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Background: Enhanced recovery after surgery (ERAS) protocols strive to optimise outcomes following elective surgery; however, there is a dearth of evidence to support its equitable application and efficacy internationally., Materials and Methods: The authors performed a systematic review and meta-analysis of studies on the uptake and impact of ERAS with the aim of highlighting differences in implementation and outcomes across high-income countries (HICs) and low-middle income countries (LMICs). The primary outcome was characterisation of global ERAS uptake. Secondary outcomes included length of hospital stay (LOS), 30-day readmission, 30-day mortality and postoperative complications., Results: Three hundred thirty-seven studies with considerable heterogeneity were included in the analysis (291 from HICs, and 46 from LMICs) with a total of 110 190 patients. The weighted median number of implemented elements were similar between HICs and LMICs ( P =0·94), but there was a trend towards greater uptake of less affordable elements across all aspects of the ERAS pathway in HICs. The mean LOS was significantly shorter in patient cohorts in HICs (5·85 days versus 7·17 days in LMICs, P <0·001). The 30-day readmission rate was higher in HICs (8·5 vs. 4·25% in LMICs, P <0·001, but no overall world-wide effect when ERAS compared to controls (OR 1·00, 95% CI: 0·88-1·13). There were no reported differences in complications ( P =0·229) or 30-day mortality ( P =0·949)., Conclusion: Considerable variation in the structure, the implementation and outcomes of ERAS exists between HICs and LMICs, where affordable elements are implemented, contributing towards longer LOS in LMICs. Global efforts are required to ensure equitable access, effective ERAS implementation and a higher standard of perioperative care world-wide., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Importance: Enhanced Recovery After Surgery (ERAS) guidelines and the World Health Organization Surgical Safety Checklist (SSC) are 2 well-established tools for optimizing patient outcomes perioperatively., Objective: To integrate the 2 tools to facilitate key perioperative decision-making., Evidence Review: Snowball sampling recruited international ERAS users from multiple clinical specialties. A 3-round modified Delphi consensus model was used to evaluate 27 colorectal or gynecologic oncology ERAS recommendations for appropriateness to include in an ERAS SSC. Items attaining potential consensus (65%-69% agreement) or consensus (≥70% agreement) were used to develop ERAS-specific SSC prompts. These proposed prompts were evaluated in a second round by the panelists with regard to inclusion, modification, or exclusion. A final round of interactive discussion using quantitative consensus and qualitative comments was used to produce an ERAS-specific SSC. The panel of ERAS experts included surgeons, anesthesiologists, and nurses within diverse practice settings from 19 countries. Final analysis was conducted in May 2022., Findings: Round 1 was completed by 105 experts from 18 countries. Eleven ERAS components met criteria for development into an SSC prompt. Round 2 was completed by 88 experts. There was universal consensus (≥70% agreement) to include all 37 proposed prompts within the 3-part ERAS-specific SSC (used prior to induction of anesthesia, skin incision, and leaving the operating theater). A third round of qualitative comment review and expert discussion was used to produce a final ERAS-specific SSC that expands on the current WHO SSC to include discussion of analgesia strategies, nausea prevention, appropriate fasting, fluid management, anesthetic protocols, appropriate skin preparation, deep vein thrombosis prophylaxis, hypothermia prevention, use of foley catheters, and surgical access. The final products of this work included an ERAS-specific SSC ready for implementation and a set of recommendations to integrate ERAS elements into existing SSCs., Conclusions and Relevance: The SSC could be modified to align with ERAS recommendations for patients undergoing major surgery within an ERAS protocol. The stakeholder- and expert-generated ERAS SSC could be adopted directly, or the recommendations for modification could be applied to an existing institutional SSC to facilitate implementation.

Background: This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low-middle-income countries (LMIC's) for elective abdominal and gynecologic care., Methods: The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC's. The group consisted of seven members from the ERAS® Society and eight members from LMIC's. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592-695, Nelson et al in Int J Gynecol Cancer 29(4):651-668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC's and LMIC's were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC's. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC's and determined through discussions and consensus., Results: In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline., Conclusions: These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC's., (© 2022. The Author(s).)

Background: Colorectal surgery is commonly performed for benign and malignant colorectal disease. The aim of this study was to describe length of stay (LOS), complications and its associated factors in patients undergoing elective colorectal surgery following implementation of an enhanced recovery after surgery (ERAS) programme in South Africa (SA)., Methods: Socio-demographic, pre- intra- and postoperative clinical details and compliance to the ERAS guidelines were recorded in all patients undergoing colorectal surgery in a private practice in Cape Town, SA. Means and standard deviations or medians and interquartile range (IQR), as appropriate, were used to describe continuous variables and frequencies and percentages for categorical variables. Bivariate and multivariate analyses using linear regression of log transformed LOS and logistic regression for development of complications were performed., Results: Between 2015 and 2019, 457 patients had elective colorectal surgical procedures. The median LOS was 5 days (IQR 3-7). Pre- and intraoperative compliance was 92% and 86% respectively. In total, 203 (44%) patients developed 346 complications, of which 61% were minor. On bivariate analysis, increased intraoperative compliance was associated with a significant decrease in LOS (coefficient [β] = 0.987, 95% confidence interval [CI] 0.984-0.991) and complications (odds ratio [OR] 0.457, 95/5 CI 0.266-0.787). For every additional 30 minutes of theatre time, irrespective of type of procedure, LOS increased by 8% and complications by 12%. On multivariate analysis, laparoscopic compared to open surgery was also associated with a shorter LOS (exp [β] = 0.667, 95% CI 0.580-0.767 p < 0.001) and reduced complications (OR 0.457, 95% CI 0.266-0.787)., Conclusion: Our results show that high compliance to the ERAS guidelines is possible in the private sector in SA and that a significant reduction in LOS can be achieved without placing the patient at a higher risk of complications., (Copyright© Authors.)

Background: The Hernia Interest Group (HIG) of South Africa (SA), following the publication of their inguinal and ventral hernia guidelines (in 2015 and 2016 respectively), developed a hernia registry, the HIG(SA) hernia registry., Methods: A retrospective analysis of the prospectively maintained HIG(SA) hernia registry from 1 February 2019 to 29 February 2020. Compliance to six recommendations made in the HIG(SA) ventral hernia guidelines were assessed in both the public and private healthcare systems., Results: Three hundred and fifty-three ventral hernia repair cases were included in the study. Fifty-four per cent were private and 46% were public sector cases. Laparoscopic repair for patients with a BMI > 35 kg/m 2 occurred in 38% of eligible cases and a minimum 5 cm of mesh overlap was achieved in 50% of cases. Overall, 80% of elective cases occurred in non-smokers; 97% of the intraperitoneal on-lay mesh (IPOM) repairs used composite mesh; 96% of ventral hernias with defects of larger than 2 cm and 95% of incisional hernias were repaired with mesh. Non-smokers undergoing repair numbered 72% in public and 85% in private practice, p = 0.01., Conclusion: Ventral hernia repair practices in SA facilities overall had good compliance to four out of the six HIG(SA) ventral hernia guidelines highlighted for the purposes of this study. The two guidelines that had poor compliance overall were 'laparoscopic repair for patients with a BMI of > 35 kg/m 2 ' and 'ensuring a mesh overlap of 5 cm'. The public sector had higher rates of current smokers undergoing elective ventral hernia repair., (Copyright© Authors.)

Background: Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided strong evidence for decreased lengths of hospital stay without increase in postoperative complications. The aim of this study was to explore the role and benefits of ERAS implemented in patients undergoing emergency laparotomy for penetrating abdominal trauma., Method: Institutional University of Cape Town Human Research Ethics Committee (UCT-HREC) approved study. A prospective cohort of 38 consecutive patients with isolated penetrating abdominal trauma undergoing emergency laparotomy were included in the study. The enhanced recovery protocols (ERPs) included: early urinary catheter removal, early nasogastric tube (NGT) removal, early feeding, early mobilisation/physiotherapy, early intravenous line removal and early optimal oral analgesia. This group was compared to a historical control group of 40 consecutive patients undergoing emergency laparotomy for penetrating abdominal trauma, prior to the introduction of the ERP. Demographics, mechanism of injury, injury severity scores (ISS) and penetrating abdominal trauma index (PATI) were determined for both groups. The primary end-points were length of hospital stay (LOS) and incidence of postoperative complications (Clavien-Dindo classification) in the 2 groups. The difference in means was tested using the t-test assuming unequal variances. Statistical significance was defined as p-value less than 0.05 (p < 0.05)., Results: The two groups were comparable with regards to age, gender, mechanism of injury, ISS and PATI scores. The mean time to solid diet, urinary catheter and nasogastric tube (NGT) removal was 3.6 (non-ERAS) and 2.8 (ERAS) days [p < 0.035], 3.3 (non-ERAS) and 1.9 (ERAS) days [p < 0.00003], 2.1 (non-ERAS) and 1.2 (ERAS) days [p < 0.0042], respectively. There was no difference in time from admission to time of laparotomy 313 (non-ERAS) vs 358 (ERAS) minutes [p < 0.07]. There were 11 and 12 complications in the non-ERAS and ERAS groups, respectively. When graded as per the Clavien-Dindo classification, there was no significant difference in the 2 groups (p < 0.59). Hospital stay was significantly shorter in the ERAS group: 5.5 (SD 1.8) days vs. 8.4 (SD 4.2) days [p < 0.00021]., Conclusion: This pilot study shows that ERPs can be successfully implemented with significant shorter hospital stays without any increase in postoperative complications in trauma patients undergoing emergency laparotomy for penetrating abdominal trauma.

Ventral hernia repair is one of the most common general surgical procedures. An estimated 20 million patients with hernias are operated on worldwide every year. An incisional hernia will develop in 10-15% of patients with an abdominal incision. The risk increases to 23% in those who develop surgical site infection. Recurrence rates of up to 69% have been reported in high-risk patients., (Copyright© Authors.)

Background: Perioperative research is currently unco-ordinated in South Africa (SA), with no clear research agenda., Objective: To determine the top ten national research priorities for perioperative research in SA., Methods: A Delphi technique was used to establish consensus on the top ten research priorities., Results: The top ten research priorities were as follows: (i) establishment of a national database of (a) critical care outcomes, and (b) critical care resources; (ii) a randomised controlled trial of preoperative B-type natriuretic peptide-guided medical therapy to decrease major adverse cardiac events following non-cardiac surgery; (iii) a national prospective observational study of the outcomes associated with paediatric surgical cases; (iv) a national observational study of maternal and fetal outcomes following operative delivery in SA; (v) a stepped-wedge trial of an enhanced recovery after surgery programme for (a) surgery, (b) obstetrics, (c) emergency surgery, and (d) trauma surgery; (vi) a stepped-wedge trial of a surgical safety checklist on patient outcomes in SA; (vii) a prospective observational study of perioperative outcomes after surgery in district general hospitals in SA; (viii) short-course interventions to improve anaesthetic skills in rural doctors; (ix) studies of the efficacy of simulation training to improve (a) patient outcomes, (b) team dynamics, and (c) leadership; and (x) development and validation of a risk stratification tool for SA surgery based on the South African Surgical Outcomes Study (SASOS) data., Conclusions: These research priorities provide the structure for an intermediate-term research agenda.

Objective: To establish a profile of injured adult pedestrians and attempt to define the role which alcohol plays in this regard., Design: Prospective survey of injured pedestrians who presented consecutively over 9 weeks to Groote Schuur Hospital. Data on fatally injured pedestrians were retrospectively collected from the State Mortuary., Setting: Hospital-based study conducted at the trauma unit, Groote Schuur Hospital., Participants: A total of 321 pedestrians--196 injured and 35 'dead on arrival'., Main Outcome Measures: Sociodemographics, blood alcohol concentration (BAC) and injury severity., Results: Patients were predominantly male and, on average, 35.6 years old. They were most frequently injured at night and over weekends. The BAC was positive in 62.1% of pedestrians, and the mean BAC was 0.19 g/dl. Most pedestrians had at least one lower limb injury and nearly half had a head injury; however, BAC-positive pedestrians were 2.6 times more likely to have a head injury (P = 0.0009). Furthermore, BAC-positive pedestrians sustained more severe injuries, more frequently required admission to the ICU, had longer hospital admission and were more likely to die of their injuries. The overall case fatality rate was 19.5%., Conclusions: The influence of alcohol intoxication among injured adult pedestrians in Cape Town is high, suggesting that alcohol plays a major role in these accidents. Consequently, there should be some degree of culpability in those who cross the road while in an intoxicated state. However, equal attention should be given to safe and convenient crossing points, good lighting and education with regard to the wearing of reflective clothing after dark.