR]

Observational studies have shown an association between hyperglycaemia and increased complications in orthopaedic patients. The aim of the study was to investigate if impaired preoperative glycaemic control, reflected by elevated HbA1c, was associated with adverse postoperative events in hip fracture patients. 160 patients (116 women and 44 men; age 80 ± 10 and BMI 24 ± 4; mean ± SD) with hip fractures were included in a prospective observational cohort study. The patients were divided into two groups, normal glycaemic control (NGC) and impaired glycaemic control (IGC) HbA1c ≥ 42 mmol/mol. The patients were also characterized according to BMI and nutritional status using MNA-SF (Minimal Nutritional Assessment Short Form). Complications within 30 days of surgery were classified according to Clavien–Dindo and 1-year mortality was compared between the groups. Out of 160 patients, 18 had diabetes and 4 more had likely occult diabetes (HbA1c ≥ 48). Impaired glycaemic control (IGC) was seen in 29 patients (18.1%) and normal glycaemic control (NGC) in 131 (81.9%). In patients with NGC and IGC, no postoperative complications (Clavien–Dindo Grade 0) were seen in 64/131 vs. 14/29 (48.9 vs. 48.3%), Grade 1-3a in 54/131 vs. 14/29 (41.2 vs. 48.3%) and Grade 3b-5 in 13/131 vs. 1/29 (9.9 vs. 3.4%) respectively, p = NS. There were no differences in 30-day complications (p = 0.55) or 1-year mortality (p = 0.35) between the groups. Elevated HbA1c at admission is not associated with increased complications or mortality after hip fracture surgery. [ABSTRACT FROM AUTHOR]

Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14–15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients. This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art. Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer. Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient. [ABSTRACT FROM AUTHOR]

The enhanced recovery after surgery (ERAS) pathway is an evidence-based approach to the use of care elements along the patient perioperative pathway. All care elements that may impact on clinically relevant outcomes have been considered and reviewed. The combined ERAS actions allow a quicker return to bowel function, oral feeding, nutritional and metabolic equilibrium, normal activity and ultimately to achieve better outcomes. Because of the multi factorial approach and the commitment of all the professionals caring for the patient, it is necessary to have the engagement of all disciplines, such as surgery, anesthesiology, clinical nutrition, nursing, physiatry, involved. ERAS is a dynamic process and new evidence are constantly integrated into the program. The primary endpoint of this review is to give updated information on the key ERAS actions to achieve optimal perioperative nutritional and metabolic care. [ABSTRACT FROM AUTHOR]

Ten years ago, European health care professional societies, health associations and members of the European Parliament convened in Brussels to discuss the necessary and urgent actions needed to improve access, initiation and follow up nutritional care for European citizens. As a response to this, in 2014 the Optimal Nutritional Care for All (ONCA) campaign was launched under the leadership of the European Nutritional for Health Alliance and its members. As of today this campaign has been rolled out in 18 European countries, whereby national multi-disciplinary platforms including patient groups work together to implement national nutritional care programs and develop good practices in care, research, education in order to increase awareness on malnutrition and improve nutritional care. This article describes the making of and evolution of the ONCA campaign, the outcomes and impact created, as well as opportunities to accelerate implementation of personalized nutritional care for all European citizens. [ABSTRACT FROM AUTHOR]

Surgery causes development of insulin resistance. Women undergoing hysterectomy have different female sex hormonal status, ranging from premenopausal to postmenopausal. The aim of the study was to explore the relation between the female sex hormones and insulin resistance (IR%) after hysterectomy. A secondary analysis from a randomised controlled single-centre study at the Department of Obstetrics and Gynaecology, Örebro University Hospital, Sweden. Twenty women were randomised to robot-assisted laparoscopic or abdominal hysterectomy. Blood were drawn before and after surgery for measurement of oestrogens, progesterone, and gonadotropins alongside determination of insulin sensitivity using the hyperinsulinemic normolycaemic clamp. Female sex hormonal status was not correlated to insulin sensitivity before operation. Premenopausal women developed more IR% than postmenopausal women (p = 0.012). Premenopausal women also showed a significant decrease in absolute levels of oestradiol (E2) (p = 0.016), and the relative decrease in E2 from preoperative to postoperative values (E2%) was significantly higher (p = 0.001). There was a significant positive correlation in the entire study population between E2% and IR% (r = 0.72, p = 0.001, r2 0.51) that remained when adjusted for age (p = 0.028), BMI (p = 0.001), and preoperative insulin sensitivity (p = 0.011) separately. Premenopausal women developed a higher degree of postoperative insulin resistance that was associated with a parallel relative change in oestradiol levels compared with the postmenopausal women. It remains unclear whether these are independent phenomena in the overall stress response or whether a causal relationship exists. [ABSTRACT FROM AUTHOR]

Summary Background & aims Despite high prevalence at hospital admission, disease related malnutrition (DRM) remains under recognized and undertreated. DRM is associated with increased morbidity, hospital readmission rate, and burden for the healthcare system. The compelling need to increase awareness and knowledge through an international survey has triggered the launch of the nutritionDay (ND) concept. Methods ND is a worldwide annual systematic collection and analysis of data in hospital wards, intensive care units and nursing homes. ND is based on questionnaires to systematically collect and analyze the patient's characteristics, food intake and nutrition support, as well as the determinants of their environment (facility, health care personal, etc …). Questionnaires, outcome documentation sheets and step-by-step guidance are available as download in 30 languages. Results ND has described the nutritional status and behavior of over 150,000 hospitalized patients and nursing home's patients in over 56 participating countries. These data allowed a local, regional, national and international benchmarking at different levels (i.e. type of medical pathologies, care facilities, etc.) and over time. Sixteen peer-reviewed publications have already been released and picture the international scene of DRM. Conclusion This review presents the 10-year of the ND project development and shows how ND serves all health care professionals to optimize nutrition care and nutrition related structures. ND keeps progressing and is likely to become a standard tool for determining the nutritional status and behavior of hospitalized patients and nursing home's population. [ABSTRACT FROM AUTHOR]

The article discusses the period of starvation within the context of the pathophysiological changes that accompany major surgery. Topics covered include ways of assessing the magnitude of the stress response, the use of minimally-invasive surgery to reduce the prolonged effects of starvation, and maltodextrin as the key composition of oral carbohydrate loading.

Summary Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: • integration of nutrition into the overall management of the patient • avoidance of long periods of preoperative fasting • re-establishment of oral feeding as early as possible after surgery • start of nutritional therapy early, as soon as a nutritional risk becomes apparent • metabolic control e.g. of blood glucose • reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • minimized time on paralytic agents for ventilator management in the postoperative period • early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice. [ABSTRACT FROM AUTHOR]

Background: Inadequate nutrition during hospitalization is strongly associated with poor patient outcome, but ensuring adequate food intake is not a priority in clinical routine worldwide. This lack of priority results in inadequate and unbalanced food intake in patients and huge amounts of wasted food. Objectives: We evaluate the main factors that are associated with reduced meal intake in hospitalized patients and the differences between geographical regions. Design: We conducted a descriptive analysis of data from 9 consecutive, annual, and cross-sectional nutritionDay samples (2006-2014) in a total of 91,245 adult patients in 6668 wards in 2584 hospitals in 56 countries. A general estimation equation methodology was used to develop a model for meal intake, and P-value thresholding was used for model selection. Results: The proportion of patients who ate a full meal varied widely (24.7-61.5%) across world regions. The factors that were most strongly associated with reduced food intake on nutritionDay were reduced intake during the previous week (OR: 0.20; 95% CI: 0.17, 0.22), confinement to bed (OR: 0.49; 95% CI: 0.44, 0.55), female sex (OR: 0.53; 95% CI: 0.5, 0.56), younger age (OR: 0.74; 95% CI: 0.64, 0.85) and older age (OR: 0.80; 95% CI: 0.74; 0.88), and low body mass index (OR: 0.84; 95% CI: 0.79, 0.90). The pattern of associated factors was homogenous across world regions. Conclusions: A set of factors that are associated with full meal intake was identified and is applicable to patients hospitalized in any region of the world. Thus, the likelihood for reduced food intake is easily estimated through access to patient characteristics, independent of world regions, and enables the easy personalization of food provision. This trial was registered at clinicaltrials.gov as NCT02820246. [ABSTRACT FROM AUTHOR]

Summary Background Patients receiving a carbohydrate drink (CHO) before major abdominal surgery display improved insulin sensitivity postoperatively and increased proteolysis of IGFBP-3 (IGFBP-3-PA) compared to patients undergoing similar surgery after overnight fasting. Aims We hypothesized that serum IGFBP-3-PA increases bioavailability of circulating IGF-I and preserves insulin sensitivity in patients given CHO. Design Matched control study. Methods At Karolinska University Hospital, patients given CHO before major elective abdominal surgery (CHO,n = 8) were compared to patients undergoing similar surgical procedures after overnight fasting (FAST,n = 10). Results from two different techniques for determination of free-dissociable IGF-I (fdIGF-I) were compared with changes in IGFBP-3-PA and insulin sensitivity. Results Postoperatively, CHO displayed 18% improvement in insulin sensitivity (hyperinsulinemic clamp) and increased IGFBP-3-PA vs. FAST. As determined by IRMA, fdIGF-I increased by 48 ± 25% in CHO while fdIGF-I decreased by 13 ± 18% in FAST (p < 0.01 vs. CHO, when corrected for duration of surgery). However, fdIGF-I determined by ultra-filtration decreased similarly in both groups (−22 ± 8% vs. −25 ± 8%, p = 0.8) and IGFBP-1 increased similarly in both groups. Patients with less insulin resistance after surgery demonstrated larger increases in fdIGF-I by IRMA (r = 0.58, p < 0.05). Fifty-three % of the variability of the changes in fdIGF-I by IRMA could be explained by changes in IGFBP-3-PA and total IGF-I levels (p < 0.05), while IGFBP-1 did not contribute significantly. Conclusion During conditions when serum IGF-I bioavailability is regulated by IGFBP-3 proteolysis, measurements of fdIGF-I by IRMA is of physiological relevance as it correlates with the associated changes in insulin sensitivity. [ABSTRACT FROM AUTHOR]

Summary Background & aims In elective surgery, postoperative hyperglycaemia and insulin resistance are independent risk factors for complications. Since the simpler HOMA method has been used as an alternative to the hyperinsulinemic normoglycemic clamp in studies of surgery induced insulin resistance, we compared the two methods in patients undergoing elective surgery. Methods Data from 113 non-diabetic patients undergoing elective surgery were used. Insulin sensitivity, both before and after surgery, was quantified by the clamp and HOMA. Pre- and postoperatively, the results of the clamp were compared to HOMA using regression- and correlation analysis. Degree of agreement between the methods was studied using weighted linear kappa and the Bland–Altman test. Results Both the clamp and HOMA recorded a mean relative reduction in insulin sensitivity of 39 ± 24% and 39 ± 61% respectively after surgery; with significant correlations ( p < 0.01) for pre- and post-operative measures as well as for relative changes. However r 2 values were low: 0.04, 0.07 and 0.03 respectively. The degree of agreement for the relative change in insulin sensitivity using the Bland–Altman test gave a mean of difference 0% but “limits of agreement” (±2SD) was ±125%. This poor inter-method agreement was consolidated by a weighted linear kappa value of 0.18. Conclusion While the hyperinsulinemic euglycemic clamp measures the postoperative changes in insulin sensitivity, HOMA measures something different. Data using the HOMA method must therefore be interpreted cautiously and is not interchangeable with data obtained from the clamp. [ABSTRACT FROM AUTHOR]

Summary: Purpose: Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery. Objectives: The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group. Evidence acquisition: A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated. Evidence synthesis: Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery. Conclusions: ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy. [ABSTRACT FROM AUTHOR]

Summary: Background & aims: Whilst preoperative carbohydrate treatment (PCT) results in beneficial physiological effects, the effects on postoperative clinical outcomes remain unclear and were studied in this meta-analysis. Methods: Prospective studies that randomised adult non-diabetic patients to either PCT (≥50 g oral carbohydrates 2–4 h pre-anaesthesia) or control (fasted/placebo) were included. The primary outcome was length of hospital stay. Secondary outcomes included development of postoperative insulin resistance, complications, nausea and vomiting. Methodological quality was assessed using GRADEpro® software. Results: Twenty-one randomised studies of 1685 patients (733 PCT: 952 control) were included. No overall difference in length of stay was noted for analysis of all studies or subgroups of patients undergoing surgery with an expected hospital stay ≤2 days or orthopaedic procedures. However, patients undergoing major abdominal surgery following PCT had reduced length of stay [mean difference, 95% confidence interval: −1.08 (−1.87 to −0.29); I 2 = 60%, p = 0.007]. PCT reduced postoperative insulin resistance with no effects on in-hospital complications over control (risk ratio, 95% confidence interval, 0.88 (0.50–1.53), I 2 = 41%; p = 0.640). There was significant heterogeneity amongst studies and, therefore, quality of evidence was low to moderate. Conclusions: PCT may be associated with reduced length of stay in patients undergoing major abdominal surgery, however, the included studies were of low to moderate quality. [Copyright &y& Elsevier]

Summary: Background & aims: Protocols for enhanced recovery provide comprehensive and evidence-based guidelines for best perioperative care. Protocol implementation may reduce complication rates and enhance functional recovery and, as a result of this, also reduce length-of-stay in hospital. There is no comprehensive framework available for pancreaticoduodenectomy. Methods: An international working group constructed within the Enhanced Recovery After Surgery (ERAS®) Society constructed a comprehensive and evidence-based framework for best perioperative care for pancreaticoduodenectomy patients. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group. The quality of evidence was rated “high”, “moderate”, “low” or “very low”. Recommendations were graded as “strong” or “weak”. Results: Comprehensive guidelines are presented. Available evidence is summarised and recommendations given for 27 care items. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. Conclusions: The present evidence-based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy. A unified protocol allows for comparison between centres and across national borders. It facilitates multi-institutional prospective cohort registries and adequately powered randomised trials. [ABSTRACT FROM AUTHOR]

Summary: Background & aims: Postoperative insulin resistance and the consequent hyperglycemia affects clinical outcome. Insulin sensitivity may be modulated by preoperative nutrition, adequate pain management and minimal invasive surgery. This study aims to disclose the impact of perioperative glucose control on postoperative insulin resistance. Methods: Twenty patients scheduled for elective open hepatectomy were enrolled in this prospective, randomized study. In the treatment group (n = 9) insulin was administered intravenously to keep blood glucose between 6 and 8 mmol/l during surgery. The control group (n = 8) received insulin if blood glucose >14 mmol/l. Insulin sensitivity was measured by a hyperinsulinemic normoglycemic clamp (0.8 mU/kg/min), performed on all patients both on the day before surgery and immediately postoperatively. Plasma cortisol, insulin and C-peptide were measured. Results: There was a significant difference in mean glucose value during surgery. In the control group 8.8 mmol/l (SD 1.5) vs. 6.9 mmol/l (SD 0.4) in the treated group, p = 0.003. In the control group insulin sensitivity decreased to 21.9% ± 16.2% of the preoperative value and in the insulin treated group to 46.8 ± 15.5%, p < 0.005. Insulin levels were significantly higher in the treatment group as well as consequently lower C-peptide levels. Conclusions: This trial revealed a significant difference in postoperative insulin resistance in the group treated with insulin during surgery. [Copyright &y& Elsevier]

Summary: Background & aims: To examine the effect of malnutrition on clinical outcomes and healthcare resource use from initial diagnosis by a general practitioner (GP) in the UK. Methods: 1000 records of malnourished patients were randomly selected from The Health Improvement Network database and matched with a sample of 996 patients’ records with no previous history of malnutrition. Patients’ outcomes and resource use were quantified for six months following diagnosis. Results: Malnourished patients utilised significantly more healthcare resources (e.g. 18.90 versus 9.12 GP consultations; p < 0.001, and 13% versus 5% were hospitalised; p < 0.05). The six-monthly cost of managing the malnourished and non-malnourished group was £1753 and £750 per patient respectively, generating an incremental cost of care following a diagnosis of malnutrition of £1003 per patient. Thirteen percent and 2% of patients died in the malnourished and non-malnourished group respectively (p < 0.001). Independent predictors of mortality were: malnutrition (OR: 7.70); age (per 10 years) (OR: 10.46); and the Charlson Comorbidity Index Score (per unit score) (OR: 1.24). Conclusion: The healthcare cost of managing malnourished patients was more than twice that of managing non-malnourished patients, due to increased use of healthcare resources. After adjusting for age and comorbidity, malnutrition remained an independent predictor of mortality. [Copyright &y& Elsevier]

Summary: Background & aims: Recognition and treatment of undernutrition in hospitalized patients are not often a priority in clinical practice. Objectives: We investigated how the nutritional risk of patients is determined and whether such assessment influences daily nutritional care across Europe and in Israeli hospitals. Methods: 1217 units from 325 hospitals in 25 countries with 21,007 patients participated in a longitudinal survey “nutritionDay” 2007/2008 undertaken in Europe and Israel. Screening practice, the type of tools used and whether energy requirements and intake are assessed and monitored were surveyed using standardized questionnaires. Results: Fifty-two percent (range 21–73%) of the units in the different regions reported a screening routine which was most often performed with locally developed methods and less often with national tools, the Nutrition Risk Screening-2002, or the Malnutrition Universal Screening Tool. Twenty-seven percent of the patients were subjectively classified as being “at nutritional risk”, with substantial differences existing between regions. Independent factors influencing the classification of nutritional risk included age, BMI <18.5 kg/m2, unintentional weight loss, reduced food intake in the previous week and on nutritionDay (for all parameters, p < 0.0001). The energy goal was defined as >=1500 kcal in 76% of the patients, but 43% of patients did not reach this goal. Conclusions: The process of nutrition risk assessment varied between units and countries. Additionally, energy goals were frequently not met. More effort is needed to implement current guidelines within daily clinical practice. [Copyright &y& Elsevier]

Summary: Background & aims: The aim of the Enhanced Recovery After Surgery (ERAS) pathway is to attenuate the stress response to surgery and enable rapid recovery. The objective of this meta-analysis was to study the differences in outcomes in patients undergoing major elective open colorectal surgery within an ERAS pathway and those treated with conventional perioperative care. Methods: Medline, Embase and Cochrane database searches were performed for relevant studies published between January 1966 and November 2009. All randomized controlled trials comparing ERAS with conventional perioperative care were selected. The outcome measures studied were length of hospital stay, complication rates, readmission rates and mortality. Results: Six randomized controlled trials with 452 patients were included. The number of individual ERAS elements used ranged from 4 to 12, with a mean of 9. The length of hospital stay [weighted mean difference (95% confidence interval): −2.55 (−3.24, −1.85)] and complication rates [relative risk (95% confidence interval): 0.53 (0.44, 0.64)] were significantly reduced in the enhanced recovery group. There was no statistically significant difference in readmission and mortality rates. Conclusion: ERAS pathways appear to reduce the length of stay and complication rates after major elective open colorectal surgery without compromising patient safety. [ABSTRACT FROM AUTHOR]

The concept of preoperative overnight fasting was challenged and proved to have no benefits over allowing patients to drink clear fluids up until 2 h before surgery. This led to changes in the guidelines for preoperative fasting in many countries around the world. This concept has more recently been developed further. Mounting evidence indicates that instead of being operated in the traditional overnight fasted state, undergoing surgery in the carbohydrate-fed state has many clinical benefits. Many of these clinical effects can be related to reduced postoperative insulin resistance by preoperative carbohydrate loading. This article summarises the present understanding of the mechanisms behind the positive clinical effects and gives an overview of the information available regarding the clinical effects of this treatment. Finally, the article summarises the most recently published national guidelines on preoperative fasting routines where preoperative carbohydrates are recommended for use before a major surgery. These are to be considered for all patients allowed to drink clear fluids and undergoing elective surgery. [ABSTRACT FROM AUTHOR]

Summary: Background & aims: Postoperative insulin resistance, resulting in hyperglycemia, is strongly associated to morbidity and mortality in surgical patients but the underlying mechanisms are unclear. As increasing data suggests a link between inflammation and insulin resistance, we aimed to evaluate if the expression of inflammatory and insulin signaling genes is regulated in skeletal muscle during surgery. Methods: Eight patients (4 females, 63 [46–69] years, body mass index 25.5 [16.5–29.8]kg/m2) undergoing major abdominal surgery were included. Biopsies from m. rectus abdominis were obtained at the beginning and at the end of the operation. mRNA levels of 45 genes were analyzed. Results: The time elapsed between the two biopsies was 224 (198–310)min. An increased (p <0.05) expression was noted for genes encoding both inflammatory mediators, such as interleukin 6, tumor necrosis factor, and nuclear factor of kappa light polypeptide gene enhancer in B cells, and metabolic regulators, such as peroxisome proliferator-activated receptor delta, while the analysis did not detect significant expression changes of the insulin signaling pathway genes. Conclusions: The observed gene expression changes in skeletal muscle during surgery occurred mainly in inflammatory pathways, suggesting a possible role for inflammation in the development of postoperative insulin resistance. [Copyright &y& Elsevier]

This chapter is complementary to the others in this volume focusing on preoperative fasting routines. In it we discuss some of the issues in need of more research to define best practice. One of these is the role of fasting in emergency patients. Modern preoperative fasting recommendations almost exclusively deal with elective patients. In emergency patients preoperative fasting cannot secure gastric emptying to reduce the risk of pulmonary aspiration. Hence, surgery should be timed according to the urgency of the situation, and the patient should always be treated as if the stomach was full. More data are needed to better define what is going on in the gastrointestinal tract during the perioperative period in these patients. In certain patient groups – such as patients with diabetes, gastro-oesophageal reflux disease and/or obesity – the data are insufficient to give complete guidance to best practice. Preoperative fasting guidelines also affect fluid balance and perioperative fluid management, a topic of debate in recent years. In addition, carbohydrate-enriched fluids for oral use in the preoperative phase have been shown to have a positive effect on postoperative metabolism. Recent studies also suggest that the immune system would be less affected by surgery with such preparations. Last but not least, new scientific evidence alone is not enough to change daily practice. Active implementation of new evidence is also needed. To improve perioperative care, anaesthesiologists, surgeons and the nursing staff must work together. [Copyright &y& Elsevier]

Summary: Background & aims: This study reviewed the case mix, clinical management, and clinical outcomes of patients undergoing colorectal resection in five European centres performing different forms of conventional or ‘fast-track’ perioperative care. Methods: The perioperative care programme and surgical practice in each centre was defined. Patient data were collected by case-note review on an internet-based audit system. Case mix was determined using ASA classification and the P-POSSUM scoring system. Results: A total of 451 consecutive patients from units practicing either conventional (Sweden, ; UK, ; Netherlands, , Norway, ) or fast-track surgery (Denmark, ), were studied between 1998 and 2001. Elements of perioperative practice varied widely both between units practicing ‘traditional’ care and the reference ‘fast-track’ unit (Denmark). Based on the P-POSSUM scores, the case mix was similar between centres. There were no differences in morbidity or 30-day mortality between the different centres. The median length of stay was 2 days in Denmark and 7–9 days in the other centres (). The readmission rate was 22% in Denmark and 2–16% in the other centres (). Conclusion: Compared with traditional care, fast-track perioperative care results in a reduced length of hospital stay but may be associated with a higher readmission rate. Morbidity and mortality appears to be similar with either approach. Prospective evaluation of the potential benefits of the fast-track approach in different European centres is merited. [Copyright &y& Elsevier]

Background: Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively.Objective: To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort.Study Design: The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates.Results: Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score ≤3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4-11). Median length of stay was 2 days in the low- and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90-0.95; P<.001) decrease in days in hospital among low-complexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82-0.93; P<.001) decrease among patients with medium/high-complexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P<.05) among low-complexity patients.Conclusion: Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation. [ABSTRACT FROM AUTHOR]

Background: Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.Purpose: This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.Study Design: This is a review article.Methods: Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.Results: Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.Conclusion: Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion. [ABSTRACT FROM AUTHOR]

Abstract: Objective: We compared the metabolic effects of postoperative total parenteral nutrition (TPN) and hypocaloric glucose after treatment with oral carbohydrates preoperatively and epidural anesthesia to proactively minimize postoperative insulin resistance. Methods: Thirteen patients undergoing colorectal resections were given oral carbohydrates preoperatively and epidural anesthesia and randomized to TPN or hypocaloric glucose during and after surgery. Insulin sensitivity (hyperinsulinemic clamp [0.8 mU·kg−1 ·min−1], normoglycemic clamps [4.5 mM]), and glucose kinetics (6,62H2-d-glucose), were studied before and on postoperative day 3. Indirect calorimetry was performed and nitrogen excretion in urine was measured. Values are presented as mean ± standard deviation. Analysis of variance, planned comparison, and Bonferroni’s correction were used for statistical analysis. Results: Three days after surgery insulin-stimulated whole-body glucose disposal decreased by 24 ± 11% versus 28 ± 23% in patients receiving TPN and hypocaloric glucose, respectively (P < 0.05 for both, not significant between groups). Endogenous glucose production during insulin stimulation was increased only in the glucose group after surgery (P < 0.05 versus before). After surgery, insulin-stimulated glucose oxidation was higher after treatment with TPN, whereas fat oxidation was lower (P < 0.05 for both versus glucose treatment). Fat oxidation increased in the glucose group at basal after surgery (P < 0.05 versus before). Nitrogen balance was less negative after treatment with TPN (P < 0.01). Conclusions: Treatment with TPN does not seem to improve postoperative peripheral insulin sensitivity in patients with minor insulin resistance after pretreatment with preoperative carbohydrates and perioperative epidural anesthesia. Hypocaloric nutrition results in changes in substrate utilization and nitrogen balance resembling starvation, whereas TPN attenuates these changes. [Copyright &y& Elsevier]

Purpose: The primary therapy in epidermoid anal cancer is radiotherapy, generally with chemotherapy. The use of neoadjuvant chemotherapy has been infrequently reported in the literature. This study presents results from a large population-based series and provides comparisons between different treatments.Methods and materials: Between 1985 and 2000, 308 patients with invasive epidermoid anal cancer were diagnosed in the Stockholm Health Care Region. Treatment was given according to defined protocols. External beam radiotherapy alone or with concomitant bleomycin and neoadjuvant chemotherapy followed by radiotherapy alone were the primary treatments. Radical surgery was reserved for poor responders or recurrences. Data were reviewed with regard to treatment, outcome, and prognostic factors.Results: Among the 276 patients (90%) treated with curative intent, 264 (96%) received treatment in accordance with the protocols. The overall 5-year survival rate was 68%. Among the 142 patients with locally advanced tumors (T ≥4 cm or N+), patients treated with neoadjuvant platinum-based chemotherapy (n = 91) had significantly better complete response rates compared with patients treated with radiotherapy with or without bleomycin (n = 51) (92% vs. 76%, p < 0.01). A significantly increased overall 5-year survival rate was also found among patients receiving neoadjuvant therapy (63% vs. 44%, p < 0.05).Conclusion: Structured treatment protocols result in favorable outcome on a population level. The results further suggest a significant therapeutic gain from including neoadjuvant chemotherapy in the treatment of locally advanced anal cancer. [Copyright &y& Elsevier]