Enhanced recovery after surgery:Progress in adapted pathways for implementation in standard and emerging surgical settings

The concept of enhanced recovery after surgery(ERAS)has been practiced for decades and has been implemented in numerous surgical specialties.ERAS is a global surgical quality improvement initiative,and it is an element in the field of perioperative care.ERAS had shown significant clinical outcomes,patientreported satisfaction,and improvements in medical service cost.ERAS has been developed for specific surgical procedures,but with the fast progress of newly introduced surgical procedures,the original ERAS have been developed and modified.Recently appearing Topics and future research trends encompass ERAS protocols for other types of surgery and the enhancement of perioperative status,including but not limited to pediatric surgery,laparoscopic and robotic assisted surgery,bariatric surgery,thoracic surgery,and renal transplantation.The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative,operative,and post-operative pathways.ERAS costs are higher than traditional care,but the patient’s clinical outcome and satisfaction are higher.ERAS is in progress in the fields of anesthetic tasks,pediatric surgery,and organ transplantation.Although ERAS has shown significant clinical outcomes,there are needs to modify the protocol for specific cases,hospital facilities,resources,and nurses training on elements of ERAS.Several challenges and limitations exist in the implementation of ERAS that deserve consideration,it includes:Frailty,maximizing nutrition,prehabilitation,treating preoperative anemia,and enhancing ERAS adoption globally are all included.

Does enhanced recovery after surgery programs improve clinical outcomes in liver cancer surgery?

Enhanced recovery after surgery(ERAS)programs have been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016 and the new recommendations in 2022.Liver surgery is usually performed in oncological patients(liver metastasis,hepatocellular carcinoma,cholangiocarcinoma,etc.),but the real impact of liver surgery ERAS programs in oncological outcomes is not clearly defined.Theoretical advantages of ERAS programs are:ERAS decreases postoperative complication rates and has been demonstrated a clear relationship between complications and oncological outcomes;a better and faster posto-perative recovery should let oncologic teams begin chemotherapeutic regimens on time;prehabilitation and nutrition actions before surgery should also improve the performance status of the patients receiving chemotherapy.So,ERAS could be another way to improve our oncological results.We will discuss the literature about liver surgery ERAS focusing on its oncological implications and future investigations projects.

Safety and feasibility of enhanced recovery after surgery-based management model for ambulatory pediatric surgical procedures

BACKGROUND There is still some room for optimizing ambulatory pediatric surgical procedures,and the preoperative and postoperative management quality for pediatric patients needs to be improved.AIM To discuss the safety and feasibility of the enhanced recovery after surgery(ERAS)-based management model for ambulatory pediatric surgical procedures.METHODS We selected 320 pediatric patients undergoing ambulatory surgery from June 2023 to January 2024 at The First People’s Hospital of Liangshan Yi Autonomous Prefecture.Of these,220 received ERAS-based management(research group)and 100 received routine management(control group).General information,postoperative ambulation activities,surgical outcomes(operation time,postoperative gastro-intestinal ventilation time,and hospital stay),postoperative pain visual analogue scale,postoperative complications(incision infection,abdominal distension,fever,nausea,and vomiting),and family satisfaction were compared.RESULTS The general information of the research group(sex,age,disease type,single parent,family history,etc.)was comparable to that of the control group(P>0.05),but the rate of postoperative(2 h,4 h,and 6 h after surgery)ambulation activities was statistically higher(P<0.01),and operation time,postoperative gastrointestinal ventilation time,and hospital stay were markedly shorter(P<0.05).The research group had lower visual analogue scale scores(P<0.01)at 12 h and 24 h after surgery and a lower incidence of total postoperative complications than the control group(P=0.001).The research group had higher family satisfaction than the control group(P=0.007).CONCLUSION The ERAS-based management model was safe and feasible in ambulatory pediatric surgical procedures and worthy of clinical promotion.

Is recovery enhancement after gastric cancer surgery really a safe approach for elderly patients?

BACKGROUND This study aimed to evaluate the safety of enhanced recovery after surgery(ERAS)in elderly patients with gastric cancer(GC).AIM To evaluate the safety of ERAS in elderly patients with GC.METHODS The PubMed,EMBASE,and Cochrane Library databases were used to search for eligible studies from inception to April 1,2023.The mean difference(MD),odds ratio(OR)and 95%confidence interval(95%CI)were pooled for analysis.The quality of the included studies was evaluated using the Newcastle-Ottawa Scale scores.We used Stata(V.16.0)software for data analysis.RESULTS This study consists of six studies involving 878 elderly patients.By analyzing the clinical outcomes,we found that the ERAS group had shorter postoperative hospital stays(MD=-0.51,I2=0.00%,95%CI=-0.72 to-0.30,P=0.00);earlier times to first flatus(defecation;MD=-0.30,I²=0.00%,95%CI=-0.55 to-0.06,P=0.02);less intestinal obstruction(OR=3.24,I2=0.00%,95%CI=1.07 to 9.78,P=0.04);less nausea and vomiting(OR=4.07,I2=0.00%,95%CI=1.29 to 12.84,P=0.02);and less gastric retention(OR=5.69,I2=2.46%,95%CI=2.00 to 16.20,P=0.00).Our results showed that the conventional group had a greater mortality rate than the ERAS group(OR=0.24,I2=0.00%,95%CI=0.07 to 0.84,P=0.03).However,there was no statistically significant difference in major complications between the ERAS group and the conventional group(OR=0.67,I2=0.00%,95%CI=0.38 to 1.18,P=0.16).CONCLUSION Compared to those with conventional recovery,elderly GC patients who received the ERAS protocol after surgery had a lower risk of mortality.

Enhanced recovery after surgery in elderly patients with non-small cell lung cancer who underwent video-assisted thoracic surgery

BACKGROUND This study was designed to investigate the clinical outcomes of enhanced recovery after surgery(ERAS)in the perioperative period in elderly patients with nonsmall cell lung cancer(NSCLC).AIM To investigate the potential enhancement of video-assisted thoracic surgery(VATS)in postoperative recovery in elderly patients with NSCLC.METHODS We retrospectively analysed the clinical data of 85 elderly NSCLC patients who underwent ERAS(the ERAS group)and 327 elderly NSCLC patients who received routine care(the control group)after VATS at the Department of Thoracic Surgery of Peking University Shenzhen Hospital between May 2015 and April 2017.After propensity score matching of baseline data,we analysed the postoperative stay,total hospital expenses,postoperative 48-h pain score,and postoperative complication rate for the 2 groups of patients who underwent lobectomy or sublobar resection.RESULTS After propensity score matching,ERAS significantly reduced the postoperative hospital stay(6.96±4.16 vs 8.48±4.18 d,P=0.001)and total hospital expenses(48875.27±18437.5 vs 55497.64±21168.63 CNY,P=0.014)and improved the satisfaction score(79.8±7.55 vs 77.35±7.72,P=0.029)relative to those for routine care.No significant between-group difference was observed in postoperative 48-h pain score(4.68±1.69 vs 5.28±2.1,P=0.090)or postoperative complication rate(21.2%vs 27.1%,P=0.371).Subgroup analysis showed that ERAS significantly reduced the postoperative hospital stay and total hospital expenses and increased the satisfaction score of patients who underwent lobectomy but not of patients who underwent sublobar resection.CONCLUSION ERAS effectively reduced the postoperative hospital stay and total hospital expenses and improved the satisfaction score in the perioperative period for elderly NSCLC patients who underwent lobectomy but not for patients who underwent sublobar resection.

Clinical study of enhanced recovery after surgery in laparoscopic appendectomy for acute appendici

BACKGROUND Enhanced recovery after surgery(ERAS)protocol is a comprehensive manage-ment modality that promotes patient recovery,especially in the patients undergo-ing digestive tumor surgeries.However,it is less commonly used in the appen-dectomy.AIM To study the application value of ERAS in laparoscopic surgery for acute appen-dicitis.METHODS A total of 120 patients who underwent laparoscopic appendectomy due to acute appendicitis were divided into experimental group and control group by random number table method,including 63 patients in the experimental group and 57 patients in the control group.Patients in the experimental group were managed with the ERAS protocol,and those in the control group were received the tra-ditional treatment.The exhaust time,the hospitalization duration,the hospita-lization expense and the pain score between the two groups were compared.RESULTS There was no significant difference in age,gender,body mass index and Sunshine Appendicitis Grading System score between the experimental group and the con-trol group(P>0.05).Compared to the control group,the patients in the expe-rimental group had earlier exhaust time,shorter hospitalization time,less hospi-talization cost and lower degree of pain sensation.The differences were statis-tically significant(P<0.01).CONCLUSION ERAS could significantly accelerate the recovery of patients who underwent la-paroscopic appendectomy for acute appendicitis,shorten the hospitalization time and reduce hospitalization costs.It is a safe and effective approach.

Optimizing outcomes:Implementing enhanced recovery after surgery in orthopedic surgery

In the realm of orthopedics,the adoption of enhanced recovery after surgery(ERAS)protocols marks a significant stride towards enhancing patient well-being.By embracing a holistic approach that encompasses preoperative counseling,dietary optimization,minimally invasive procedures,and early postoperative mobilization,these protocols have ushered in a new era of surgical care.Despite encountering hurdles like resistance to change and resource allocation challenges,the efficacy of ERAS protocols in improving clinical outcomes is undeniable.Noteworthy benefits include shortened hospital stays and bolstered improved patient-safety measures.Looking ahead,the horizon for ERAS in orthopedics appears bright,with an emphasis on tailoring care to individual needs,integrating cutting-edge technologies,and perpetuating research endeavors.This shift towards a more personalized,streamlined,and cost-efficient model of care underscores the transformative potential of ERAS in reshaping not only orthopedic surgery but also the journey to patient recovery.This editorial details the scope and future of ERAS in the orthopedic specialty.

Compliance with enhanced recovery after surgery predicts long-term outcome after hepatectomy for cholangiocarcinoma

BACKGROUND Enhanced recovery after surgery(ERAS)program has been proved to improve postoperative outcome for many surgical procedures,including liver resection.There was limited evidence regarding the feasibility and benefit of ERAS in patients who underwent liver resection for cholangiocarcinoma.AIM To evaluate the feasibility of ERAS in patients who underwent liver resection for cholangiocarcinoma and its association with patient outcomes.METHODS We retrospectively analyzed 116 cholangiocarcinoma patients who underwent hepatectomy at Srinagarind Hospital,Khon Kaen University between January 2015 and December 2016.The primary outcome was the compliance with ERAS.To determine the association between ERAS compliance and patient outcomes.the patients were categorized into those adhering more than and equal to 50%(ERAS≥50),and below 50%(ERAS<50)of all components.Details on type of surgical procedure,preoperative and postoperative care,tumor location,postoperative laboratory results,and survival time were evaluated.The compliance with ERAS was measured by the percentage of ERAS items achieved.The Kaplan-Meier curve was used for survival analysis.RESULTS The median percentage of ERAS goals achieved was 40%(±12%).Fourteen patients(12.1%)were categorized into the ERAS≥50 group,and 102 patients were in the ERAS<50 group.Postoperative hospital stay was significantly shorter in the ERAS≥50 group[8.9 d,95%confidence interval(CI):7.3-10.4 d]than in the ERAS<50 group(13.7 d,95%CI:12.2-15.2 d)(P=0.0217).No hepatobiliary-related complications or in-hospital mortality occurred in the ERAS≥50 group.Overall survival was significantly higher in the ERAS≥50 group.The median survival of the patients in the ERAS<50 group was 1257 d(95%CI:853.2-1660.8 d),whereas that of the patients in the ERAS≥50 group was not reached.CONCLUSION Overall ERAS compliance for patients who underwent liver resection for cholangiocarcinoma is poor.Greater ERAS compliance could predict in-hospital,short-term,and long-term outcomes of the patients.

Application of multidisciplinary collaborative nursing with family care for enhanced recovery after surgery in children with inguinal hernia

BACKGROUND Perioperative nursing can reduce the stress reaction and improve the prognosis of children.AIM To elucidate the influence of multidisciplinary collaborative nursing for enhanced recovery after surgery(ERAS)with family care in perioperative nursing children with an inguinal hernia and its impact on the prognosis.METHODS The data of 100 children with inguinal hernia were retrospectively analyzed.The participants were divided into three groups according to different nursing methods:Groups A(n=38),B(n=32),and C(n=30).Group A received multidisciplinary collaborative ERAS nursing combined with family care nursing;Group B received multidisciplinary collaborative nursing for ERAS;and Group C received routine nursing.The postoperative recovery results of the three groups were compared,including intraoperative blood loss and postoperative feeding time,time of getting out of bed,hospitalization time,and defecation time.Furthermore,the incidence of common complications was also compared between the three groups.RESULTS There was less intraoperative blood loss in Groups A and B than in Group C(P<0.05),and the time of getting out of bed and postoperative hospitalization and defecation times were also decreased in Group C(P<0.05).There was no significant difference in postoperative feeding time among the three groups(P>0.05).Each index had no statistical significance between Groups A and B(P>0.05).The incidence of urinary retention,infection,hematoma,and hernia recurrence in Group A was less than that in Group C(P<0.05).No significant difference was observed in the overall complication rate between Groups A and B and between Groups B and C(P>0.05).CONCLUSION The application of multidisciplinary collaborative nursing combined with family care in the perioperative care of children with an inguinal hernia for ERAS may promote postoperative rehabilitation for children and reduce the incidence of complications.

Explore the clinical nursing path of daytime laparoscopic cholecystectomy under the guidance of enhanced recovery after surgery

Objective:To explore the safety and effectiveness nursing of 12 h discharged daytime laparoscopic cholecystectomy guided by enhanced recovery after surgery(ERAS)concept.Methods:Included 180 cases from the 12 h discharged daytime laparoscopic cholecystectomy patients which assessmended and guided by ERAS,with the 180 case of routine cholecystectomy patients as control group at the same time.To quantitatively analyze the related indexes of perioperative period and ERAS concept,and evaluate the clinical safety,and effectiveness.Results:It displayed no significant differences in average age,gender distribution,duration of gallbladder related disease and distribution of clinical symptoms between the two groups(P>0.05).There were also no significant differences in preoperative smoking history,hypertension history,cardio-cerebrovascular history,abdominal operation history and disease composition ratio between the two groups(P>0.05).None of the patients had conversion to laparotomy.Compared with the conventional surgery group,there were no significant differences in the average amount of intraoperative blood loss,operation time and muscle strength before returning to the ward in patients with ERAS guided day surgery(P>0.05).When compared with the conventional surgery group,ERAS guided day surgery group had no significant difference in muscle strength between the two groups when going under the ground(t=1.64,P=0.082).Also,the level of peripheral white blood cells in patients with ERAS guided day surgery group was not significantly increased at 6 h after surgery.Meanwhile,liver function related indexes,transaminase,total bilirubin,indirect bilirubin were not significantly abnormal(P>0.05).Conclusion:12 h daytime laparoscopic cholecystectomy guided by ERAS concept can improve the clinical efficacy of patients with cholecystolithiasis,which is safe and feasible.

Application of early enteral nutrition nursing based on enhanced recovery after surgery theory in patients with digestive surgery

BACKGROUND Postoperative nursing can improve the restlessness and gastrointestinal function of patients with tracheal intubation under general anesthesia in digestive surgery.Wide application of various nursing methods and routine nursing in periop-erative nursing of patients with general anesthesia in digestive surgery.AIM To investigate the impact of early postoperative enteral nutrition nursing based on the enhanced recovery after surgery(ERAS)theory on postoperative agitation and gastrointestinal recovery in patients undergoing general anesthesia that experienced tracheal intubation.METHODS The data of 126 patients with digestive surgery from May 2019 to February 2022 were retrospectively analyzed.According to different nursing methods,they were divided into control group and observation group,with 63 cases in observation group and 63 cases in control group.The patients in the control group had standard perioperative nursing care,whereas those in the observation group got enteral nourishment as soon as possible after surgery in accordance with ERAS theory.Both the rate and quality of gastrointestinal function recovery were compared between the two groups after treatment ended.Postoperative anes-thesia-related adverse events were tallied,patients'nutritional statuses were monitored,and the Riker sedation and agitation score(SAS)was used to measure the incidence of agitation.RESULTS When compared to the control group,the awake duration,spontaneous breathing recovery time,extubation time and postoperative eye-opening time were all considerably shorter(P<0.05).There was no significant difference in the recovery time of orientation force between the two groups(P>0.05);however,the observation group had a lower SAS score than the control group(P<0.05).The recovery time for normal intestinal sounds,the time it took to have the first postoperative exhaust,the time it took to have the first postoperative defecation,and the time it took to have the first postoperative half-fluid feeding were all faster in the observation group than in the control group(P<0.05);Fasting blood glucose was lower in the observation group compared to the control group(P<0.05),while the albumin and hemoglobin levels were higher on the first and third postoperative days;however,there was no statistically significant difference in the incidence of anesthesia-related adverse reactions between the two groups(P>0.05).CONCLUSION The extremely early postoperative enteral nutrition nursing based on ERAS theory can reduce the degree of agitation,improve the quality of recovery,promote the recovery of gastrointestinal function,and improve the nutritional status of patients in the recovery period after tracheal intubation under general anesthesia.

Implementation and achievements of enhanced recovery after surgery program in perioperative management of gastric cancer patients

Objective:The enhanced recovery after surgery(ERAS)program is less implemented in gastric cancer patients.The purpose of this survey is to investigate the implementation status of ERAS in perioperative period in gastric cancer.Methods:This clinical observational study enrolled 329 patients between January 2020 and August 2020 in a single gastric cancer center.The questionnaire consisted of 4 par ts:basic information,preoperative status,intraoperative status,and postoperative status of ERAS implementation in gastric cancer surgery.Results:In the preoperative period,patients'education and counseling(100%)were well adopted.Smoking cessation(34.6%),drinking cessation(36.9%),avoidance of preoperative mechanical bowel preparation(24.3%),respiratory function training(11.2%),and administration of carbohydrate-rich drink before surgery(0.6%)were relatively not well adopted.During the operation,maintenance of intraoperative normothermia and fluid management(100%),as well as epidural analgesia(81.5%),were well adopted.Thromboprophylaxis was performed in 133(40.4%)patients.In the postoperative period,early active mobilization was implemented about 9.5 h,and early ambulation was implemented about 39.5 h,after surgery.A total of 140(42.5%)patients received prolonged prophylactic antibiotics;268(81.5%)patients were provided diet upon gas passage;and 320(97.3%)patients received intravenous fluid administration more than 5 d after surgery.The practice rate of early removal of urinary catheter(0%)and nasogastric tube(15.5%)was relatively low.A total of 11(3.3%)patients experienced postoperative complication,and 1(0.3%)patient received unplanned reoperation.The average costs were￥59,500,and the average hospital stay was 12(5,36)d.Conclusions:Standard perioperative management of ERAS program in gastric cancer surgery in China still requires improvement.

Optimizing surgical outcomes for elderly gallstone patients with a high body mass index using enhanced recovery after surgery protocol

BACKGROUND Rehabilitation of elderly patients with a high body mass index(BMI)after cholecystectomy carries risks and requires the adoption of effective perioperative management strategies.The enhanced recovery after surgery(ERAS)protocol is a comprehensive treatment approach that facilitates early patient recovery and reduces postoperative complications.AIM To compare the effectiveness of traditional perioperative management methods with the ERAS protocol in elderly patients with gallbladder stones and a high BMI.METHODS This retrospective cohort study examined data from 198 elderly patients with a high BMI who underwent cholecystectomy at the Shanghai Fourth People's Hospital from August 2019 to August 2022.Among them,99 patients were managed using the traditional perioperative care approach(non-ERAS protocol),while the remaining 99 patients were managed using the ERAS protocol.Relevant indicator data were collected for patients preoperatively,intraoperatively,and postoperatively,and surgical outcomes were compared between the two groups.RESULTS The comparison results between the two groups of patients in terms of age,sex,BMI,underlying diseases,surgical type,and preoperative hospital stay showed no statistically significant differences.However,the ERAS group had a significantly shorter preoperative fasting time than the non-ERAS group(4.0±0.9 h vs 7.6±0.9 h).Regarding intraoperative indicators,there were no significant differences between the two groups of patients.However,in terms of postoperative recovery,the ERAS protocol group exhibited significant advantages over the non-ERAS group,including a shorter hospital stay,lower postoperative pain scores and postoperative hunger scores,and higher satisfaction levels.The readmission rate was lower in the ERAS protocol group than in the non-ERAS group(3.0%vs 8.1%),although the difference was not significant.Furthermore,there were significant differences between the two groups in terms of postoperative nausea and vomiting severity,postoperative abdominal distention at 24 h,and daily life ability scores.CONCLUSION The findings of this study demonstrate that the ERAS protocol confers significant advantages in postoperative outcomes following cholecystectomy,including reduced readmission rates,decreased postoperative nausea and vomiting,alleviated abdominal distension,and enhanced functional capacity.While the protocol may not exhibit significant improvement in early postoperative symptoms,it does exhibit advantages in long-term postoperative symptoms and recovery.These findings underscore the importance of implementing the ERAS protocol in the postoperative management of cholecystectomy patients,as it contributes to improving patients'recovery and quality of life while reducing health care resource utilization.

Analysis of the impact of ERAS-based respiratory function training on older patients’ability to prevent pulmonary complications after abdominal surgery

BACKGROUND In China,as the population grows older,the number of elderly people who have died from respiratory problems has increased.AIM To investigate whether enhanced recovery after surgery(ERAS)-based respiratory function training may help older patients who had abdominal surgery suffer fewer pulmonary problems,shorter hospital stays,and improved lung function.METHODS The data of 231 elderly individuals having abdominal surgery was retrospectively analyzed.Based on whether ERAS-based respiratory function training was provided,patients were divided into ERAS group(n=112)and control group(n=119).Deep vein thrombosis(DVT),pulmonary embolism(PE),and respiratory tract infection(RTI)were the primary outcome variables.Secondary outcome variables included the Borg score Scale,FEV1/FVC and postoperative hospital stay.RESULTS The percentage of 18.75%of ERAS group participants and 34.45%of control group participants,respectively,had respiratory infections(P=0.007).None of the individuals experienced PE or DVT.The ERAS group’s median postoperative hospital stay was 9.5 d(3-21 d)whereas the control groups was 11 d(4-18 d)(P=0.028).The Borg score decreased on the 4th d following surgery in the ERAS group compared to the 2nd d prior(P=0.003).The incidence of RTIs was greater in the control group than in the ERAS group among patients who spent more than 2 d in the hospital before surgery(P=0.029).CONCLUSION ERAS-based respiratory function training may reduce the risk of pulmonary complications in older individuals undergoing abdominal surgery.

Enhanced recovery after surgery with laparoscopic radical gastrectomy for stomach carcinomas

AIM: To study the efficacy of the enhanced recovery after surgery(ERAS) program in laparoscopic radical gastrectomy for stomach carcinomas.METHODS: From June 2010 to December 2012, 61 gastric cancer patients who underwent laparoscopicassisted radical gastrectomy with D2 lymphadenectomy at First Hospital of Jilin University were enrolled in this randomized controlled trial.(Clinical Trials.gov, registration ID: NCT01955096). The subjects were divided into the ERAS program group and the conventional control group. The clinical characteristics, recovery variables, and complications of patients were analyzed.RESULTS: The time to first ambulation, oral food intake, and time to defecation were significantly shorter in the ERAS group(n = 30), compared to the conventional group(n = 31; P = 0.04, 0.003, and 0.01, respectively). The postoperative hospital stay was less in the ERAS group(6.8 ± 1.1 d) compared to the conventional group(7.7 ± 1.1 d)(P = 0.002). There was no significant difference in postoperative complications between the ERAS(1/30) and conventional care groups(2/31)(P = 1.00). There were no readmissions or mortality during the 30-d follow-up period.CONCLUSION: The ERAS program is associated with a shorter hospital stay in gastric cancer patients undergoing laparoscopic radical gastrectomy. The ERAS protocol is useful in the treatment of gastric cancer.

Enhanced recovery after surgery programs in patients undergoing hepatectomy:A meta-analysis

AIM:To evaluate the impact of enhanced recovery after surgery(ERAS) programs in comparison with traditional care on liver surgery outcomes.METHODS:The Pub Med,EMBASE,CNKI and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials(RCTs) comparing the ERAS program with traditional care in patients undergoing liver surgery. Studies selected for the meta-analysis met all of the following inclusion criteria:(1) evaluation of ERAS in comparison to traditional care in adult patients undergoing elective open or laparoscopic liver surgery;(2) outcome measures including complications,recovery of bowel function,and hospital length of stay; and(3) RCTs. The following exclusion criteria were applied:(1) the study was not an RCT;(2) the study did not compare ERAS with traditional care;(3) the study reported on emergency,non-elective or transplantation surgery; and(4) the study consisted of unpublished studies with only the abstract presented at a national or international meeting. The primary outcomes were complications. Secondary outcomes were length of hospital stay and time to first flatus.RESULTS:Five RCTs containing 723 patients were included in the meta-analysis. In 10/723 cases,patients presented with benign diseases,while the remaining 713 cases had liver cancer. Of the five studies,three were published in English and two were published in Chinese. Three hundred and fifty-four patients were in the ERAS group,while 369 patients were in the traditional care group. Compared with traditional care,ERAS programs were associated with significantly decreased overall complications(RR = 0.66; 95%CI:0.49-0.88; P = 0.005),grade?Ⅰ?complications(RR = 0.51; 95%CI:0.33-0.79; P = 0.003),and hospitallength of stay [WMD =-2.77 d,95%CI:-3.87-(-1.66); P < 0.00001]. Similarly,ERAS programs were associated with decreased time to first flatus [WMD =-19.69 h,95%CI:-34.63-(-4.74); P < 0.0001]. There was no statistically significant difference in grade Ⅱ-Ⅴ complications between the two groups.CONCLUSION:ERAS is a safe and effective program in liver surgery. Future studies should define the active elements to optimize postoperative outcomes for liver surgery.

Enhanced recovery after surgery programs hasten recovery after colorectal resections

Colorectal resection was traditionally associated with significant morbidity and prolonged stay in hospital.Laparoscopic colorectal resection was first described in 1991 as a minimally invasive form of colorectal surgery.It was later on assessed by multiple randomized controlled trials and meta-analysis and was found to be associated with a faster recovery,lower complication rates and a shorter stay in hospital compared with open resection.To assess the effect of enhanced recovery after surgery (ERAS) program on postoperative length of stay after elective colorectal resections,a literature review was conducted,supplemented by the results of 111 ERAS colorectal resections at regional NWS Hospital using a protocol based on the Fast Track approach described by Kehlet in 1999.ERAS has been shown to improve postoperative recovery,reduce length of stay and enhance early return to normal function when compared with traditional colorectal surgical protocols.The role of laparoscopic surgery in colorectal resections within a fast-track (ERAS) program is controversial.The current evidence suggests that within such a program,there is no difference between laparoscopic and open colorectal surgery in terms of postoperative recovery rates or length of hospital stay.

Introducing an enhanced recovery after surgery program in colorectal surgery:A single center experience

AIM:To study the implementation of an enhanced recovery after surgery(ERAS)program at a large University Hospital from"pilot study"to"standard of care".METHODS:The study was designed as a prospective single centre cohort study.A prospective evaluation of compliance to a protocol based on full application of all ERAS principles,through the progressive steps of its implementation,was performed.Results achieved in the initial pilot study conducted by a dedicated team(n=47)were compared to those achieved in the shared protocol phase(n=143)three years later.Outcomes were length of postoperative hospital stay,readmission rate,compliance to the protocol and morbidity.Primary endpoint was the description of the results and the identification of critical issues of large scale implementation of an ERAS program in colorectal surgery emerged in the experience of a single center.Secondary endpoint was the identification of interventions that have been proven to be effective for facilitating the transition from traditional care pathways to a multimodal management protocol according to ERAS principles in colorectal surgery at a single center.RESULTS:During the initial pilot study(March 2009 to December 2010;47 patients)conducted by a dedicated multidisciplinary team,compliance to the items of ERAS protocol was 93%,with a median length of hospital stay(LOS)of 3 d.Early anastomotic fistulas were observed in 2 cases(4.2%),which required reoperation(Clavien-Dindo gradeⅢb).None of the patients had been discharged before the onset of the complication,which could therefore receive prompt treatment.There were also four(8.5%)minor complications(ClavienDindo gradeⅡ).Thirty days readmission rate was 4%.Perioperative mortality was nil.After implementation of the protocol throughout the Hospital in unselected patients(May 2012 to December 2012;147 patients)compliance was 74%,with a median LOS of 6 d.Early anastomotic fistulas were observed in 11 cases(7.7%),5(3.5%)of which required reoperation(Clavien-Dindo gradeⅢb).Two early anastomotic fistulas were treated by radiologic/endoscopic manoeuvres and 4 were treated conservatively.There were also 36(25.2%)minor complications,21(14.7%)of which were Clavien-Dindo gradeⅡand 15(10.5%)of which were Clavien-Dindo gradeⅠ.Only two patients whose course was adversely affected by the development of an anastomotic leak had been discharged before the onset of the complication itself,requiring readmission.Readmission rate within 30 d was 4%.Perioperative mortality was 1%.CONCLUSION:Our results confirm that introduction of an ERAS protocol for colorectal surgery allows quickerpostoperative recovery and shortens the length of stay compared to historical series.

Application of enhanced recovery after gastric cancer surgery: An updated meta-analysis

AIM To provide an updated assessment of the safety and efficacy of enhanced recovery after surgery(ERAS) protocols in elective gastric cancer(GC) surgery.METHODS Pub Med, Medline, EMBASE, World Health Organization International Trial Register, and Cochrane Library were searched up to June 2017 for all available randomized controlled trials(RCTs) comparing ERAS protocols and standard care(SC) in GC surgery. Thirteen RCTs, with a total of 1092 participants, were analyzed in this study, of whom 545 underwent ERAS protocols and 547 received SC treatment.RESULTS No significant difference was observed between ERAS and control groups regarding total complications(P = 0.88), mortality(P = 0.50) and reoperation(P = 0.49). The incidence of pulmonary infection was significantly reduced(P = 0.03) following gastrectomy. However, the readmission rate after GC surgery nearly tripled under ERAS(P = 0.009). ERAS protocols significantly decreased the length of postoperative hospital stay(P < 0.00001) and medical costs(P < 0.00001), and accelerated bowel function recovery, as measured by earlier time to the first flatus(P = 0.0004) and the first defecation(P < 0.0001). Moreover, ERAS protocols were associated with a lower level of serum inflammatory response, higher serum albumin, and superior shortterm quality of life(QOL).CONCLUSION Collectively, ERAS results in accelerated convalescence, reduction of surgical stress and medical costs, improved nutritional status, and better QOL for GC patients. However, high-quality multicenter RCTs with large samples and long-term follow-up are needed to more precisely evaluate ERAS in radical gastrectomy.

Application value of enhanced recovery after surgery for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy

AIM To evaluate the safety and feasibility of enhanced recovery after surgery(ERAS) for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy.METHODS The clinical data of 42 patients who were divided into an ERAS group(n = 20) and a control group(n = 22) were collected. The observed indicators included operation conditions, postoperative clinical indexes, and postoperative serum stress indexes. Measurement data following a normal distribution are presented as mean ± SD and were analyzed by t-test. Count data were analyzed by χ~2 test.RESULTS The operative time, volume of intraoperative blood loss, and number of patients with conversion to opensurgery were not significantly different between the two groups. Postoperative clinical indexes, including the time to initial anal exhaust, time to initial liquid diet intake, time to out-of-bed activity, and duration of hospital stay of patients without complications, were significantly different between the two groups(t = 2.045, 8.685, 2.580, and 4.650, respectively, P < 0.05 for all). However, the time to initial defecation, time to abdominal drainage-tube removal, and the early postoperative complications were not significantly different between the two groups. Regarding postoperative complications, on the first and third days after the operation, the white blood cell count(WBC) and C reactive protein(CRP) and interleukin-6(IL-6) levels in the ERAS group were significantly lower than those in the control group.CONCLUSION The perioperative ERAS program for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy is safe and effective and should be popularized. Additionally, this program can also reduce the duration of hospital stay and improve the degree of comfort and satisfaction of patients.