Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Multimodal perioperative care plus immunonutrition versus traditional care in total hip arthroplasty: a randomized pilot study [Fast track rehabilitation in colonic surgery: results of a prospective trial]. A systematic review of enhanced recovery protocols in colorectal surgery. Chewing Xylitol Gum could Accelerate Bowel motility Recovery after Elective Open Proctectomy for Rectal Cancer. Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Preoperative Education in Cholecystectomy in the Context of a Multimodal Protocol of Perioperative Care: A Randomized, Controlled Trial Urethral catheter‐less robotic‐assisted radical prostatectomy Recovery after open and laparoscopic right hemicolectomy: a comparison. Benefits of post-operative oral protein supplementation in gastrointestinal surgery patients: A systematic review of clinical trials. Prehabilitation with Whey Protein Supplementation on Perioperative Functional Exercise Capacity in Patients Undergoing Colorectal Resection for Cancer: A Pilot Double-Blinded Randomized Placebo-Controlled Trial. Observation of clinical efficacy of application of enhanced recovery after surgery in perioperative period on esophageal carcinoma patients. EnROL: A multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. Can Medical Hypnosis Accelerate Post-Surgical Wound Healing? Results of a Clinical Trial Fast‐track surgery: the next revolution in surgical care following laparoscopy Implementation of evidence-based practices for surgical site infection prophylaxis: results of a pre- and postintervention study. Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study. Preoperative albumin and surgical site identify surgical risk for major postoperative complications. Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients.
Background This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery , and to provide grade d recommendations for items for an evidence d-based enhanced recovery protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omized controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( evidence grade : high or moderate ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , European Society for Clinical Nutrition and Metabolism ( ESPEN ) and International Association for Surgical Metabolism and Nutrition ( IASMEN ) present a comprehensive evidence -based consensus review of perioperative care for rectal surgery Background This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery Background Multimodal protocol s of perioperative care may enhance postoperative recovery . However , limited information is available on preoperative immune and carbohydrate (CHO)-enriched drinks in patients undergoing hip arthroplasty . We aim ed to investigate the effect of a multimodal protocol ( ACERTO protocol ) plus preoperative immune nutrition on the length of stay ( LOS ) and the postoperative acute phase response of patients undergoing total hip arthroplasty . Methods Thirty-two patients ( mean age , 58 years ; range , 26–85 years ; 16 males ) were r and omized to receive either the  ACERTO protocol  ( n = 15 , ACERTO Group ) , which consisted of 6 h preoperative fasting for solids , an oral drink ( 200 mL of 12.5 % maltodextrin ) up to 2 h before induction of anesthesia , restricted intravenous fluids ( only 1000 mL of crystalloid fluid after surgery ) and preoperative immune nutrition ( 600 mL/day of Impact - Nestlé , Brazil ) for five days prior to surgery , or traditional care ( n = 17 ; control group ) , which consisted of 6–8 h preoperative fasting , intravenous hydration until the 1st postoperative day and no preoperative immune supplementation . The main endpoint was LOS . C-reactive protein ( CRP ) was the secondary endpoint and was assessed during induction of anesthesia and on postoperative day 2 . Results Neither deaths nor postoperative complications occurred . The median LOS was 3 ( 2–5 ) days in the ACERTO group and 6 ( 3–8 ) days in controls ( P < 0.01 ) . Postoperative CRP was higher in the control group ( P < 0.01 ) . Conclusion The ACERTO multimodal protocol of perioperative care plus preoperative immune nutrition may decrease LOS and postoperative CRP levels in total hip arthroplasty . Trial registration Clinical Trials : OBJECTIVE In elective large bowel surgery the incidence of general complications with st and ard perioperative care is up to 27 % . Hospital discharge occurs 10 to 15 days after a conventional or laparoscopic colonic resection . The aim of a fast track management is to reduce the number of general complications and the length of hospital stay . MATERIAL AND METHODS We prospect ively evaluated a multimodal protocol in our service utilizing a combined thoracic epidural analgesia , an early mobilization and oral nutrition to accelerate postoperative recovery after elective colonic surgery  . RESULTS One hundred thirty-two consecutive patients aged an average of 66 years ( range 22 - 88 ) were operated by laparotomy ( n = 71 ) or laparoscopy ( n = 61 ) and treated with the fast track rehabilitation protocol .  Surgical complications occurred in 15 patients ( 11 % ) , four of these had an anastomotique leakage ( 3 % ) . General complications occurred in 11 patients ( 8 % ) , the mortality was 1 % . The median length of hospital stay was four days ( range 3 - 77 ) and 14 patients ( 11 % ) had to be readmitted . CONCLUSION Application of a fast track rehabilitation protocol lowered the number of general complications and reduced the duration of hospital stay in our study INTRODUCTION Colorectal surgery has been associated with a complication rate of 15 - 20 % and mean post-operative inpatient stays of 6 - 11 days . The principles of enhanced recovery after surgery ( ERAS ) are well established and have been developed to optimise peri-operative care and facilitate discharge . The purpose of this systematic review is to present an up date d review of peri-operative care in colorectal surgery from the available evidence and ERAS group recommendations . METHODS Systematic search es of the PubMed and Embase ™ data bases and the Cochrane library were conducted . A h and search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy . RESULTS A total of 59 relevant studies were identified . These included six r and omised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria . These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates . CONCLUSIONS Review ing the data reveals that ERAS protocol s have a role in reducing post-operative morbidity and result in an accelerated recovery following colorectal surgery . Similarly , both primary and overall hospital stays are reduced significantly . However , the available evidence suggests that ERAS protocol s do not reduce hospital readmissions or mortality . These findings help to confirm that ERAS protocol s should now be implemented as the st and ard approach for peri-operative care in colorectal surgery Background A number of studies with conflicting results have evaluated the effect of chewing gum on post-operative gastrointestinal recovery in patients after major colorectal surgery . Objective The objective of the study was to study the efficacy of chewing gum in patients with rectal cancer after elective open proctectomy only . Methods A r and omized controlled clinical trial was performed . We recruited patients who would undergo elective open proctectomy for rectal cancer in Sichuan Academy of Medical Sciences and Sichuan Provincial People 's Hospital . Patients in the intervention arm received chewing gum 3 times a day postoperatively . All patients in the trial were placed on the same perioperative management and st and ardized post-operative care plans . The primary outcome was time to the first peristalsis sounds , time to first flatus and the first defecation . Results A total of 89 patients were recruited . The time to the first flatus was 42.33 ± 3.46 h in the gum group and 49.20 ± 1.42 h in the control group ( p < 0.05 ) . The time to the first defecation was significantly shorter in the gum-chewing group than in the control group ( 66.07 ± 2.36 vs. 78.37 ± 1.62 h ; p < 0.05 ) . Post-operative ileus ( POI ) was confirmed in 2 patients in the gum-chewing group and in 7 in the control group ( 7.0 % vs. 23.9 % ; p = 0.028 ) . Discussion The present study suggests that chewing gum is a method to reduce the time to first flatus , time to first defecation and POI in patients undergoing elective open proctectomy for rectal cancer Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety Background Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . Methods An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated “ high ” , “ moderate ” , “ low ” or “ very low ” . Recommendations were grade d as “ strong ” or “ weak ” . Results Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . Conclusions The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials BACKGROUND & AIMS Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . METHODS An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated " high " , " moderate " , " low " or " very low " . Recommendations were grade d as " strong " or " weak " . RESULTS Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . CONCLUSIONS The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials Abstract Background Preoperative education is a key point in multimodal protocol s of perioperative care . We investigated whether preoperative education for patients undergoing open cholecystectomy would reduce the incidence of perioperative symptoms . Methods This was a r and omized , single-blinded , clinical trial that included adult ( 18–65 years old ) c and i date s for elective open cholecystectomy . All patients took part in the ERAS/ACERTO protocol of perioperative care except that only the intervention group received preoperative education .  The main endpoints of the study were the presence and intensity of postoperative symptoms ( e.g. , nausea , vomiting , pain ) measured by a visual analogue scale , 24 h after the operation . Results A total of 74 patients ( 34 in the intervention group , 40 in the control group ) completed the study . The intervention group had significantly lower median ( interquartile range ) scores for nausea [ 0 ( 4 ) vs. 2.5 ( 5.8 ) , p = 0.04 ] and pain [ 0.2 ( 2.3 ) vs. 3.1 ( 3.45 ) , p < 0.01 ] than the controls . High well-being ( score ≥6 ) was reported by 79.4 % ( 27 patients ) of the intervention group in contrast to 57.5 % ( 23 patients ) of the controls ( p = 0.04 ) . Conclusions Preoperative education is highly effective in the context of a multimodal protocol for enhancing the recovery of patients su bmi tted to open cholecystectomy © 2 0 1 0 T H E A U T H O R S J O U R N A L C O M P I L A T I O N © 2 0 1 0 B J U I N T E R N A T I O N A L 1 2 0 1 8 Faiz O , Brown T , Colucci G , Kennedy RH . A cohort study of results following  elective colonic resection  within an enhanced recovery programme . Colorectal Dis 2009 ; 11 : 366–72 9 Lassen K , Soop M , Nygren J et al. Consensus review of optimal perioperative care in colorectal surgery . Enhanced Recovery After Surgery ( ERAS ) Group Recommendations . Arch Surg 2009 ; 144 : 961–9 10 Halaszynski TM , Juda R , Silverman DG . Optimizing postoperative outcomes with efficient preoperative assessment and management . Crit Care Med 2004 ; 32 ( Suppl . ) : S76–86 11 Guenaga KF , Matos D , Castro AA , Atallah A , Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery . Cochrane Data base Syst Rev 2005 ; ( 1 ) : CDOO1544 12 Shafii M , Murphy DM , Donovan MG , Hickey DP . Is mechanical bowel preparation necessary in patients undergoing cystectomy and urinary diversion . BJU Int 2002 ; 89 : 879–81 13 Smith AF , Pittaway AJ . Premedication for anxiety in adult day surgery : up date of Cochrane Data base Syst Rev 2000 : CD002192 . Cochrane Data base Syst Rev 2003 ; ( 1 ) : CD002192 14 Gerts WH , Pineo GF , Heit JA et al. Prevention of venous thromboembolism : the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy . Chest 2004 ; 126 : 338S–400S 15 Fearon KC , Luff R. The nutritional management of surgical patients : enhanced recovery after surgery . Proc Nutr Soc 2003 ; 62 : 807–11 16 Noblett SE , Watson DS , Huong H , Davison B , Hainsworth PJ , Horgan AF . Pre-operative oral carbohydrate loading in colorectal surgery : a r and omized controlled trial . Colorectal Dis 2006 ; 8 : 563–9 17 Wong PF , Kumar S , Bohra A et al. R and omized clinical trial of perioperative systemic warming in major elective abdominal surgery . Br J Surg 2007 ; 94 : 421–6 18 Ratnaraj J , Kabon B , Talcoff MR , Sessler DI , Kurz A. Supplemental oxygen and carbon dioxide each increase subcutaneous and intestinal intramural oxygenation . Anesth Analg 2004 ; 99 : 207–11 19 Grief R , Akça O , Horn EP , Kurz A , Sessler DI . Supplemental perioperative oxygen to reduce the incidence of surgical wound infection . Outcomes Research Group . N Engl J Med 2000 ; 342 : 161–7 20 Grief R , Laciny S , Rapf B , Hickle RS , Sessler DI . Supplemental oxygen reduces the incidence of post operative nausea and vomiting . Anesthesiology 1999 ; 91 : 1246–52 21 HTA . Full report : systematic review of the clinical effectiveness and cost effectiveness of oesophageal Doppler monitoring in critically ill and high risk surgical patients . Available at : http:// www.hta.ac.uk/project/.asp . Accessed 5 December 2009 22 Cepeda MS , Carr DB , Mir and a N , Diaz A , Silva C , Morales O. Comparison of morphine , ketorolac , and their combination for postoperative pain : results from a large , r and omised , double blind trial . Anaesthesiology 2005 ; 103 : 1225–32 23 Arumainayagam N , McGrath J , Jefferson KP , Gillatt DA . Introduction of an enhanced recovery protocol for radical cystectomy . BJU Int 2008 ; 101 : 698–701 24 Pruthi RS , Chun J , Richman M. Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan . Urology 2003 ; 62 : 661–6 25 Chang SS , Baumgartner RG , Wells N et al. Causes of increased hospital stay after radical cystectomy in a clinical pathway setting . J Urol 2002 ; 167 : 208– BACKGROUND Enhanced Recovery after Surgery ( ERAS ) programs have gained popularity with potential to accelerate recovery and reduce morbidity after colectomy . We were interested in comparing recovery after open right colectomy within an ERAS program compared with laparoscopic right colectomy in a st and ard care perioperative environment . METHODS Between October 2005 and June 2009 , prospect i ve data were collected on consecutive patients undergoing elective open right colectomy within an established ERAS setting ( OpERAS ) . Similarly , between March 2008 and June 2009 , data were collected on consecutive patients undergoing laparoscopic right hemicolectomy with conventional care ( LapCon ) . Exclusion criteria for both groups were : ASA > or= 4 , formation of a stoma , and dementia or mental illness rendering the patient unable to comply with instructions . Perioperative variables were collected . The surgical recovery score ( SRS ) was used as a vali date d means to measure convalescence on d 1 , 3 , 7 , 30 , and 60 postoperatively . RESULTS There were 74 patients in the OpERAS and 39 patients in the LapCon groups . At baseline , there were no significant demographic differences except that more patients had malignancy in OpERAS group .  Mean operating time was longer in the LapCon group . Median day stay was 4 ( 3 - 28 ) in OpERAS and 5 ( 2 - 18 ) in LapCon ( P = 0.032 ) . There was no statistical difference in the incidence of complications or the severity of complications . There were no significant differences in SRS after surgery at any time point . CONCLUSION When perioperative care is optimized , recovery after elective open right hemicolectomy is comparable with laparoscopic resection . Studies looking at the combination of laparoscopy and ERAS are warranted AIM To evaluate published trials examining oral post-operative protein supplementation in patients having undergone gastrointestinal surgery and assessment of reported results . METHODS Data base search es ( MEDLINE , BIOSIS , EMBASE , Cochrane Trials , Cinahl , and CAB ) , search es of reference lists of relevant papers , and expert referral were used to identify prospect i ve r and omized controlled clinical trials . The following terms were used to locate articles : " oral ' ' or " enteral ' ' and " postoperative care ' ' or " post-surgical ' ' and " proteins ' ' or " milk proteins ' ' or " dietary proteins ' ' or " dietary supplements ' ' or " nutritional supplements ' ' . In data bases that allowed added limitations , results were limited to clinical trials that studied humans , and publications between 1990 and 2014 . Quality of collated studies was evaluated using a qualitative assessment tool and the collective results interpreted . RESULTS Search es identified 629 papers of which , following review , 7 were deemed eligible for qualitative evaluation . Protein supplementation does not appear to affect mortality but does reduce weight loss , and improve nutritional status . Reduction in grip strength deterioration was observed in a majority of studies , and approximately half of the studies described reduced complication rates . No changes in duration of hospital stay or plasma protein levels were reported . There is evidence to suggest that protein supplementation should be routinely provided post-operatively to this population . However , despite comprehensive search es , clinical trials that varied only the amount of protein provided via oral nutritional supplements ( discrete from other nutritional components ) were not found . At present , there is some evidence to support routinely prescribed oral nutritional supplements that contain protein for gastrointestinal surgery patients in the immediate post-operative stage . CONCLUSION The optimal level of protein supplementation required to maximise recovery in gastrointestinal surgery patients is effectively unknown , and may warrant further study BACKGROUND A previous comprehensive prehabilitation program , providing nutrition counseling with whey protein supplementation , exercise , and psychological care , initiated 4 weeks before colorectal surgery for cancer , improved functional capacity before surgery and accelerated functional recovery . Those receiving st and ard of care deteriorated . The specific role of nutritional prehabilitation alone on functional recovery is unknown . OBJECTIVE This study was undertaken to estimate the impact of nutrition counseling with whey protein on preoperative functional walking capacity and recovery in patients undergoing colorectal resection for cancer . DESIGN We conducted a double-blinded r and omized controlled trial at a single university-affiliated tertiary center located in Montreal , Quebec , Canada . Colon cancer patients ( n=48 ) awaiting elective surgery for nonmetastatic disease were r and omized to receive either individualized nutrition counseling with whey protein supplementation to meet protein needs or individualized nutrition counseling with a nonnutritive placebo . Counseling and supplementation began 4 weeks before surgery and continued for 4 weeks after surgery . MAIN OUTCOME MEASURE The primary outcome was change in functional walking capacity as measured with the 6-minute walk test . The distance was recorded at baseline , the day of surgery , and 4 weeks after surgery . A change of 20 m was considered clinical ly meaningful . RESULTS The whey group experienced a mean improvement in functional walking capacity before surgery of + 20.8 m , with a st and ard deviation of 42.6 m , and the placebo group improved by + 1.2 ( 65.5 ) m ( P=0.27 ) . Four weeks after surgery , recovery rates were similar between groups ( P=0.81 ) . CONCLUSION Clinical ly meaningful improvements in functional walking capacity were achieved before surgery with whey protein supplementation . These pilot results are encouraging and justify larger-scale trials to define the specific role of nutrition prehabilitation on functional recovery after surgery PURPOSE To observe the clinical efficacy of the application of enhanced recovery after surgery ( ERAS ) in the perioperative period of esophageal carcinoma patients . METHODS A total of 114 patients who were admitted to Affiliated Hospital of Jining Medical University for surgical treatment of esophageal carcinoma between June 2012 and June 2016 were enrolled and r and omly divided into the intervention group and the regular group according to the difference of management procedures during the perioperative period . ERAS was carried out in 57 patients in the intervention group , while conventional management procedures were applied in 57 patients in the regular group . Thereafter , compared were the fluctuations in nutritional indicators and immunological indicators , postoperative complications , time to recovery of gastrointestinal function , length of stay ( LOS ) in hospital and cost of patients between the two groups . RESULTS Seven days post-operation in the intervention group , the evaluation indexes of nutrition status , including total protein ( TP ) , albumin ( ALB ) , prealbumin ( PA ) and transferrin ( TF ) , and of immunological functions , including immunoglobulin G ( IgG ) , immunoglobulin A ( IgA ) , immunoglobulin M ( IgM ) and total blood lymphocyte count ( TLC ) , were significantly higher than those in the regular group . As for postoperative complications , the incidence rate of the intervention group was remarkably lower than that of the regular group ; the recovery time of gastrointestinal function in the intervention group was shorter than that in the regular group ; the LOS in the intervention group was also shorter than that in the regular group ; the in-hospital cost in the intervention group was also lower than that in the regular group . All differences above were statistically significant ( p<0.05 ) . CONCLUSION During the perioperative period of esophageal carcinoma patients , ERAS should be fully applied to sustain the good status , and promote the recovery of immunological functions and gastrointestinal functions ; at the same time , ERAS also reduces the incidence rate of postoperative complications , LOS and in-hospital cost , and we maintain that ERAS should be performed in clinical practice Background During the last two decades the use of laparoscopic resection and a multimodal approach known as an enhanced recovery programme , have been major changes in colorectal perioperative care . Clinical outcome improves using laparoscopic surgery to resect colorectal cancer but until recently no multicentre trial evidence had been reported regarding whether the benefits of laparoscopy still exist when open surgery is optimized within an enhanced recovery programme . The EnROL trial ( Enhanced Recovery Open versus Laparoscopic ) examines the hypothesis that laparoscopic surgery within an enhanced recovery programme will provide superior postoperative outcomes when compared to conventional open resection of colorectal cancer within the same programme . Methods / design EnROL is a phase III , multicentre , r and omised trial of laparoscopic versus open resection of colon and rectal cancer with blinding of patients and outcome observers to the treatment allocation for the first 7 days post-operatively , or until discharge if earlier . 202 patients will be recruited at approximately 12 UK hospitals and r and omised using minimization at a central computer system in a 1:1 ratio . Recruiting surgeons will previously have performed > 100 laparoscopic colorectal resections  and > 50  open total mesorectal excisions to minimize conversion . Eligible patients are those suitable for elective resection using either technique . Excluded patients include : those with acute intestinal obstruction and patients in whom conversion from laparoscopic to open procedure is likely . The primary outcome is physical fatigue as measured by the physical fatigue domain of the multidimensional fatigue inventory 20 ( MFI-20 ) with secondary outcomes including postoperative hospital stay ; complications ; reoperation and readmission ; quality of life indicators ; cosmetic assessment s ; st and ardized performance indicators ; health economic analysis ; the other four domains of the MFI-20 . Pathological assessment of surgical quality will also be undertaken and compliance with the enhanced recovery programme will be recorded for all patients . Discussion Should this trial demonstrate that laparoscopic surgery confers a significant clinical and /or health economic benefit this will further support the transition to this type of surgery , with implication s for the training of surgeons and re source allocation . Trial registration IS RCT N48516968 IMPORTANCE The effect of surgeons ' disrupted sleep on patient outcomes is not clearly defined . OBJECTIVE To assess if surgeons operating the night before have more complications of elective surgery performed the next day . DESIGN , SETTING , AND PARTICIPANTS Population -based , matched , retrospective cohort study using administrative health care data bases in Ontario , Canada ( 2012 population , 13,505,900 ) . Participants were 2078 patients who underwent elective laparoscopic cholecystectomies performed by surgeons who operated the night before , matched with 4 other elective laparoscopic cholecystectomy recipients ( n = 8312 ) . EXPOSURE In total , 94,183 eligible elective laparoscopic cholecystectomies were performed between 2004 and 2011 . Of these surgeries , there were 2078 procedures in which 331 different surgeons across 102 community hospitals had operated between midnight and 7 am the night before . Each " at-risk " surgery was r and omly matched with 4 other elective laparoscopic cholecystectomies ( n = 8312 ) performed by the same surgeon , who had no evidence of having operated the night before . MAIN OUTCOMES AND MEASURES The primary outcome was conversion from a laparoscopic cholecystectomy to open cholecystectomy . Secondary outcomes included evidence of iatrogenic injuries or death . Risks were quantified using generalized estimating equations . RESULTS No significant association was found in conversion rates to open operations between surgeons when they operated the night before compared with when they did not operate the previous night ( 46/2031 [ 2.2 % ] vs 157/8124 [ 1.9 % ] ; adjusted odds ratio [ OR ] , 1.18 ; 95 % CI , 0.85 - 1.64 ) . There was no association between operating the night before vs not operating the night before , and risk of iatrogenic injuries ( 14/2031 [ 0.7 % ] vs 72/8124 [ 0.9 % ] ; adjusted OR , 0.77 ; 95 % CI , 0.43 - 1.37 ) or death ( ≤5/2031 [ ≤0.2 % ] vs 7/8124 [ 0.1 % ] ) . CONCLUSIONS AND RELEVANCE No significant association was found between operating the night before and not operating the previous night for conversion to open cholecystectomy , risk of iatrogenic complications , or death for elective daytime cholecystectomy . These findings do not support safety concerns related to surgeons operating the night before performing elective surgery Abstract Although medical hypnosis has a long history of myriad functional applications ( pain reduction , procedural preparation etc . ) , it has been little tested for site-specific effects on physical healing per se . In this r and omized controlled trial , we compared the relative efficacy of an adjunctive hypnotic intervention , supportive attention , and usual care only on early post-surgical wound healing . Eighteen healthy women presenting consecutively for medically recommended reduction mammaplasty at an ambulatory surgery practice underwent the same surgical protocol and postoperative care  following preoperative r and omization ( n = 6 each ) to one of the three treatment conditions : usual care , 8 adjunctive supportive attention sessions , or 8 adjunctive hypnosis sessions targeting accelerated wound healing . The primary outcome data of interest were objective , observational measures of incision healing made at 1,7 weeks postoperatively by medical staff blind to the participants ' group assignments . Data included clinical exams and digitized photographs that were scored using a wound assessment inventory ( WAI ) . Secondary outcome measures included the participants ' subjectively rated pain , perceived incision healing ( VAS Scales ) , and baseline and post-surgical functional health status ( SF-36 ) . Analysis of variance showed the hypnosis group 's objective ly observed wound healing to be significantly greater than the other two groups ' , p < .001 , through 7 postoperative weeks ; st and ard care controls showed the smallest degree of healing . In addition , at both the 1 and 7 week post-surgical observation intervals , one-way analyses showed the hypnosis group to be significantly more healed than the usual care controls , p < 0 . 02 . The mean scores of the subjective assessment s of postoperative pain , incision healing and functional recovery trended similarly . Results of this preliminary trial indicate that use of a targeted hypnotic intervention can accelerate postoperative wound healing and suggest that further tests of using hypnosis to augment physical healing are warranted Fast-track surgery , also named enhanced recovery after surgery ( ERAS ) , is in my opinion the most important innovation after the advent of laparoscopy ( in the 1990s ) in the field of  colorectal surgery  ( as in other fields of surgery ) . It is defined as a multimodal pathway aim ing to reduce surgical stress by using pain-free procedures with less organ dysfunction , less morbidity and better recovery . ERAS has been popularized by Henrik Kehlet and his team since the early 2000s [ 1 ] and has rapidly gained popularity around the world because of its remarkable benefits and safety . The concept of ERAS is to make use of the improvement of anaesthetic and analgesic techniques , the development of minimally invasive surgery and evidence -based perioperative care . It involves a number of items , beginning from the first medical visit before surgery to discharge . The items are all evidence based being derived from r and omized controlled trials or meta-analyses . The reader can find the references related to the ERAS items in the valuable consensus review published by the European ERAS group [ 2 ] and the paper of Kehlet and Wilmore [ 3 ] . Through this pathway , the patient can benefit from the best available evidence in anaesthesia , analgesia , perioperative fluid management , surgical procedures , nutrition and ambulation . I will focus in this editorial on the role of ERAS in colorectal surgery , but readers should be aware that ERAS has been applied and vali date d in other abdominal procedures , and in urology , gynaecology , vascular sugery , endocrine surgery , orthopaedic surgery , etc . [ 3 ] . The numerous items or components ( Figure 1 ) involve the preoperative , intra-operative and postoperative periods , necessitating close collaboration between surgeons ( no bowel preparation , no routine nasogastric tube , minimally invasive surgery , no routine abdominal drainage and early postoperative diet ) , anaesthesiologists ( fasting duration of two hours for liquids and six hours for solids , carbohydrate loading , no routine preoperative sedation , avoiding long-acting opioids , epidural analgesia , preventing postoperative nausea and vomiting , preventing intra-operative hypothermia , perioperative fluid restriction and postoperative analgesia ) and nurses and physiotherapists ( early nutrition and mobilisation ) . Several r and omized trials and four meta-analyses [ 4–7 ] have demonstrated the safety and efficacy of ERAS , not only in reducing total length of hospital stay and morbidity , but also in improving patient satisfaction when compared with conventional care . The metaanalyses included both r and omized and non-r and omized studies , the most recent and the largest [ 6 ] showing a reduction of 2.5 days in total hospital stay and significantly less morbidity ( OR 0.54 [ 0.45–0.69 ] ) in favour of the ERAS group , with no difference in readmission rate . A recent meta- analysis focusing on major colorectal surgery demonstrated that the ERAS programme can reduce morbidity by up to 50 % [ 7 ] . ERAS raises three questions . ( i ) What is the respective role of each ERAS item ? ( ii ) Does the ERAS protocol increase the workload of ward nursing staff ? ( iii ) How should this new paradigm be implemented ? Several anaesthesiologists are reluctant to use epidural analgesia in daily practice , mainly when patients are undergoing laparoscopic surgery . Epidural analgesia ( well known to be associated with less pain ) during laparoscopic surgery has been assessed in meta-analyses and r and omized trials but the conclusions are not concordant [ 8,9 ] . In my own daily practice , epidural analgesia is safe and efficacious in relieving pain and allowing early oral intake and mobilization , but it is obvious that its proper role in the ERAS protocol compared with other analgesic regimens such as non-opioid multimodal analgesia , local anaesthesia and continuous wound perfusion , in the era of laparoscopic surgery needs further evaluation . The roleof laparoscopyhas also been debated [ 10 ] . Two small r and omized trials have shown conflicting results [ 11,12 ] , but a recent large r and omized trial [ 13 ] involving four arms ( laparoscopy with ERAS vs laparoscopy with conventional care , vs open surgery with ERAS vs open surgery with conventional care ) has demonstrated a shorter hospital stay after laparoscopic colonic surgery with ERAS , the other outcomes being similar . The conclusion of the authors was that ‘ the most optimal perioperative treatment for patients requiring segmental colectomy for coloncancer is laparoscopic resection embedded in an ERAS program ’ , suggesting that laparoscopic surgery is an important component of ERAS . The same team has performed a futher multivariate linear regression analysis on the same data and showed that the components significantly associated with a successful ERAS programme were laparoscopic surgery , normal diet at postoperative days one , two and three and enforced mobilization at postoperative days one , two and three ( Vlug M , personal communication ) . There is a feeling that the ERAS programme could increase the workload of nursing staff . The nursing BACKGROUND Although evidence -based guidelines for best practice s pertaining to surgical site infection ( SSI ) prophylaxis exist , the feasibility of implementing such practice s remains to be demonstrated outside of a controlled clinical trial . This study was design ed to assess the safety and feasibility of implementing evidence -based care practice s to prevent SSIs . STUDY DESIGN A prospect i ve , double-cohort ( pre- and postintervention ) trial in elective , general surgery patients was conducted . All patients undergoing elective , major colorectal or hepatobiliary operations were enrolled . Postintervention cohort patients were exposed to new strategies to improve antibiotic administration times , perioperative normothermia rates , and  perioperative glucose control .  They were compared with the preintervention cohort , which received st and ard practice at the time . Outcomes evaluated include timing of antibiotic administration , perioperative temperatures , and postoperative glucose levels . SSI rates between cohorts were also compared . RESULTS A total of 208 patients were enrolled . The proportion of patients receiving their preoperative antibiotics within 60 minutes improved from 5.9 % to 92.6 % ( p < 0.001 ) ; perioperative normothermia rates improved from 60.5 % to 97.6 % ( p < 0.001 ) between cohorts . There was no improvement in rates of hyperglycemia . SSI rates improved but did not reach statistical significance ( 14.3 % versus 8.7 % ; p = 0.21 ) . CONCLUSIONS Implementation of evidence -based care practice s to prevent SSI is both safe and practical outside the setting of a r and omized , controlled trial . Sustained compliance remains to be demonstrated , although practice audits at our institution suggest ongoing success is possible OBJECTIVE A minimal extracorporeal circulation ( MECC ) circuit integrates the advances in cardiopulmonary bypass ( CPB ) technology into a single circuit and is associated with improved short-term outcome . The aim of this study was to prospect ively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures . DESIGN Prospect i ve r and omized study . SETTING All patients scheduled for elective coronary artery surgery were evaluated , excluding those considered particularly high risk for fast-track failure . The fast-track protocol included careful preoperative patient selection , a fast-track anesthetic technique based on minimal administration of fentanyl , surgery at normothermia , early postoperative extubation in the cardiac recovery unit , and admission to the cardiothoracic ward within the first 24 hours postoperatively . PARTICIPANTS One hundred twenty patients were assigned r and omly into 2 groups ( 60 in each group ) . INTERVENTIONS Group A included patients who were operated on using the MECC circuit , whereas patients in Group B underwent surgery on conventional CPB . MEASUREMENTS AND MAIN RESULTS Incidence of fast-track recovery was significantly higher in patients undergoing MECC ( 25 % v 6.7 % , p = 0.006 ) . MECC also was recognized as a strong independent predictor of early recovery , with an odds ratio of 3.8 ( p = 0.011 ) . Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion , duration of inotropic support , need for an intra-aortic balloon pump , and development of postoperative atrial fibrillation and renal failure . CONCLUSIONS MECC promotes successful early recovery after elective coronary revascularization procedures , even in a nondedicated cardiac intensive care unit setting BACKGROUND Although malnutrition contributes to morbidity , studies of pre- and postoperative nutrition often include well-nourished patients unlikely to benefit from therapy and usually do not stratify by the site of surgical pathology . This study evaluates whether perceived preoperative markers of nutritional status recorded in charts correlates with postoperative complications and re source use in patients who receive no preoperative nutrition support  and reinterprets the results of several conflicting r and omized , prospect i ve studies in this context . METHODS This is a retrospective cohort study of 526 surgical patients who had preoperative serum albumin levels measured and were undergoing elective esophageal , gastric , pancreaticoduodenal , or colon surgery between 1992 and 1996 who could have received preoperative nutrition but did not .  RESULTS Most medical records contained inadequate analysis of preoperative nutritional status , but preoperative albumin correlated inversely with complications , length of stay , postoperative stay , intensive care unit ( ICU ) stay , mortality , and resumption of oral intake .  Patients undergoing esophageal or pancreatic procedures sustained a significantly higher complication rate at most albumin levels , whereas colonic surgery result ed in lower complication rates at the same albumin levels . Re source use ( eg , length of stay and ICU stay ) related to these complication rates ; esophageal and pancreatic procedures used the most re sources and colon procedures used the fewest at most albumin levels . This lack of appreciation for nutritional risk and operative site can explain discrepancies in outcome noted in several r and omized , prospect i ve nutritional studies and must be applied to the design and implementation of new studies . CONCLUSIONS Elective , non-emergent esophageal and pancreatic procedures performed in patients who could have had surgery delayed for preoperative nutrition , but did not , result in higher risk than colon surgery at any given level of serum albumin below 3.25 g/dL. Patient population s in trials should be stratified by operative site and by markers of nutritional status . Degree of hypoalbuminemia and other potential markers of nutritional status may explain many of the discrepancies between trials of nutrition support . Preexisting hypoalbuminemia in patients undergoing elective surgery remains underappreciated , unrecognized , and untreated in many hospitalized patients BACKGROUND older people undergoing elective surgery have significant post-operative problems prolonging hospitalisation . OBJECTIVE to design , embed , and evaluate an evidence -based comprehensive geriatric assessment ( CGA ) service for at-risk older patients undergoing elective surgery . SETTING urban teaching hospital . SUBJECTS elective surgical patients aged 65 + . INTERVENTION multidisciplinary preoperative CGA service with post-operative follow-through ( proactive care of older people undergoing surgery [ ' POPS ' ] ) . METHODS observational cohort study and multilevel surveys ( development and modelling phase ) . Prospect i ve ' before and after ' comparison ( exploratory evaluation ) . RESULTS findings from the development phase showed high levels of preoperative co-morbidity , no multidisciplinary preoperative input , and multiple potentially preventable post-operative problems delaying discharge in older elective surgery patients . Comparison of 2 cohorts of elective orthopaedic patients ( pre-POPS vs POPS , N = 54 ) showed the POPS group had fewer post-operative medical complications including pneumonia ( 20 % vs 4 % [ p = 0.008 ] ) and delirium ( 19 % vs 6 % [ p = 0.036 ] ) , and significant improvements in areas reflecting multidisciplinary practice including pressure sores ( 19 % vs 4 % [ p = 0.028 ] ) , poor pain control ( 30 % vs 2 % [ p<0.001 ] ) , delayed mobilisation ( 28 % vs 9 % [ p = 0.012 ] ) and inappropriate catheter use ( 20 % vs 7 % [ p = 0.046 ] ) . Length of stay was reduced by 4.5 days . There were fewer delayed discharges relating to medical complications ( 37 % vs 13 % ) or waits for OT assessment or equipment ( 20 % vs 4 % ) . CONCLUSION a proactive evidence -based CGA service for at-risk older elective surgical patients was developed according to MRC framework for complex interventions . Pre/post comparison in elective orthopaedic patients showed improved ( within method ological limitations ) post-operative outcomes indicative of better clinical effectiveness and efficiency , and contributed to the service obtaining mainstream funding . Informed by the present study , a r and omised controlled trial is ongoing
this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons , the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery .
The prescription of these recommendations can accelerate the postoperative recovery of patients su bmi tted to elective general surgery , with decrease in morbidity , length of stay and rehospitalization , and consequently , of costs
OBJECTIVE to present recommendations based on the ACERTO Project ( Acceleration of Total Post-Operative Recovery ) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures .