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The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice. [ABSTRACT FROM AUTHOR]

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations. The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma. The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice. [ABSTRACT FROM AUTHOR]

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management. The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma. The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice. [ABSTRACT FROM AUTHOR]

Preoperative malnutrition and weight loss negatively impact postoperative outcomes in various surgical fields. However, for gynecologic surgery, evidence is still scarce, especially if surgery is performed within enhanced recovery after surgery (ERAS) pathways. This study aimed to assess the prevalence and impact of preoperative weight loss in patients undergoing major gynecologic procedures within a standardized ERAS pathway between October 2013 and January 2017. Out of 339 consecutive patients, 33 (10%) presented significant unintentional preoperative weight loss of more than 5% during the 6 months preceding surgery. These patients were less compliant to the ERAS protocol (>70% of all items: 70% vs. 94%, p < 0.001) presented more postoperative overall complications (15/33 (45%) vs. 69/306 (22.5%), p = 0.009), and had an increased length of hospital stay (5 ± 4 days vs. 3 ± 2 days, p = 0.011). While patients experiencing weight loss underwent more extensive surgical procedures, after multivariate analysis, weight loss ≥5% was retained as an independent risk factor for postoperative complications (OR 2.44; 95% CI 1.00–5.95), and after considering several surrogates for extensive surgery including significant blood loss (OR 2.23; 95% CI 1.15–4.31) as confounders. The results of this study suggest that systematic nutritional screening in ERAS pathways should be implemented. [ABSTRACT FROM AUTHOR]

Background: Enhanced Recovery After Surgery (ERAS) guidelines advocate early postoperative mobilisation to counteract catabolic changes due to immobilisation and maintain muscle strength. The present study aimed to assess compliance to postoperative mobilisation according to ERAS recommendations.Materials and Methods: This is a retrospective cohort study on consecutive colorectal surgical procedures treated within an established ERAS protocol within a single center between May 2011 and May 2017. Demographics, surgical details, ERAS related items and surgical outcome were prospectively assessed in a dedicated database and compared between ambulant patients (at least 6 h out of bed at postoperative day (POD) 1) vs. patients not meeting the target (delayed mobilisation). Risk factors for decreased postoperative mobilisation were identified through multivariable logistic regression.Results: 1170 patients were retained. 676 patients (58%) did not mobilise as recommended by ERAS protocol at POD1. Emergency operation (Odds Ratio (OR) 0.40; 95% Confidence Interval (CI) 0.18-0.91, p = 0.028), age > 70 years (OR 0.69; 95% CI 0.47-1.00, p = 0.050) and intraoperative total fluids > 2000 mL (OR 0.59; 95% CI 0.37-0.93, p = 0.025) were independent risk factors for delayed mobilisation. Patients with delayed mobilisation had significantly more overall (Clavien grade IV) (55% vs. 29%, p=<0.001), major (Clavien grade IIIb-V) (16% vs. 7%, p=<0.001) and respiratory (12% vs. 4%, p=<0.001) complications, as well as longer length of stay (12 ± 14 vs. 6±7days, p=<0.001).Conclusions: More than half of patients did not mobilise as recommended by ERAS guidelines. Emergency surgery, advanced age and fluid overload were independent risk factors for delayed mobilisation, which was associated with increased postoperative complications. [ABSTRACT FROM AUTHOR]

Enhanced Recovery After Surgery (ERAS) protocols advocate early postoperative resumption of normal diet to decrease surgical stress and prevent excessive catabolism. The aim of the present study was to identify reasons for delayed tolerance of normal postoperative diet. This was a retrospective analysis including all consecutive colorectal surgical procedures since May 2011 until May 2017. Data was prospectively recorded by an institutional data manager in a dedicated database. Uni- and multivariate risk factors associated with delayed diet (beyond POD 2) were identified by multiple logistic regression among demographic, surgery- and modifiable pre- and intraoperative ERAS-related items. In a second step, univariate analysis was performed to compare surgical outcomes for patients with early vs. delayed oral intake. The study cohort consisted of 1301 consecutive colorectal ERAS patients. Herein, 691 patients (53%) were able to resume normal diet within two days of surgery according to ERAS protocol, while in 610 patients (47%), a delay in tolerance of normal diet was observed. Male gender was independently correlated to early tolerance (Odds Ratio (OR) 0.66; 95% Confidence Interval (CI) 0.46-0.84, p = 0.002), while ASA score ≥ 3 (OR 1.60; 95% CI 1.12-2.28, p = 0.010), abdominal drains (OR 1.80; 95% CI 1.10-2.49, p = 0.020), right colectomy (OR 1.64; 95% CI 1.08-2.49, p = 0.020) and Hartmann reversal (OR 2.61; 95% CI 1.32-5.18, p = 0.006) constituted risk factors for delayed tolerance of normal diet. Patients with delayed resumption of normal diet experienced more overall (Clavien grade I-V) (47% vs. 21%, p < 0.001) and major (Clavien grade IIIb-V) (11% vs. 4%, p < 0.001) complications and had a longer length of stay (9 ± 5 vs. 5 ± 4 days, p < 0.001). Over half of patients could not tolerate early enteral realimentation and were at higher risk for postoperative complications. Prophylactic drain placement was the only independent modifiable risk factor for delayed oral intake. [ABSTRACT FROM AUTHOR]

Background/Aims: Enhanced recovery after surgery (ERAS) protocols for elective colorectal surgery reduce the intensity of postoperative complications, hospital stays and costs. Improvements in clinical outcome are directly proportional to the adherence to the recommended pathway (compliance). The aim of the present study was to analyze reasons for the non-compliance of colorectal surgeries with the ERAS protocol. Methods: A consecutive cohort of patients undergoing elective colorectal surgery was prospectively analyzed with regards to the surgery's compliance with the ERAS protocol. The reason for every single protocol deviation was documented and the decision was categorized based on whether it was medically justified or not. Results: During the 8-month study period, 76 patients were included. The overall compliance with 22 ERAS items was 76% (96% in the preoperative, 82% in the perioperative, and 63% in the postoperative period). The decision to deviate from the clinical pathway was mainly a medical decision, while patients and nurses were responsible in 26 and 14% of the cases, respectively. However, reasons for non-compliance were medically justified in 78% of the study participants. Conclusion: 'Non-compliance' with the ERAS protocol was observed mostly in the postoperative period. Most deviations from the pathway were decided by doctors and in a majority of cases it appeared that they were due to a medical necessity rather than non-compliance. However, almost a quarter of deviations that were absolutely required are still amenable to improvement. [ABSTRACT FROM AUTHOR]

Background& Aims: The importance of nursing for surgical patients has been frequently underestimated. The success of enhanced recovery programs after surgery (ERAS) depends on preferably complete fulfillment of the protocol and nurses are an important part of it. Due to the additional nursing action required, such protocols are suspected to increase the nursing workload. The aim of the present study was to observe and measure objectively nursing workload before, during and after systematic implementation of a comprehensive enhanced recovery pathway in colorectal surgery.Methods: The program ERAS was introduced systematically in our tertiary academic centre 2011, since then our experience is based on more than 1500 ERAS patients. Nursing workload was prospectively assessed for all patients on a routine basis by means of a standardized and validated point system (PRN). In a retrospective cohort study, we compared nursing workload based on prospective data before, during and after ERAS implementation and correlated nursing workload to the compliance with the ERAS protocol.Results: The study cohort included 50 patients before ERAS implementation (2010) and 69 (2011) and 148 (2012) consecutive patients after implementation; the baseline characteristics of the 3 groups were similar. Mean PRN values were 61.2 ± 19.7 per day in 2010 and decreased to 52.3 ± 13.7 (P = 0.005) and 51.6 ± 18.6 (P < 0.002) in 2011 and 2012, respectively. Increasing compliance with the ERAS protocol was significantly correlated to decreasing nursing workload (ρ = -0.42; P < 0.001).Conclusions: Nursing workload is--against a common belief--decreased by systematic implementation of enhance recovery protocol. The higher the compliance with the pathway, the lower the burden for the nurses! [ABSTRACT FROM AUTHOR]

Background and Objective: Key factors of Fast Track (FT) programs are fluid restriction and epidural analgesia (EDA). We aimed to challenge the preconception that the combination of fluid restriction and EDA might induce hypotension and renal dysfunction. Methods: A recent randomized trial (NCT00556790) showed reduced complications after colectomy in FT patients compared with standard care (SC). Patients with an effective EDA were compared with regard to hemodynamics and renal function. Results: 61/76 FT patients and 59/75 patients in the SC group had an effective EDA. Both groups were comparable regarding demographics and surgery-related characteristics. FT patients received significantly less i.v. fluids intraoperatively (1900 mL [range 1100–4100] versus 2900 mL [1600–5900], P < 0.0001) and postoperatively (700 mL [400–1500] versus 2300 mL [1800–3800], P < 0.0001). Intraoperatively, 30 FT compared with 19 SC patients needed colloids or vasopressors, but this was statistically not significant (P = 0.066). Postoperative requirements were low in both groups (3 versus 5 patients; P = 0.487). Pre- and postoperative values for creatinine, hematocrit, sodium, and potassium were similar, and no patient developed renal dysfunction in either group. Only one of 82 patients having an EDA without a bladder catheter had urinary retention. Overall, FT patients had fewer postoperative complications (6 versus 20 patients; P = 0.002) and a shorter median hospital stay (5 [2–30] versus 9 d [6-30]; P< 0.0001) compared with the SC group. Conclusions: Fluid restriction and EDA in FT programs are not associated with clinically relevant hemodynamic instability or renal dysfunction. [Copyright &y& Elsevier]

Résumé: ERAS (Enhanced Recovery After Surgery – réhabilitation améliorée) est un concept multimodal pour diminuer le stress chirurgical et les complications postopératoires. Comme effet secondaire, ERAS réduit la durée d’hospitalisation et les coûts de la chirurgie colorectale et est donc considéré comme standard. Les récentes recommandations ERAS fournissent un aperçu complet des mesures fondées sur des preuves. Sa mise en œuvre nécessite une équipe pluridisciplinaire dédiée, de contrôler sa mise en place ainsi que les progrès réalisés et de signaler les problèmes rencontrés (audit). [ABSTRACT FROM AUTHOR]

Early re-alimentation is advocated by enhanced recovery pathways (ERP). This study aimed to assess compliance to ERP-set early re-alimentation policy and to compare outcomes of early fed patients and patients in whom early feeding was withhold due to the independent decision making of the surgeon. For this purpose, demographic, surgical and outcome data of all consecutive elective colorectal surgical procedures (2011–2016) were retrieved from a prospectively maintained institutional ERP database. The primary endpoint was postoperative ileus (POI). Surgical 30-day outcome and length of stay were compared between patients undergoing the pathway-intended early re-alimentation pattern and patients in whom early re-alimentation was not compliant. Out of the 7103 patients included, 1241 (17.4%) were not compliant with ERP re-alimentation. Patients with delayed re-alimentation presented with more postoperative complications (37 vs. 21%, p < 0.001) and a prolonged length of hospital stay (8 ± 7 vs. 5 ± 4 days, p < 0.001). While male gender (odds ratio (OR) 1.24; 95% confidence interval (CI) 1.04–1.32), fluid overload (OR 1.38; 95% CI 1.16–1.65) and high American Society of Anaesthesiologists (ASA) score (OR 1.51; 95% CI 1.27–1.8) were independent risk factors for POI, laparoscopy (OR 0.51; 95% CI 0.38–0.68) and ERP compliant diet (OR 0.46; 95% CI 0.36–0.6) were both protective. Hence, this study provides further evidence of the beneficial effect of early oral feeding after colorectal surgery. [ABSTRACT FROM AUTHOR]

Background: Reported incidence of surgical site infections (SSI) after colonic surgery varies widely. These variations depend not only on patient- and surgery-related parameters but are influenced by type and quality of follow-up. The aim of the study was to compare SSI assessed by two independent prospective surveillance systems, a national surveillance program based on recommendations of the National Healthcare Safety Network (Swissnoso) versus an international audit system, the ERAS® Interactive Audit System (EIAS; Encare, Stockholm, Sweden).Methods: Comparative study of a consecutive cohort of colonic resections at a single institution from September 2015 to March 2017. Independent prospective SSI monitoring was available from Swissnoso and EIAS. Inter-observer reliability was calculated using Cohen k. Sensitivity, specificity, and accuracy of EIAS in assessing SSI was compared with Swissnoso, considered as gold standard.Results: The final sample included 143 patients. Of these, 136 (95.1%) were classified into the same category by both systems, identifying 17 patients (12.5%) with SSI and 119 patients (87.5%) without SSI, respectively. Discrepant results were found for the remaining seven patients (4.9%) with four SSI categorization according to Swissnoso but not EIAS, and three SSI categorization in EIAS but not in Swissnoso; all miscategorized patients presented superficial SSI. Sensitivity, specificity, and accuracy of EIAS for SSI recording was 81%, 97.5%, and 95.1%, respectively. Inter-observer agreement was high (Cohen k value of 0.801, p < 0.001). Case-by-case analysis of discrepant findings revealed mainly discrepant interpretation of clinical symptoms and erroneous labeling of non-procedure-related infections.Conclusions: Surgical site infection recording by two independent systems showed high concordance and good inter-rater reliability. [ABSTRACT FROM AUTHOR]

The purpose of this prospective cohort study was to compare multimodal pain management and pain perception after open vs. laparoscopic colorectal surgery within enhanced recovery care. Pain scores at rest and at mobilization were prospectively assessed in consecutive patients using Visual Analog Scales (VAS 0-10) and consumption of different analgesics was recorded daily until 96 hours postoperatively. Uni- and multivariate risk factors for pain peaks (≥ 4/10) were identified by logistic regression and compared between two propensity score matched groups (open vs. laparoscopic). 156 open and 176 laparoscopic procedures were included. Mean VAS scores were consistently < 3 until 96 hours at rest and at mobilization. Patients operated by laparoscopy experienced more pain peaks (≥ 4) within 24 hours (p < 0.05), while patients operated by open approach experienced more pain peaks (≥ 4) during mobilization at 72 hours (p < 0.05). Independent risk factors for insufficient pain control (≥ 4) within 24 hours from surgery were duration of the procedure (OR 3.37, 95%CI 2.03- 5.59), emergency surgery (OR 3.01, 95%CI 1.72-5.31), wound infiltration (OR 3.23, 95%CI 0.97-10.70), age < 70 years (OR 2.03, 95% CI 1.18-3.48) and ASA I-II score (OR 2.06, 95% CI 1.19-3.56). The perioperative adding of lidocaine ± ketamine to opioids did not improve postoperative pain perception nor decrease morphine equivalents. In conclusion, overall pain scores were low after colorectal surgery. However, pain peaks remained a concern early after minimally invasive surgery and after epidural removal for open surgery. Multimodal strategies were not superior to opioids alone. [ABSTRACT FROM AUTHOR]

Background Enhanced recovery after surgery (ERAS) guidelines for colorectal surgery suggest routine transurethral bladder drainage with early removal to prevent urinary tract infection (UTI). The aim of this study was to identify risk factors for urinary retention (UR). Methods This retrospective analysis included all colorectal patients since ERAS implementation in May 2011-November 2014. From the prospective ERAS database, over 100 items related to demographics, surgery, compliance, and outcome were analyzed. Risk factors for UR were identified by multiple logistic regressions; then, UR was correlated to functional outcomes and UTI and acute kidney injury rates. Results The study cohort consisted of 513 consecutive patients. Of these, 73 patients (14%) presented with UR. Multivariate analysis identified male gender (odds ratio 1.4; 95% CI, 1-1.8; P = 0.045) and postoperative thoracic epidural analgesia (EDA; odds ratio 2.6; 95% CI, 1.6-4.3; P ≤ 0.001) as independent risk factors for postoperative UR. Functional recovery was impeded in patients with UR, who were less mobile (mobilization day 1 >4 h: 57% versus 70%, P = 0.024) and gained more weight (2.8 ± 2.5 kg versus 1.6 ±3 kg on day 1, P = 0.001) due to fluid overload. Furthermore, patients with urinary catheters reported more pain (visual analog scales day 3: 3.1 ± 2.5 versus 2.2 ± 2.4, P = 0.002) and depended longer on intravenous fluid administration (termination of intravenous fluids later than day 1: 53% versus 39%, P = 0.021). Ten of 73 patients (14%) developed UTI in patients with UR and 42 of 440 (10%) in patients without UR ( P = 0.276). Six of 73 patients (8%) developed acute kidney injury in patients with UR and 36 of 440 (8%) in patients without UR ( P = 0.991). Conclusions Male gender and EDA were independent risk factors for postoperative UR which appeared to be a significant impediment for functional recovery. [ABSTRACT FROM AUTHOR]