Enhanced Recovery After Surgery Protocol Research Articles

Current approach to loop ileostomy closure: a nationwide survey on behalf of the Italian Society of ColoRectal Surgery (SICCR).

Compared to standardized minimally invasive colorectal procedures, there is considerable perioperative heterogeneity in loop ileostomy reversal. This study aimed to investigate the current perioperative practice and technical variations of loop ileostomy reversal following rectal cancer surgery. A nationwide online survey was conducted among members of the Italian Society of ColoRectal Surgery (SICCR). A link to the questionnaire was sent via mail. The survey consisted of 31 questions concerning the main procedural steps and application of the ERAS protocol after loop ileostomy reversal. Overall, 219 participants completed the survey. One respondent in four used a combination of water-soluble contrast studies (WSCS) and digital rectal examination to assess the integrity of the anastomosis before ileostomy closure. Conversely, 17.8% of them used either only WSCS or only endoscopy. Surgeons routinely perform hand-sewn or stapled anastomoses in 45.2% and 54.8% of the cases, respectively. Side-to-side antiperistaltic stapled anastomosis was the most performed anastomosis (36%). Most surgeons declared that they have never used prostheses for abdominal wall closure (64%), whereas 35% preferred retromuscular mesh placement in selected cases only. Forty-six respondents (66.7%) reported using interrupted stitches for skin closure, while 65 (29.7%) a purse-string suture. Furthermore, skin approximation at the stoma site using open methods was significantly more common among surgeons with greater experience in ileostomy reversal (p = 0.031). Overall, a good compliance with the ERAS protocol was found. However, colorectal surgeons were significantly more likely to follow the ERAS pathway than general surgeons (p < 0.05). Surgeons use different anastomotic techniques for ileostomy reversal after rectal cancer surgery. Based on current evidence, purse-string skin closure and ERAS pathway should be implemented, while the role of mesh prophylactic strategy needs to be explored further.

Improving Enhanced Recovery after Surgery (ERAS): The Effect of a Patient-Centred Mobile Application and an Activity Tracker on Patient Engagement in Colorectal Surgery.

The Enhanced Recovery After Surgery (ERAS) protocol improved perioperative colorectal care. Although the protocol is firmly implemented across hospital settings, there are benefits to gain by actively involving patients in their recovery. The main objective of this study was to investigate whether compliance with selected items in the ERAS protocol could further improve by using a patient-centred mobile application. This multicentre, randomised controlled trial was conducted between October 2019 and September 2022. Patients aged 18 years or older who underwent elective colorectal surgery, and in possession of a smartphone were included. The intervention group used a mobile application combined with an activity tracker to be guided and supported through the ERAS pathway. The control group received standard care and wore an activity tracker to monitor their daily activities. The primary outcome was overall compliance with selected active elements of the ERAS protocol. In total, 140 participants were randomised to either the intervention (n = 72) or control group (n = 68). The use of the ERAS App demonstrated a significant improvement in overall compliance by 10%, particularly in early solid food intake by 42% and early mobilization by 27%. Postoperative or patient reported outcomes did not differ between groups. The smartphone application 'ERAS App' is able to improve adherence to the active elements of the ERAS protocol for colorectal surgery. This is an important step towards optimizing perioperative care for colorectal surgery patients and enabling patients to optimize being in control of their own recovery. Trial registration: ERAS APPtimize, NTR7314 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON29410).

Utilization of Enhanced Recovery After Surgery (ERAS) protocol in pediatric laparoscopic sleeve gastrectomy: a quality improvement project.

The obesity epidemic has led to an increased number of adolescents requiring metabolic and bariatric surgery (MBS), but there is paucity of data on the impact of implementing all aspects of Enhanced Recovery After Surgery (ERAS) protocols to improve outcomes in this population. We implemented a comprehensive ERAS pathway for adolescents undergoing laparoscopic sleeve gastrectomy (LSG). Key elements included pre-operative fasting with carbohydrate loading in the morning of surgery, comprehensive anti-emetic and analgesic regimens including intra-operative lidocaine infusion (initiated before formal ERAS launch), regional anesthesia, and early goal-directed ambulation. We tracked opioidutilization, rescue anti-emetic use, time to oral intake,and hospital length of stay (HLOS) as outcome measures, and post-operative pain and returns to the system as balancing measures. Eighty-six patients(52 patients pre-ERAS and 34 patients post-ERAS) underwent LSGwith no differences in demographics. The post-ERAS group had earlier time to oral intake (3.0 vs. 5.5 h, p = 0.003), used less rescue anti-emetics, (8.0vs.16.0 mg, p < 0.001), and had shorter HLOS (33 vs. 54 h, p < 0.001) but no difference in opioid use (0.370 vs. 0.435 MME/kg, p = 0.17), post-operative pain scores or return to the system. Our novel use of bariatric-specific ERAS protocol with intra-operative lidocaine infusion accelerates the time to goal-directed oral intake and decreases HLOS without increasing the rate of returns to the system. This study highlights the feasibility and effectiveness of adapting adult ERAS protocols to the pediatric MBS population. Level III.

The Impact of ERAS and Multidisciplinary Teams on Perioperative Management in Colorectal Cancer.

The Enhanced Recovery After Surgery (ERAS) protocol, a comprehensive multimodal approach, aims to mitigate surgical stress, expedite recovery, and improve postoperative outcomes. Its implementation has notably advanced perioperative care in colorectal cancer surgeries. Integrating ERAS with multidisciplinary collaboration, involving surgery, anesthesia, nursing, and nutrition, may further enhance patient outcomes, making it a significant focus in clinical practice. This study assessed the effectiveness of integrating the ERAS model with multidisciplinary collaboration during the perioperative period in colorectal cancer patients. A total of 117 patients scheduled for elective surgery at Haiyan People's Hospital between August 2023 and April 2024 were randomly assigned to either a control group (n = 59), receiving traditional care, or an experimental group (n = 58), receiving ERAS-based multidisciplinary care. Key outcomes related to postoperative rehabilitation were evaluated. Patients in the ERAS group demonstrated significantly shorter hospital stays, quicker catheter removal, and earlier mobilization compared to the control group (P < 0.0001 for all). Additionally, the ERAS group exhibited reduced postoperative inflammatory responses, as indicated by significantly lower interleukin-6 levels on the first postoperative day (P = 0.0247). The quality of life was significantly higher in the ERAS group (P < 0.05). Furthermore, the ERAS group incurred lower total hospitalization expenses than the control group (P = 0.0011). These findings confirm the benefits of the ERAS protocol in enhancing postoperative recovery in colorectal cancer surgeries. The study highlights the importance of a multidisciplinary approach in optimizing patient outcomes and reducing the burden on hospital resources.

Enhanced Recovery After Craniotomy: Global Practices, Challenges, and Perspectives.

The global demand for hospital care, driven by population growth and medical advances, emphasizes the importance of optimized resource management. Enhanced Recovery After Surgery (ERAS) protocols aim to expedite patient recovery and reduce health care costs without compromising patient safety or satisfaction. Its principles have been adopted in various surgical specialties but have not fully encompassed all areas of neurosurgery, including craniotomy. ERAS for craniotomy has been shown to reduce the length of hospital stay and costs without increasing complications. ERAS protocols may also reduce postoperative nausea and vomiting and perioperative opioid requirements, highlighting their potential to enhance patient outcomes and health care efficiency. Despite these benefits, guidelines, and strategies for ERAS in craniotomy remain limited. This narrative review explores the current global landscape of ERAS for craniotomy, assessing existing literature and highlighting knowledge gaps. Experts from 26 countries with diverse cultural and socioeconomic backgrounds contributed to this review, offering insights about current ERAS protocol applications, implementation challenges, and future perspectives, and providing a comprehensive global overview of ERAS for craniotomy. Representatives from all 6 World Health Organization geographical world areas reported that barriers to the implementation of ERAS for craniotomy include the absence of standardized protocols, provider resistance to change, resource constraints, insufficient education, and research scarcity. This review emphasizes the necessity of tailored ERAS protocols for low and middle-income countries, addressing differences in available resources. Acknowledging limitations in subjectivity and article selection, this review provides a comprehensive overview of ERAS for craniotomy from a global perspective and underscores the need for adaptable ERAS protocols tailored to specific health care systems and countries.

Effect of Enhanced Recovery after Surgery (ERAS) Protocol on Maternal Outcomes Following Caesarean Delivery

Background: Caesarean Section is a commonly performed surgical procedure in obstetric practice, with its incidence rising every year. This increase has led to higher bed occupancy and cost burdens. Conventional Caesarean Sections have several drawbacks, including patients being kept nil per oral overnight before surgery and for 12-24 hours after surgery, immobilization for up to 24 hours or more, continuation of catheter use for 24 hours or more, and the use of opioid-based anesthetics. To address these issues, Enhanced Recovery after Surgery (ERAS) has been introduced. ERAS consists of multimodal pathways during the pre-, intra-, and post-operative periods. Numerous clinical trials, systematic reviews, and meta-analyses have shown that applying ERAS in Caesarean delivery reduces the length of hospital stay, decreases the use of opioid-based anesthetics, improves patient satisfaction, reduces post-operative pain scores, and increases compliance with breastfeeding. Objectives: To determine the outcome of Enhanced Recovery after Surgery (ERAS) pathway in Caesarean Delivery. Methodology: This was a prospective observational study conducted at Paropakar Maternity and Women’s Hospital. Total duration of study period was 3 months from July 2024 to September 2024. A total of 106 patients meeting the inclusion criteria were included in the study. Those receiving care as per the ERAS protocols and standard conventional protocols were observed throughout pre, intra and post-operative period. The two groups were compared in terms of demographic characteristics, intravenous fluid requirement, duration of surgery, length of hospital stay, post-operative pain scores and other post-operative characteristics such as nausea, vomiting, headache, urinary retention, hospital readmission and neonatal outcome. Results: Total of 106 patients were included in the study with 53 in each of ERAS and SC group. In this study, there was no statistical difference in age group, Body Mass Index (BMI), co morbid conditions, gravidity, duration of gestation, indication of CS, duration of surgery and estimated blood loss. The average amount of intravenous fluid required intra operatively in ERAS group was 1350 ml and in SC group was 1650 ml with difference of 300 which was statistically significant, p &lt; .001. The mean length of post-operative hospital stay was 54 hrs. in ERAS group and 71 hrs. in SC group with difference of 17 hrs. which was statistically significant with p = 0.023. The mean post-operative score in ERAS group on Day 0, Day 1 and Day 2 were lower than in SC group with p value &lt; .001. There was no significant difference in post-operative complications between two groups. Conclusion: This study showed that implementation of ERAS protocol is associated with decrease in intra operative fluid requirement, decrease in post-operative length of hospital stay and is associated with significant difference in post-operative pain with use of multi modal analgesia. ERAS can be implemented in Caesarean delivery for addressing the issues of prolonged immobilization, delayed discharge, increased bed occupancy and many more issues associated with it.

ERAS (Enhanced Recovery After Surgery) Protocol in Oral and Maxillofacial Surgery: Narrative Review

Introduction: Oral and maxillofacial surgery is a specialty that involves the diagnosis and treatment of pathologies related to the oral cavity, mandible, jaws and facial structures. In recent years, the ERAS (Enhanced Recovery After Surgery) Protocol has been implemented in various surgical areas with the aim of optimizing postoperative recovery. Objective: To understand the impact of this approach on the patient experience and clinical outcomes. Methodology: This narrative review was conducted through a systematic search of the PubMed, Scopus and Google Scholar databases. The aim was to identify studies investigating the implementation of the ERAS Protocol in oral and maxillofacial surgery. Results: The studies reviewed showed that the implementation of the ERAS Protocol in oral and maxillofacial surgery resulted in a significant reduction in the length of hospital stay, with patients being discharged in 1 to 2 days. In addition, pain control was improved, with a reduction in the use of opioids by up to 50%. The reduction in post-operative complications, such as infections and respiratory problems, was another benefit observed, with a reduction of up to 40% in these complications. Discussion: The adoption of the ERAS Protocol has shown promising results in the recovery of patients undergoing oral and maxillofacial surgery. The benefits include better pain management, early mobilization and lower complication rates. Conclusion: The ERAS Protocol in oral and maxillofacial surgery has the potential to transform surgical practice, promoting faster and more effective recovery. More studies are needed to standardize its implementation and evaluate its long-term effects.

Promoting application of enhanced recovery after surgery protocols during perioperative localized abdominal and thoracic neuroblastomas.

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). 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 30days. 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 8.0days (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 (5.0mL/kg/h vs 8.0mL/kg/h), time of early ambulation (1.0days vs 3.0days), first anal exhaust (2.0days vs 2.0days), TEN (5.0 vs 7.0days), discontinuation of intravenous infusion (5.0days vs 8.0days), 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). The application of ERAS protocols has a significant potential to accelerate perioperative rehabilitation in children undergoing abdominal and thoracic NBs' surgical resection.

ERAS and Gastrointestinal Site Infections: Insights from a Comprehensive Systematic Review and Meta-Analysis.

Background: Enhanced recovery after surgery (ERAS) protocols are proposed to enhance perioperative care, but their impact on various surgical outcomes requires further insight. Objective: This extensive meta-analysis aimed to systematically estimate the effectiveness of ERAS in reducing postoperative complications and improving recovery metrics. Materials and Methods: We meticulously searched multiple databases and rigorously screened studies, ultimately including 16 high-quality research articles in our meta-analysis. We carefully assessed heterogeneity using the Cochran Q test and I2 index. Results were visualized using forest plots, displaying effect sizes and 95% confidence intervals (CIs). Results: The current meta-analysis reveals compelling evidence of ERAS protocols' impact on postoperative effects. Lung infection rates were significantly reduced, with an odds ratio (OR) of 0.4393 (95% CI: 0.2674; 0.7216, p = 0.0012), highlighting the protocols' effectiveness. Although the reduction in surgical site infections (SSIs) was not significant, with an OR of 0.8003 (95% CI: 0.3908; 1.6389, p = 0.5425), the data suggests a trend toward benefit. Urinary tract infections (UTI) also showed a promising decrease, with an OR of 0.4754 (95% CI: 0.2028; 1.1143, p = 0.0871), revealing ERAS protocols may mitigate UTI risks. No significant effects were observed on postoperative anastomotic leakage or ileus, with ORs indicating neutrality. The incidence of readmission was similarly unaffected, with an OR of 1.4018 (95% CI: 0.6860; 2.8647, p = 0.3543). These outcomes underscore the selective efficacy of ERAS protocols, advocating for their strategic implementation to optimize surgical recovery. Conclusions: This meta-analysis offers compelling evidence supporting the implementation of ERAS in mitigating specific post-surgical conditions. It underscores the potential of ERAS to enhance recovery experiences and improve healthcare efficiency. Further targeted research is warranted to fully understand the impact of ERAS on SSI, anastomotic leakage, ileus, and readmissions and to optimize its benefits across diverse surgical populations.

Enhanced Recovery Protocol Decreases Postoperative Opioid Use after Penile Inversion Vaginoplasty.

Penile inversion vaginoplasty (PIV) entails considerable soft-tissue dissection to the perineal region and involves complex tissue rearrangement. This study examines the role of an enhanced recovery after surgery (ERAS) pathway after PIV in reducing opioid use and controlling postoperative pain. A retrospective study of 50 transfemale patients who underwent PIV at a single institution from June 2021 to January 2023 was completed. The study compared 2 groups of patients who were given different postoperative pain management regimens: group A received standard postoperative analgesics and group B received ERAS. Variables such as postoperative pain scores on the numeric pain rating scale (0-10), use of opioid medication, length of hospital stay, and patient comorbidities were recorded and compared across the 2 groups. The average hospital stay length was 4.92 (±0.85) days. Group A had a slightly longer average stay compared with group B. The average pain level in both groups was 4.25 (SD ±1.51). Group A exhibited a slightly higher average pain level of 4.31 (±1.53), whereas group B exhibited 4.16 (SD±1.51) (P = 0.77). Although pain levels did not significantly vary between the 2 groups, there was a statistically significant decrease in the amount of opioid medication used in group B with a P value of 0.009. ERAS protocol is effective in decreasing opioid usage in the immediate postoperative setting after PIV.

An interdisciplinary multicentre study on the use of Enhanced Recovery After Surgery protocol in colorectal surgery from Turkiye

BackgroundThis study aims to determine the use of surgical nurses, general surgeons, and anaesthesiologists regarding the implementation of Enhanced Recovery After Surgery (ERAS) protocol in colorectal surgery and the barriers to its implementation. MethodThis descriptive study was conducted with three different professionals (surgical nurses, surgeons, anaesthesiologists) in four different hospitals and 268 healthcare professionals who voluntarily participated in the study and had written consent were included in the research sample. Data were collected between March 2020–July 2021 via Personal Information Form and Evaluation Form of ERAS Protocol in Colorectal Surgery. ResultsIn the study, 57.8 % were nurses, 15.7 % were general surgeons and 26.5 % were anaesthesiologists. It was observed that 73.1 % of the participants hadn’t heard of the ERAS Protocol before, and eight participants who answered the application of the ERAS Protocol steps in colorectal surgery in their clinics answered as "Yes". It was determined that very few of the participants correctly knew and/or implemented the recommendations of the ERAS protocol (preoperative, intraoperative and postoperative stages) in colorectal surgery. In addition, the participants reported the obstacles to the implementation of protocol steps as the lack of knowledge (18.1 %), the problems caused by the multidisciplinary work (16.6 %), the resistance to change (12.4 %), and the lack of institutional support (11.4 %). ConclusionIt has been determined that the ERAS Protocol in colorectal surgery is not known enough by health professionals, information and opinions are not compatible with the protocol recommendations, and the barriers to implementation are multifactorial.

Impact of an Enhanced Recovery After Surgery (ERAS) program on the management of complications after laparoscopic or robotic colectomy for cancer.

Enhanced Recovery After Surgery (ERAS) reduces postoperative complications (POCs) after colorectal surgery; however, its impact on the management of POCs remains unclear. This study compared the diagnosis and management of POCs before and after implementing our ERAS protocol after laparoscopic or robotic colectomy for cancer and examined the short- and mid-term oncologic impacts. This single-center, retrospective study evaluated all consecutive patients who underwent laparoscopic or robotic colectomy for cancer between 2012 and 2021, focusing on the incidence of POCs within 90 days. We compared outcomes before (standard group) and after (ERAS group) the implementation of our ERAS protocol in January 2016. Significantly fewer patients in the ERAS group developed POCs (standard vs. ERAS, 136 of 380 patients [35.8%] vs.136 of 660 patients [20.6%]; P<0.01). The ERAS group had a significantly shorter mean total length of stay after POCs (13.1 days vs. 11.4 days, P=0.04), and the rates of life-threatening complications (6.7% vs. 0.7%) and 1-year mortality (7.4% vs. 1.5%) were significantly lower in the ERAS group than in the standard group. Among patients with anastomotic complications, laparoscopic reoperation was significantly more common in the ERAS group than in the standard group (8.3% vs. 75.0%, P<0.01). Among patients with postoperative ileus, the diagnosis and recovery times were significantly shorter in the ERAS group than in the standard group, resulting in a shorter total length of stay (13.5 days vs. 10 days, P<0.01). The implementation of an ERAS protocol did not eliminate all POCs, but it did accelerate their diagnosis and management and improved patient outcomes.

Enhanced Recovery After Surgery for Pediatric Abdominal Tumor Resections: A Prospective Multi-institution Study

BackgroundEnhanced recovery after surgery (ERAS) protocols are multi-disciplinary approaches to standardize perioperative care. This is the first prospective, multi-institutional study to evaluate ERAS in pediatric patients undergoing abdominal tumor resections. MethodsAll patients >1-month-old undergoing abdominal tumor resection at one of three children’s hospitals between 2020 and 2022 were eligible. ERAS counseling was performed, and informed consent obtained. The ERAS protocol was standardized across institutions. We compared the prospective cohort to a propensity-matched historical cohort (2014–2020) from each institution utilizing 16 variables. Categorical variables were compared using McNemar’s and/or Stuart–Maxwell testing. Continuous data was compared using logistic regression. ResultsNinety-five patients enrolled in the prospective cohort and were compared to 95 well-matched historic patients. Median LOS was 5.3 (4.1–7.2) days in the historic cohort, and 4.3 (3.3–6.2) days in the ERAS cohort (p = 0.053). Post-operative opioid consumption was lower in ERAS patients at 0.08 (0.03–0.16) MME mg/kg/day versus 0.23 (0.12–0.52) in historic patients (p = 0.013). ERAS patients received clear (POD#0, 0-0) and regular (POD#1, 1.0–1.0) diets two days sooner (both p < 0.001). ERAS patients ambulated two days sooner (1.0, 1.0–2.0 versus 3.0, 2.0–5.0). The number of patients who experienced any complication was significantly lower in the ERAS cohort (44, 44.2 %) compared to historic (82, 86.3 %, p < 0.001). This reduction was seen across each Clavien-Dindo grade 1–3 category (all p < 0.05). ConclusionERAS protocols are feasible in pediatric patients undergoing abdominal tumor resections. Use of an ERAS protocol significantly reduced complications, opioid consumption, time to mobility, and time to diets. Level of EvidenceII.

Implementation of ERAS Protocols: In Theory and Practice.

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.

Cost-consequence analysis of the enhanced recovery after surgery protocol in major lung resection with minimally invasive technique (VATS).

ERAS is an evidence-based multimodal perioperative protocol focused on stress reduction and promoting a return to function. The aim of this work is to perform a cost-consequence analysis for the implementation of ERAS in major lung resection by means of minimally invasive surgery (VATS) from the public health service perspective, evaluating resource consumption and clinical outcomes with respect to a control group of past patients, which did not adopt an ERAS protocol. Outcome differences (re-intervention rates, major and minor intraoperative and postoperative complications, readmissions, and mortality) as well as the costs of preoperative, operative, and postoperative care were estimated. The sample consisted of 64 consecutive patients enrolled in the ERAS programme between April 2021 and August 2022, compared to a control group (historical cohort) comprising 31 patients treated from April 2020 to December 2020, prior to the implementation of the ERAS programme. The study sample comprises patients who fulfil the established ERAS protocol inclusion criteria, including general criteria (acceptance of the protocol, proximity of residence, absence of contraindications to physiotherapy and early mobilisation), surgical criteria (anatomical lung resection up to lobectomy, absence of extensive resection, good possibility of conducting the operation in VATS) and anaesthesiologic criteria (ASA ≤2). Costs were quantified using the national health system perspective. The average length-of-stay was at least one day shorter in the ERAS group [<0.001. Average total costs including entire pathway healthcare costs were substantially reduced for ERAS-VATS patients (mean: € 5,955.71 vs. €6,529.41 Δ = -573.70 p = 0.018)]. Specifically, the median costs of the admission phase were significantly different between the two groups (median: €4,648.82 vs. €5,596.58, p = 0.008), with a reduction in hospital stay expenditure in the ERAS-VATS group (median: €1,599.62 vs. €2,399.43, p = 0.025). No significant differences were found regarding major clinical outcomes. The implementation of an ERAS programme is a dominant strategy, representing an intervention capable of reducing overall costs in the context of elective anatomical lung resection with VATS without any significant differences in major complications and re-intervention rates.

Implementation of enhanced recovery protocols in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for metastatic ovarian cancer following neoadjuvant chemotherapy. A feasibility study

ObjectiveThe aim of this study is to evaluate the implementation of the elements of enhanced recovery (ERAS) protocols in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for metastatic ovarian cancer. ERAS protocols have shown improvement in the perioperative outcomes of patients who underwent cytoreductive surgery for metastatic ovarian cancer by reducing the length of stay as well as the postoperative complications and by improving patients’ postoperative experience. MethodsThis is a feasibility study involving retrospective analysis from (31) patients who underwent cytoreductive surgery and HIPEC versus (35) a control group that underwent cytoreductive surgery only, prior to the introduction of the HIPEC programme for metastatic ovarian cancer. All patients had undergone neoadjuvant chemotherapy prior to surgery. We compared the compliance for each element of the ERAS protocol between the two study groups. ResultsWe analyzed data from 66 patients, 31 in HIPEC group and 35 in the control goup. We found no significant difference in the patients’ characteristics between the two groups and there were no differences in the implementation of 8 elements of the ERAS protocols (100 % for both groups). The use of nasogastric tube was more frequently observed in patients undergoing surgery and HIPEC compared to those undergoing surgery alone (42 % vs 0 %, respectively; p < 0.001). The number of patients who were mobilized on the first postoperative day was higher in the group undergoing surgery and HIPEC (87.1 % vs 57.1 %, respectively; p = 0.007), however there was no significant difference in the percentage of patients that had early removal of the urinary catheter (p = 0.12), nor in the percentage of patients that received early feeding (p = 0.18). Finally, there were no statistically significant differences in the complication rates, the length of hospital stay and the re-admission rates between the two groups. ConclusionEnhanced recovery protocols can be implemented safely in patients undergoing cytoreductive surgery and HIPEC for ovarian cancer.

Implementing enhanced recovery after surgery protocol in elderly patients following multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases.

Enhanced recovery after surgery (ERAS) is an evidence-based multimodal perioperative management strategy. The aim of the present study was to analyze the clinical efficacy of ERAS in elderly patients (> 70 years old) undergoing multi-level posterior lumbar or thoracolumbar instrumented fusion for degenerative diseases. Patients older than 70 years undergoing multi-level lumbar or thoracolumbar instrumented fusion for degenerative disk diseases or spinal stenosis from January 2017 to December 2018 (non-ERAS group) and from January 2020 to December 2021 (ERAS group) were enrolled in present study. Patient-specific and procedure-specific clinical characteristics were collected. Univariate and multivariate regression were performed to determine the risk factors related to length of stay (LOS) and complications. A total of 233 patients were enrolled in this study, 70 in non-ERAS group and 163 in ERAS group. There were comparable baseline characteristics between groups. Further there were no significant differences in 90-day readmission rates and complication rates. However, we observed a significant reduction in LOS (14.89 ± 7.78 days in non-ERAS group versus 11.67 ± 7.26 days in ERAS group, p = 0.002) and overall number of complications (38 in non-ERAS group versus 58 in ERAS group, p = 0.008). Univariate linear regression denoted that operation time (p < 0.001), intraoperative blood loss (p < 0.001), intraoperative blood transfusion (p < 0.001), fusion number ≥ 5 (p < 0.001), spinal surgery including the thoracic spine (p < 0.001), CCI > 2 (p = 0.018), ERAS (p = 0.003) and spinal surgery including lumbar (p = 0.030) were associated with LOS. Furthermore, multivariate linear regression showed that ERAS (p = 0.001), CCI > 2 (p = 0.014), and Fusion number ≥ 5 (p = 0.002) were independent risk factors for LOS. Analogously, univariate logistic regression revealed that longer operation time (p = 0.005), more intraoperative blood loss (p < 0.001), more intraoperative blood transfusion (p = 0.001), fusion number ≥ 5 (p = 0.001), ERAS (p = 0.004) and spinal surgery including thoracic spine (p = 0.002) were related to complications, while implementing ERAS was associated with less complications. Multivariate logistic regression denoted that implementation of ERAS (p = 0.003), Intraoperative blood loss (p = 0.003) and Fusion number ≥ 5 (p = 0.008) were independent risk factors for postoperative complications. In conclusion, the present study reported the first ERAS principles performed in multi-level lumbar or thoracolumbar instrumented fusion for degenerative conditions. Our outcomes shown that the implementation of ERAS in these populations is favorable for reducing LOS and decreasing overall number of complications though the comparable complication rates between two groups. Totally, our ERAS protocols were safe and feasible in these populations.

Hip fractures redefined - ERAS protocol’s impact: the Indian scenario

This article delves into the profound impact of enhanced recovery after surgery (ERAS) protocols on the management of hip fractures within the Indian healthcare landscape. Hip fractures, particularly prevalent among the elderly, represent a significant clinical challenge, often leading to high rates of morbidity and mortality. The integration of the geriatric fracture center (GFC) model with ERAS protocols offers a sophisticated, multidisciplinary approach that prioritizes early surgical intervention, comprehensive geriatric care, and standardized, evidence-based practices. This synergy has the potential to significantly enhance patient outcomes by reducing hospital stays, minimizing complications, and expediting recovery.

Transforming care: Optimizing ERAS pathway in breast cancer surgery with latissimus dorsi flap.

This study aims to establish, execute, and assess the effectiveness of a perioperative enhanced recovery after surgery (ERAS) clinical care pathway in breast reconstruction patients with LD flap breast cancer treatment. The goal is to improve early recovery outcomes, reduce hospitalization time, and enhance patient satisfaction by implementing a standardized approach to postoperative care. This study was conducted at the University of Malaya Medical Center. The outcomes of 21 breast cancer patients who underwent autologous reconstructive breast surgery with the latissimus dorsi (LD) flap within six months before the implementation of the ERAS pathway (pre-ERAS) were compared with 26 patients who underwent the same surgery with the ultrasound-guided erector spinae plane (ESP) block for the (ERAS protocol implementation) cohort. The study was conducted from November 2019 to October 2020. The length of hospital stay, amount of analgesic usage, and incidence of postoperative nausea vomiting (PONV) were recorded. The implementation of the ERAS clinical care pathway resulted in shorter hospital stays compared with the preceding care. On average, ERAS patients were mostly discharged on Day 2 post-surgery, whereas pre-ERAS patients were mostly discharged on Day 7. ERAS patients had a lower incidence of PONV from Days 1 to 5, starting with 88.5% not experiencing the condition on Days 1 and 2 and increasing to 100% on Day 5. All pre-ERAS patients experienced PONV in the first 5days post-surgery. Fewer ERAS patients required antiemetics post-surgery (88.5%) compared with pre-ERAS patients (42.9%). The implementation of the ERAS protocol as part of clinical care in autologous reconstructive breast surgery with the LD flap can improve recovery by shortening hospital stay, decreasing the use of analgesia, and alleviating PONV.

Enhanced Recovery After Surgery Protocols in One- or Two-Level Posterior Lumbar Fusion: Improving Postoperative Outcomes.

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.