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BACKGROUND: The efficacy and safety of opioid-free anaesthesia during bariatric surgery remain debated, particularly when administering multimodal analgesia. As multimodal analgesia has become the standard of care in many centres, we aimed to determine if such a strategy coupled with either dexmedetomidine (opioid-free anaesthesia) or remifentanil with a morphine transition (opioid-based anaesthesia), would reduce postoperative morphine requirements and opioid-related adverse events. METHODS: In this prospective double-blind study, 172 class III obese patients having laparoscopic gastric bypass surgery were randomly allocated to receive either sevoflurane-dexmedetomidine anaesthesia with a continuous infusion of lidocaine and ketamine (opioid-free group) or sevoflurane-remifentanil anaesthesia with a morphine transition (opioid-based group). Both groups received at anaesthesia induction a bolus of magnesium, lidocaine, ketamine, paracetamol, diclofenac, and dexamethasone. The primary outcome was 24-h postoperative morphine consumption. Secondary outcomes included postoperative quality of recovery (QoR40), incidence of hypoxaemia, bradycardia, and postoperative nausea and vomiting (PONV). RESULTS: Eighty-six patients were recruited in each group (predominantly women, 70% had obstructive sleep apnoea). There was no significant difference in postoperative morphine consumption (median [inter-quartile range]: 16 [13-26] vs 15 [10-24] mg, P=0.183). The QoR40 up to postoperative day 30 did not differ between groups, but PONV was less frequent in the opioid-free group (37% vs 59%, P=0.005). Hypoxaemia and bradycardia were not different between groups. CONCLUSIONS: During bariatric surgery, a multimodal opioid-free anaesthesia technique did not decrease postoperative morphine consumption when compared with a multimodal opioid-based strategy. Quality of recovery did not differ between groups although the incidence of PONV was less in the opioid-free group. CLINICAL TRIAL REGISTRATION: NCT05004519.

ABSTRACT Enhanced recovery after surgery (ERAS) pathways have been shown to improve patient outcomes, increase patient satisfaction, and decrease costs. First created and implemented in the adult population, these pathways are now commonplace and continue to expand in the pediatric realm. While there are many proven benefits to ERAS pathways, there continue to be challenges to their proper implementation and long‐term success. This article aims to explore common challenges in pediatric ERAS development and implementation, along with strategies to avoid potential pitfalls. Key themes include departmental and institutional support, stakeholder engagement, awareness of pathways, data management and dissemination, and long‐term maintenance including Plan‐Do‐Study‐Act (PDSA) cycles. Pathway development teams should be aware of these considerations and potential pitfalls, and focusing on them can promote long‐term success for a well‐designed pathway. [ABSTRACT FROM AUTHOR]

Background: With the adjustment of China's birth policy, the repeat cesarean sections raises concerns about potential gastrointestinal mechanical injuries and disturbances in gastrointestinal neurohormonal regulation, affecting the postoperative recovery of gastrointestinal function. These affect maternal nutritional status, prolong recovery, extend hospitalization, increase medical costs, and lead to neonatal care challenges.This study is to examine the effects of different postoperative feeding protocols on the restoration of gastrointestinal function in women undergoing repeat cesarean section. Methods: A total of 103 women were randomly assigned to three groups: experimental group A (n = 35), experimental group B (n = 34), and a control group (n = 34). In group A, women without choking symptoms received a clear fluid diet postoperatively, followed by a pureed diet after 6 h, and a regular soft diet after passing flatus. In group B, women chewed gum postoperatively, followed by a clear fluid diet after 2 h, a pureed diet after 6 h, and a regular soft diet after passing flatus. The control group received a clear fluid diet, a pureed diet after passing flatus, and a regular soft diet after defecation. Outcomes measured included recovery of gastrointestinal function, blood biochemical markers, comfort level, exclusive breastfeeding rate, and newborn weight loss. Results: The baseline maternal data across the three groups demonstrated no significant differences (P > 0.05). Both experimental groups A and B showed earlier recovery of postoperative gastrointestinal function compared to the control group, though there was no significant difference between the two experimental groups (P > 0.05). Additionally, postoperative comfort levels were significantly higher in both experimental groups than in the control group (P < 0.05). Conclusions: Early feeding is safe and effective for women who underwent repeat cesarean sections.It has been shown to accelerate gastrointestinal recovery, significantly improve maternal comfort and satisfaction.In cases where immediate postoperative oral intake is not feasible, chewing gum demonstrates a comparable promotive effect, providing a viable substitute in facilitating recovery. Trial registration: This trial has been prospectively registered at Chinese Clinical Trial Registry (ChiCTR2200065825) and the first registration date was 11/16/2022. [ABSTRACT FROM AUTHOR]

Aim Method Results Conclusion Most of the literature on the environmental impact of surgery has analysed operating theatre practice in terms of its contribution to global warming (by greenhouse gas effects). The aim of this study was to assess the overall environmental impact of a complete perioperative pathway with and without implementation of an enhanced recovery programme (ERP).We compared two scenarios: an ERP scenario and a conventional scenario (CONV) for colorectal surgery. We carried out a lifecycle analysis for perioperative procedures, devices and consumables. We measured the impact on 17 environmental variables in addition to global warming.The overall environmental impact of ERP was 6% lower than that of conventional care. The reduction of impact due to ERP ranged from 5% for greenhouse gas emissions (18 kg CO2 equivalent less per intervention) to 27% for water consumption (3 m3 less). The stages that had the most impact on the environment were the preoperative stage (essentially owing to patient travel) and the intraoperative stage with the surgical part (medical devices representing 83.3% of the impact of the procedure) and the anaesthesia part (halogenated gases and ventilation representing 54.9% of the impact of anaesthesia care).This study found an ERP approach to be more eco‐responsible than conventional care. This is an additional benefit of ERP implementation. The impact of ERP implementation might be further reduced by action on the preoperative and intraoperative stages. [ABSTRACT FROM AUTHOR]

Background: Open liver surgery remains a primary surgical approach for complex liver resections and liver transplantation. However, the postoperative pain management is still a major challenge. Ultrasound-guided external oblique intercostal (EOI) plane block is a novel approach of regional anaesthesia and has a great potential to relieve postoperative pain after upper abdominal surgeries. This study aims to investigate the efficacy and safety of ultrasound-guided EOI plane block in managing postoperative pain after open liver surgery. Methods: Seventy-four participants scheduled for open liver surgery will be randomly assigned to either the intervention group, receiving an ultrasound-guided EOI plane block with a single dose of 30 ml 0.375% ropivacaine, or the control group, which will not receive this block. All participants will be provided with opioid-based patient-controlled intravenous analgesia (PCIA) postoperatively. The primary outcome is resting pain score at 3 h postoperatively, assessed using numerical rating scale. Secondary outcomes include pain score at 6, 24, 48, and 72 h postoperatively, perioperative opioid consumption, remedial analgesics within 72 h postoperatively, PCIA usage within postoperative 72 h, postoperative recovery, length of hospital stay, postoperative side effects, block-related complications, and ropivacaine plasma concentration of participants receiving the block. Discussion: This study is a randomised controlled trial to evaluate the efficacy and safety of ultrasound-guided EOI plane block for postoperative analgesia after open liver surgery. As regional anaesthesia plays an important role in the multimodal pain management, EOI plane block may prove to be an effective regional technique for enhancing postoperative pain relief and contributing to enhanced recovery after open liver surgery. Trial registration: Chinese Clinical Trial Registry ChiCTR2200065745. Registered on November 14, 2022. [ABSTRACT FROM AUTHOR]

Purpose: Enhanced recovery after surgery (ERAS) protocols are widely used in the post-operative care of hernia patients. Despite their prevalence, an absence of published consensus guidelines creates significant heterogeneity in practices. The aim of this study was to evaluate elements in ERAS protocols utilized in ventral hernia repair from institutions across the United States and provide consensus recommendations for each identified element. Methods: Institutional members of the Abdominal Core Health Quality Collaborative (ACHQC) Quality Improvement (QI) committee submitted current ERAS protocols. Items within each protocol were classified as "elements", then assigned a topic. Any topic with ≥ 2 elements from separate institutions were labeled as a "theme," then grouped by stage in the patient care cycle. A brief review of current evidence was provided in addition to a ACHQC QI committee consensus statement. Results: A total of 295 elements from 6 tertiary referral centers specializing in hernia care were compiled into 24 themes and grouped by four separate stages: Pre-Admission Optimization, Pre-Operative Care, Intra-operative Care, and Post-Operative Management. Conclusion: This article represents a multi-institutional review of ERAS protocols for ventral hernia repair and identifies common themes that may provide the framework for a unified ERAS protocol in hernia surgery. Future work may serve to develop societal guidelines defined specifically for enhanced recovery in ventral hernia repair. [ABSTRACT FROM AUTHOR]

Conventional mini percutaneous nephrolithotomy (mPCNL) typically necessitates the pre-operative placement of ureteral catheters. With the development of enhanced recovery after surgery (ERAS), we introduce a novel approach: no ureteral catheter mini percutaneous nephrolithotomy (NUC-mPCNL). To evaluate the efficacy and safety of this innovative procedure compared to mPCNL, we compared the total operative time, stone clearance rate (SCR), stone-free rate (SFR), and complications among patients undergoing either modality from January to September 2021. Our findings revealed a statistically significant reduction in the mean total operative time for the NUC-mPCNL group (42.6 ± 2.4 vs. 60.2 ± 3.4 min, p < 0.001). The SCR, SFR and CSFR were comparable between two groups (98.5% vs. 97.8%, 84.3% vs. 76.0%, 64.7% vs. 60.0%, p = 0.337, 0.295, 0.625). WBC rise, hemoglobin drop and neutrophil percentage rise were similar in both groups. The overall complication rate in the NUC-mPCNL group was lower; however, the difference was not statistically significant (Clavien I, II and III; 11 vs. 13, 1 vs. 2 and 1 vs. 1). Consequently, we conclude that NUC-mPCNL effectively shortens the operative time and holds potential for expedited postoperative recovery. [ABSTRACT FROM AUTHOR]

Aim: Patients requiring a beyond total mesorectal excision (bTME) procedure for locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LRRC) will probably benefit from enhanced recovery after surgery (ERAS) protocols. However, implementation of ERAS protocols in such groups of patients is considered challenging. The aims of this study were to evaluate ERAS‐related outcomes of patients with LARC or LRRC undergoing bTME and to investigate the possibility of designing a tailored ERAS protocol. Method: This study was divided into four phases. Phase one consisted of a literature study to compare functional recovery and postoperative outcomes in patients undergoing bTME. In phase two, outcomes on ERAS care elements in bTME were retrospectively evaluated. In phase three, differences in ERAS‐related outcomes and compliance of the colorectal ERAS protocol in patients who had undergone bTME were studied. In phase four, multidisciplinary team meetings were held to develop an ERAS protocol for bTME patients. Results: Seven studies reported on ERAS‐related outcomes in patients undergoing bTME. Median length of hospital stay was 9–19 days, median stay in the intensive care unit was 2–4 days and 30‐day postoperative major complication rates were 22.6%–61.3%. Seventy‐five bTME patients were included for retrospective analysis. In these patients, length of stay was 9.0 days and major postoperative complications were observed in 40.0%. The overall ERAS compliance was 44.4%. Compared with the colorectal ERAS protocol, the largest differences in management were observed in the use of epidural anaesthesia, the postoperative use of urethral catheters, oral intake and mobilization. Conclusion: Patients undergoing bTME for LARC or LRRC are substantially different from patients treated with the colorectal ERAS protocol, regarding ERAS‐related outcomes. A tailored, multimodal ERAS protocol with specific modifications was developed by an expert multidisciplinary team for patients undergoing bTME for LARC or LRRC. [ABSTRACT FROM AUTHOR]

Aim: To investigate the safety and efficacy of the application of enhanced recovery after surgery (ERAS) protocols in the perioperative period of abdominal and thoracic localized neuroblastomas (NBs). Methods: In this retrospective study, 68 children with NBs who underwent surgical resection of the tumor were enrolled. The ERAS protocols for NB excision were implemented in the ERAS group (n = 39) and the consequences were compared with children treated with traditional care (n = 29, TRAD group). The main outcomes of our interest included the incidence of surgery-related complications, the postoperative length of stay (LOS), and the Face/Legs/Activity/Cry/Consolability (FLACC) quantitative table from postoperative days (POD) 1–5. We also evaluated the median intraoperative fluid volume and anesthesia recovery time; blood glucose levels at the beginning of anesthesia, POD1, and 3; WBC counts, CRP values, and the concentration of plasma nutritional indicators on POD1 and 3; time of early ambulation, first anal exhaust, total enteral nutrition (TEN), and discontinue intravenous infusion postoperatively; usage proportion and duration of abdominal and thoracic drainages, nasogastric decompression tubes and urinary catheters; cost of hospitalization, parental satisfaction rate, and readmission rate of surgery ward within 30 days. Results: Compared to the TRAD group, the ERAS group had lower surgery-related complications, albeit not significantly (P > 0.05); the median postoperative LOS decreased from 11.0 to 8.0 days (P < 0.001), the LOS of abdominal NB was significantly shortened (P < 0.001) compared to thoracic NB (P = 0.07) between the two groups; the FLACC scores decreased significantly from POD1–5 (all P < 0.01). The ERAS group had an improved median intraoperative infusion speed (5.0 mL/kg/h vs 8.0 mL/kg/h), time of early ambulation (1.0 days vs 3.0 days), first anal exhaust (2.0 days vs 2.0 days), TEN (5.0 vs 7.0 days), discontinuation of intravenous infusion (5.0 days vs 8.0 days), and total cost of hospitalization (33,897.2 Yuan vs 38,876.3 Yuan); (all P < 0.01). The usage proportion and duration of surgical drainages and tubes were apparently reduced. The mean blood glucose level was higher at the beginning of anesthesia but lower on POD1 and 3 in the ERAS group (P < 0.01). No statistically significant difference was detected in WBC counts and concentrations of hemoglobin and albumin between the two groups of patients (P > 0.05), while the concentrations of prealbumin on POD3 were higher and the CRP level on POD1 was lower in the ERAS group than the TRAD group (P < 0.01). The satisfaction rate of parents was only slightly higher, but the difference was not statistically significant (P = 0.730). No obvious differences were observed in the aspects of NB resection (P = 0.462) and 30-day readmissions of surgery ward (P = 1.000). Conclusion: The application of ERAS protocols has a significant potential to accelerate perioperative rehabilitation in children undergoing abdominal and thoracic NBs' surgical resection. [ABSTRACT FROM AUTHOR]

Objective: To explore the effect of multimodal analgesia based on the concept of enhanced recovery after surgery (ERAS) in patients undergoing laparoscopic radical gastrectomy (LRG) for gastric cancer (GC). Methods: Clinical data of 128 patients undergoing LRG for GC, admitted to Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from March 2021 to March 2022, were retrospectively analyzed. Among them, 66 patients received a multimodal analgesic management based on ERAS (ERAS group), and 62 patients were treated with conventional mode of analgesia (control group). Pain levels, rehabilitation status, as well as inflammatory factors and stress response indicators before and after surgery were compared between the two groups. Results: There was no significant difference in baseline data between the two groups (P>0.05). The postoperative pain and recovery in the ERAS group were better than those in the control group (P<0.05). After the surgery, serum levels of tumor necrosis factor-alpha (TNF-α), Interleukin 6 (IL-6), and C-reactive protein (CRP) in both groups increased compared to before the surgery, but were significantly lower in the ERAS group compared to the control group (P<0.05). After the surgery, serum malondialdehyde (MDA) and xanthine oxidase (XOD) levels in both groups increased, while superoxide dismutase (SOD) levels decreased compared to preoperative levels. The observed postoperative levels of serum MDA and XOD were significantly lower in the ERAS group, while the postoperative SOD levels were higher compared to the control group (P<0.05). Conclusions: Patients undergoing LRG for GC can benefit from a multimodal pain management plan based on ERAS to reduce postoperative pain, alleviate inflammation, stress responses, and shorten the postoperative recovery process. [ABSTRACT FROM AUTHOR]

Objectives: Enhanced recovery after surgery (ERAS) protocols are multimodal evidence‐based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aimed to explore whether worldwide fetal therapy centers offering prenatal myelomeningocele repair implement the ERAS principles and to provide recommendations for improved perioperative management of patients. Methods: In this survey study, a total of 53 fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre‐, intra‐ and postoperative management. An overall score was calculated per center based on compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for Cesarean section, gynecological oncology and colorectal surgery. Each item was awarded a score of 1 or 0, depending, respectively, on whether the center did or did not comply with that principle, with a maximum score of 20. Results: The questionnaire was completed by 46 centers in 17 countries (response rate, 87%). In total, 22 (48%) centers performed exclusively open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offered both open and fetoscopic procedures and 10 (22%) used only fetoscopy. The perioperative management of patients undergoing fetoscopic and open surgery was very similar. The median ERAS score was 12 (range, 8–17), with a mean ± SD of 12.5 ± 2.4. Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%) and thromboprophylaxis (96%), while the lowest compliance was observed for preoperative carbohydrate loading (15%), a 2‐h fasting period for clear fluids (20%), postoperative nausea and vomiting prevention (33%) and early feeding (35%). ERAS scores were similar in centers with a short (2–5 days), medium (6–10 days) and long (≥ 11 days) hospital stay (mean ± SD, 12.9 ± 2.4, 12.1 ± 2.0 and 10.3 ± 3.2, respectively, P = 0.15). Furthermore, there was no significant association between ERAS score and surgical technique or case volume. Conclusions: The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardized protocols integrating ERAS principles may improve patient recovery, reduce maternal morbidity and shorten the hospital stay after fetal spina bifida surgery. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

In the era of minimally invasive surgery, esophagectomy remains a highly invasive procedure with a high rate of postoperative complications. Preoperative risk assessment is essential for planning esophagectomy in patients with esophageal cancer, and it is crucial to implement evidence‐based perioperative management to mitigate these risks. Perioperative support from multidisciplinary teams has recently been reported to improve the perioperative nutritional status and long‐term survival of patients undergoing esophagectomy. Intraoperative management of anesthesia and fluid therapy also significantly affects short‐term outcomes after esophagectomy. In this narrative review, we outline the recent updates in the perioperative management of esophagectomy, focusing on preoperative risk assessment, intraoperative management, and perioperative support by multidisciplinary teams to improve operative outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Obesity is one of the biggest modern health issues worldwide. Owing to the failure of both behavioral and pharmacological measures, the surgical approach has been established as the main conduct to follow, with bariatric surgery being one of the most effective and safe procedures. One of the bases for the optimal analgesic strategy is the use of adjuvants during the perioperative period. One of the main drugs in use is lidocaine. Aim: To evaluate postoperative pain after perioperative lidocaine infusion in patients undergoing bariatric surgery and describe the presence of nausea and vomiting during the first 24 h. Methods: This was a retrospective study of patients who underwent laparoscopic bariatric surgery at ABC Medical Center. Two study arms were established: a group of patients who received lidocaine infusion and a control group. The presence of pain, nausea, or vomiting was evaluated upon admission to the recovery area and 1 h and 24 h after the intervention. The normal distribution of the data was first verified via the Shapiro–Wilk test. The data are presented as medians for quantitative variables and as frequencies for qualitative variables. Results: A total of 50 surgeries were performed, with a significant correlation between lidocaine infusion and lower pain values at 1 h (p = 0.04). Similarly, there was a marked trend in the presence of nausea in control group 4 (18.6%) vs. 15 (53.5%). Conclusions: Our data suggest that the use of intraoperative lidocaine infusion is limited in postoperative pain management; nonetheless, it significantly improves the incidence of postoperative nausea. [ABSTRACT FROM AUTHOR]

Purpose: Evaluation of a kidney-adjusted enhanced recovery after surgery (ERAS®) protocol (kERAS) in patients undergoing nephron-sparing surgery (PN). Methods: The kERAS protocol is a multidimensional protocol focusing on optimized perioperative fluid and nutrition management as well as strict intraoperative and postoperative blood pressure limits. It was applied in a prospective cohort (n = 147) of patients undergoing open or robotic PN. Patients were analyzed for the development of acute postoperative renal failure (AKI), achievement of TRIFECTA criteria, upstaging or new onset of chronic kidney disease (CKD) and length of hospital stay (LOS) and compared to a retrospective cohort (n = 162) without application of the protocol. Results: Cox regression analyses could not confirm a protective effect of kERAS on the development of AKI post-surgery. A positive effect was observed on TRIFECTA achievement (OR 2.2, 95% CI 1.0-4.5, p = 0.0374). Patients treated with the kERAS protocol showed less long-term CKD upstaging compared to those treated with the standard protocol (p = 0.0033). There was no significant effect on LOS and new onset of CKD. Conclusion: The implementation of a kERAS protocol can have a positive influence on long-term renal function in patients undergoing PN. It can be used safely without promoting AKI. Furthermore, it can be realized with a manageable amount of additional effort. [ABSTRACT FROM AUTHOR]

Background: Degenerative lumbar disease significantly impairs the quality of life in elderly individuals, with short-segment lumbar degenerative disease being particularly prevalent. When conservative treatment proves ineffective, surgical intervention becomes the optimal choice for managing lumbar disease. The implementation of Enhanced Recovery After Surgery (ERAS) in spinal surgery has been progressively refined, leading to greater patient benefits. However, age and the associated decline in physiological function remain critical factors influencing surgical decision-making. Currently, there is a paucity of research focused on elderly patients undergoing lumbar fusion surgery to substantiate that advanced age does not diminish the benefits derived from ERAS in this demographic. Methods: This is a retrospective cohort study of prospectively collected data. Patients who underwent short-segment (1 or 2 segments) transforaminal lumbar interbody fusion (TLIF) under the care of the same surgical team at our institution were recruited, and divided into no-ERAS-elder, ERAS-elder, and ERAS-younger groups. Subsequently, time to physiological function recovery and other outcomes were compared. Results: The outcomes of the ERAS-elder group (n = 113) and the no-ERAS-elder group (n = 120) were compared. The overall physiological function recovery was significantly faster (6.71 ± 2.6 days vs. 8.6 ± 2.67 days, p = 0.01) in the ERAS-elder group. Next, the outcomes of the ERAS-elder group (n = 113) were compared with those of the ERAS-younger group (n = 100), and no significant difference in total physiological function recovery was found between the two groups (6.71 ± 2.6 days vs. 6.14 ± 1.63 days, p = 0.252). Conclusions: This study shows that the implementation of the ERAS program can effectively shorten the recovery time of physiological function in elderly patients after short-segment lumbar surgery, reduce the incidence of some complications, alleviate pain, and significantly shorten the length of hospital stay. ERAS enables elderly patients to achieve outcomes comparable to those of younger patients. [ABSTRACT FROM AUTHOR]

Background/Objectives: Enhanced recovery after surgery (ERAS) protocols optimize perioperative care and improve recovery. This study evaluated the effectiveness of ERAS in one- or two-level posterior lumbar fusion surgeries, focusing on perioperative medication use, pain management, and functional outcomes. Methods: Eighty-eight patients undergoing lumbar fusion surgery between March 2021 and February 2022 were allocated into pre-ERAS (n = 41) and post-ERAS (n = 47) groups. Outcomes included opioid and antiemetic consumption, pain scores (numerical rating scale (NRS)), functional recovery (Oswestry Disability Index (ODI) and EuroQol 5 Dimension (EQ-5D)), and complication rates. Pain was assessed daily for the first four postoperative days and at 6 months. Linear Mixed Effects Model analysis evaluated pain trajectories. Results: The post-ERAS group showed significantly lower opioid (p = 0.005) and antiemetic (p < 0.001) use. No significant differences were observed in NRS pain scores in the first 4 postoperative days. At 6 months, the post-ERAS group reported significantly lower leg pain (p = 0.002). The time:group interaction was not significant for back (p = 0.848) or leg (p = 0.503) pain. Functional outcomes at 6 months, particularly ODI and EQ-5D scores, showed significant improvement in the post-ERAS group. Complication rates were lower in the post-ERAS group (4.3% vs. 19.5%, p = 0.024), while hospital stay and fusion rates remained similar. Conclusions: The ERAS protocol significantly reduced opioid and antiemetic use, improved long-term pain management and functional recovery, and lowered complication rates in lumbar fusion patients. These findings support the implementation of ERAS protocols in spinal surgery, emphasizing their role in enhancing postoperative care. [ABSTRACT FROM AUTHOR]

Background: Despite the implementation of enhanced recovery programs, the reported average postoperative length of stay after robotic lobectomy remains as 4 days. In this prospective study, we present the outcomes of early discharge (on day 2) with telehealth home monitoring device after robotic lobectomy for lung cancer in selected patients. Methods: All patients with a caregiver were discharged on postoperative day 2 (POD 2) with a telemonitoring device provided they met the specific discharge criteria. Inclusion criteria: <75 years old, stage I-II NSCLC, with caregiver, ECOG 0–2, scheduled for lobectomy, logistic proximity to hospital (<60 km); intra-postoperative exclusion criteria: conversion to open surgery, early complications needing hospital monitoring or redo-operation, difficult pain management, <92 HbO2% saturation on room air or need for O2 supplementation, altered vital or laboratory parameters. Teleconsultations were scheduled as follows: the first one in afternoon of POD2, two on POD3, then once a day until chest tube removal. After discharge, patients recorded their vital signs at least four times a day using the device, which allowed two surgeons to monitor them via a mobile application. In the event of sudden changes in vital signs or the occurrence of adverse events, patients had access to a direct phone line and a dedicated re-hospitalization pathway. The primary outcome was safety, assessed by the occurrence of post-discharge complications or readmissions, as well as feasibility. Secondary outcomes: comparison of safety profile with a matched control group in which the standard of care and the evaluation of resource optimization were maintained and economic evaluation. Results: Between July 2022 and February 2024, 48 patients were enrolled in the present study. Six patients (12.5%) dropped out due to unsatisfied discharge criteria on POD2. Exclusion causes were: significant air leaks (n:2) requiring monitoring and the use of suction device, uncontrolled pain (n:2), atrial fibrillation, and occurrence of cerebral ischemia (n:1 each). The adherence rate to vital signs monitoring by patients was 100%. A mean number of four measurements per day was performed by each patient. During telehealth home monitoring, a total of 71/2163 (1.4%) vital sign measurements violated the established acceptable threshold in 22 (52%) patients. All critical violations were managed at home. During the surveillance period (defined as the time from POD 2 to the day of chest tube removal), a persistent air leak was recorded in one patient requiring readmission to the hospital (on POD 13) and re-intervention with placement of a second thoracic drainage due to unsatisfactory lung expansion. No other postoperative complication occurred nor was there any readmission needed. Compared to the control group, the discharge gain was 2.5 days, with an economic benefit of 528 €/day (55.440 € on the total enrolled population). Conclusions: Our results confirm that the adoption of telehealth home monitoring is feasible and allows a safe discharge on postoperative day two after robotic surgery for stage I-II NSCLC in selected patients. A potential economic benefit (141 days of hospitalizations avoided) for the healthcare system could result from the adoption of this protocol. [ABSTRACT FROM AUTHOR]

Pancreatic surgery is complex and associated with higher rates of morbidity and mortality compared to other abdominal surgeries. Over the past decade, the introduction of new technologies, such as minimally invasive approaches, improvements in multimodal treatments, advancements in anesthesia and perioperative care, and better management of complications, have collectively improved patient outcomes after pancreatic surgery. In particular, the adoption of Enhanced Recovery After Surgery (ERAS) recommendations has reduced hospital stays and improved recovery times, as well as post-operative outcomes. The aim of this narrative review is to highlight the surgeon's perspective on the ERAS program for pancreatic surgery, with a focus on its potential advantages for perioperative functional recovery outcomes. [ABSTRACT FROM AUTHOR]

Background: Coronary artery bypass grafting is associated with a high occurrence of postoperative cardiopulmonary complications. Preliminary evidence suggested that enhanced recovery after surgery can effectively reduce the occurrence of postoperative cardiopulmonary complications. However, enhanced recovery after surgery with systematic integration of cardiopulmonary rehabilitation (ERAS-CaRe) into for Coronary artery bypass grafting has not been evaluated so far. We thus design the ERAS-CaRe randomized-controlled trial to evaluate possible superiority of embedding cardiopulmonary rehabilitation in ERAS over ERAS alone as well as to investigate effects of differential timing of cardiopulmonary rehabilitation within enhanced recovery after surgery (pre-, post-, perio-operative) on post-operative cardiopulmonary complications following Coronary artery bypass grafting surgery. Methods: ERAS-CaRe is a pragmatic, randomized-controlled, parallel four-arm, clinical trial. Three hundred sixty patients scheduled for Coronary artery bypass grafting in two Chinese hospitals will be grouped randomly into (i) Standard enhanced recovery after surgery or (ii) pre-operative ERAS-CaRe or (iii) post-operative ERAS-CaRe or (iv) perio-operative ERAS-CaRe. Primary outcome is the occurrence of cardiopulmonary complications at 10 days after Coronary artery bypass grafting. Secondary outcomes include the occurrence of other individual complications including cardiac, pulmonary, stroke, acute kidney injury, gastrointestinal event, ICU delirium rate, reintubation rate, early drainage tube removal rate, unplanned revascularization rate, all-cause mortality, ICU readmission rate, plasma concentration of myocardial infarction-related key biomarkers etc. Discussion: The trial is designed to evaluate the hypothesis that a cardiopulmonary rehabilitation based enhanced recovery after surgery program reduces the occurrence of cardiopulmonary complications following Coronary artery bypass grafting and to determine optimal timing of cardiopulmonary rehabilitation within enhanced recovery after surgery. The project will contribute to increasing the currently limited knowledge base in the field as well as devising clinical recommendations. Trial registration: The trial was registered at the Chinese Clinical Trials Registry on 25 August 2023 (ChiCTR2300075125; date recorded: 25/8/2023, https://www.chictr.org.cn/). [ABSTRACT FROM AUTHOR]

Early extubation after pediatric cardiac surgery has come full circle from being practiced in the early days of pediatric cardiac surgery, falling out of favor with opioid-heavy cardiostable anesthesia, and resurfacing again in more recent times as part of enhanced recovery after surgery practice. Early extubation is variably defined, but is mostly accepted as extubation that occurs within 6–8 h from the end of surgery. In recent years, the debate has shifted from early extubation in the intensive care unit to immediate extubation in the operating theatre. In this review, we examined the benefits and pitfalls of early and immediate extubation, factors that influence the success of early extubation, and potential guidelines for practice and implementation. [ABSTRACT FROM AUTHOR]

Background: The transversus abdominis plane block (TAPB) is frequently used for postoperative analgesia in abdominal surgery. However, it remains insufficient for analgesia during upper abdominal surgeries. Therefore, we compared the efficacy of the subcostal transversus abdominis plane block (STAPB) or rectus sheath block (RSB), in addition to the posterior transversus abdominis plane block (PTAPB), for postoperative analgesia in major gynecologic cancer surgeries. Methods: This prospective randomized study included 50 patients aged > 18 years (American Society of Anesthesiologists physical status II or III), who underwent gynecologic cancer surgery through a midline incision. All patients underwent PTAPB, STAPB, or RSB according to the randomization. The following parameters were recorded and compared: demographic data; intraoperative hemodynamic parameters; numeric rating scale (NRS) pain levels at the 1st, 6th, 12th, and 24th postoperative hours; opioid consumption; number of requests and boluses; adverse effects; surgical complications within 24 h. Results: Forty-seven patients were included in this study. In the STAPB group, postoperative 1, 12 and 24 h NRS values were lower; opioid consumption, opioid demand, and bolus numbers were lower during the postoperative 24 h as compared to RSB (P < 0.05). The intraoperative opioid and hemodynamic values were similar in both groups. Conclusions: STAPB in addition to PTAPB provides more effective analgesia than RSB for postoperative pain management in open gynecologic cancer surgeries. [ABSTRACT FROM AUTHOR]

OBJECTIVES This single-centre prospective observational study aimed to investigate reasons for prolonged hospitalization [over the median length of stay (LOS)] after enhanced recovery thoracoscopic [ERAS 3-port video-assisted thoracoscopic surgery (VATS)] wedge resection. METHODS All patients were evaluated twice-daily by an investigator for reasons of hospitalization. Each reason was analysed individually. Predictors for prolonged hospitalization were identified using a multivariable backward stepwise logistic regression model. RESULTS A total of 150 consecutive patients (lymphadenectomy 8.7%) were included from November 2022 to December 2023, with a median LOS of 1 (interquartile range 1–2) day. Of these, 55 patients (36.7%) experienced prolonged hospitalization. The main reasons included postoperative pain (16.0%), air leak (14.7%) and social factors (14.7%), followed by oxygen dependency (7.3%), gastrointestinal factors (5.3%), urinary factors (4.7%), pneumonia (1.3%), pleural effusion (1.3%), chylothorax (0.7%), atrial fibrillation (0.7%), confusion (0.7%) and fatigue (0.7%). Multivariable analysis revealed that an increase in the percentage of predicted forced expiratory volume in 1 s (FEV1%pre) by 1% [odds ratio (OR) 0.41, P = 0.023) and percentage of predicted diffusing capacity for carbon monoxide (DLCO%pre) by 1% (OR 0.95, P = 0.002) decreased likelihood of prolonged hospitalization. Conversely, each additional pack-year (OR 1.01, P = 0.028) and living alone (OR 3.55, P = 0.005) increased the risk of prolonged hospitalization. CONCLUSIONS Prolonged hospitalization (LOS > 1 day) after ERAS 3-port VATS wedge resection, with 8.7% lymphadenectomy, was mainly due to pain, air leak and social factors. Smokers with decreased FEV1%pre or DLCO%pre and patient living alone were at increased risk. Clinical trial registration number ClinicalTrials.gov: NCT06118593 (https://clinicaltrials.gov/study/NCT06118593?cond=why%20in%20hospital&rank=2). [ABSTRACT FROM AUTHOR]

The enhanced recovery after surgery (ERAS) pathway is a perioperative care pathway intended to facilitate early recovery and minimize hospital stays among patients undergoing major surgery. Critical factors for successful ERAS implementation, which may vary depending on care processes, include a multidisciplinary team, organizational commitment to change, and a real-time system for compliance and outcome audits. As most clinicians and health organizations can attest, incorporating and implementing new evidence-based practice changes almost always involves overcoming systemic challenges and obstacles. The same holds true for ERAS programs. The main barriers to ERAS protocol implementation have been resistance to change, lack of time and resources, and inadequate communication and coordination among departments. According to evidence-based ERAS guidelines, the best way to efficiently implement all recommendations into practice is to discover. Implementation science aims to identify and address care gaps, support change in practice, and enhance healthcare quality. Implementation research should also build a robust and generalizable evidence base to inform implementation practice. Most implementation investigations focus on one of two approaches to achieving change. Implementation can progress through top-down or bottom-up processes depending on factors such as national policies, organizational properties, or the implementation culture of society, especially for health issues. Although the ERAS guidelines are based on evidence-based knowledge, only a limited number of health centers around the world have officially been able to implement them. The purpose of this review is to analyze the implementation of the ERAS pathways in theory and practice in Turkey, considering the absence of an ERAS-qualified center in Turkey. [ABSTRACT FROM AUTHOR]

(1) Introduction: Enhanced Recovery After Surgery (ERAS) protocols can create a cultural shift that will benefit patients by significantly reducing patient length of stay when compared to an equivalent group of surgical patients not following an ERAS protocol. (2) Methods: In this retrospective study of 2236 patients in a multi-center, community-based healthcare system, matching was performed based on a multitude of variables related to demographics, comorbidities, and surgical outcomes across seven ERAS protocols. These cohorts were then compared pre and post ERAS protocol implementation. (3) Results: ERAS protocols significantly reduced hospital length of stay from 3.0 days to 2.1 days (p <0.0001). Additional significant outcomes included reductions in opioid consumption from 40 morphine milligram equivalents (MMEs) to 20 MMEs (p <0.001) and decreased pain scores on postoperative day zero (POD 0), postoperative day one (POD 1), and postoperative day two (POD 2) when stratified into mild, moderate, and severe pain (p <0.001 on all three days). (4) Conclusions: ERAS protocols aggregately reduce hospital length of stay, pain scores, and opioid consumption. [ABSTRACT FROM AUTHOR]

Despite the general agreement that implementation of Enhanced Recovery After Surgery (ERAS) pathways decrease hospital length of stay, a continuous challenge that has often been neglected is a procedure- and patient-specific approach. For example, asking 'Why is the patient still in hospital?' is the original premise for ERAS. Outcomes improve with increased compliance with recommended elements, but overcomplication of pathways can lead to cherry picking of elements that are convenient, resulting in 'partial ERAS'. As there are few high-quality randomised clinical trials (RCTs) that evaluate the specific role of individual preoperative, intraoperative, and postoperative elements, challenges lie ahead to identify essential ERAS elements to facilitate more widespread implementation. To achieve this goal, the balance between large RCTs and smaller detailed hypothesis-generating observational studies needs to be addressed in order to enhance knowledge and limit waste of research resources. [ABSTRACT FROM AUTHOR]

Perioperative pain management affects cost and outcomes in elective spine surgery. This study investigated the association between liposomal bupivacaine (LB) and outpatient spine surgery outcomes, including perioperative, postoperative, and postdischarge opioid use and healthcare resource utilization. This was a retrospective comparative study. Eligibility criteria included adults with ≥6 months of continuous data before and after outpatient spine procedures including discectomy, laminectomy, or lumbar fusion. Patients receiving LB were matched 1:3 to patients receiving non-LB analgesia by propensity scores. Outcomes included (1) opioid use in morphine milligram equivalents (MMEs) during the perioperative and postdischarge periods and (2) postdischarge readmission and emergency department (ED) visits up to 3 months after surgery. Generalized linear mixed-effects modeling with appropriate distributions was used for analysis. Deidentified data from the IQVIA linkage claims databases (2016-2019) were used for the analysis. This study was funded by Pacira BioSciences, Inc. In total, 381 patients received LB and 1143 patients received non-LB analgesia. Baseline characteristics were well balanced after propensity score matching. The LB cohort used fewer MMEs versus the non-LB cohort before discharge (80 vs 132 MMEs [mean difference, −52 MMEs; p=.0041]). Following discharge, there was a nonsignificant reduction in opioid use in the LB cohort versus the non-LB cohort within 90 days (429 vs 480 MMEs [mean difference, −50 MMEs; p=.289]) and from >90 days to 180 days (349 vs 381 MMEs [mean difference, −31 MMEs; p=.507]). The LB cohort had significantly lower rates of ED visits at 2 months after discharge versus the non-LB cohort (3.9% vs 7.6% [odds ratio, 0.50; p=.015]). Postdischarge readmission rates did not differ between cohorts. Use of LB for outpatient spine surgery was associated with reduced opioid use at the hospital and nonsignificant reduction in opioid use at all postoperative timepoints examined through 90 days after surgery versus non-LB analgesia. ED visit rates were significantly lower at 60 days after discharge. These findings support reduced cost and improved quality metrics in patients treated with LB versus non-LB analgesia for outpatient spine surgery. [ABSTRACT FROM AUTHOR]

With the goal of improving patient outcomes, the Integrated Spine Center at UT Southwestern Medical Center implemented an enhanced recovery after surgery (ERAS) protocol which includes pre- and postsurgery guidelines. Numerous studies have shown benefit of implementation of ERAS protocols to standardize perioperative care in line with best practices; however, the literature on complication rates, LOS, and readmissions shows mixed results. The goal of this study was to investigate the impact of the ERAS protocol implementation on complication rates in the perioperative period, as well as hospital and ICU length of stay and hospital re-admission rates. A retrospective cohort study was performed on all patients who underwent spine surgery between September 2016 and September 2021 at a single institution. Patients who met inclusion criteria were divided into non-ERAS and ERAS groups, and comparative statistics were used to evaluate ERAS protocol effectiveness. All patients who underwent spine surgery at UT Southwestern between September 2016 and September 2021 were evaluated for inclusion in the study. The patient sample was further refined to include only complex patient cases which were able to receive the full ERAS protocol (nonemergent admissions). Presence of absence of postoperative complications including surgical site infection, AKI, DVT, MI, sepsis, pneumonia, PE, stroke, shock, and other complications were compared between groups, as were hospital and ICU length of stay, and 7, 30, and 90 day readmissions. Self-reported or functional measures were not used in outcome evaluation. A database of patient and surgery characteristics was built using an EMR query tool with spot checks performed by the authors. Control and treatment groups were matched for gender, age, BMI, ASA score, and surgery type. Total number of complication rates was compared between ERAS and non-ERAS groups, and comparative statistics were used to determine significance. Significant differences between ERAS versus non-ERAS groups were found in rates of UTI (6.8% vs 3.1%, respectively; p=.031), constipation (20.6% vs 11.4%, respectively; p=.001), and any complications (31.4% vs 19.4%, respectively; p<.001). There was no significant difference in the rates of other complications, in length of hospital or ICU stay, or readmissions at 7, 30, and 90 days. Implementation of the ERAS protocol did not decrease complication rates or length of stay, and ERAS patients had significantly higher rates of UTI, constipation, and any complications. There may have been confounding factors due to the impact of COVID-19 on delivery of care, as well as misalignment between ERAS goals and outcome measures. [ABSTRACT FROM AUTHOR]

To compare perioperative outcomes in patients undergoing pelvic exenteration for gynecologic malignancies before and after implementation of Enhanced Recovery After Surgery (ERAS) protocols. We performed an institutional retrospective cohort study of patients undergoing pelvic exenteration for gynecologic malignancies before (1/1/2006–12/30/2014) and after (1/1/2015–6/30/2023) ERAS implementation. We described ERAS compliance rates. We compared outcomes up to 60 days post-exenteration. Complication grades were defined by the Clavien-Dindo system. Overall, 105 women underwent pelvic exenteration; 74 (70.4%) in the pre-ERAS and 31 (29.5%) in the ERAS cohorts. There were no differences between cohorts in age, body mass index, race, primary disease site, type of exenteration, urinary diversion, or vaginal reconstruction. All patients had complications, with at least one grade II+ complication in 94.6% of pre-ERAS and 90.3% of ERAS patients. The ERAS cohort had more grade I-II gastrointestinal (61.3% vs 21.6%, p < 0.001) and hematologic (61.3% vs 36.5%, p = 0.030) and grade III-IV renal (29.0% vs 12.2%, p = 0.048) and wound (45.2% vs 18.9%, p = 0.008) complications compared to the pre-ERAS cohort. ERAS patients had a higher rate of ileus (38.7% vs 10.8%, p = 0.002), urinary leak (22.6% vs 5.4%, p = 0.014), pelvic abscess (35.5% vs 10.8%, p = 0.005), postoperative bleeding requiring intervention (61.3% vs 28.4%, p = 0.002), and readmission (71.4% vs 46.5%, p = 0.025). Median ERAS compliance was 60%. Pelvic exenteration remains a morbid procedure, and complications were more common in ERAS compared to pre-ERAS cohorts. ERAS protocols should be optimized and tailored to the complexity of pelvic exenteration compared to standard gynecologic oncology ERAS pathways. • In an institutional retrospective cohort study, postoperative complications were more common in ERAS vs pre-ERAS patients. • ERAS patients had more low-grade gastrointestinal and hematologic and high-grade genitourinary and wound complications. • In the ERAS cohort, ERAS compliance was 60% overall and was lowest in postoperative components including pain control. • In the ERAS cohort, there was no difference in overall complication rate between high and low ERAS compliance. [ABSTRACT FROM AUTHOR]

After emergency surgery for intestinal obstruction caused by colorectal cancer, postoperative ileus (POI) is more likely to occur in the early-stage oral intake. POI incited the occurrence of postoperative complications and prolongs hospital stay. Reducing the occurrence of POI will Enhance Recovery After Surgery (ERAS). Aim: The aim of this study is to observe and evaluate the preventive effect of postoperative oral administration of 76% Meglumine Diatrizoate in reducing the incidence of POI and promoting intestinal absorption during the recovery of intestinal peristalsis in patients after intestinal obstruction surgery. Methods: From October 2018 to December 2021, 94 patients (47 vs 47) with intestinalobstruction were rolled. Patients with an ASA score of 4 or higher and gastrointestinal perforation with peritonitis were excluded. After 24 hours of surgery, the patients were divided into experimental group and control group disposed of with an opaque airtight envelope method, patient-side single blind. After intestinal peristalsis recovery (2.45 ± 0.62 d vs 2.60 ± 0.68 d, P > 0.05), the experimental group was given 76% Meglumine Diatrizoate 20 ml orally 9am and the control group was given 10% glucose 20 ml for three consecutive days. POI cases, the time taken to achieve full daily oral calorie and discharge days were counted. Results: The time required to achieve full daily oral calorie (11.04 ± 2.70 d vs 14.09 ± 3.74 d, p < 0.05), POI cases (10/47 vs 20/47, p < 0.05) and discharge days (14.00 ± 4.89 d vs 16.77 ± 5.94 d, p < 0.05) are significantly different between the two groups. Conclusions: Oral 76% Meglumine Diatrizoate is safe and effective, which can reduce the occurrence of POI, promote the recovery of intestinal absorption and shorten the length of hospital stay effectively. [ABSTRACT FROM AUTHOR]

This prospective study aimed to compare the complication rates and clinical outcomes of propensity-matched patients who received fast-track total knee arthroplasty (FT TKA) in outpatient versus inpatient settings. Patients (n = 629) who received FT TKA at various outpatient (n = 176) and inpatient (n = 462) surgery rates were prospectively followed until 90 days after surgery. The decision between inpatient versus outpatient FT TKA was made on a case-by-case basis, depending on consultation between the surgeon and patient. Complications were collected to distinguish between intraoperative complications, complications with no readmission, complications with readmission, and complications with reoperation. Propensity scores based on age, sex, body mass index, and the American Society of Anesthesiologists score were used to match outpatient to inpatient FT TKA. A cumulative incidence function was computed by taking the time to diagnose any postoperative complication in the first 90 days as the end point. Propensity score matching (1:2 ratio) for comparison resulted in 173 outpatient FT TKAs and 316 inpatient FT TKAs. No significant differences were observed between outpatient versus inpatient FT TKA for intraoperative complication rates (2% in both groups). At 90-day follow-up, no significant differences were observed between outpatient versus inpatient FT TKA for total complications with no readmission (8.0 versus 7.9%), complications with readmission but no reoperation (1.1 versus 0.6%), and complications with reoperation (4.0 versus 4.4%). A comparison of postoperative complication diagnosis time using the cumulative incidence function revealed no significant differences between outpatient versus inpatient FT TKA. The present study revealed that there were no differences in 90-day postoperative complication rates between outpatient and inpatient FT TKA and that there were also no differences in rates of intraoperative complications, readmissions, or reoperations. These findings may encourage hesitant surgeons to move toward outpatient TKA pathways, as there is no greater risk of early postoperative complications that could be more difficult to manage after discharge. Level II. [ABSTRACT FROM AUTHOR]

Background Increased length of stay after surgery is associated with increased healthcare utilization and adverse patient outcomes. While enhanced recovery after surgery (ERAS) protocols have been shown to reduce length of stay after colorectal surgery in trial settings, their effectiveness in real-world settings is more uncertain. The aim of this study was to assess the impact of ERAS protocol implementation on length of stay after colorectal surgery, using real-world data. Methods In 2012, ERAS protocols were introduced at 15 Ontario hospitals as part of the iERAS study. A cohort of patients undergoing colorectal surgery treated at these hospitals between 2008 and 2019 was created using health administrative data. Mean length of stay was computed for the intervals before and after ERAS implementation. Interrupted time series analyses were performed for predefined subgroups, namely all colorectal surgery, colorectal surgery without complications, right-sided colorectal surgery, and left-sided colorectal surgery. Sensitivity analyses were then conducted using adjusted length of stay, accounting for length of stay predictors, including: patient age, sex, marginalization, co-morbidities, and diagnosis; surgeon volume of cases, years in practice, and colorectal surgery expertise; hospital volume; and other contextual factors, including procedure type and timing, surgical approach, and in-hospital complications. Results A total of 32 612 patients underwent colorectal surgery during the study interval. ERAS implementation led to a decrease in length of stay of 1.05 days (13.7%). Larger decreases in length of stay were seen with more complex surgeries, with a level change of 1.17 days (15.6%) noted for the subgroup of patients undergoing left-sided colorectal surgery. The observed decreases in length of stay were durable for the length of the study interval in all analyses. When adjusting for predictors of length of stay, the effect of ERAS implementation on length of stay was larger (reduction of 1.46 days). Conclusion Introducing formal ERAS protocols reduces length of stay after colorectal surgery significantly, independent of temporal trends toward decreasing length of stay. These effects are durable, demonstrating that ERAS protocol implementation is an effective hospital-level intervention to reduce length of stay after colorectal surgery. [ABSTRACT FROM AUTHOR]

Introduction: The ERAS protocol is a set of international guidelines established to expedite patients' discharge after colorectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few, and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients' return to home at earlier rates than traditional practice. Methods: A prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively. Results: In total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within 24 h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative antibiotics use of preoperative gabapentin. Conclusion: UHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improvement required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland. [ABSTRACT FROM AUTHOR]

Background: To improve perioperative frailty status in patients undergoing laparoscopic colorectal cancer surgery (LCCS), we explored a new intensive prehabilitation program that combines prehabilitation exercises with standard enhanced recovery after surgery (ERAS) and explored its impact. Methods: We conducted a prospective randomized controlled trial. Between April 2021 to August 2021, patients undergoing elective LCCS were randomized into the standardized ERAS (S-ERAS) group or ERAS based on prehabilitation (group PR-ERAS). Patients in the PR-ERAS group undergoing prehabilitation exercises in the perioperative period in addition to standard enhanced recovery after surgery. We explored the effects of this prehabilitation protocol on frailty, short-term quality of recovery (QoR), psychological status, postoperative functional capacity, postoperative outcomes, and pain. Results: In total, 125 patientswere evaluated, and 95 eligible patients were enrolled and randomly allocated to the S-ERAS (n = 45) and PR-ERAS (n = 50) groups. The Fried score was higher in the PR-ERAS group on postoperative day (7 (2(2,3) vs. 3 (2,4), P = 0.012). The QoR-9 was higher in the PR-ERAS group than in the S-ERAS group on the 1st, 2nd, 3rd, and 7th postoperative days. The PR-ERAS group had an earlier time to first ambulation (P < 0.050) and time to first flatus (P < 0.050). Conclusion: Prehabilitation exercises can improve postoperative frailty and accelerate recovery in patients undergoing LCCS but may not improve surgical safety. Therefore, better and more targeted prehabilitation recovery protocols should be explored. [ABSTRACT FROM AUTHOR]

Da Vinci robot-assisted pancreaticoduodenectomy offers advantages, including minimal invasiveness, precise, and safe procedures. This study aimed to investigate the clinical effectiveness of implementing enhanced recovery after surgery (ERAS) concepts in Da Vinci robot-assisted pancreaticoduodenectomy. A retrospective analysis was conducted on clinical data from 62 patients who underwent Da Vinci robot-assisted pancreaticoduodenectomy between January 2018 and December 2022. Among these patients, 30 were managed with ERAS principles, while 32 were managed using traditional perioperative management protocols. Surgical time, intraoperative blood loss, postoperative oral intake time, time to return of bowel function, time to ambulation, visual analog scale (VAS) pain scores, fluid replacement volume, length of hospital stay, total hospital expenses, complications, and patient satisfaction were recorded and compared between the two groups. Postoperative follow-up included assessment of postoperative functional scores, reoperation rates, SF-36 quality of life scores, and survival rates. The average follow-up time was 35.6 months (range: 12–56 months). There were no statistically significant differences in general characteristics, including age, surgical time, intraoperative blood loss, and preoperative medical history between the two groups (P > 0.05). Compared to the control group, the intervention group had an earlier postoperative oral intake time, faster return of bowel function, rapid ambulation, and shorter hospital stays (P < 0.05). The intervention group also had lower postoperative VAS scores, lower fluid replacement volume, lower total hospital expenses, and a lower rate of complications (P < 0.05). Patient satisfaction was higher in the intervention group (P < 0.05). There were no statistically significant differences between the two groups in two-year functional scores, reoperation rates, quality of life scores, and survival rates (P > 0.05). Implementing ERAS principles in Da Vinci robot-assisted pancreaticoduodenectomy substantially expedited postoperative recovery, lowered pain scores, and diminished complications. However, there were no notable differences in long-term outcomes between the two groups. [ABSTRACT FROM AUTHOR]

Introduction The War-Related Illness and Injury Study Center at the VA New Jersey Health Care System (WRIISC-VANJ) serves as one of the three tertiary referral centers for combat deployed Veterans of all eras with medically unexplained or difficult-to-diagnose conditions that may be related to deployment-related exposures. Many of the Veterans seen at the WRIISC experience chronic multisymptom illness (CMI), also known as Gulf War Illness (GWI). Given the complexity and interconnectedness of symptoms, Veterans with GWI are often unlikely to produce meaningful results when addressing single symptoms. Further, Veterans with GWI often have co-morbid cognitive and behavioral health conditions (e.g. TBI, PTSD, Depression), which further compromise their self-efficacy in following treatment recommendations. Thus, the WRIISC-NJ, in collaboration with Wellness Solutions Group, developed a virtual Functional Medicine-based Interdisciplinary and Integrative Intervention to improve the health of Veterans by assisting them in implementing lifestyle changes. Methods The 6-month telehealth program included functional medicine assessments, nutrition and adaptive exercise coaching, mindfulness meditation and yoga, guest health lectures, character strength coaching, and targeted nutritional supplements. Aspects of the program were tailored to the unique clinical needs of each Veteran. Participants completed baseline and 6 month follow-up assessments of physical and emotional symptoms and overall functioning. Follow-up scores were compared with baseline data. Results The program was well received by Veterans with attendance across all offered sessions ranging from 70 to 100%. Further, at the end of the clinical pilot program, improvements were demonstrated in physical and mental health symptoms, intentional weight loss/gain, functional movement, and sleep quality. Conclusions These preliminary results demonstrate the possibility of creating positive health outcomes across multiple health indicators in medically complex combat-deployed Veterans. Our early success and participant enthusiasm for this clinical pilot program also illustrate an opportunity to provide individualized, innovative solutions for the evaluation and treatment of Veterans with GWI. [ABSTRACT FROM AUTHOR]

Background Enhanced recovery after surgery (ERAS) pathways have been widely shown to yield positive outcomes, including in plastic surgery. Our group has previously validated ERAS in our deep inferior epigastric perforator flap breast reconstruction population. Objectives We evaluated whether the ERAS protocol and addition of liposomal bupivacaine affected patient outcomes at the time of mastectomy and first-stage tissue expander reconstruction. Methods All patients treated between July 2021 and May 2022 were reviewed retrospectively. The ERAS protocol was implemented in December 2021. Two patient groups were compared: pre-ERAS and ERAS. The ERAS protocol included use of liposomal bupivacaine in the pectoralis nerve block 1/2 planes. Primary outcomes were observed with postoperative length of stay and hospital narcotic use. Results Eighty-one patients were analyzed in this cohort. The pre-ERAS group was composed of 41 patients, the ERAS group was composed of 83 patients. Postoperative length of stay was significantly reduced in the ERAS group (1.7 pre-ERAS vs 1.1 ERAS, P =.0004). When looking at morphine equivalents during the hospital stay, the degree of narcotics in the recovery room was relatively similar. Average PACU pain morphine equivalents were 6.1 pre-ERAS vs 7.1 ERAS (P =.406). However, total hospital morphine equivalents were significantly lower in the ERAS group (65.0 pre-ERAS vs 26.2 ERAS, P = <.001). Conclusions The introduction of an enhanced recovery after surgery protocol with liposomal bupivacaine pectoralis 1/2 nerve blocks decreased postoperative opioid consumption and hospital length of stay in mastectomy patients undergoing tissue expander–based reconstruction. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

The adoption of enhanced recovery after surgery (ERAS) protocols in multiple surgical disciplines has revolutionized perioperative care, demonstrating reduced complications and shorter hospital stays across surgical specialties. ERAS protocols have increasingly been incorporated in plastic surgery, yet a notable gap in the literature on ERAS for gender-affirming surgery (GAS) still exists. A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies on ERAS protocols in GAS. The aim of this review was to assess the current status of ERAS adoption in GAS, evaluate its impact on perioperative care, and provide recommendations for future research and clinical practice. While there is an overall scarcity of evidence-based ERAS protocols across GAS, published studies on the application of ERAS in GAS have demonstrated promising early outcomes and illustrate an area for further investigation and innovation in plastic surgery. Level of Evidence: 5 [ABSTRACT FROM AUTHOR]

Background: Acute intestinal obstruction is a blockage of the intestine which causes a range of clinical symptoms such as acute and severe abdominal pain, nausea, and obstipation. Intestinal obstruction is a medical emergency and can be life‐threatening when left untreated. In cases where treatment involves emergency abdominal surgery, a multimodal perioperative care pathway (enhanced recovery after surgery ERAS) has shown to accelerate patient recovery after surgery, reduce hospital length of stay, and improve overall outcomes. The objective of this scoping review was to identify and synthesize the existing evidence regarding the implementation of ERAS components with a focus on postoperative components in patients undergoing surgery for acute intestinal obstruction. Methods: This scoping review followed the preferred reporting items for systematic reviews and meta‐analysis extension for scoping reviews framework. PubMed‐Medline and Embase database were searched. Results: The search identified 1860 studies of which 16 were included in the final analysis. All the studies were quantitative. Eleven studies used 10 or more ERAS interventions (range 10–28). The most common interventions were multimodal systemic analgesia, and the least common were the management of blood glucose and screening tools. Conclusion: This scoping review found that 56% (n = 9/16) of the identified studies used 10 or more ERAS interventions out of a possible 35. This review highlighted the need for studies on the ERAS emergency laparotomy guidelines. [ABSTRACT FROM AUTHOR]

Aim: ERAS (Enhanced recovery after surgery) protocols are a set of rules that aim to improve the patient's well-being from admission to discharge, shorten the duration of hospitalization, and at the same time reduce costs. In this study, we aimed to evaluate whether ERAS protocols are superior to patient follow-up our hospital's protocol for gynecologic surgery patients. Materials and Methods: The study included 50 patients who will undergo total abdominal hysterectomy and bilateral oophorectomy under general anesthesia. After the patients were divided into two groups, One group received the ERAS protocol while the other group received the routine protocol of our hospital. For both groups, patient's satisfactions and length of hospital stay were recorded. Results: Patient's satisfaction during the entire hospitalization process (p=0.000), was significantly higher in the ERAS Group. The duration of hospitalization (p=0.02) were significantly shorter in ERAS Group. Conclusions: In gynecological cases where the ERAS protocol was used, patient satisfaction and length of hospital stay were more favorable compared to the routine protocol of the hospital. [ABSTRACT FROM AUTHOR]

Background: This study aimed to explore the quality of life and anxiety status of patients with ovarian tumor undergoing enhanced recovery after surgery (ERAS). Methods: This article retrospectively analyzed the clinical data of 300 patients with ovarian tumor admitted in the First Affiliated Hospital of Hebei North University. The patients were divided into two groups according to the perioperative management methods. A total of 156 patients who received traditional perioperative management were included in the control group, and the ERAS group included 144 patients who received traditional perioperative management combined with ERAS management. Quality of life questionnaire-C30 (QLQ-C30) and self-rating anxiety scale (SAS) were used to compare the postoperative quality of life and anxiety status. Results: The ERAS group showed significantly shorter first feeding time (p < 0.001), exhaust time (p < 0.001) and defecation time (p = 0.002), infusion time (p = 0.026), and hospitalization time (p < 0.001) than the control group. Inter-group comparison showed no significant difference in QLQ-C30 scores in terms of physical (p = 0.345), role (p = 0.509), emotional (p = 0.235), cognitive (p = 0.462), and social functions (p = 0.645) before surgery. The scores of physical, role, emotional, cognitive, and social functions in the ERAS group were significantly higher than the control group after surgery (p < 0.001). There was no significant difference in preoperative anxiety scores between the two groups (p = 0.056). The postoperative anxiety score of the ERAS group was significantly lower than that of the control group (p = 0.002). Conclusions: ERAS could alleviate the postoperative negative emotions such as anxiety, promote the physical and mental health and improve the quality of life of patients with ovarian tumor. [ABSTRACT FROM AUTHOR]

In cardiac surgery, poststernotomy pain is a significant issue, peaking within 48 h and requiring proper analgesia for both acute relief and avoidance of chronicization. Opioids are commonly used for pain management postsurgery but pose risks such as adverse effects and dependency. Post-cardiac surgery pain can stem from various sources—somatic, visceral, and neuropathic—making opioid reliance a concern. Multimodal analgesia, which combines different medications and regional anesthesia techniques, is increasingly recommended to decrease opioid use and its related problems. Strategies include acetaminophen, gabapentinoids, NMDA antagonists, alpha-2 agonists, intravenous lidocaine, anti-inflammatory drugs, and regional anesthesia. These approaches can enhance pain control, reduce opioid reliance, and improve cardiac surgery outcomes. The ERAS® Cardiac Society strongly advocates for an opioid-sparing multimodal approach to improve patient recovery by reducing complications and increasing patient satisfaction. This review aims to consolidate current evidence to assist healthcare providers in customizing pain management for patients post-cardiac surgery, emphasizing reduced opioid use and optimizing the recovery process. [ABSTRACT FROM AUTHOR]

Objective: Enhanced recovery after surgery (ERAS) protocols have been introduced in gynecology. Postoperative pain management after vaginal procedures remains a relevant issue. In the present study we aimed to evaluate the effectiveness of pre‐emptive uterosacral/cervical block (PUCB) for postoperative pain control in patients with uterovaginal prolapse undergoing vaginal hysterectomy and pelvic floor repair. We also evaluated the impact on the length of recovery. Methods: This was a pilot study analyzing 40 women who underwent pelvic organ prolapse repair through uterosacral ligament suspension. Patients who chose to undergo PUCB were considered as cases, otherwise as controls. After general or spinal anesthesia induction, the treatment group received the PUCB with ropivacaine plus clonidine injections at 2, 4, 8, and 10 o'clock of the cervix. The control group did not receive additional treatment. Pain intensity was measured at rest and after forceful cough at 1, 4, 8, 12, 24, and 48 h postoperatively. Results: We found a significant reduction in pain values at 1 h (rest and forceful cough) and 24 h (forceful cough) in the PUCB group. The incidence of moderate/severe pain was inferior in the PUCB group at 1 h (rest) and 24 h (rest and forceful cough). There were no differences in terms of the use of rescue opioids (0% vs. 5%; P = 0.311) and length of hospital stay (2.5 ± 0.6 vs. 2.3 ± 0.6; P = 0.180). Conclusions: For the first time, we demonstrated the impact of pre‐emptive uterosacral/cervical block on pain control up to 24 h after surgery. Clonidine as a sensory blockade extender appears promising in enhancing the efficacy of local anesthetics. Synopsis: Pre‐emptive uterosacral/cervical block showed efficacy on pain control up to 24 h after vaginal surgery for pelvic organ prolapse. [ABSTRACT FROM AUTHOR]

Non-intubated video-assisted thoracoscopic surgery combines a minimally invasive technique with multimodal locoregional analgesia to enhance recovery. The mainstay sedation protocol involves propofol and fentanyl. Dexmedetomidine, given its opioid-sparing effect with minimal respiratory depression, facilitates sedation in non-intubated patients. This study aimed to evaluate the efficacy of dexmedetomidine during non-intubated video-assisted thoracoscopic surgery. A total of 114 patients who underwent non-intubated video-assisted thoracoscopic surgery between June 2015 and September 2017 were retrospectively evaluated. Of these, 34 were maintained with dexmedetomidine, propofol, and fentanyl, and 80 were maintained with propofol and fentanyl. After a 1:1 propensity score-matched analysis incorporating sex, body mass index, American Society of Anesthesiologists classification, pulmonary disease and hypertension, the clinical outcomes of 34 pairs of patients were assessed. The dexmedetomidine group showed a significantly lower opioid consumption [10.3 (5.7–15.1) vs. 18.8 (10.0–31.0) mg, median (interquartile range); P = 0.001] on postoperative day 0 and a significantly shorter postoperative length of stay [3 (2–4) vs. 4 (3–5) days, median (interquartile range), P = 0.006] than the control group. During operation, the proportion of vasopressor administration was significantly higher in the dexmedetomidine group [18 (53) vs. 7 (21), patient number (%), P = 0.01]. On the other hand, the difference of the hypotension and bradycardia incidence, short-term morbidity and mortality rates between each group were nonsignificant. Adding adjuvant dexmedetomidine to propofol and fentanyl is safe and feasible for non-intubated video-assisted thoracoscopic surgery. With its opioid-sparing effect and shorter postoperative length of stay, dexmedetomidine may enhance recovery after surgery. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: This study was designed to compare the clinical and patient-reported outcomes (PROs) between the enhanced recovery after surgery (ERAS) protocol and conventional care in patients undergoing esophagectomy for cancer, which have not previously been compared. Methods: This single-center retrospective study included prospective PRO data from August 2019 to June 2021. Clinical outcomes included perioperative complications and postoperative length of stay (PLOS). Patient-reported outcomes were assessed by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30) and esophagus-specific module (QLQ-OES18) preoperatively to 6 months postoperatively. Mixed-effects models were used to longitudinally compare quality of life (QOL) scores between the two modes. Results: Patients undergoing conventional care and ERAS were analyzed (n = 348 and 109, respectively). The ERAS group had fewer overall complications, pneumonia, arrhythmia, and a shorter PLOS than the conventional group, and outperformed the conventional group in five functional QLQ-C30 domains and five symptom QLQ-OES18 domains, including less dysphagia (p < 0.0001), trouble talking (p = 0.0006), and better eating (p < 0.0001). These advantages persisted for 3 months postoperatively. For the cervical circular stapled anastomosis, the initial domains and duration of benefit were reduced in the ERAS group. Conclusions: The ERAS protocol has significant advantages over conventional care in terms of clinical outcomes, lowering postoperative symptom burden, and improving functional QOL in patients who have undergone esophagectomy. Selection of the optimal technique for cervical anastomosis is a key operative component of ERAS that maintains the symptom domains and duration of the advantages of PROs. [ABSTRACT FROM AUTHOR]

The overall frequency of postoperative complications in patients with esophageal and gastric cancer diverges between studies. We evaluated the frequency and assessed the relationship between complications and demographic and clinical features. For this observational study, data were extracted from the ERAS Registry managed by the University of Verona, Italy. Patients were evaluated and compared for postoperative complications according to the consensus-based classification and the Clavien–Dindo scale. The study population was 877 patients: 346 (39.5%) with esophageal and 531 (60.5%) with gastric cancer; 492 (56.2%) reported one or more postoperative complications, 213 (61.6%) of those with esophageal and 279 (52.5%) of those with gastric cancer. When stratified by consensus-based classification, patients with esophageal cancer reported general postoperative complications more frequently (p < 0.001) than those with gastric cancer, but there was no difference in postoperative surgical complications between the two groups. Multiple logistic regression models revealed an association between postoperative complications and the Charlson Comorbidity Index (adjusted odds ratio [OR] 1.22; 95% confidence interval [CI] 1.08–1.36), operation time (adjusted OR, 1.08; 95% CI 1.00–1.15), and days to solid diet intake (adjusted OR, 1.39; 95% CI 1.20–1.59). Complications in patients with esophageal and gastric cancer are frequent, even in those treated according to ERAS principles, and are often associated with comorbidities, longer operative time, and longer time to solid diet intake. [ABSTRACT FROM AUTHOR]

Abstract Background Open liver surgery remains a primary surgical approach for complex liver resections and liver transplantation. However, the postoperative pain management is still a major challenge. Ultrasound-guided external oblique intercostal (EOI) plane block is a novel approach of regional anaesthesia and has a great potential to relieve postoperative pain after upper abdominal surgeries. This study aims to investigate the efficacy and safety of ultrasound-guided EOI plane block in managing postoperative pain after open liver surgery. Methods Seventy-four participants scheduled for open liver surgery will be randomly assigned to either the intervention group, receiving an ultrasound-guided EOI plane block with a single dose of 30 ml 0.375% ropivacaine, or the control group, which will not receive this block. All participants will be provided with opioid-based patient-controlled intravenous analgesia (PCIA) postoperatively. The primary outcome is resting pain score at 3 h postoperatively, assessed using numerical rating scale. Secondary outcomes include pain score at 6, 24, 48, and 72 h postoperatively, perioperative opioid consumption, remedial analgesics within 72 h postoperatively, PCIA usage within postoperative 72 h, postoperative recovery, length of hospital stay, postoperative side effects, block-related complications, and ropivacaine plasma concentration of participants receiving the block. Discussion This study is a randomised controlled trial to evaluate the efficacy and safety of ultrasound-guided EOI plane block for postoperative analgesia after open liver surgery. As regional anaesthesia plays an important role in the multimodal pain management, EOI plane block may prove to be an effective regional technique for enhancing postoperative pain relief and contributing to enhanced recovery after open liver surgery. Trial registration Chinese Clinical Trial Registry ChiCTR2200065745. Registered on November 14, 2022.

Abstract Conventional mini percutaneous nephrolithotomy (mPCNL) typically necessitates the pre-operative placement of ureteral catheters. With the development of enhanced recovery after surgery (ERAS), we introduce a novel approach: no ureteral catheter mini percutaneous nephrolithotomy (NUC-mPCNL). To evaluate the efficacy and safety of this innovative procedure compared to mPCNL, we compared the total operative time, stone clearance rate (SCR), stone-free rate (SFR), and complications among patients undergoing either modality from January to September 2021. Our findings revealed a statistically significant reduction in the mean total operative time for the NUC-mPCNL group (42.6 ± 2.4 vs. 60.2 ± 3.4 min, p

Abstract In the era of minimally invasive surgery, esophagectomy remains a highly invasive procedure with a high rate of postoperative complications. Preoperative risk assessment is essential for planning esophagectomy in patients with esophageal cancer, and it is crucial to implement evidence‐based perioperative management to mitigate these risks. Perioperative support from multidisciplinary teams has recently been reported to improve the perioperative nutritional status and long‐term survival of patients undergoing esophagectomy. Intraoperative management of anesthesia and fluid therapy also significantly affects short‐term outcomes after esophagectomy. In this narrative review, we outline the recent updates in the perioperative management of esophagectomy, focusing on preoperative risk assessment, intraoperative management, and perioperative support by multidisciplinary teams to improve operative outcomes.