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In light of the worsening opioid epidemic and nationwide parenteral opioid shortage, our institution created an enhanced recovery after surgery (ERAS) protocol. Our objective was to evaluate our initial experience transitioning to ERAS in cardiac surgery. An institutional cardiac ERAS protocol was implemented in April 2018, consisting of opioid-sparing analgesia, liberalization of fasting and activity restrictions, and goal-directed standardization of perioperative care. Clinical outcomes, opioid administration, and pain scores of patients undergoing nonemergent cardiac surgery were reviewed from March 2017 to July 2018. Patients were propensity score matched into pre-ERAS and transition-to-ERAS (t-ERAS) cohorts and compared by univariate analysis. Of 467 patients, 236 patients were well-matched (118 per cohort). The transition to ERAS resulted in a 79% reduction in morphine equivalents through postoperative day 1 (359.3 mg pre-ERAS vs 75.4 mg ERAS, P < 0.0001). Despite less opioid utilization, t-ERAS patients reported lower pain scores (median 4.88 vs 4.14, P = 0.011). There was no difference in mortality (2% vs 0%, P = 0.498) or postoperative complications including initial hours ventilated (5.3 vs 5.2 hours, P = 0.380), prolonged ventilation (9.3% vs 6.8%, P = 0.473), renal failure (3.4% vs 2.5%, P = 0.701), and ICU length of stay (58.3 vs 70.4 hours, P = 0.272). The transition to cardiac ERAS resulted in significantly reduced opioid administration and improved patient pain scores while maintaining excellent outcomes. Well-supported, multidisciplinary teams of cardiac surgeons, anesthesiologists, and intensivists can dramatically reduce opioid use without sacrificing pain control or excellent clinical outcomes. [ABSTRACT FROM AUTHOR]

Deep inferior epigastric perforator (DIEP) surgery is one of the most difficult breast reconstruction techniques available, both in terms of operating complexity and patient recovery. Enhanced recovery after surgery (ERAS) pathways were recently introduced in numerous subspecialties to reduce recovery time, patient pain, and cost by providing multimodal perioperative care. Plastic surgery has yet to widely integrate ERAS with DIEP reconstruction, mostly due to insufficient data on patient outcomes with this combined approach. Five major medical databases were queried using predetermined search criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Statistical analysis was performed using Cochrane's RevMan (v5.4). A total of 466 articles were identified. A total of 14 studies were included in the review with a combined sample of 2102 patients. Eight studies were included in the meta-analysis with a combined sample of 1679 patients. On average, the included studies utilized 11.69 of 18 suggested protocols for ERAS with breast reconstruction. Our primary outcome, length of stay, was reduced by a mean of 1.12 (95% confidence interval [CI] [−1.30, −0.94], n = 1627, p < 0.001) days in the ERAS group. Postoperative oral morphine equivalents (OME) were also reduced in the ERAS group by 104.02 (95% CI [−181.43, −26.61], n = 545, p = 0.008) OME. The ERAS group saw a significant 3.54 (95% CI [−4.43, −2.65], n = 527, p < 0.001) standardized mean difference cost reduction relative to the control groups. The surgery time was reduced by 60.46 (95% CI [−125, 4.29], n = 624, p < 0.07) min, although this was not statistically significant. The ERAS pathway in DIEP breast reconstruction is consistently associated with reduced hospital stay, opioid use, and patient cost. Moreover, there appears to be no evidence of serious adverse outcomes associated with the application of the ERAS protocol. [ABSTRACT FROM AUTHOR]

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Purpose: Enhanced recovery protocols (ERP) have been shown to improve patient outcomes and is now regarded as standard of care in elective surgical setting. However, the literature addressing the use of ERP in trauma and emergency abdominal surgery (EAS) is limited and heterogenous. A scoping review was conducted to comprehensively assess the literature on ERP in trauma laparotomy and EAS. Methods: Three bibliographic databases were searched for studies addressing ERP in trauma laparotomy and EAS. We extracted the study characteristics including study design, country, year, surgical procedures, ERP components used, and outcomes. Reporting was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Extension for Scoping Reviews. Results: After screening of 1631 articles for eligibility, 39 studies were included in the review. There has been an increase in the number of articles in the field, with 44% of the identified studies published between 2020 and 2022. Fourteen different protocols were identified, with varying components for each operative phase (preoperative; 29, intraoperative; 20, postoperative; 27). The majority of the studies addressed the effectiveness of ERP on clinical outcomes (31/39: 79%). Only two studies (5%) included purely trauma populations. Conclusions: Studies on ERP implementations in the EAS populations were published across a range of countries, with improved outcomes. However, a clear gap in ERP research on trauma laparotomy was identified. This scoping review indicates that standardization of care through ERP implementation has potential to improve the quality of care in both EAS and trauma laparotomy. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the clinical efficacy of accelerated rehabilitation surgery for the treatment of Gustilo type IIIA/B open tibiofibular fracture with emergency stage I debridement, internal fracture fixation, bone grafting, coverage of the wound surface with a muscle flap combined with vacuum sealing drainage (VSD), and internal and lateral leg reduction. Methods: A retrospective analysis was performed on the clinical data of 15 patients with Gustilo type IIIA/B open tibiofibular fracture who were admitted to the Affiliated Zhongshan Hospital of Dalian University from January 2015 to December 2018. There were 12 males and 3 females. The patients ranged in age from 20 to 62 years, with an average of 39.5 years. After admission, the patients underwent stage I emergency debridement (including exploration and repair of nerves and tendons), open reduction and internal fixation of the tibia and fibula, iliac bone grafting, muscle flap and VSD coverage of the bone defect, complete tensioning of the calf inside and outside, tibia-sparing incision before healing, and stage II free skin grafting. Patients were followed up periodically to observe muscle flap survival, fracture healing time, length of hospitalization, wound healing time, delayed union, bone nonunion, osteomyelitis and other complications. At the last follow-up, the Johner–Wruhs criteria were used to evaluate the rate of good functional recovery from tibial shaft fracture, fracture healing quality was evaluated by the Merchant score, and limb function was evaluated by the LEFS. Results: All 15 cases were followed up for 12–32 months, with an average of 22.8 months. All the fractures healed; the range of healing time was 14–30 weeks (mean 18.5 weeks). The length of hospitalization was 25.1 ± 7.6 days, and wound healing took 12.2 ± 2.0 days. None of the patients had complications such as osteomyelitis infection. When the Johner–Wruhs evaluation criteria for functional recovery from tibial shaft fracture were applied at the last follow-up, the outcomes were as follows: excellent in 13 cases, good in 1 case and fair in 1 case, for an excellent and good rate of 93.3%. When fracture healing was evaluated according to the Merchant scoring standard, the outcomes were as follows: excellent in 12 cases, good in 1 case, fair in 1 case, and poor in 1 case, for an excellent and good rate of 86.7%. The mean LEFS score of the affected limb at the last follow-up was 70 (59–80). Conclusion: For Gustilo type IIIA/B open tibiofibular fractures, emergency stage I debridement, internal fixation of the fracture, bone grafting, coverage of the wound with a muscle flap, complete tensioning of the calf inside and outside, and application of VSD can improve the repair of leg soft-tissue defects, shorten hospitalization time, promote fracture healing, and effectively reduce infection and complications related to bone exposure. More importantly, this treatment protocol provides effective wound repair, guarantees the recovery of limb function, significantly speeds up recovery, and improve patients' quality of life. [ABSTRACT FROM AUTHOR]

Background: Same-day discharge after a cholecystectomy is a common practice in the adult population and has been demonstrated as safe and viable for children as well. However, there is a lack of comprehensive teaching models for pediatric cholecystectomy. Drawing inspiration from standardized outpatient procedures, this study aimed to assess the clinical outcomes and feasibility of teaching programs and an Enhanced Recovery After Surgery (ERAS) protocol following ambulatory laparoscopic cholecystectomy in pediatric patients. Methods: In 2015, an ERAS pathway for laparoscopic cholecystectomy (LC) was implemented, focusing on admission procedures, surgery timing, anesthetic choices, analgesia, postoperative feeding, mobilization, and pain assessment. Day-case surgery was not applicable for acute cholecystitis, choledochal lithiasis, sickle cell disease, and hereditary spherocytosis cases. The protocol was employed for a group of attending surgeons and fellows, as well as a group of residents under the supervision of experienced surgeons. A retrospective analysis was conducted to evaluate the feasibility and effectiveness of ambulatory cholecystectomy in children and its utilization in training pediatric surgical trainees. Results: Between 2015 and 2020, a total of 33 patients were included from a cohort of 162 children who underwent LC, with 15 children operated on by senior surgeons and 18 by young surgeons. The primary diagnoses were symptomatic gallbladder lithiasis (n = 32) and biliary dyskinesia (n = 1). The median age at the time of surgery was 11.3 years (interquartile range (IQR) 4.9–18), and the median duration of surgery was 54 min (IQR 13–145). One intraoperative complication occurred, involving gallbladder rupture and the dissemination of lithiasis into the peritoneal cavity. Three patients (9%) required an overnight stay, while no postoperative complications or readmissions within 30 days were observed. ERAS was successfully implemented in 30 patients (91%). No significant differences in surgical outcomes were noted between senior and young surgeons. At an average follow-up of 55 months, no long-term sequelae were identified. Conclusions: These findings align with the current trend of increasing use of outpatient laparoscopic cholecystectomy and underscore its feasibility in the pediatric population. The application of a structured ERAS protocol appears viable and practical for training the next generation of pediatric surgeons. Level of Evidence: Level III. [ABSTRACT FROM AUTHOR]

Process mining organizatioQn (PMO) is an innovative approach based on artificial intelligence (AI) decision making suitable for designing healthcare processes for human resource (HR) organizations. The proposed work suggests some examples of PMO-based Business Process Modeling and Notation (BPMN) workflows by highlighting the advances in HR management and in risk decrease according to healthcare scenarios. Specifically proposed are different examples of "TO BE" process pipelines related to an upgrade of the organizational healthcare framework, including digital technologies and telemedicine. Important elements are provided to formulate HR management guidelines supporting PMO design. The proposed BPMN workflows are the result of different consulting actions in healthcare institutions based on the preliminary mapping of "AS IS" processes highlighting bottlenecks and needs in HR organization. A pilot experimental dataset is used to show how it is possible to apply AI algorithms providing organization corrective actions. The paper is mainly focused on discussing some validated BPMN models managing HR in the healthcare sector. The methodology is based on the application of the BPMN approach to deploy human resource organizational processes. The results show AI data-driven workflows adopted in healthcare and examples of AI fuzzy c-means outputs addressing organizational actions. [ABSTRACT FROM AUTHOR]

Background and Aims: With advancements in imaging and microelectrode recording techniques, general anesthesia (GA) has emerged as an alternative option for Parkinson's disease (PD) patients undergoing subthalamic nucleus deep brain stimulation (STN‐DBS). In this study, we compared the advantages and disadvantages of using GA and local anesthesia for STN‐DBS in enhanced recovery after surgery (ERAS). Methods: Surgical outcomes of STN‐DBS were evaluated using the unified PD rating scales (UPDRS). CT and magnetic resonance imaging scans are used to evaluate intracranial conditions. State‐trait anxiety inventory and hospital anxiety and depression scale are used to evaluate patients' perioperative psychology. Results: Anesthesia method does not significantly impact the accuracy of microelectrode placement or the improvement of postoperative symptoms. However, the local anesthesia group had a higher incidence of intracranial air, as well as higher rates of postoperative complications such as headache, dizziness, vomiting, and delirium. GA effectively alleviated preoperative anxiety and resulted in lower levels of perioperative anxiety and psychological stress compared to local anesthesia. Additionally, the GA group had shorter surgery duration, earlier ambulation, and a shorter average hospital stay. Conclusion: DBS under GA is safe and effective. Due to shorter surgical duration, reduced occurrence of perioperative complications, effective reduction of preoperative anxiety, and faster postoperative recovery, DBS under GA is better aligned with the concept of ERAS. [ABSTRACT FROM AUTHOR]

ABSTRACT: Like many innovations in surgery, implementing enhanced recovery after surgery (ERAS) programs in pediatric surgery has lagged behind its adult counterpart. Our institutions have recently made a concerted effort to introduce and implement ERAS widely throughout the Department of Pediatric Surgery, which includes 10 surgical specialties. Our strategy revolved around the early inclusion of all stakeholders, significant educational efforts, and creating a roadmap for development and implementation of ERAS programs. It culminated in the first Canadian pediatric ERAS conference, which was held in Montreal on April 28, 2023, and served as a launching pad for instituting an ERAS culture in our hospital. Throughout the process, we identified specific themes that helped emphasize the rationale for pediatric ERAS programs and kept stakeholders engaged in the efforts. In this paper, we share these strategies and themes, believing they can aid other pediatric institutions seeking to initiate an ERAS culture.Level of evidence: V

Background: Enhanced recovery after surgery (ERAS) protocols have gained popularity in many surgical specialties. The overarching goals of ERAS include the use of comprehensive perioperative interventions to minimize postoperative nausea and vomiting (PONV), incorporate multimodal pain control, including reduced postoperative opioid utilization, encourage early postoperative mobilization and ambulation, and achieve prompt re-initiation of enteral nutrition. While many adult surgical programs have demonstrated successful implementation of ERAS protocols, there have been few descriptions in pediatric surgical literature focused on implementation of such strategies. In this review, we provide an overview of current pediatric-focused ERAS literature and highlight our institution's experience with implementing an ERAS protocol in our pediatric metabolic and bariatric surgery program. Methods: A literature search was conducted to review ERAS experience in adult and pediatric surgery. Our institution's bariatric surgery program is described from the pre-ERAS period to the inception of our ERAS protocol, and the evolution into its current form. Over this time, we eliminated the routine use of nasogastric tubes and urinary catheters, expanded our pre-operative initiatives, limited intra-operative fluids, updated the intraoperative anesthetic regimen, broadened our multimodal pain and PONV management, and developed post-operative recovery-focused patient goals to improve fluid intake, increase early ambulation and pulmonary toilet resulting in a shortened hospital length of stay. Conclusion: Pediatric surgical programs can benefit from utilization of ERAS strategies to decrease the time to enteral nutrition, provide comprehensive pain and PONV control, facilitate early ambulation, and reduction in hospital length of stay. Our a single-institutional experience deploying ERAS within the pediatric metabolic and bariatric surgery service has been successful and serves as a model for other surgical sub-specialty service lines within our organization.

Introduction. Implementation of enhanced recovery after surgery protocol (ERAS) is becoming more and more widespread due to their effectiveness and safety. At the same time, there is a rather limited number of studies focusing on the opportunities of ERAS in the context of its association with metabolic syndrome in patients with colorectal cancer. This study represents the results of our early experience implementing elements of the ERAS program in the perioperative management of patients with colorectal cancer associated with metabolic syndrome. The aim. To conduct a comparative analysis and evaluate the results of surgical treatment using the enhanced recovery after surgery protocol in patients with colorectal cancer and accompanying metabolic syndrome. Materials and methods. This study included 106 patients with colorectal cancer and accompanying metabolic syndrome, divided into two groups: the first group with the use of elements of the ERAS protocol in colorectal surgery from 2018 – 56 patients, and the second group in which the principles of ERAS were not used (50 patients). Results. In the first group, with a statistically significant difference, a less severe pain syndrome was observed according to VAS (p

Enhanced recovery after cardiac surgery (ERACS) is a multi-disciplinary approach to improve patient outcomes and reduce complications following cardiac surgery. The aim of ERACS protocol is to optimize pre-operative preparation, reduce surgical trauma, and minimize post-operative stress.The protocol has been shown to improve patient outcomes, including shorter hospital stays, lower rates of complications, and faster return to normal activities. It is important to note that ERACS is a multi-disciplinary approach, and requires close collaboration between surgeons, anaesthesiologists, nurses, and other healthcare professionals to ensure successful implementation. Anaesthesiologists play a crucial role in the ERACS protocol, as they are responsible for the management of the patient’s anaesthesia and pain management during and after surgery. In this paper provide an overview of the ERACS protocol from the perspective of an anaesthesiologist.

Enhanced recovery after surgery (ERAS) has established benefits in open gynecologic oncology surgery. However, the benefits for gynecologic oncology patients undergoing minimally invasive surgery (MIS) are less well defined. We conducted a review of this topic after a comprehensive search of the peer-reviewed literature using MEDLINE and PubMed databases. Our search yielded 25 articles, 14 of which were original research articles, in 10 distinct patient cohorts describing ERAS in minimally invasive gynecologic oncology surgery. Major benefits of ERAS in MIS included: decreased length of stay and increased rates of same-day discharge, cost-savings, decreased opioid use, and increased patient satisfaction. ERAS in minimally invasive gynecologic oncology surgery is an area of great promise for both patients and the healthcare system.

Opioid-free anesthetic techniques are increasingly popular lately to reduce postoperative complications associated with opioid consumption. Reported the success of opioid free techniques in a 61-year-old woman who underwent craniotomy resection of metastatic tumors. On preoperative examination, level of consciousness was compos mentis, blood pressure 150/80 mmHg, pulse 72 beats per minute, respiratory rate 24 times/minute, body temperature 36.6 ºC, oxygen saturation 99%. Prior to induction, patient was nebulized with 4% lidocaine, sedation was used for inserting the arterial line with target controlled infusion (TCI) propofol 0.5–1 mcg/ml and dexmedetomidine continuously. Anesthesia induction was performed by increasing the TCI to 3.5–4 mcg/ml, followed by injection of 4% lidocaine at the cricoid membrane before intubation. Maintenance was carried out with sevoflurane 0.5–1 MAC, O2, compressed air (FiO2 50%), TCI propofol and dexmedetomidine continuously. The surgery lasted three and a half hours, the patient was successfully extubated and transferred to the intensive care unit. The patient was treated for 1 day in the ICU with an analgesic combination of 1 gram paracetamol and 25 mg dexketoprofen every 8 hours intravenously. Opioid free technique in craniotomy supports Enhanced Recovery After Surgery (ERAS) concept in neurosurgery, but the usage should be with analgesia and anesthesia multimodal agents, preoperatively until postoperatively.

Abstract Background Distal radius fractures (DRF) account for one in five bony injuries in both primary and secondary trauma care. Enhanced recovery after surgery (ERAS) has been adopted successfully to improve clinical outcomes in multiple surgical disciplines; however, no study has investigated the effect of different degrees of compliance with ERAS protocol on short-term outcomes following distal radius surgery. We aimed to analyze whether different degrees of compliance with the ERAS pathway are associated with clinical improvement following surgery for DRF. Methods We retrospectively analyzed all consecutive patients with ERAS who underwent surgery for DRF at our department between May 2019 and October 2022. Their pre-, peri-, and post-operative compliance with the 22 elements of the ERAS program were assessed. We compared parameters between low- ( 68.1%) groups, including patient complications, total length of hospitalization, discharge time after surgery, hospital costs, time taken to return to preinjury level performance level, number of visual analogue scale (VAS) pain scores > 3 points during hospitalization, disabilities of the arm, shoulder and hand (DASH) scores. We performed multiple linear regression analyses to assess the impact of ERAS compliance on the postoperative function level (DASH scores). Results No significant differences were detected between the high- and low-compliance groups with respect to demographics, including sex, age, body mass index (BMI), and comorbidities (P > 0.05). We observed significant differences between the high- and low-compliance groups in terms of the DASH score (32.25 ± 9.97 vs. 40.50 ± 15.65, p 3 points during hospitalization (0.88, [0.44, 1.31], p

Abstract Aims Robot-assisted total hip arthroplasty (rTHA) boasts superior accuracy in implant placement, but there is a lack of effective assessment in perioperative management in the context of enhanced recovery after surgery (ERAS). This study aimed to compare the effectiveness and safety of rTHA versus conventional total hip arthroplasty (cTHA) in ERAS-managed patients. Methods In this prospective trial, a total of 60 eligible patients aged between 18 and 80 years were randomly divided into two groups to undergo either rTHA or cTHA. The primary outcomes included blood loss parameters. Secondary outcomes were the duration of the operation, surgical time, WOMAC pain score, WOMAC stiffness score, WOMAC physical function score, Harris score, and postoperative complications. Results The study cohort analyzed 59 eligible participants, 30 of whom underwent rTHA and 29 of whom underwent cTHA. Analysis could not be conducted for one patient due to severe anemia. Notably, the cTHA group had a significantly shorter surgical time than the rTHA group (69.49 ± 18.97 vs. 104.20 ± 19.63 min, P

Introduction: The United States Medical Licensing Examination (USMLE) Step 1 score is one of the few standardized metrics used to objectively review applicants for residency. In February 2020 the USMLE program announced that the numerical Step 1 scoring would be changed to a binary (Pass/Fail) system. In this study we sought to characterize how this change in score reporting will impact the application review process for emergency medicine (EM) program directors (PD).  Methods: In March 2020 we electronically distributed a validated anonymous survey to EM PDs at 236 US EM residency programs accredited by the Accreditation Council for Graduate Medical Education. Results: Of 236 EM PDs, 121 responded (51.3% response rate). Overall, 72.7% believed binary Step 1 scoring would make the process of objectively comparing applicants more difficult. A minority (19.8%) believed it was a good idea, and 33.1% felt it would improve medical student well-being. The majority (88.4%) reported that they will increase their emphasis on Step 2 Clinical Knowledge (CK) for resident selection, and 85% plan to require Step 2 CK scores at application submission time.  Conclusion: Our study suggests most EM PDs disapprove of the new Step 1 scoring. As more objective data is peeled away from the residency application, EM PDs will be left to rely more heavily on the few remaining measures, including Step 2 CK and standardized letters of evaluation. Further changes are needed to promote equity and improve the overall quality of the application process for students and PDs.

The 2020-2021 General Surgery Residency Match presents unique challenges in the setting of the COVID-19 pandemic and highlights pre-existing concerns. In order to move toward an equitable and manageable surgical residency application process for both programs and applicants, systemic change is warranted.

Abstract Background Opioid use has come under increasing scrutiny, driven in part by the opioid crisis and growing concerns that up to 6% of opioid-naïve patients may become chronic opioid users. This has resulted in a revaluation of perioperative practice. For this reason, we implemented a multidisciplinary pathway to reduce perioperative opioid usage through education and standardization of practice. Methods A single-centre retrospective evaluation was performed after 1 year, comparing the outcomes to those of the 2 years prior to pathway implementation. Comparisons were made between pre- vs. post pathway change by 2:1 propensity matching between cohorts. Univariate linear regression models were created using demographic variables with those that were p

William Mitchell,1,&ast; Thomas Roser,1,&ast; Jessica Heard,2 Shankar Logarajah,2 John Ok,1,2 John Jay,2 Houssam Osman,1,2 D Rohan Jeyarajah1,2 1Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA; 2Methodist Richardson Medical Center, Richardson, TX, USA&ast;These authors contributed equally to this workCorrespondence: D Rohan Jeyarajah, Tel +1 972 619 3500, Email rohanjeyarajah@tcu.eduBackground: Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, complications can arise related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominis plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA.Methods: This is a case series of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block without TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, post-operative hypotension, fluid administration, postoperative pain scores, development of anastomotic leak, and 30-day readmission.Results: The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. Thirty-four (81%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only seven patients (16.7%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain.Conclusion: The results of this study demonstrated immediate extubation is possible using TAP blocks while limiting post-operative hypotension and fluid administration. This was shown despite the elevated comorbidity burden of this study’s population. Overall, this study supports the use of TAP blocks as a possible alternative for primary analgesia in patients undergoing trans-hiatal esophagectomy.Trial Registration: This study includes participants who were retrospectively registered. IRB&num; 037.HPB.2018.R.Keywords: trans-hiatal, esophagectomy, transversus abdominis plane, TAP, quadratus lumborum, QL, block, epidural, ERAS, analgesia

Early Recovery After Surgery (ERAS) in neurosurgery is a promising and developing concept directed to enhance postoperative recovery for neurosurgical patient. ERAS application to supratentorial brain tumor patient’s will provide advantage of early functional recovery and shorter length of stay. We reported a successful anesthetic management for a 45-year-old woman, diagnosed with a left frontotemporal extra axial tumor, suspected left parasagittal meningioma. Preoperative, patient was fully conscious but complained occasional headache and blurred vision with normal hemodynamic parameters. We performed general anesthesia with additional scalp block for this patient to facilitate the surgery, which lasted 3 hours 20 minutes. The surgery went uneventful with a stable hemodynamic, patient was extubated in the operating theatre and monitored in the Intensive Care Unit (ICU). After two days in the ICU, we transferred the patient to the ward. She was discharged on the fifth day and controlled as an outpatient care. Perioperative management of patients with supratentorial tumor whom undergo craniotomy for tumor removal could be performed to facilitate early recovery. Appropriate multidisciplinary management in the preoperative, intraoperative and postoperative periods, with regard to the underlying disease, is important to successfully perform the ERAS

Abstract Objective Enhanced recovery after surgery (ERAS) has significant effects in gastrointestinal surgery, urology, and orthopedic department, but the application of ERAS in liver cancer patients undergoing hepatectomy is less reported. This study aims to identify the effectiveness and safety of ERAS in liver cancer patients undergoing hepatectomy. Methods Patients who performed ERAS and no-ERAS after hepatectomy due to liver cancer from 2019 to 2022 were prospectively and retrospectively collected, respectively. Preoperative baseline data, surgical characteristics, and postoperative outcomes of patients in ERAS and non-ERAS groups were compared and analyzed. Logistic regression analysis was conducted to identify the risk factors of complications occurrence and prolonged hospital stay. Results In total, 318 patients were included in the study, 150 and 168 individuals in the ERAS group and non-ERAS group, respectively. The preoperative baseline and surgical characteristics between the ERAS and non-ERAS groups were comparable and not statistically different. Postoperative visual analogue scale pain score, the median day of gastrointestinal function recovery postoperative, complications rate, and postoperative hospitalization days were lower in the ERAS group than in the non-ERAS group. In addition, multivariate logistic regression analysis found that the implementation of the ERAS was an independent protective factor for prolonged hospitalization stay and complications occurrence. The rate of rehospitalization after discharge (

Abstract Background Multimodal analgesic strategies that reduce perioperative opioid consumption are well-supported in Enhanced Recovery After Surgery (ERAS) literature. However, the optimal analgesic regimen has not been established, as the contributions of each individual agent to the overall analgesic efficacy with opioid reduction remains unknown. Perioperative ketamine infusions can decrease opioid consumption and opioid-related side effects. However, as opioid requirements are drastically minimized within ERAS models, the differential effects of ketamine within an ERAS pathway remain unknown. We aim to pragmatically investigate through a learning healthcare system infrastructure how the addition of a perioperative ketamine infusion to mature ERAS pathways affects functional recovery. Methods The IMPAKT ERAS trial (IMpact of PerioperAtive KeTamine on Enhanced Recovery after Abdominal Surgery) is a single center, pragmatic, randomized, blinded, placebo-controlled trial. 1544 patients undergoing major abdominal surgery will be randomly allocated to receive intraoperative and postoperative (up to 48 h) ketamine versus placebo infusions as part of a perioperative multimodal analgesic regimen. The primary outcome is length of stay, defined as surgical start time until hospital discharge. Secondary outcomes will include a variety of in-hospital clinical end points derived from the electronic health record. Discussion We aimed to launch a large-scale, pragmatic trial that would easily integrate into routine clinical workflow. Implementation of a modified consent process was critical to preserving our pragmatic design, permitting an efficient, low-cost model without reliance on external study personnel. Therefore, we partnered with leaders of our Investigational Review Board to develop a novel, modified consent process and shortened written consent form that would meet all standard elements of informed consent, yet also allow clinical providers the ability to recruit and enroll patients during their clinical workflow. Our trial design has created a platform for subsequent pragmatic studies at our institution. Trial registration NCT04625283, Pre-results.

Intro: AIS surgery generates a high inflammatory stress response which might influence the outcome in the perioperative period. Enhanced Recovery After Surgery (ERAS) is a global multidisciplinary care pathway aimed to improve patient's recovery. Research question: The purpose of this article is to expose our actual ERAS protocol for AIS surgery and compare it with the earlier non ERAS management in our institution.Our primary outcome focus on the re-hospitalisation and complications rates at 30 and 90 days postoperatively. Our secondary outcomes focus on the overall morphine consumption, pain scores and side effects during the hospitalisation. Material: We compare the results of the ERAS group (2019–2022) with the previous existing classical care pathway (2017–2019). The data were collected in our standard medical files. Results: Our ERAS care pathway for AIS surgery lead to consequently improve the outcome regarding the VAS scores, the morphine consumption, the LOS and the complication and re hospitalisation rates. Discussion: Regarding our results, ERAS care pathway for AIS surgery appears to be efficient in terms of benefits on complications rates, LOS and opioid consumption.Intrathecal morphine and “anti-inflammatory” anaesthesia provides a good quality of pain management and allows the patient to get up early.A superiority trial might be interesting to highlight the role of the ERAS pathway in AIS surgery.

ERAS is a global surgical quality improvement program that has demonstrated benefit across numerous surgical disciplines in terms of both clinical outcome improvements for patients and cost savings for the healthcare system. Successful implementation of ERAS is contingent on a well-functioning multidisciplinary team that uses audit to iterate towards increased ERAS protocol compliance. Although pediatric surgery was slow initially to adopt ERAS, there have been several important developments over the last 5 years including publication of the first ERAS® Society guideline in neonatal intestinal surgery and formation of the Pediatric ERAS® Society. The time is right to implement ERAS broadly across pediatric surgery.

Purpose: To investigate perioperative risk factors that affect the recovery of postoperative gastrointestinal function in patients undergoing gynecological surgery and to establish a preoperative risk prediction scoring system. Methods: In this retrospective cohort study, characteristics and perioperative factors of patients who underwent elective gynecological surgery at Union Hospital from January 2021 to March 2022 were extracted from electronic medical records. Patients were grouped according to the Intake, Feeling nauseated, Emesis, physical Exam, and Duration of symptoms (I-FEED) scoring system to compare collected data. Results: In total, clinical data from 208 gynecological patients were extracted. The incidence of poor postoperative gastrointestinal recovery was 7.21 %. The number of previous abdominal surgeries (0.73 ± 0.06 vs 1.20 ± 0.24, p = 0.044), the incidence of malignant disease (20.2 % vs 53.3 %, p = 0.003), postoperative maximum WBC count (9.15 vs 12.44, p = 0.005) and postoperative minimum potassium (3.97 ± 0.36 vs 3.76 ± 0.37, p = 0.036) were not only associated with poor postoperative gastrointestinal recovery, but also malignant disease (p = 0.000), postoperative maximum WBC count (p = 0.027) and postoperative minimum potassium (p = 0.024) were significantly associated with the severity of postoperative gastrointestinal function. An increased number of previous abdominal surgeries and malignant primary disease could increase the risk of an I-FEED score >2 as independent risk factors. Conclusion: Patients with poor postoperative GI function had poorer postoperative recovery outcomes. A preoperative score prediction system was established, in which patients with ≥2 points had a 19.4 % risk of poor postoperative gastrointestinal recovery. Higher-quality prospective studies should be performed to achieve more precise risk stratification and to construct a more accurate prediction system.

Background: Postoperative analgesia is an essential component of enhanced recovery after surgery following abdominal surgery. Studies comparing the effectiveness of epidural analgesia with that of other analgesic modalities after liver surgery have reported inconsistent results. Consequently, the use of epidural analgesia for open hepatectomy is controversial. Objective: The present single-center retrospective study aimed to compare the efficacy and safety of patient-controlled epidural analgesia (PCEA) and patient-controlled intravenous analgesia (PCIA) in adults undergoing open hepatectomy. Methods: Patients who underwent open hepatectomy between January 2018 to December 2019 at Zhongshan Hospital, Fudan University were retrospectively analyzed. Propensity score matching was used to adjust baseline information between the PCEA and PCIA groups. The primary outcome measure was scores of the numeric rating scales (NRSs) for resting, exercise, and nocturnal pain at postoperative 24 h (postoperative day 1 [POD1]) and 48 h (POD2). The secondary outcome indicators included postoperative nausea and vomiting (PONV), hypotension, pruritus, respiratory depression, functional activity score (FAS), effective analgesic pump compression ratio, analgesic relief rate, discontinuation of the analgesic pump, reasons for discontinuation of the analgesic pump, and patient satisfaction with postoperative analgesia. Results: The NRS scores of the PCEA group on POD1 were significantly lower than those of the PCIA group (P

Abstract Background and Aims With advancements in imaging and microelectrode recording techniques, general anesthesia (GA) has emerged as an alternative option for Parkinson's disease (PD) patients undergoing subthalamic nucleus deep brain stimulation (STN‐DBS). In this study, we compared the advantages and disadvantages of using GA and local anesthesia for STN‐DBS in enhanced recovery after surgery (ERAS). Methods Surgical outcomes of STN‐DBS were evaluated using the unified PD rating scales (UPDRS). CT and magnetic resonance imaging scans are used to evaluate intracranial conditions. State‐trait anxiety inventory and hospital anxiety and depression scale are used to evaluate patients' perioperative psychology. Results Anesthesia method does not significantly impact the accuracy of microelectrode placement or the improvement of postoperative symptoms. However, the local anesthesia group had a higher incidence of intracranial air, as well as higher rates of postoperative complications such as headache, dizziness, vomiting, and delirium. GA effectively alleviated preoperative anxiety and resulted in lower levels of perioperative anxiety and psychological stress compared to local anesthesia. Additionally, the GA group had shorter surgery duration, earlier ambulation, and a shorter average hospital stay. Conclusion DBS under GA is safe and effective. Due to shorter surgical duration, reduced occurrence of perioperative complications, effective reduction of preoperative anxiety, and faster postoperative recovery, DBS under GA is better aligned with the concept of ERAS.

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.