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BACKGROUND: This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS: Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS: Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS: These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

BACKGROUND: This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS: Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS: Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS: These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS: Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Background: Enhanced Recovery After Surgery (ERAS) and prehabilitation programs are evidence-based and patient-focused, yet meaningful patient input could further enhance these interventions to produce superior patient outcomes and patient experiences. We conducted a qualitative study with patients who had undergone colorectal surgery under ERAS care to determine how they prepared for surgery, their views on prehabilitation and how prehabilitation could be delivered to best meet patient needs. Methods: We conducted semistructured interviews with adult patients who had undergone colorectal surgery under ERAS care within 3 months after surgery. Patients were enrolled between April 2018 and June 2019 through purposive sampling from 1 hospital in Alberta. The interview transcripts were analyzed independently by a researcher and a trained patient-researcher using inductive thematic analysis. Results: Twenty patients were interviewed. Three main themes were identified. First, waiting for surgery: patients described fear, anxiety, isolation and deterioration of their mental and physical states as they waited passively for surgery. Second, preparing would have been better than just waiting: patients perceived that a prehabilitation program could prepare them for their operation if it addressed their emotional and physical needs, provided personalized support, offered home strategies, involved family and included surgical expectations (both what to expect and what is expected of them). Third, partnering with patients: preoperative preparation should occur on a continuum that meets patients where they are at and in a partnership that respects patients' expertise and desired level of engagement. Conclusion: We identified several patient priorities for the preoperative period. Integrating these priorities within ERAS and prehabilitative programs could improve patient satisfaction, experiences and outcomes. Actively engaging patients in their care might alleviate some of the anxiety and fear associated with waiting passively for surgery. Contexte : Les protocoles de récupération optimisée après une chirurgie (ERAS, pour Enhanced Recovery After Surgery) et les programmes de préadaptation se fondent sur des données probantes et sont centrés sur les patients et pourtant, une plus grande contribution de ces derniers permettrait d'améliorer ces interventions et donneraient lieu à des résultats et des expériences plus satisfaisants pour les patients. Nous avons procédé à une étude qualitative auprès de patients ayant subi une chirurgie colorectale avec protocole ERAS afin de savoir comment ils se sont préparés à la chirurgie, quel est leur point de vue sur la préadaptation et en quoi cette dernière pourrait mieux répondre à leurs besoins. Méthodes : Nous avons réalisé des entrevues semi-structurées auprès de patients adultes ayant subi une chirurgie colorectale avec protocole ERAS dans les 3 mois suivant leur chirurgie. Les patients ont été inscrits dans un hôpital albertain entre avril 2018 et juin 2019 par le biais d'un échantillonnage dirigé. Les transcriptions des entrevues ont fait l'objet d'une analyse thématique inductive indépendante par une chercheuse et une patientechercheuse dûment formée. Résultats : Vingt patients ont été interrogés. Trois grands thèmes ont été dégagés : 1) en attente de la chirurgie (les patients ont fait état de peur, d'anxiété, d'un sentiment d'isolement et d'une détérioration de leur état de santé mentale et physique durant l'attente passive de la chirurgie); 2) une préparation leur a semblé préférable à une simple attente (les patients ont senti qu'un programme de préadaptation les aiderait à se préparer à leur chirurgie s'il tenait compte de leurs besoins émotionnels et physiques, s'il fournissait un soutien personnalisé, des stratégies de soutien à domicile, s'il impliquait les familles et incluait une discussion sur les attentes vis-à-vis de la chirurgie); et 3) partenariat avec les patients (la préparation devrait se dérouler selon un continuum adapté à la situation de chaque patient sous la forme d'un partenariat qui respecte son expertise et son niveau d'engagement). Conclusion : Nous avons identifié plusieurs priorités pour les patients durant l'étape préopératoire. Intégrer ces priorités dans les protocoles ERAS et les programmes de préadaptation pourrait améliorer la satisfaction, les expériences et les résultats chez les patients. Faire participer activement les patients à leurs soins pourrait contribuer à soulager une part de l'anxiété et de la peur associées à l'attente passive de la chirurgie., The Enhanced Recovery After Surgery (ERAS) program for colorectal surgery involves the implementation and evaluation of more than 20 multimodal elements of perioperative care. (1) Collectively, these elements standardize surgical [...]