Enhanced Recovery Program Research Articles

Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative.

Enhanced Recovery After Surgery (ERAS) was first established in 2001 focusing on recovery from complex surgical procedures in adults and recently expanded to ambulatory surgery. The evidence for ERAS in children is limited. In 2018, recognized experts began developing needed pediatric evidence. Center-wide efforts involving all ambulatory surgical patients and procedures have not previously been described. A comprehensive assessment and gap analysis of ERAS elements in our ambulatory center identified 11 of 19 existing elements. The leadership committed to implementing an Enhanced Recovery Program (ERP) to improve existing elements and close as many remaining gaps as possible. A quality improvement (QI) team was launched to improve 5 existing ERP elements and to introduce 6 new elements (target 17/19 ERP elements). The project plan was broken into 1 preparation phase to collect baseline data and 3 implementation phases to enhance existing and implement new elements. Statistical process control methodology was used. Team countermeasures were based on available evidence. A consensus process was used to resolve disagreement. Monthly meetings were held to share real-time data, gather new feedback, and modify countermeasure plans as needed. The primary outcome measure selected was mean postanesthesia care unit (PACU) length of stay (LOS). Secondary outcomes measures were mean maximum pain score in PACU and patient/family satisfaction scores. The team had expanded the pool of active ERP elements from 11 to 16 of 19. The mean PACU LOS demonstrated significant reduction (early in phase 1 and again in phase 3). No change was seen for the mean maximum pain score in PACU or surgical complication rates. Patient/family satisfaction scores were high and sustained throughout the period of study (91.1% ± 5.7%). Patient/family and provider engagement/compliance were high. This QI project demonstrated the feasibility of pediatric ERP in an ambulatory surgical setting. Furthermore, a center-wide approach was shown to be possible. Additional studies are needed to determine the relevance of this project to other institutions.

QLTI-16. ENHANCED RECOVERY AFTER LASER ABLATION SURGERY: A PRELIMINARY ANALYSIS OF A NOVEL PROGRAM

Abstract INTRODUCTION The concept of enhanced recovery after surgery (ERAS) due to standardized interventions has been gaining more relevance within neurosurgery. Advances were made both in protocols for spine and cranial surgery. These experiences described many benefits such as less psychological stress, reduction in hospitalization days, and lower hospital costs, without increasing the incidence of complications. However, no experience has described to date the applicability of an ERAS program for laser ablation thermal therapy (LITT). OBJECTIVE To describe our initial experience with the first enhanced recovery program reported for laser ablation for brain tumors. Secondly, to summarize the perioperative clinical outcomes of ERAS applied to LITT. METHODS We performed a retrospective analysis of all adult patients who underwent LITT for oncological lesions from 2013 to 2021. A multidisciplinary program was created by protocolizing interventions carried out along the path of the patient's hospitalization. Each recommendation was individually assessed for its appropriateness for enhancing recovery and for its validity with a focused literature review process. RESULTS A total of 184 patients were included, with a mean age of 60.7 ± 13.5 years, 35% males. 167 tumors were located in the supratentorial compartment, and 17 were infratentorial; the mean tumor diameter was 1.84 ± 1.04 cm. Among the pathologies treated 50.0% were metastasis, and 36.9% were glioblastomas. The mean postoperative day discharge was 1.2 ± 0.8 days. The readmission rate due to surgical complications within 30 days of surgery was 2.7%. These readmission rates fall into what is expected according to published literature without an ERAS program and longer hospital admissions. One death was recorded in the perioperative period. CONCLUSION Clinical interventions that could constitute an ERAS program are feasible in laser ablation of brain tumors. This study could be useful as a preliminary framework for the development of future guidelines.

Determining Hospital Cost for Postoperative Complications: A Strategy to Drive Investment into Your Colorectal Surgery Quality Improvement Program

INTRODUCTION: Postoperative complication (POC) significantly increase healthcare cost. Identifying sources of cost variation helps implement or justify quality improvement programs. This study focuses on the incidence and POC cost after colorectal surgery (CRS). METHODS: Institutional data using the American College of Surgeons NSQIP was queried from 2013 to 2019 for patients undergoing CRS and merged with our financial database. Incidence of NSQIP-defined POC was determined in addition to index hospitalization (IHC) and 30-day post-discharge direct cost (PDCC). PDCC includes labs, imaging, clinic visits, readmission, and emergency department visits to our institution. RESULTS: A total of 2233 patients were identified, with 23.9% experiencing a POC resulting in a 1.5-4.5-fold increase in IHC and 2-15-fold increase in PDCC compared with patients who experienced no POCs. Each complication led to a significant increase in IHC/PDCC cost (p < 0.001). Most of these patients experienced one POC (N = 307, 13.7%) but the remaining experienced 2-6 POCs (N = 227, 10.1%). Anastomotic leak occurred in 5.5% (N = 123) of cases and were categorized by treatment: reoperation (N = 63), nonoperative intervention, ie percutaneous or endoscopic (N = 35), or no intervention (N = 25). All treated leaks resulted in additional significant IHC/PDCC (p <0.001). Overall rate of readmission was 10.5% and unplanned reoperation was 8.0% (Table). CONCLUSION: POC after CRS is common and adds a significant healthcare, cost both during the index hospitalization and post-discharge. This underscores the importance of and should justify investment in enhanced recovery programs, surgical site infection prevention bundles, and prehabilitation programs, which can mitigate the occurrence of many of the POCs considered. Table. - NSQIP Complication and Cost after Colorectal Surgery Characteristic N Incidence Mean index of hospitalization cost Mean 30-day post-discharge cost All Patients 2233 $27,123 ± 31,428 $3,127 ± 13,752 No Postoperative Complication 1699 76.1% $19,424 ± 12,158 $1,352 ± 5,503 Post Operative Complication(s) 534 23.9% $51,620 ± 53,621 $8,774 ± 25,563 Deep SSI 51 2.3% $49,885 ± 50,417 $21,747 ± 43,915 Organ/Space SSI 125 5.6% $54,832 ± 54,065 $13,448 ± 21,045 Sepsis 103 4.6% $40,455 ± 34,456 $7,286 ± 12,608 Respiratory Failure 184 8.2% $85,807 ± 64,197 $10,142 ± 34,231 Prolonged NPO/NGT Use aka “ileus” 494 22.1% $48,153 ± 49,561 $7,701 ± 26,274 Anastomotic Leak treated with Reoperation 63 2.8% $83,344 ± 82,075 $20,340 ± 33,018

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.

Advances in perioperative patient blood management with enhanced recovery in orthopedics: current situation and future prospects

<p indent="0mm">Blood is the essence of life and plays a crucial role in ensuring the normal functioning of organs. During orthopedic surgery, a large volume of blood loss is inevitable; moreover, it is worse in surgeries after traumas, which could affect the function of vital organs and increase the incidence of serious complications and postoperative mortality. Perioperative patient blood management is one of the key components and a prerequisite for enhanced recovery after orthopedic surgery. Multidisciplinary cooperation is needed to examine the key technique of perioperative patient blood management and thus promote the development of enhanced recovery programs in orthopedics. The key techniques of perioperative patient blood management in orthopedics included the following: (1) strengthening the diagnosis and treatment of preoperative anemia, increasing the hemoglobin level, and establishing self-blood banks for patients, which are the basis for reducing blood transfusion to achieve “Kai Yuan” of patient blood management, (2) adopting advanced comprehensive measures, particularly research and application of antifibrinolytic drug tranexamic acid to reduce intraoperative and postoperative bleeding and blood transfusion, thus achieve the “Jie Liu” of patient blood management, (3) reducing postoperative bleeding, treating postoperative anemia, and keeping the balance between fibrinolysis and coagulation to reduce blood loss and occurrence of deep venous thrombosis, and (4) establishing transfusion evaluation mechanism in elective orthopedic surgery. Thus, perioperative patient blood management in enhanced recovery after orthopedic surgery will gradually reduce complications caused by bleeding, fibrinolysis, and coagulation. Moreover, it will eventually achieve the goal of less or no blood transfusion surgery and accelerated rehabilitation and promote further development of the hospital.

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

Lessons learned from 3,867 mastectomy w/ reconstruction surgical cases at a freestanding ambulatory oncology center

Objectives: The breast cancer surgical population is at increased risk of postoperative nausea and vomiting (PONV), with a reported incidence ranging from 21-68% in the literature .We describe our enhanced recovery program (ERP) experience in a high volume center with reporting of narcotic utilization and PONV, providing breast mastectomy ERP benchmarking data.

Health literacy is associated with enhanced recovery adherence and post-operative outcomes

Objectives: Enhanced Recovery Programs (ERPs) improve surgical outcomes in colorectal surgery but is dependent on adherence to its individual components. Limited health literacy is associated with poor surgical outcomes and its relationship to ERP adherence is unclear. Therefore, we aimed to determine the association of health literacy with ERP adherence and post-operative outcomes.

Cost-effectiveness of the enhanced recovery program in patients undergoing colon surgery. Results of randomized clinical trial

AIM: to evaluate the cost-effectiveness of the enhanced recovery program (ERP).PATIENTS AND METHODS: a randomized clinical trial was carried out. A total of 152 patients were divided into ERP (n = 77) and conventional (n = 75) groups. To study the cost-effectiveness of ERP, direct medical costs were assessed at all stages of treatment (outpatient, inpatient, and also within 30 days after discharge from the hospital). Cost minimization analysis (CMA) was used.RESULTS: the median total costs at the stage of outpatient check-up ERP and conventional groups where comparable (33115-35146 rubles; p = 0.1). The total cost of inpatient treatment in the main group was 175,535 rubles, in the control group — 199,055 rubles (p &lt; 0.0001). The costs of outpatient follow-up in ERP group were significantly higher compared to the conventional group (p = 0.0005). The difference, according to Hodges-Lehmann estimation, was 940.7 rubles. The cost of the entire cycle of treatment in the ERP group was 214805 rubles, in the conventional — 237890 rubles (p &lt; 0.0001). Thus, the total reduction in treatment costs associated with ERP amounted to 23,085 rubles (9.7% expenditures)CONCLUSION: a cost-effectiveness analysis of the implementation of the Enhanced Recovery Program showed an overall cost reduction of 9.7% due to a reduction in costs at the inpatient stage.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation.

BackgroundAs enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay.MethodsMembers of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020–2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes.ResultsEarly experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing.ConclusionsThe SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

The orange-III study: the use of preoperative laxatives prior to liver surgery in an enhanced recovery programme, a randomized controlled trial.

This study evaluates the effect of preoperative macrogol on gastrointestinal recovery and functional recovery after liver surgery combined with an enhanced recovery programme in a randomized controlled setting. Patients were randomized to either 1 sachet of macrogol a day, one week prior to surgery versus no preoperative laxatives. Postoperative management for all patients was within an enhanced recovery programme. The primary outcome was recovery of gastrointestinal function, defined as Time to First Defecation. Secondary outcomes included Time to Functional Recovery. Between August 2012 and September 2016, 82 patients planned for liver resection were included in the study, 39 in the intervention group and 43 in the control group. Median Time to First Defecation was 4.0 days in the intervention group (IQR 2.8-5.0) and 4.0 days in the control group (IQR 2.9-5.0), P=0.487. Median Time to Functional Recovery was day 6 (IQR 4.0-8.0) in the intervention group and day 5 (IQR 4.0-7.5) in the control group, P=0.752. No significant differences were seen in complication rate, reinterventions or mortality. This randomized controlled trial showed no advantages of 1 sachet of macrogol preoperatively combined with an enhanced recovery programme, for patients undergoing liver surgery.

Safety and Feasibility of a Discharge within 23 Hours after Colorectal Laparoscopic Surgery.

Background: Enhanced or accelerating recovery programs have significantly reduced hospital length stay after elective colorectal interventions. Our work aims at reporting an initial experience with ambulatory laparoscopic colectomy (ALC) to assess the criteria of discharge and outcomes. Methods: Between 2006 and 2016, data regarding patients having benefited from elective laparoscopic colorectal resections in two main centres in the United Kingdom have been analysed. Both benign and malignant pathologies were included. A standardised enhanced recovery program was performed for each patient, except epidural analgesia was replaced with single shot spinal infiltration. Patients were followed up through a telephone call system by a nurse. Short-term clinical outcomes were analysed. Results: A total of 833 patients were included and 51 (6.1%) were discharged within 24 h following surgery. Of these, 4 out of 51 (7.8%) patients came back hospital within 30 days of discharge; 2 (3.9%) required reoperation (Small bowel obstruction and wound abscess drainage). Conclusions: This study highlights that a 24-h discharge following elective laparoscopic colorectal interventions seems safe and feasible in selected patients. Although challenging to achieve, a standardised approach to laparoscopic surgery in combination with strict adherence to an enhanced recovery protocol are the fundamental elements of this path.

Can an incomplete ERAS protocol reduce postoperative complications compared with conventional care in laparoscopic radical resection of colorectal cancer? A multicenter observational cohort and propensity score-matched analysis.

BackgroundThe patients undergoing laparoscopic radical colorectomy in many Chinese hospitals do not achieve high compliance with the ERAS (enhanced recovery programs after surgery) protocol.MethodsThe clinical data from 1,258 patients were collected and divided into the non-ERAS and incomplete ERAS groups.ResultsA total of 1,169 patients were screened for inclusion. After propensity score-matched analysis (PSM), 464 pairs of well-matched patients were generated for comparative study. Incomplete ERAS reduced the incidence of postoperative complications (p = 0.002), both mild (6.7% vs. 10.8%, p = 0.008) and severe (3.2% vs. 6.0%, p = 0.008). Statistically, incomplete ERAS reduced indirect surgical complications (27,5.8% vs. 59, 12.7) but not local complications (19,4.1% vs. 19, 4.1%). The subgroup analysis of postoperative complications revealed that all patients benefited from the incomplete ERAS protocol regardless of sex (male, p = 0.037, 11.9% vs. 17.9%; female, p = 0.010, 5.9% vs. 14.8%) or whether neoadjuvant chemotherapy was administered (neoadjuvant chemotherapy, p = 0.015, 7.4% vs. 24.5%; no neoadjuvant chemotherapy, p = 0.018, 10.2% vs. 15.8%). Younger patients (<60 year, p = 0.002, 7.6% vs. 17.5%) with a low BMI (<22.84, 9.4% vs. 21.1%, p < 0.001), smaller tumor size (<4.0 cm, 8.1% vs. 18.1%, p = 0.004), no fundamental diseases (8.8% vs. 17.0%, p = 0.007), a low ASA score (1/2, 9.7% vs. 16.3%, p = 0.004), proximal colon tumors (ascending/transverse colon, 12.2% vs. 24.3%, p = 0.027), poor (6.1% vs. 23.7%, p = 0.012)/moderate (10.3% vs. 15.3%, p = 0.034) tumor differentiation and no preoperative neoadjuvant radiotherapy (10.3% vs. 16.9%, p = 0.004) received more benefit from the incomplete ERAS protocol.ConclusionThe incomplete ERAS protocol decreased the incidence of postoperative complications, especially among younger patients (<60 year) with a low BMI (<22.84), smaller tumor size (<4.0 cm), no fundamental diseases, low ASA score (1/2), proximal colon tumors (ascending/transverse colon), poor/moderate differentiation and no preoperative neoadjuvant radiotherapy. ERAS should be recommended to as many patients as possible, although some will not exhibit high compliance. In the future, the core elements of ERAS need to be identified to improve the protocol.

735 Day Case Hemithryroidectomy Audit

Abstract Aim Post-operative haematomas are a serious complication of thyroid surgery, causing potential airway compromise and fatality. Over time, hemithyroidectomy operations are increasingly being carried out as day case procedures to encourage enhanced recovery programmes post-operatively as well as reduce bed pressures on an overwhelmed National Health Service due to the COVID-19 pandemic. Method Hemithyroidectomy procedures carried out from 2018–2021 were analysed in 3 separate audit cycles. Outcome measures included total length of stay (LOS) in hospital, average time of operation note documentation, admission reason and any complication during or after the procedure, including complications within a 10-day period of the procedure. Results The percentage of same-day discharges increased reliably from audit cycle 1 (2018) to audit cycle 2 (2019) to audit cycle 3 (2021); it was found that same-day discharges increased from 48% to 64% to 70%, respectively. It was further found that if operation notes (assumed to act as a proxy for approximate time-out for procedure) were documented towards the end of the working day i.e., 5pm in most units, it was more likely for patients to be admitted overnight. There was one patient from the period of 2018–2021 that was deemed to have had a serious post-operative event. Conclusions There was a reliably increase in same-day discharges for each successive audit cycle. There is a limited requirement for patients undergoing hemithyroidectomy procedures to have a surgical drain placed. Hemithyroidectomy operations can be carried out safely as day case procedures based on the observations of this audit.

Cardiac Enhanced Recovery Program Implementation and Its Effect on Opioid Administration in Adult Cardiac Surgery

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

WE1.6 Effects of prehabilitation programme on outcomes after colorectal cancer surgery

Abstract Aims Surgery for colorectal cancer is associated with risks of complications and death. These are associated with higher mortality and morbidity rates, lower quality of life and increased expenditure in healthcare. We aimed to determine the impact of prehabilitation on patient outcomes with regards to length of hospital stay and postoperative complications. Methods The prehabilitation programme was introduced to our unit in March 2021. We compared outcomes of all patients undergoing elective colorectal cancer surgery before and after introduction of the programme from a prospectively maintained database. Records of patients in the non prehabilitation group (NP) between January to June 2019 and those in the prehabiltation group (PhP) between April to October 2021 were analysed. Our primary aim was to compare the length of stay between the groups with a secondary aim to compare postoperative complications. Results A total of 151 elective colorectal cancer patients were included. There were 64 patients in the NP group and 87 patients in the PhP group. The median length of stay in the NP group was 7 days and in the PhP group was 5 days. 30% of patients in the NP group developed post-operative complications while only 19% of patients in the PhP group developed post-operative complications. Conclusion Prehabilitation is a vital component in a patient's treatment journey. Results from our study have shown an improvement in postoperative outcomes. It should therefore be an element of all enhanced recovery programmes. Further research in this domain could include individualised programs to obtain more benefits

Nutrition practices with a focus on parenteral nutrition in the context of enhanced recovery programs: An exploratory survey of gastrointestinal surgeons.

Ensuring patients have adequate physiological reserves to meet the demands of major surgery may necessitate nutritional prehabilitation and perioperative medical nutrition therapy (MNT). Parenteral nutrition (PN) via central or peripheral routes is indicated when requirements cannot be met orally or enterally. While patients undergoing major gastrointestinal (GI) surgery are at high nutritional and catabolic risk, guidance on PN is limited in Enhanced Recovery After Surgery (ERAS) protocols. This survey-based study characterized MNT practices among GI surgeons, and the challenges and opportunities for MNT within the context of ERAS. This on-line survey comprised questions and attitudinal statements centred on MNT, particularly PN, for major GI surgery patients, and encompassed the spectrum of the surgical pathway (prehabilitation to postoperative care). GI surgeons in Europe were invited to complete the survey. Respondents described their current clinical practices, while their perceptions, unmet needs, and opportunities to improve nutritional management were explored via Likert-scale responses to statements. GI surgeons (N=130) from different centres in France, Germany, Italy, Poland, and Spain completed the survey. Enhanced recovery protocols (75%) and multidisciplinary nutritional care teams (72%) were established in the centres of most respondents; surgeons, dieticians/nutritionists, and nurses were most frequently involved in MNT. Nutritional risk screening was common in the centres surveyed prior to surgery (range: 62% in Italy to 96% in Poland) and undertaken less frequently postoperatively (range: 19% in Poland to 54% in Germany) with varied screening methods. Enteral nutrition insufficiency was the most common reason for prescribing PN (83%) and 56% of surgeons prescribed PN when enteral nutrition (EN) was not feasible. Overall, 71% of respondents agreed that peripherally administered PN (PPN), which does not require a central access route, lessens invasive procedures and benefits selected patients who are in a catabolic state, malnourished, or at nutritional/metabolic risk when oral intake/EN is insufficient. However, only 35% of surgeons used PPN in this scenario and only 47% utilized PPN when a central venous catheter is not available. Most surgeons (69%) agreed that PPN is in line with the ERAS concept of using minimally invasive approaches. The respondents raised a need for increasing awareness of PPN indications (81%), inclusion of PPN recommendations in clinical guidelines (79%), implementation of nutritional support teams (79%), and increased PPN-trained personnel (78%) to improve PPN delivery. PPN is perceived by surgeons (with ≥10 patients per month who receive PN) as a favourable strategy to support timely nutritional support in selected patients undergoing major GI surgery. However, from this clinical practice survey it seems PPN is underutilized in nutritional care practices. Findings from this survey of GI surgeons in Europe emphasize the need to improve early identification of patients who are malnourished or at nutritional/metabolic risk and integrate PPN into ERAS GI surgical pathways, within the framework of minimally invasive approaches.

Probiotics/Synbiotics to Reduce Infectious Complications after Colorectal Surgery: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

Aim: The aims of this systematic review and meta-analysis were to assess to what extent probiotics/synbiotics reduce infectious complications after colorectal surgery and whether probiotics or synbiotics should be considered as perioperative measures preventing or reducing infectious complications after CRS and should be included in enhanced recovery programmes (ERP). Secondary aims were to answer practical questions precisely on the best formulation and the type and timing of probiotics or synbiotics in CRS. Method: This systematic review and quantitative meta-analysis were conducted in accordance with PRISMA 2020 guidelines. Inclusion criteria were randomised trials comparing perioperative probiotics/synbiotics with a placebo or standard care in elective colorectal surgery. Exclusion criteria were non-randomised trials. Overall infectious complications and surgical site infections (SSIs including both deep abdominal infections and wound (skin or under the skin) infections) were the primary outcomes. Secondary outcomes were pulmonary and urinary infections, wound infections, and anastomotic leaks. The databases consulted were Medline, Cochrane Database of Systematic Reviews, Scopus, and Clinical Trials Register. Risk of bias was assessed according to the GRADE approach. The analysis calculated the random effects estimates risk ratio (RR) for each outcome. Results: 21 trials were included; 15 evaluated probiotics, and 6 evaluated synbiotics. There were significantly fewer infectious complications (risk ratio (RR) 0.59 [0.47–0.75], I2 = 15%) and fewer SSI (RR 0.70 [0.52–0.95], I2 = 0%) in the probiotic or synbiotic group. There were also significantly fewer pulmonary infections (RR 0.35 [0.20–0.63]) and urinary infections RR 0.41 [0.19–0.87]) as opposed to anastomotic leaks (RR 0.83 [0.47–1.48]) and wound infections (RR 0.74 [0.53–1.03]). Sensitivity analyses showed no significant difference between probiotics and synbiotics in reducing postoperative infections (RR 0.55 [0.42–0.73] versus RR 0.69 [0.42–1.13], p = 0.46). Conclusions: Based on the finding of this study, probiotics/synbiotics reduce infectious complications after colorectal surgery. The effect size was more pronounced for pulmonary and urinary infections. From a practical aspect, some of the questions related to formulations and duration of probiotics or synbiotics need to be answered before including them definitively in enhanced recovery after colorectal surgery programmes.

Early and late readmissions after enhanced recovery thoracoscopiclobectomy.

The purpose of this study was to describe the incidence of and reasons for early (0-30 days) and late (31-90 days) readmissions after enhanced recovery video-assisted thoracoscopic surgery lobectomy. We performed a retrospective analysis of prospectively collected consecutive VATS lobectomy data in an institutional database from January 2019 through December 2020. All reasons for readmission with complete follow-up were individually evaluated. Univariable and multivariable analyses were used to assess predictors. In total, 508 patients were included; the median length of stay after the operation was 3 days. There were 77 (15%) early and 54 (11%) late readmissions, respectively. There were 33 (7%) multiple readmissions during postoperative days 0-90 ; pneumonia (19.8%) and pneumothorax (18.3%) were the dominant reasons for early readmissions, and the side effects of adjuvant chemotherapy (22.0%), for late readmissions. In multivariable analyses, current smoking (P = 0.001), alcohol abuse (P = 0.024) and chronic obstructive pulmonary disease (P = 0.019) were predictors of early readmissions, whereas Clavien-Dindo I-II grade gastrointestinal complications predicted late readmissions (P = 0.006) and multiple readmissions (P = 0.007). Early discharge (< 3 days) was not a predictor of readmissions. Early readmission did not increase late readmission. Early and late readmissions after video-assisted thoracoscopic lobectomy are frequent even when enhanced recovery programmes are followed. Pulmonary complications and adjuvant chemotherapy are the most predominant reasons for early and late readmissions.

Enhanced Recovery After Surgery (ERAS) protocols decrease length of hospital stay and maintain functional independence in elderly patients undergoing colorectal surgery

A clinical decision report using: Ostermann S, Morel P, Chalé JJ, et al. Randomized controlled trial of enhanced recovery program dedicated to elderly patients after colorectal surgery. Dis Colon Rectum. 2019;62(9):1105-1116. https://doi.org/10.1097/DCR.0000000000001442 for an elderly patient undergoing colorectal surgery.