Enhanced Recovery Pathway Research Articles

N-Acetylcysteine and Postoperative Atrial Fibrillation: Reply.

We thank Dr. Kinoshita and Dr. Kawashima,1 and Dr. Wen, Dr. Huang, and Dr. Li2 for their comments and their interest in our work. In the comments from Kinoshita and Kawashima,1 they speculate that exposing our patients to a high fraction of inspired oxygen during one-lung ventilation negated the potential antioxidant effects of N-acetylcysteine during the 48 h after surgery. In our study, N-acetylcysteine was started only 1 to 2 h after the patient arrived at the postanesthesia care unit, where they had been receiving oxygen, by nasal cannula in most cases and occasionally by face mask, with varying degrees of inspired oxygen (typically in the range of 30 to 40%). In our practice, oxygen administration is usually titrated off as long as the patient is able to maintain an oxygen saturation measured by pulse oximetry greater than 94% on room air. Most lung-resection patients at our center are ambulating the day after surgery; among the patients in our study,3 some were discharged from the hospital upon completion of 48 h of N-acetylcysteine or placebo infusions. Although Dr. Kinoshita’s and Dr. Kawashima’s work in experimental animals is very interesting, it cannot be assumed that these findings apply to humans, nor is it warranted to speculate on which of the mechanisms that they identify apply to postoperative patients.Dr. Wen, Dr. Huang, and Dr. Li suggest the performance of a subgroup analysis by surgical modailty.2 However, because of the small number of patients within the groups and the lack of power to do so, we did not perform a secondary subgroup analysis of the incidence of atrial fibrillation by type of surgery, whether open or minimally invasive. We have previously shown that the extent of lung resection affects the incidence of atrial fibrillation, and it is for this reason that we included patients who underwent anatomical lung or esophageal resection.4 However, on the basis of our work—and the recommendations from the American Association for Thoracic Surgery task force on this topic—we disagree that the side of surgery affects the incidence of atrial fibrillation.5,6 We also disagree with the authors’ assertion that our finding of a lack of effect for N-acetylcysteine on inflammatory or oxidative stress markers is attributable to a lack of power. First, the number of patients in each of the randomized groups in our study was not small, and both groups were well balanced in terms of demographic and surgical characteristics. Second, all patients participated in an institutional enhanced recovery pathway and received similar intraoperative and postoperative opioid analgesics. Finally, the inflammatory and oxidative marker data were well distributed and did not require log transformation before statistical analysis. Considering that our use of N-acetylcysteine or placebo was intravenous over the course of 48 h and was started in the postanesthesia care unit long after intraoperative drugs, such as dexmedetomidine, were used, we do not believe that these pharmacologic agents influenced our findings.Support was provided solely from institutional and/or departmental sources.Dr. Jones serves as a consultant for AstraZeneca (Cambridge, United Kingdom) and on a Clinical Trial Steering Committee for Merck (Kenilworth, New Jersey). The other authors declare no competing interests.

GPP06 Presentation Time: 8:50 AM: Enhanced Recovery Pathway (ERP) in Patients Undergoing Brachytherapy for Gynecologic Cancer (GYN-BT)

<h3>Purpose</h3> ERPs have been adopted by many surgical specialties and have demonstrated improved outcomes, including shorter hospital stay, decreased healthcare costs, improved time to functional recovery and patient satisfaction.¹ There is no current literature evaluating ERP for patients undergoing brachytherapy as part of their radiation treatment. We plan to implement an ERP to standardize and optimize the peri-operative phase and to determine the impact on patient outcomes. <h3>Methods</h3> A single institution, prospective study evaluating the outcomes of patients undergoing GYN-BT before (33 patients) and after (33 patients) the implementation of an ERP. The ERP will include multidisciplinary interventions that span the pre-, intra-, and post-operative phases; including pre-habilitation, early referral to social work and psychiatric services, patient/caregiver education, pre-operative carbohydrate-loading, goal directed fluids, and opioid-sparing analgesia. Questionnaires (MDASI-PeriOp-GYN, EORTC QLQ-C30, and EORTC QLQ-CX24) to assess patient reported outcomes (PROs) at baseline, post-brachytherapy, and 60-day follow-up are collected. MDASI-PeriOp-GYN consists of 28 questions, scored from 0 to 10, with a score ≥7, considered severe. <h3>Results</h3> Twenty patients have enrolled and completed baseline PROs, of these 7 have completed post-brachytherapy surveys. Baseline mean total score was 3.07 (range, 1.3-7.9) and post-BT was 2.78 (range, 0.1-5.5). Mean number of severe events at baseline was 7 vs. 5.7 after brachytherapy. Independent symptom scores for the baseline population were worse for distress (3.7 vs 3), sadness (3.9 vs 2.4), ability to work (4.9 vs 4.4), relations with others (2.7 vs 2.1), pain (2.6 vs 2.0), constipation (3.1 vs 2.0) and bloating (3.1 vs 1.9); while post-BT scores were worse for dysuria (1.4 vs 0), diarrhea (4.6 vs 4.1), vomiting (1.4 vs 1.1), dizziness (2.1 vs 1.4), fatigue (6.1 vs 5.6), and hot flashes (2.9 vs 1.7) (Figure 1). <h3>Conclusion</h3> Female patients with gynecologic malignancies represent a population with high-symptom burden and social stress throughout treatment. Baseline data show that patient experience may be improved through early focus on social support and pain control and optimization of symptom management after brachytherapy; including nausea/vomiting, diarrhea, dehydration, and urinary toxicity. Our proposed ERP plans to address both of these initiatives.

Development of a predictive model for unplanned Intensive Care Unit admission after pancreatic resection within an enhanced recovery pathway

Development of a predictive model for unplanned Intensive Care Unit admission after pancreatic resection within an enhanced recovery pathway

Benefits of Implementing an Enhanced Recovery After Surgery Protocol in Ambulatory Surgery.

Enhanced recovery after surgery (ERAS) protocols in orthopaedic surgery have garnered significant focus due to their ability to control pain adequately in the immediate postoperative window, allowing for earlier mobilization, shorter hospital stays, and fewer complications. Virginia Commonwealth University created a multimodal pain management approach in which patients receive a preoperative femoral nerve block followed by periarticular intraoperative local injection anesthesia consisting of bupivacaine, ketamine, and ketorolac. We hypothesized that implementation of the ERAS protocol will decrease postoperative pain scores, decrease recovery time in the postanesthesia care unit (PACU), and decrease opioid use in anterior cruciate ligament (ACL) reconstruction. Cohort study; Level of evidence, 3. Two patient cohorts were involved: before ERAS implementation (pre-ERAS) and after (post-ERAS). Patients with ACL reconstruction only and patients with ACL reconstruction with meniscal repair were analyzed separately. Post-ERAS patients received an intraoperative periarticular injection of bupivacaine, ketamine, and ketorolac and a postoperative multimodal pain regimen. Outcomes included time spent in the PACU, short-term and long-term opioid consumption, and pain score at discharge from the PACU. Compared with pre-ERAS patients, post-ERAS patients had decreased pain (2.1 vs 0.84 out of 10, respectively), spent less time in the PACU (79.4 vs 62.8 minutes, respectively), and had less opioid consumption in the immediate postoperative period (4.55 vs 2.26 total morphine milligram equivalents [MMEs], respectively) (P < .001 for all). After ERAS implementation, long-term MME use decreased from 410 to 321 between 0 and 2 weeks postoperatively, 92.6 to 1.69 between 2 and 6 weeks, and 494.5 to 323 between 0 and 6 weeks (P < .001 for all). All domains showed significant improvements for both the ACL and the ACL plus meniscal repair cohorts, with the exception of pain at discharge in the ACL plus meniscal repair group. The study findings suggest that an enhanced recovery pathways protocol that includes a standardized intraoperative periarticular bupivacaine, ketamine, and ketorolac injection improves pain scores in the immediate postoperative window, decreases opioid consumption, and reduces recovery time in the PACU for patients undergoing ACL reconstruction.

Baseline Characteristics of Patients Undergoing Brachytherapy for Gynecologic Cancer (GYN-BT) and the Role for an Enhanced Recovery Pathway (ERP)

<h3>Purpose/Objective(s)</h3> ERPs have been adopted by many surgical specialties and have demonstrated improved outcomes, including shorter hospital stay, decreased healthcare costs, improved time to functional recovery and patient satisfaction.¹ There is no current data evaluating ERP for patients undergoing brachytherapy. We plan to implement an ERP for patients with gynecologic malignancies, who will receive brachytherapy, with the goal to standardize and optimize the peri-operative phase and evaluate the impact on patient experience. <h3>Materials/Methods</h3> A single institution, prospective study evaluating the outcomes of patients undergoing GYN-BT before (33 patients) and after (33 patients) the implementation of an ERP. The ERP will include multidisciplinary interventions that span the pre-, intra-, and post-operative phases; including pre-habilitation, early referral to social work and psychiatric services, patient/caregiver education, pre-operative carbohydrate-loading, goal directed fluids, and opioid-sparing analgesia. Questionnaires to assess patient reported outcomes (PROs) at baseline, post-brachytherapy, and 60-day follow-up are collected. The EORTC QLQ-C30 consists of 30 items scored on a 4-point Likert scale and linearly transformed to a score, ranging from 0-100. Higher scores for functional scales and global health represent a favorable outcome, whereas a higher score for a symptom is unfavorable. A difference >10 was considered significant. <h3>Results</h3> Sixteen patients have been enrolled on study and completed baseline PRO questionnaires. Mean EORTC-QLQ-C30 global health score was 41.7, comparing unfavorably to the reference population of females with any cancer diagnosis²(59.3). Social functioning was worse (58.3) compared to the reference population (72.1), but there was no significant difference in physical, role, emotional or cognitive functioning. Additionally, this patient population had a significantly higher symptom burden, specifically fatigue (48.6 vs 37.7), nausea/vomiting (21.9vs 10.8), appetite loss (35.4 vs 23.8), and diarrhea (20.8 vs 9.3). Notably, mean score for financial difficulties was 45.8, more than double the reference value of 17.5. A significant proportion of patients described depression (56.3%), worry (68.8%) and interference with family life (62.5%). <h3>Conclusion</h3> Baseline data show that female patients with gynecologic malignancies represent a population with high-symptom burden and social stress. This data highlights the significant need for improved social support and multi-disciplinary care. We propose an ERP, with pre-habilitation and medical optimization, in combination with early referral to social work and psychiatric resources to standardize and improve care for this high-risk patient population.

Racial Disparity in Postoperative Outcomes Persists for Patients with Inflammatory Bowel Disease under a Colorectal Enhanced Recovery Program

INTRODUCTION: Enhanced recovery pathways (ERPs) have been shown to reduce racial disparity in postoperative recovery for colorectal surgery. Inflammatory bowel disease (IBD) presents additional recovery challenges; whether disparity for IBD patients is impacted by ERP is unclear. This study hypothesized that ERP would reduce racial disparity in postoperative outcomes for IBD patients. METHODS: Retrospective study comparing IBD patients undergoing major elective colorectal operation before (2006-2014) and after (2015-2021) ERP implementation using institutional American College of Surgeons NSQIP data. The primary outcome of length of stay (LOS) was analyzed by negative binomial regression, and secondary outcomes of complication and readmission by logistic regression. RESULTS: Of 651 IBD patients, 221 (34%) were pre-ERP and 430 (66%) were ERP patients. Overall, 18% were Black. ERP patients had higher American Society of Anesthesiologists status ([ASA] 3/4 76% vs 64%, p < 0.01), use of preoperative steroid (69% vs 45%, p < 0.001), more frequent abdominal perineal resection/low anterior resection/partial colectomy procedures (83% vs 61%, p = 0.001), and Crohn’s (65% vs 50%, p < 0.01). ERP patients had shorter LOS (4, interquartile range [IQR] 3-8 vs6, IQR 5-10 days, p < 0.01) and lower complication rate (24% vs 32%, p = 0.03). In multivariable analysis of pre-ERP patients, Black race was associated with more readmissions (odds ratio [OR] 3.51, 95% CI 1.18-10.20), but not complication (OR 2.10, 95% CI 0.94-4.66) or LOS (incidence rate ratio [IRR] 1.16, 95% CI 0.92-1.46). Within the ERP group, Black race was associated with more readmission (OR 2.28, 95% CI 1.22-4.21) and complication (OR 2.61, 95% CI 1.48-4.59), as well as increased LOS (IRR 1.23, 95% CI 1.01-1.49). CONCLUSION: Racial disparity in operative outcomes persists for patients with IBD even under ERP. Further work is needed to promote equitable operative recovery for IBD patients.

Hyponatremia after Autologous Breast Reconstruction: A Cohort Study Comparing Two Fluid Management Protocols.

Perioperative fluid management is an important component of enhanced recovery pathways for microsurgical breast reconstruction. Historically, fluid management has been liberal. Little attention has been paid to the biochemical effects of different protocols. This study aims to reduce the risk of postoperative hyponatremia by introducing a new fluid management protocol. A single-institution cohort study comparing a prospective series of patients was managed using a new "modestly restrictive" fluid postoperative fluid management protocol to a control group managed with a "liberal" fluid management protocol. One-hundred thirty patients undergoing microsurgical breast reconstruction, at a single institution during 2021, are reported. Hyponatremia is demonstrated to be a significant risk with the original liberal fluid management protocol. At the end of the first postoperative day, mean fluid balance was +2,838 mL (± 1,630 mL). Twenty-four patients of sixty-five (36%) patients had low blood sodium level, 14% classified as moderate-to-severe hyponatremia. Introducing a new, "modestly-restrictive" protocol reduced mean fluid balance on day 1 to +844 mL (±700) (p ≤ 0.0001). Incidence of hyponatremia reduced from 36 to 14% (p = 0.0005). No episodes of moderate or severe hyponatremia were detected. Fluid intake, predominantly oral water, between 8am and 8pm on the first postoperative day is identified as the main risk factor for developing hyponatremia (odds ratio [OR]: 7; p = 0.019). Modest fluid restriction, as guided by the new protocol, protects patients from low sodium level (OR: 0.25; confidence interval: 95%; 0.11-1.61; p = 0.0014). The original "liberal" fluid management protocol encouraged unrestricted postoperative oral intake of water. Patients were often advised to consume in excess of 5 L in the first 24 hours. This unintentionally, but frequently, was associated with moderate-to-severe hyponatremia. We present a new protocol characterized by early cessation of intravenous fluid and an oral fluid limit of 2,100 mL/day associated with a significant reduction in the incidence of hyponatremia and fluid overload.

Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience

ObjectivesTo evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes.MethodsThis retrospective...

Sufentanil sublingual tablet system for enhanced recovery after total knee arthroplasty: a prospective observational case study

BackgroundPostoperative pain is one of the main factors that delays recovery after prosthetic knee surgery. The use of sufentanil sublingual tablet systems (SSTS) can effectively relieve postoperative pain, but their value in facilitating early mobilization has been little studied so far. Our aim here was to assess whether their use could facilitate recovery after knee arthroplasty in an enhanced recovery program.Case presentationIn a prospective observational single-center study, thirty patients operated on for primary knee arthroplasty in the enhanced recovery pathway were included. Patients who received the SSTS (n=15) were compared with those who received an intravenous morphine patient-controlled analgesia (PCA) (n=15). Our recovery program included in particular the use of an adductor canal block, periarticular infiltration of local anesthetic by the surgeon, removal of the venous cannula from the recovery room if possible, the use of an SSTS when available or an IV morphine PCA otherwise, and early physiotherapy. Recovery parameters including the Timed-Up and Go test, pain scores at rest and on exertion, knee flexions, complications, and lengths of hospital stay were not significantly different between the two groups. However, the postoperative opioid consumption in morphine equivalents was significantly greater in the SL-sufentanil group and these patients had their venous cannula removed earlier than in IV-morphine group.ConclusionIn our center, the use of a SSTS was suitable for treating postoperative pain after knee arthroplasty, but it did not improve early recovery in comparison with a morphine PCA.

Quality of recovery after intrathecal morphine for elective Caesarean deliveries

Background: Recent supply issues with diamorphine have meant a change in practice to use of intrathecal morphine. The Obstetric Anaesthetists’ Association (OAA)1 guidelines state that intrathecal diamorphine or morphine provides adequate analgesia after Caesarean section. They discourage the use of parenteral opioids in women who have received neuraxial opioids, owing to the increased risk of respiratory depression. Other side-effects such as nausea and vomiting and pruritus may differ in severity for each drug. We reviewed the side-effects and adherence to the enhanced recovery pathway in elective deliveries receiving intrathecal morphine. Methods: Prospective data were collected for 50 women undergoing Caesarean section with intrathecal opioid analgesia (fentanyl 15 μg and morphine 100 μg) within a 5-week period. Data were collected at Day 1 and Day 2 postoperatively. These included: pain score, postoperative nausea and vomiting (PONV), pruritus, oral opioid use, anti-emetic use, chlorphenamine use, time spent in recovery, and occurrence of urinary retention. Pain score, nausea and vomiting, and pruritus were recorded using a verbal rating scale (VRS). Results: The majority (56.5%) of patients reported only mild pain, 37% reported moderate to severe pain, but of these most (94.7%) only required 20–40 mg of oral morphine in addition to simple analgesia. In addition, the majority (58.7%) of patients reported no PONV. Meanwhile, 45.7% of patients reported mild pruritus, and 43.5% reported no pruritus. Only three of the 50 women did not follow the enhanced recovery pathway. Two remained as inpatients for monitoring after obstetric haemorrhage, and one for intravenous antibiotics. There was no reported respiratory depression. Time spent in recovery was between 1 and 4 h. Although the reason for prolonged recovery stay was not audited, it was thought that requirement for oxytocin infusion increased recovery stay as the ward did not accept patients on an infusion. Conclusions: Our results show an acceptable side-effect profile after elective Caesarean delivery using intrathecal morphine, with adherence to the current enhanced recovery pathway. We aim to implement updated Caesarean delivery guidelines which include prescription of regular ondansetron and chlorphenamine as required, in conjunction with patient education, to try and reduce the incidence of bothersome PONV and pruritus. 1. Obstetric Anaesthetists’ Association, OAA commentary on alternatives to intrathecal and epidural diamorphine for caesarean section analgesia, 2018. Available from: https://www.oaa-anaes.ac.uk/ui/content/content.aspx?ID=4717

Editorial introductions.

Current Opinion in Anesthesiology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of anesthesiology is divided into 16 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Anthony AbsalomAnthony AbsalomProf. Anthony Absalom studied medicine at the University of Cape Town, South Africa, and underwent specialist training in East Anglia and Scotland in the UK. He is currently Professor of Anaesthesiology at the University Medical Center Groningen, Netherlands. His clinical interests are procedural sedation, anaesthesia for neurosurgery, and intravenous anaesthesia techniques. His research interests are mostly in the domains of pharmacology and neuroscience. He is an editor of the British Journal of Anaesthesia, past President of the Society for Intravenous Anaesthesia, and a former vice-president of the World Society for Intravenous Anaesthesia. He is currently Chairman of the Neuroanaesthesia Section of the Dutch Association of Anaesthetists and past-Chair of the General Anaesthesia Scientific Sub-committee of the European Society of Anesthesiology. Ellen SoffinEllen SoffinEllen M. Soffin, MD, PhD is an Associate Professor of Anesthesiology, Weill Cornell Medical College, New York, USA and an anesthesiologist at Hospital for Special Surgery, New York, USA. She is the Director of the Anesthesia-Spine Service, and Co-Director of the Hospital for Special Surgery's interdisciplinary spine research program. Dr Soffin earned her medical degree at King's College Medical School, London, UK and PhD in neuroscience at Edinburgh University, Edinburgh, UK, before moving to the United States. She completed residency training in anesthesiology at The Johns Hopkins Hospital, Baltimore, Maryland, USA and a fellowship in regional anesthesia and acute pain medicine at Hospital for Special Surgery. Dr Soffin's research interests include evaluating the role and value of field and fascial plane blocks for the spine surgery patient; optimizing surgical outcomes using enhanced recovery pathways for total joint arthroplasty and spine surgery; and implementation of regulatory, institutional, and clinical strategies for opioid stewardship programs. She has published extensively on outcomes related to pathway-based care, regional analgesia techniques, and opioid-minimizing approaches to the perioperative care of the orthopedic surgery patient. Dr Soffin serves on the editorial board of Regional Anesthesia & Pain Medicine and is the Section Editor, Acute Pain and Perioperative Care, for Journal of Pain Research. She is an active faculty member of American Society of Regional Anesthesia & Pain Medicine, the American Academy of Pain Medicine, and the Society of Anesthesia & Sleep Medicine, where she is the co-chair of the research committee.

Pain-free DrEaMing – the impact of a 7-day inpatient pain team on colorectal recovery in a postoperative care unit

Background: An ageing colorectal surgical population has resulted in an increasing emphasis on the minimisation of postoperative complications. The advent of enhanced recovery programmes1 coupled with postoperative or post-anaesthetic care units, support the delivery of multi-modal analgesia whilst prioritising mobilisation and oral intake in the postoperative period. Integral to this perioperative pathway is a dedicated inpatient pain team as safe and effective analgesia is vital to facilitate mobilisation and oral intake. Adapting enhanced recovery strategies enabled us to focus on encouraging drinking, eating, and mobilisation (DrEaM). Methods: Patients for colorectal surgery were screened for suitability for the enhanced recovery programme at the time of booking, with data shared between colorectal secretaries and the inpatient pain team when patients were identified. All eligible elective colorectal surgery patients were seen regularly by the inpatient pain team for up to 5 days postoperatively (including weekends) either on the postoperative care unit or subsequent surgical ward. Data were collected prospectively via an electronic pain team database over a 42-week period between June 2020 and May 2021. Results: There were 136 colorectal surgical patients enrolled onto the enhanced recovery programme in the 42-week period: 55% were female with 86% undergoing laparoscopic surgery. There were no patients who reported severe pain at rest throughout the postoperative period. The facilitation of good pain management ensured that all patients were drinking free fluids and 60% were eating by the first postoperative day. The analgesia regimen facilitated early mobilisation of 18.5% of patients on the day of surgery and 85.9% by the first postoperative day (Fig. 4). Conclusions: Postoperative pain remains a major factor in limiting mobilisation for the colorectal surgery patient population. The formation of enhanced recovery pathways with an integrated inpatient pain team facilitated an optimisation of analgesia, which then encourages early mobilisation and nutrition resulting in a decreased length of stay. 1.Gustafsson UO, Scott MJ, Hubner M, et al. World J Surg 2019; 43: 659

Evaluating the implementation of enhanced recovery after transoral robotic surgery for oropharyngeal cancer

Objectives: To evaluate the impact and patient related outcomes from local implementation of a standardised enhanced recovery pathway for patients undergoing transoral robotic oropharyngeal surgery (TORS) for head and neck cancer.

Prescribing Narcotics for Pain: Reconsider the Fifth Vital Sign.

Prescribing Narcotics for Pain: Reconsider the Fifth Vital Sign.

Effect of goal-directed haemodynamic therapy guided by non-invasive monitoring on perioperative complications in elderly hip fracture patients within an enhanced recovery pathway

BackgroundGoal-directed haemodynamic therapy (GDHT) has been shown to reduce morbidity and mortality in high-risk surgical patients. However, there is little evidence of its efficacy in patients undergoing hip fracture surgery. This study aims to evaluate the effect of GDHT guided by non-invasive haemodynamic monitoring on perioperative complications in patients undergoing hip fracture surgery.MethodsPatients > 64 years undergoing hip fracture surgery within an enhanced recovery pathway (ERP) were enrolled in this single-centre, non-randomized, intervention study with a historical control group and 12-month follow-up. Exclusion criteria were patients with pathological fractures, traffic-related fractures and refractures. Control group (CG) patients received standard care treatment. Intervention group (IG) patients received a GDHT protocol based on achieving an optimal stroke volume, in addition to a systolic blood pressure > 90 mmHg and an individualized cardiac index. No changes were made between groups in the ERP during the study period. Primary outcome was percentage of patients who developed intraoperative haemodynamic instability. Secondary outcomes were intraoperative arrhythmias, postoperative complications (cardiovascular, respiratory, infectious and renal complications), administered fluids, vasopressor requirements, perioperative transfusion, length of hospital stay, readmission and 1-year survival.ResultsIn total, 551 patients (CG=272; IG=279) were included. Intraoperative haemodynamic instability was lower in the IG (37.5% vs 28.0%; p=0.017). GDHT patients had fewer postoperative cardiovascular (18.8% vs 7.2%; p < 0.001), respiratory (15.1% vs 3.6%; p<0.001) and infectious complications (21% vs 3.9%; p<0.001) but not renal (12.1% vs 33.7%; p<0.001). IG patients had less vasopressor requirements (25.5% vs 39.7%; p<0.001) and received less fluids [2.600 ml (IQR 1700 to 2700) vs 850 ml (IQR 750 to 1050); p=0.001] than control group. Fewer patients required transfusion in GDHT group (73.5% vs 44.4%; p<0.001). For IG patients, median length of hospital stay was shorter [11 days (IQR 8 to 16) vs 8 days; (IQR 6 to 11) p < 0.001] and 1-year survival higher [73.4% (95%CI 67.7 to 78.3 vs 83.8% (95%CI 78.8 to 87.7) p<0.003].ConclusionsThe use of GDHT decreases intraoperative complications and postoperative cardiovascular, respiratory and infectious but not postoperative renal complications. This strategy was associated with a shorter hospital stay and increased 1-year survival.Trial registrationClinicalTrials.gov NCT02479321.

TU1.8 Laparoscopic partial gastrectomy as day-case surgery: Our 12-month experience

Abstract Aim Procedures performed in ambulatory surgical centers (ASC) can provide several advantages over hospital-based surgery. We present our experience in same-day discharge after laparoscopic partial gastrectomy (LPG) in 19 consecutive patients during 2021. Our aim was to review our outcomes and assess the safety and efficacy of outpatient LPG over 12 months to determine if this procedure can be safely performed in the ambulatory setting. Methods Retrospective review of all consecutive patients who underwent ambulatory LPG from January 2021 to December 2021. Patient age, social circumstances, and other demographics were recorded as well as any comorbidities and ASA score. All patients were discharged home the same day after surgery without an overnight stay at the hospital. Incidence of complications and re-admission to the hospital after discharge were reviewed up to 30 days from surgery. Results From January 2021 to December 2021, 19 consecutive patients underwent LPG. The mean age was 47 years (range, 23–74 yr). 17 patients (89%) had gastric GIST tumor resected. Mean recovery room time was 131 minutes (30–385 min). No patients (0%) were readmitted within 30 days. There were no complications and no open conversions or deaths occurred in the series. Conclusion With stringent patient selection and utilization of enhanced recovery pathways, our study indicates that LPG may be suitable for the outpatient setting. Our low overall readmission and complication rate portends to the feasibility of laparoscopic PG as a safe outpatient procedure.

Compliance with preoperative glucose testing and USPSTF diabetes screening guidelines in gynecologic oncology patients on an enhanced recovery pathway (408)

Compliance with preoperative glucose testing and USPSTF diabetes screening guidelines in gynecologic oncology patients on an enhanced recovery pathway (408)

Can Enhanced Recovery Pathways Prevent Opioid-Related Harm in Thoracic Surgical Patients?

The focus of enhanced recovery after surgery (ERAS) is the quality of a patient’s recovery.1 By blunting the harmful stress response to surgery, recovery is quicker with a lower likelihood of a poor postoperative outcome. Minimizing opioid use is a key component of ERAS pathways, not least because opioids are associated with delayed recovery from surgery. Their side effects (nausea, constipation, sedation, depressed ventilation, and suppression of coughing) impact on a variety of ERAS targets including nausea control, early mobilization, and a quick return to oral diet.

The effectiveness of acupuncture point stimulation for the prevention of postoperative sore throat: A meta-analysis.

Enhanced recovery pathways can be further improved for postoperative sore throat (POST) that occurs after surgery under general anesthesia. Medications have shown some effectiveness in preventing POST, but acupuncture or related techniques with better safety and lower cost can be used as an alternative or adjuvant therapy to treat perioperative symptoms by stimulating acupuncture point (acupoint). Therefore, we aimed to conduct a meta-analysis to assess whether acupoint stimulation helps patients prevent POST in adults undergoing tracheal intubation for general anesthesia. Publications in PubMed, the Cochrane Central Register, ScienceDirect, and ClinicalTrial.gov were surveyed from January 2000 through August 2020. Studies that compared interventions between true acupoint stimulation and no or sham acupoint stimulation were included. The primary outcomes were the incidence and severity of POST at 24h. Four randomized control trials and 1 comparative study involving 1478 participants were included. Compared with the no or sham acupoint stimulation, the true acupoint stimulation was associated with a reduced incidence (risk ratio, 0.32; 95% confidence interval (CI), 0.18-0.55; P < .001) and decreased severity (standardized mean difference, -2.79; 95% CI, -4.59 to - 0.99; P = .002) of POST. There were no significant adverse events related to acupoint stimulation. The finding for POST was assured by subgroup, sensitivity, and trial sequential analyses. Acupoint stimulation may reduce the occurrence of POST. It can be considered as one of nonpharmacological methods to prevent POST in enhanced recovery pathways. Further rigorous studies are needed to determine the effectiveness of acupoint stimulation.

Long-term Opioid Use Reduced With Enhanced Recovery Pathways, But the Job Is Not Done

Long-term opioid use after thoracic surgery is prevalent, affecting ∼50% of patients who undergo thoracotomy and ∼33% of patients who undergo minimally invasive surgery.1 Enhanced recovery protocols (ERPs) have the potential to prevent the onset of chronic pain and correspondingly reduce opioid dependence, critical in our fight against the opioid epidemic. ERPs represent multidisciplinary collaborations, and in thoracic surgery they reduce early postoperative opioid use and improve short-term pain control, an established predictor of chronic pain.