Surgery Guidelines Research Articles

Enhanced recovery after surgery (ERAS) protocol improves patient outcomes in free flap surgery for head and neck cancer

BackgroundIn recent years, enhanced recovery after surgery (ERAS) guidelines have been developed to optimize pre-, intra-, and postoperative care of surgical oncology patients. The aim of this study was to compare management outcome of patients undergoing head and neck cancer (HNC) surgery with free flap reconstruction at our institution before and after the implementation of the ERAS guidelines.MethodsThis retrospective study comprised 283 patients undergoing HNC surgery with free flap reconstruction between 2013 and 2020. Patients operated before and after the implementation of the ERAS protocol in October 2017 formed the pre-ERAS group (n = 169), and ERAS group (n = 114), respectively.ResultsIn the pre-ERAS group the mean length of stay (LOS) and intensive care unit length of the stay (ICU–LOS) were 20 days (range 7–79) and 6 days (range 1–32), and in the ERAS group 13 days (range 3–70) and 5 days (range 1–24), respectively. Both LOS (p < 0.001) and ICU–LOS (p = 0.042) were significantly reduced in the ERAS group compared to the pre-ERAS group. There were significantly fewer medical complications in the ERAS group (p < 0.003). No difference was found between the study groups in the surgical complication rate or in the 30-day or 6-month mortality rate after surgery.ConclusionsWe found reduced LOS, ICU–LOS, and medical complication rate, but no effect on the surgical complication rate after implementation of the ERAS guidelines, which supports their use in major HNC surgery.

The transit of oral premedication beyond the stomach in patients undergoing laparoscopic sleeve gastrectomy: a retrospective observational multicentre study

BackgroundAntiemetic and analgesic oral premedications are frequently prescribed preoperatively to enhance recovery after laparoscopic sleeve gastrectomy. However, it is unknown whether these medications transit beyond the stomach or if they remain in the sleeve resection specimen, thereby negating their pharmacological effects.MethodsA retrospective cohort study was performed on patients undergoing laparoscopic sleeve gastrectomy and receiving oral premedication (slow-release tapentadol and netupitant/palonosetron) as part of enhanced recovery after bariatric surgery program. Patients were stratified into the Transit group (premedication absent in the resection specimen) and Failure-to-Transit group (premedication present in the resection specimen). Age, sex, body mass index, and presence of diabetes were compared amongst the groups. The premedication lead time (time between premedications’ administration and gastric specimen resection), and the premedication presence or absence in the specimen was evaluated.ResultsOne hundred consecutive patients were included in the analysis. Ninety-nine patients (99%) were morbidly obese, and 17 patients (17%) had Type 2 diabetes mellitus. One hundred patients (100%) received tapentadol and 89 patients (89%) received netupitant/palonosetron. One or more tablets were discovered in the resected specimens of 38 patients (38%). No statistically significant differences were observed between the groups regarding age, sex, diabetes, or body mass index. The median (Q1‒Q3) premedication lead time was 80 min (57.8‒140.0) in the Failure-to-Transit group and 119.5 min (85.0‒171.3) in the Transit group; P = 0.006. The lead time required to expect complete absorption in 80% of patients was 232 min (95%CI:180‒310).ConclusionsPreoperative oral analgesia and antiemetics did not transit beyond the stomach in 38% of patients undergoing laparoscopic sleeve gastrectomy. When given orally in combination, tapentadol and netupitant/palonosetron should be administered at least 4 h before surgery to ensure transition beyond the stomach. Future enhanced recovery after bariatric surgery guidelines may benefit from the standardization of premedication lead times to facilitate increased absorption.Trial registrationAustralian and New Zealand Clinical Trials Registry; number ACTRN12623000187640; retrospective registered on 22/02/2023.

Developing an International Framework for Informed Consent in Plastic Surgery: A Focus on Cosmetic Breast Augmentation.

Informed consent is a fundamental pillar of patient rights and is an essential part of good clinical practice. In 2019, the International Confederation of Plastic Surgery Societies launched a survey to collect feedback on informed consent practices, with an aim to develop an international guideline for cosmetic surgery. A 15-question survey was sent to delegates of the International Confederation of Plastic Surgery Societies for dissemination to their national society members. The survey comprised a range of quantitative and qualitative questions. Descriptive and thematic analysis was performed. There were 364 respondents. Over half of the respondents reported no local informed consent policy, whereas others noted national society, specialist college, or government policies. The majority of respondents believed that the performing surgeon should be responsible for obtaining informed consent with at least two face-to-face consultations. Most respondents agreed with a cooling-off period (duration based on procedure type and use of high-risk devices). Regarding cosmetic breast augmentation, the majority of respondents felt that the performing surgeon should be responsible for postoperative management, including cases that occur as part of surgical tourism. Some respondents incorporate financial consent as part of their informed consent practice. Most supported the development of an international informed consent guideline. Informed consent should result from face-to-face consultations with the performing surgeon. There should be a minimum cooling-off period. Postoperative surveillance should be available in all settings. The findings of this survey will help inform an international standardized informed consent guideline for cosmetic surgery.

Effectiveness of an Educational Intervention with Guidelines from the Total Acceleration of Postoperative Recovery Project (ACERTO) in Gynecology.

To evaluate the effectiveness of an educational intervention among gynecologists about recommendations of the Total Acceleration of Postoperative Recovery (ACERTO, in the Portuguese acronym) project derived from the solid foundations of Enhanced Recovery After Surgery (ERAS) guidelines to optimize hospital care for surgical-gynecological patients. Educational intervention through monthly 1-hour long meetings (3 months), with the application of an objective questionnaire about specific knowledge of the ACERTO project between before and after educational intervention phases, for gynecologists, after approval by the ethics committee and signature of informed consent by participants, in a federal university hospital. Among the 25 gynecologists who agreed to participate, the educational intervention could be effective with a statistically significant difference between the phases before and after the intervention for the main recommendations of the ACERTO project, such as abbreviation of preoperative fasting (p = 0.006), venous thromboembolism prophylaxis (p = 0.024), knowledge and replication of ACERTO (p = 0.034), and multimodal analgesia (p = 0.021). An educational intervention, through clinical meetings with exposition and discussion of the recommendations of the ACERTO project based on the ERAS protocol can be effective for the knowledge and possibility of practical application of the main measures, such as abbreviation of preoperative fasting, multimodal analgesia, and prophylaxis of thrombosis among gynecologists.

Naturalistic Evaluation of ERAS Bundle Implementation Feasibility in Elective Cesarean Deliveries of Tertiary Care Hospital in a Low-Middle-Income Country

The present study assessed whether applying enhanced recovery after surgery (ERAS) guidelines for cesarean delivery is feasible in the tertiary care setting with an add-on objective to identify barriers to successful implementation. The cross-sectional study included women undergoing elective CS and willing to participate. The study attempted to understand barriers to ERAS implementation through timely interviewing study participants. Sixty-two patients participated in the study. Antenatal and fetal complications were observed in 39(63%) and 32(51%) participants. The study observed that at least 80% of the proposed components could be applied to 71% of the study population. All 15 components could be applied to 7(11.2%) patients, and at least 50% could be applied to 58(94%) patients. The least applied component was minimizing starvation by taking clear liquids until 2 hrs before surgery in 26(42%) patients due to waiting hours outside the operation-theater (OT). When fitness-for-discharge was assessed against the percent components of ERAS implemented, the area under the curve (AUC) value was 0.75, with a specificity value of 95.65% and a positive predictive value of 94.12%. In the postoperative ERAS bundle, fitness-for-discharge on day-two was statistically associated with early and frequent breastfeeding (p = 0.000) and prevention of intra-op hypotension (p = 0.03). In conclusion, the primary barriers to implementing ERAS were resource limitations in the form of single functional OT and limited doctors.

Assessment of the effect of the American Society of Breast Surgery guidelines on contralateral prophylactic mastectomy rates for unilateral breast cancer

BackgroundIn July 2016, the American Society of Breast Surgeons published guidelines discouraging contralateral prophylactic mastectomy for average-risk women with unilateral breast cancer. We incorporated these into practice with structured patient counseling and aimed to assess the effect of this initiative on contralateral prophylactic mastectomy rates. MethodsWe evaluated female patients with unilateral breast cancer undergoing mastectomy at our institution from January 2011 to November 2022. Variables associated with contralateral prophylactic mastectomy and trends over time were analyzed using the Wilcoxon rank sum test or χ2 analysis as appropriate. ResultsAmong 3,208 patients, (median age 54 years) 1,366 (43%) had a unilateral mastectomy, and 1,842 (57%) also had a concomitant contralateral prophylactic mastectomy. Across all patients, contralateral prophylactic mastectomy rates significantly decreased post-implementation from 2017 to 2019 (55%) vs 2015 to 2016 (62%) (P = .01) but increased from 2020 to 2022 (61%). Immediate breast reconstruction rate was 70% overall (81% with contralateral prophylactic mastectomy and 56% without contralateral prophylactic mastectomy, P < .001). Younger age, White race, mutation status, and earlier stage were also associated with contralateral prophylactic mastectomy. Genetic testing increased from 27% pre-guideline to 74% 2020 to 2022, as did the proportion of patients with a pathogenic variant (4% pre-guideline vs 11% from 2020–2022, P < .001), of whom 91% had a contralateral prophylactic mastectomy. Among tested patients without a pathogenic variant and patients not tested, contralateral prophylactic mastectomy rates declined from 78% to 67% and 48% to 38% pre -and post-guidelines, respectively, P < .001. ConclusionImplementation of specific patient counseling was effective in decreasing contralateral prophylactic mastectomy rates. While recognizing that patient choice plays a significant role in the decision for contralateral prophylactic mastectomy, further educational efforts are warranted to affect contralateral prophylactic mastectomy rates, particularly in the setting of negative genetic testing.

Impact of Enhanced Recovery Protocols on Short-Term Outcomes in Esophagectomy: A Retrospective Cohort Study from Cancer Research Institute, Uttarakhand, India.

Surgery for esophageal cancer is associated with high mortality and morbidity, especially in low and middle-income countries. The recent enhanced recovery after surgery guidelines for esophagectomy (2018) which attempt to reduce complications and length of stay (LOS) have rarely been validated in these settings. This study aimed to analyse the effect of this protocol on short-term outcomes in our subset of patients. A retrospective review was conducted to investigate the outcomes of enhanced recovery protocol (ERP) compared to standard pre-protocol care (PP) in patients who underwent esophagectomy for cancer (31 in ERP vs 61 in PP group) at Cancer Research Institute, Uttarakhand, India. The main outcomes measured were 30-day mortality, morbidity and LOS. Risk assessment was stratified as per Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) systems while complications were classified as per the Clavien-Dindo scale. Preoperative clinical characteristics were similar between groups. Though the predicted POSSUM mortality and morbidity were significantly higher in the ERP group (p = 0.007), 30-day morbidity (19.35% vs 42.62%, p = 0.027) as well as median LOS (12 vs 15days, p < 0.001) was significantly lower in ERP group. The PP group reported 4 deaths within 30days ascompared to none in the ERP group (p = 0.296). Furthermore, the ERP group reported lower occurrence of pulmonary complications (6.4%vs24.6%,p = 0.046), hemodynamic instability (0%vs14.75%,p = 0.026) as well as need for prolonged postoperative ventilation (> 24h; 0% vs 11.48%, p = 0.004). Both minor and major complications as assessed by the Clavien-Dindo scale were lower in the group ERP though these differences were not statistically significant (0.059). Implementation of ERP improved short-term outcomes; hence can be strongly recommended in patients undergoing esophagectomy.

One-year aneurysm-sac dynamics are associated with reinterventions and rupture following infrarenal endovascular aneurysm repair

ObjectiveOne-year aneurysm sac changes have previously been found to be associated with mortality and may have the potential to guide personalized follow-up following endovascular aneurysm repair (EVAR). In this study, we examined the association of these early sac changes with long-term reintervention and rupture. MethodsWe identified all patients undergoing first-time EVAR for intact abdominal aortic aneurysm between 2003 and 2018 in the Vascular Quality Initiative with linkage to Medicare claims for long-term outcomes. We included patients with an imaging study at 1 year postoperatively. Aneurysm sac behavior was defined as per the Society for Vascular Surgery guidelines: stable sac (<5 mm change), sac regression (≥5 mm), and sac expansion (≥5 mm). Outcomes included mortality, reintervention, and rupture within 8 years, which were assessed with Kaplan-Meier methods and multivariable Cox regression analysis. Secondarily, we utilized polynomial spline interpolation to demonstrate the continuous relationship of diameter change to 8-year hazard of reintervention, rupture, or mortality as a composite outcome. ResultsOf 31,185 EVAR patients, 16,102 (52%) had an imaging study at 1 year and were included in this study. At 1 year, 44% of sacs remained stable, 49% regressed, and 6.2% displayed expansion. Following risk adjustment, compared with a stable sac at 1 year, sac regression was associated with lower 8-year mortality (49% vs 53%; hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.85-0.99; P = .036), reintervention rate (8.9% vs 15%; HR, 0.58; 95% CI, 0.50-0.68; P < .001), and rupture rate (2.0% vs 4.0%; HR, 0.45; 95%CI, 0.29-0.69; P < .001). Conversely, compared with a stable sac, sac expansion was associated with higher 8-year mortality (64% vs 53%; HR, 1.31; 95% CI, 1.14-1.51; P < .001) and reintervention rate (27% vs 15%; HR, 1.98; 95% CI, 1.57-2.51; P < .001), but similar risk of rupture (7.2% vs 4.0%; HR, 1.61; 95% CI, 0.88-2.96; P = .12). Polynomial spline interpolation demonstrated that, compared with no diameter change at 1 year, increased sac regression was associated with an incrementally lower risk of late outcomes, whereas increased sac expansion was associated with an incrementally higher risk of late outcomes. ConclusionsFollowing EVAR, compared with a stable sac at 1-year imaging, sac regression and expansion are associated with a lower and higher risk respectively of long-term mortality, reinterventions, and ruptures. Moreover, the amount of regression or expansion seems to be incrementally associated with these late outcomes, too. Future studies are needed to determine how to improve 1-year sac regression, and whether it is safe to extend follow-up intervals for patients with regressing sacs.

Current need for guidelines in emergency surgery in peritoneal carcinomatosis

Malignant bowel obstruction caused by peritoneal carcinomatosis is a common complication that affects a large proportion of gastrointestinal and ovarian oncology patients and predicts poor longterm survival. The management strategy for these patients includes a variety of medical therapies and surgical options; however, how to choose the best treatment strategy remains a mystery. The purpose of this narrative review was to summarize the most recent evidence on multimodal malignant bowel obstruction treatment and determine whether or not progress had been made. We should work to establish consensus guidelines, where possible, to ensure that this unique patient group receives the appropriate treatment or compassionate care during this often terminal event.

Creation of an enhanced recovery after surgery protocol for children with Wilms tumours in low- and middle-income countries

IntroductionEnhanced Recovery After Surgery guidelines have been developed and shown to improve outcomes for many surgical procedures. Most existing guidelines have been created for patients in high-resource settings. There is a dearth of guidelines for pediatric populations particularly in low- and middle-income countries (LMIC). All children with Wilms tumours require resection for cure and therefore a perioperative care pathway can streamline care for all curative-intent nephrectomies. MethodsA two-round Delphi consensus of clinicians in LMICs was utilized to determine the scope and content of recommendations for an enhanced recovery protocol for children with Wilms tumours undergoing nephrectomy in LMICs. Consensus was predefined a priori as ≥70% of panelists indicating a topic or recommendation should be included. ResultsTwenty-six topics met consensus for inclusion and were consolidated into twenty recommendations for implementation in the preoperative, intraoperative, and postoperative setting. Predominant themes included perioperative nutrition, surgical safety, anesthetic concerns, and interdisciplinary oncology care. Ten participants completed round one and six completed round two. All recommendations met consensus for inclusion after two rounds. ConclusionsA consensus-derived perioperative care pathway for children with Wilms tumours in low-resource settings is presented. Recommendations share many priorities with high-resource pathways, but also contain unique considerations for a low-resource setting.

Decreasing prevalence of centers meeting the Society for Vascular Surgery abdominal aortic aneurysm guidelines in the United States

ObjectiveBased on data supporting a volume-outcome relationship in elective aortic aneurysm repair, the Society of Vascular Surgery (SVS) guidelines recommend that endovascular aortic repair (EVAR) be localized to centers that perform ≥10 operations annually and have a perioperative mortality and conversion-to-open rate of ≤2% and that open aortic repair (OAR) be localized to centers that perform ≥10 open aortic operations annually and have a perioperative mortality ≤5%. However, the number and distribution of centers meeting the SVS criteria remains unclear. This study aimed to estimate the temporal trends and geographic distribution of Centers Meeting the SVS Aortic Guidelines (CMAG) in the United States. MethodsThe SVS Vascular Quality Initiative was queried for all OAR, aortic bypasses, and EVAR from 2011 to 2019. Annual OAR and EVAR volume, 30-day elective operative mortality for OAR or EVAR, and EVAR conversion-to-open rate for all centers were calculated. The SVS guidelines for OAR and EVAR, individually and combined, were applied to each institution leading to a CMAG designation. The proportion of CMAGs by region (West, Midwest, South, and Northeast) were compared by year using a χ2 test. Temporal trends were estimated using a multivariable logistic regression for CMAG, adjusting by region. ResultsOverall, 67,865 patients (49,264 EVAR; 11,010 OAR; 7591 aortic bypasses) at 336 institutions were examined. The proportion of EVAR CMAGs increased nationally by 1.7% annually from 51.6% (n = 33/64) in 2011 to 67.1% (n = 190/283) in 2019 (β = .05; 95% confidence interval [CI], 0.01-0.09; P = .02). The proportion of EVAR CMAGs across regions ranged from 27.3% to 66.7% in 2011 to 63.9% to 72.9% in 2019. In contrast, the proportion of OAR CMAGs has decreased nationally by 1.8% annually from 32.8% (n = 21/64) in 2011 to 16.3% (n = 46/283) in 2019 (β = −.14; 95% CI, −0.19 to −0.10; P < .01). Combined EVAR and OAR CMAGs were even less frequent and decreased by 1.5% annually from 26.6% (n = 17/64) in 2011 to 13.1% (n = 37/283) in 2019 (β = −.12; 95% CI, −0.17 to −0.07; P < .01). In 2019, there was no significant difference in regional variation of the proportion of combined EVAR and OAR CMAGs (P = .82). ConclusionsAlthough an increasing proportion of institutions nationally meet the SVS guidelines for EVAR, a smaller proportion meet them for OAR, with a concerning downward trend. These data question whether we can safely offer OAR at most institutions, have important implications about sufficient OAR exposure for trainees, and support regionalization of OAR.

Dressings for Wound Infection Prophylaxis in Colorectal Surgery: A Review.

In patients who require colorectal surgery, the rate of surgical site infection (SSI) is amongst the highest of any surgical specialty. Guided by the enhanced recovery after surgery (ERAS) guidelines for colorectal surgery, there is a large focus on preoperative and intraoperative measures to reduce the risk of bacterial transmission and surgical site inoculation There are many novel and developing dressing types being explored for colorectal surgery. To date, no consensus guidelines for surgical dressings that optimize healing outcomes and reduce infection from postoperative incisions have been established. The purpose of this review is to discuss various dressings used for surgical site wound infection prophylaxis for patients who have colorectal surgery. The database, PubMed, was used for this literature review. Keywords included: colorectal surgery or abdominal surgery or clean-contaminated surgery + surgical site infection prophylaxis or negative-pressure wound therapy or bandages or biological dressings or occlusive dressings + surgical wound infection. Five prophylactic dressings were selected for discussion. This article will review current use and research surrounding the utilization of negative pressure wound therapy devices, silver-containing dressings, mupirocin dressings, gentamicin-c sponge, and vitamin- e and silicon sponges. Alternative dressings discussed in this article show significant promise in reducing SSI compared to conventional dressing. Additional studies to assess cost-benefit analysis and integration into general practice are needed to determine practical application.

Generative artificial intelligence fails to provide sufficiently accurate recommendations when compared to established breast reconstruction surgery guidelines

Generative artificial intelligence fails to provide sufficiently accurate recommendations when compared to established breast reconstruction surgery guidelines

328 From delirium detection to correction: enhancing peri-operative care for older patients

Abstract Background Delirium is a common peri-operative complications in older adults. It is associated with poorer outcomes including functional decline, increased length of hospital stays, increased admissions to long term care and higher mortality. Therefore, this project aimed to assess the peri-operative care of older patients admitted under the surgical service in accordance with the standards set by the Collaborative for Peri-operative Optimisation of People (CPOP) and British Geriatrics Society (BGS) Peri-operative Care for People Living with Frailty undergoing Elective and Emergency Surgery Guidelines. Methods The study examined four key aspects of the guidelines: (1) surgical staff training on delirium; (2) proactive screening in for delirium in surgical patients; (3) proactively documenting delirium and implementing delirium guidelines; and (4) documentation of delirium diagnosis in discharge summaries. Results Data were collected from 72 surgical admissions over a fourteen-day period, of which 26 patients were aged &amp;gt;65. Results indicated suboptimal adherence to the guidelines, with only 4/26 older patients (15.4%) being screened for delirium. Three of 4 of these patients screened positive for delirium using the 4AT. No patients had delirium mentioned in their discharge summaries. Additionally, a survey of surgical non-consultant hospital doctors revealed that only 4/16 (25%) had received formal training on delirium. Conclusion In response to these findings, interventions were implemented, including teaching at surgical grand rounds, hospital-wide education for World Delirium Awareness Day, introduction of delirium care bundles, and an updated discharge summary template for surgical patients to include a delirium diagnosis. A reaudit is underway to evaluate the impact of these interventions on guideline adherence and the peri-operative care quality for older patients. These initial findings underscore the need for improved staff education and adherence to CPOP and BGS guidelines. The reaudit will provide valuable insights into the effectiveness of the implemented interventions in enhancing the perioperative care experience for the older patient cohort.

A national clinician survey on the British Society for Dermatological Surgery guidelines on antithrombotic agent use in skin surgery.

Antithrombotic medication is taken by 14-22% patients undergoing skin surgery, with more patients now taking direct oral anticoagulants (DOACs). The latest evidence suggests that the risk of stopping DOACs perioperatively is low in skin surgery, particularly for primary closures, but remains unclear for more complex procedures. The 2016 British Society for Dermatological Surgery (BSDS) guidelines suggest that clinicians could consider stopping DOACs in patients for 24-48 h, based on individual bleeding risk. We surveyed BSDS members to better understand clinical practice and guideline adherence with a view to updating the guidance. The results demonstrated that there is consistency among clinicians in the management of patients on more established antithrombotic agents, such as aspirin, clopidogrel and warfarin. However, there is a higher perceived risk of significant haematomas following higher-risk procedures such as larger flaps or grafts with DOACs vs. other antithrombotics postoperatively. Stopping DOACs perioperatively for 24-48 h for higher-risk procedures can be cautiously considered following an individual risk assessment and informed discussion with the patient.

Nutrition Care Process and its Impact on Remission of “Diabesity” and Allied Factors Post Roux-En Y Gastric Bypass Bariatric Surgery - A Case-Control Cohort Study

With a rising trend in obesity, diabetes and bariatric surgeries in India, nutrition care and management of patients post-surgery is still a cause of concern. To assess the impact of the nutrition care process on remission of “diabesity” and associated factors post Roux-en YGastric Bypass (RYGB) bariatric surgery. A single-point, hospital-based, Cohort- Case-Control, 3-month longitudinal study of 73 RYGB patients enrolled based on consent. Experimental (E) group (n=36) received nutritional care through personal counselling, group counselling and digital means under 3 broad management categories: 1) Pre-surgery nutritional assessment, diagnosis and counselling (deficiencies and diet), 2) Post-surgery diet progression, nutritional therapy for early and late complications, physical activity progression and behaviour related eating complications; and 3) Guidance and recommendations for lifelong follow-ups and importance of supplementation, as compared to the Control (C) group (n=37) which received care as per old protocols. Pre-post indicators related to weight loss and remission of diabetes were done as per the American Society for Metabolic and Bariatric Surgery guidelines and quality of life post bariatric surgery was done as per Bariatric Analysis and Reporting Outcome System (BAROS). All data were analyzed using SPSS-23 software. Post 3 mos. significant (≤0.001) weight loss (34 kg vs. 29 kg), remission in diabetes (49% vs. 34%) and improved quality of life scores were recorded in the experimental group as compared to the control group. A customized 3-section Nutritional Care Process is recommended in all bariatric surgery settings for improved nutritional and quality of life outcomes post-surgery.

Efficiency based updating of evidence based surgical guidelines - Experiences from a multidisciplinary guideline upon Minimally Invasive Surgery.

Updating evidence-based clinical practice guidelines is an onerous process and there is a call for more efficient determination of key questions that need updating. Especially for surgical techniques it is unclear if new evidence will result in substantial changes after wide implementation and if continuous updating is always necessary. This study analyses the impact of updating a surgical guideline and proposes suggestions for optimising this process. The Dutch Minimally Invasive Surgery guideline was developed in 2011 and updated in 2021. For both versions a multidisciplinary guideline working group (GDG) was created, that determined key questions. Changes in conclusions and recommendations were analysed by the GDG and statements for expected change of recommendations in the future were made. 15 key questions were formed, of which 12 were updates of the previous guideline. For only 27% of the updated key questions, the conclusions changed. In ten years, the body grew only marginally for most key questions and quality of the evidence did not improve substantially for almost all key questions. However, in this first update of the MIC guideline, many recommendations did change due to a more robust interpretation of the conclusions by the GDG. Based on analysis of this updating process, the GDG expects that only four out of 15 recommendations may change in the future. We propose an additional step at the end of guideline development and updating, where the necessity for updating in the future is determined for each key question by the GDG, using their valuable knowledge gained from developing or updating the guideline. For surgical guidelines, the authors suggest updating key issues if it includes a relatively newly introduced surgical- or adapted technique or a new patient group. Low quality or small body of evidence should not be a reason in itself for updating, as this mostly does not lead to new evidence-based conclusions. This new step is expected to result in a more efficient prioritising of key questions that need updating. By adding one additional step at the end of the updating process, the future updating process could become more efficient.

378 Improving Opioid Stewardship in General Surgical Practice

Abstract Aim The last 30 years has demonstrated a steady increase in drug-related deaths, with opioids implicated in at least 2,219 deaths in 2021 in England and Wales1. Inpatient opioid prescribing in surgery has been demonstrated to correlate with long term use post-discharge2. We aim to improve opioid stewardship at our DGH to reduce ‘opioid-load’ in the community, thereby reducing likelihood of long-term post-operative use. Method Intervention included teaching for junior doctors, audit meeting presentation and posters designed collaboratively with acute pain team. Prospective data collected for 92 patients discharged from general surgery from October 2022 and compared to previous data pre-intervention from June 2020. Opioid prescriptions were converted to Milligrams of Morphine Equivalence (MMgEq) for analysis. Results Following intervention, max average 58.64 MMgEq/day compared to 85.88 MMgEq/day previously. Max PRN prescription now 49.77 MMgEq/day compared to 57.18 MMgEq/day. Increased involvement of acute pain team (15.9% to 20%) and improved use of multimodal analgesia (PCA - 3% to 13%, NSAIDS - 2% to 16.5%, rectus sheath blocks – 1% to 4.2%). Discharge prescribing also improved; only 57.6% discharged with opioids, 89% had documented plan for GP and 49% had specific duration. Conclusions Our results demonstrate marked improvement in surgical opioid prescribing. There is potential for further improvement including introduction of opioid misuse risk calculator and formalising opiate prescribing guidelines in surgery.

251 Use of Self-expanding Metal Stents (SEMS) in Emergency Colonic Obstruction (a retrospective study)

Abstract Aim Colorectal cancer is becoming increasingly common in UK, presenting as an emergency in 20% of cases. This carries significantly higher (six-fold) mortality compared with an elective presentation. There is high level evidence that self-expanding metal stents (SEMS) can be successfully used both for palliation (as a definitive procedure) and as a bridge to surgery (BTS) in patients with colorectal cancer. ACPGBI consensus guidelines in emergency general surgery suggest expected success rate of 90% whilst requesting units to audit their figures to evaluate success rates and complications. Method We performed a retrospective audit of SEMS placement over nearly 5-year period in our colorectal unit (spanning from July 2016 to May 2021). We accessed local reporting systems and electronic patient notes for pathology, site, results and outcome post attempted stenting. Results Total number of SEMS inserted = 30. One patient was excluded due to incomplete data present. Male:female ratio = 1.5:1. Mean age at application = 71.5 (range 37-96). Most common site was sigmoid (48%), followed by descending colon (28%). Success rate was 86%. Majority of SEMS were used as a palliative procedure - 86% vs 10% as BTS. 10% of patients had complications following stent insertion, including blockage and leak, in all cases leading to emergency Hartmann’s procedure. Conclusions Data shows significant SEMS use locally particularly for palliation. Success rates are comparable with national and show stenting can be performed by an experienced radiologist. However, complication risks are not insignificant, and patients should be counselled accordingly prior to procedure.

302. IMPACT OF ERAS BENCHMARK ACHIEVEMENTS AND HYBRID ROBOTIC ASSISTED ESOPHAGECTOMY ON RECOVERY AND READMISSION IN AN ERAS CENTER OVER TIME

Abstract Background Early recovery after surgery (ERAS) guidelines have provided an effective recovery approach for esophagectomy. Adherence to ERAS benchmarks leads to improvements in accelerated recovery over time. We evaluated differences in ERAS clinical benchmark achievements in patients undergoing hybrid robotic assisted esophagectomy (hRAMIE) and the impact on length of hospital stay (LOS). We also examined the overall performance of our ERAS program and impact of operative technique on recovery and readmissions over time. Methods A single-center prospective database of esophageal cancer patients was retrospectively analyzed between January 2020 and December 2022. All consecutive patients underwent hRAMIE within a standardized ERAS pathway. Impact of individual ERAS benchmark achievements on postoperative outcomes were evaluated according to LOS groups: accelerated (≤6 days, AR), targeted (7–8 days, TR), and delayed recovery (≥9 days, DR). Ability to achieve AR and readmission rates were compared with previous esophagectomy patient cohorts and institutional published data. Data were tested for normality with Shapiro–Wilk testing. Continuous variables were compared via ANOVA or Kruskal-Wallis testing. Categorical variables were compared via Fisher testing. Results Sixty-four patients underwent hRAMIE with a median LOS 5.5 days. AR, TR, and DR was achieved by 75.0%, 18.8%, and 6.3% patients, respectively. AR outperformed the other groups in ICU stay (p = 0.0046), transition to PO medications (p &amp;lt; 0.0001), and chest tube removal (p = 0.0002). Complications (48.4%) were more frequent among the TR and DR groups (p = 0.0051). 30-day readmission rate of 9.4% did not differ among the recovery groups (AR 6.2%, TR 25.0%, DR 0%, p = 0.114). 90-day mortality was 4.7% and disproportionately impacted the DR group (p = 0.0203). AR increased overtime without impacting readmission rate compared to previous cohorts in our ERAS center (Figure 1). Conclusion Within a common ERAS pathway at a single center, adherence to recovery benchmarks in patients undergoing hRAMIE multiplies the impact of ERAS and evolving operative technique on accelerated recovery across time. Improvements in AR can be achieved without affecting readmission rates. Routine audit of achievements of ERAS benchmarks is necessary to maintain post-esophagectomy outcomes in a time of changing health care resources.