Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations 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 Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model Urethral catheter‐less robotic‐assisted radical prostatectomy Enhanced Recovery After Surgery Protocols Are Valuable in Pancreas Surgery Patients. Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery Fast‐track surgery: the next revolution in surgical care following laparoscopy The effect of formalizing enhanced recovery after esophagectomy with a protocol. The Effectiveness of Psychosocial Interventions as Adjuncts to Orthopaedic Surgery: A Systematic Review Protocol Enhanced Recovery Program following Colorectal Resection in the Elderly Patient Enhanced recovery after liver surgery. Evidence-Based Protocol for Infection Control in Immediate Implant-Based Breast Reconstruction Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: A randomized controlled trial. Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial A systematic review of enhanced recovery protocols in colorectal surgery. Enhanced recovery in colorectal surgery: a multicentre study Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. Initial Experiences of an Enhanced Recovery Protocol in Esophageal Surgery Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients Multimodal optimization of surgical care shows beneficial outcome in gastrectomy surgery. Processes of Care in Autogenous Breast Reconstruction with Pedicled TRAM Flaps: Expediting Postoperative Discharge in an Ambulatory Setting Pregabalin in acute and chronic pain Increased Risk for Complications After Colorectal Surgery With Selective Cyclo-oxygenase 2 Inhibitor Etoricoxib Fluid Management for Laparoscopic Colectomy: A Prospective, Randomized Assessment of Goal-Directed Administration of Balanced Salt Solution or Hetastarch Coupled with an Enhanced Recovery Program Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists Use of activity tracking in major visceral surgery—the Enhanced Perioperative Mobilization (EPM) trial: study protocol for a randomized controlled trial Prospective comparison of perioperative antibiotic management protocols in oncological head and neck surgery. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Enhanced Recovery After Surgery Versus Conventional Perioperative Care in Rectal Surgery Perioperative Nonselective Non-steroidal Anti-inflammatory Drugs Are Not Associated with Anastomotic Leakage After Colorectal Surgery Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial) Perioperative Blood Transfusion Requirements in Pediatric Scoliosis Surgery: The Efficacy of Tranexamic Acid Substitution of Usual Perioperative Care by eHealth to Enhance Postoperative Recovery in Patients Undergoing General Surgical or Gynecological Procedures: Study Protocol of a Randomized Controlled Trial Is multimodal analgesia as effective as postoperative patient-controlled analgesia following upper extremity surgery? Web-Based Education Prior to Knee Arthroscopy Enhances Informed Consent and Patient Knowledge Recall: A Prospective, Randomized Controlled Study. Cost-effectiveness of Enhanced Recovery Versus Conventional Perioperative Management for Colorectal Surgery Goal-directed Fluid Therapy Does Not Reduce Primary Postoperative Ileus after Elective Laparoscopic Colorectal Surgery: A Randomized Controlled Trial Perioperative goal-directed therapy and postoperative outcomes in patients undergoing high-risk abdominal surgery: a historical-prospective, comparative effectiveness study Recovery after open and laparoscopic right hemicolectomy: a comparison. Value of Delayed-Enhancement Cardiovascular Magnetic Resonance Imaging in Predicting Myocardial Viability After Surgical Revascularization A comparison in five European Centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection Blood lactate and pyruvate levels in the perioperative period of liver resection with Pringle maneuver. Prospective, randomized trial comparing fluids and dobutamine optimization of oxygen delivery in high-risk surgical patients [ISRCTN42445141] Transversus abdominis plane block versus perioperative intravenous lidocaine versus patient-controlled intravenous morphine for postoperative pain control after laparoscopic colorectal surgery: study protocol for a prospective, randomized, double-blind controlled clinical trial Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. Multimodal perioperative care plus immunonutrition versus traditional care in total hip arthroplasty: a randomized pilot study Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets. The future of fast‐track surgery Managing novel oral anticoagulants in patients with atrial fibrillation undergoing device surgery: Canadian survey. Surgical Management of Bile Duct Injuries Sustained During Laparoscopic Cholecystectomy: Perioperative Results in 200 Patients The Effect of Elevated Body Mass Index on Outcomes Following Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program Perioperative antibiotics in the setting of microvascular free tissue transfer: current practices. Effect of early administration of the N-methyl-d-aspartate receptor antagonist amantadine on the development of postmastectomy pain syndrome: a prospective pilot study. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. Propranolol Attenuates Surgical Stress–Induced Elevation of the Regulatory T Cell Response in Patients Undergoing Radical Mastectomy Antibiotic Prophylaxis in High-Risk Head and Neck Surgery: One-Day vs. Five-Day Therapy The Effect of Transversus Abdominis Plane Blocks on Postoperative Pain in Laparoscopic Colorectal Surgery: A Prospective, Randomized, Double-Blind Trial Short-term quality of life in patients undergoing colonic surgery using enhanced recovery after surgery program versus conventional perioperative management Magnesium infusion reduces perioperative pain. The Feasibility and Perioperative Complications of Outpatient Knee Arthroplasty Effects of goal-directed fluid therapy on enhanced postoperative recovery: An interventional comparative observational study with a historical control group on oesophagectomy combined with ERAS program. The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer Observation of clinical efficacy of application of enhanced recovery after surgery in perioperative period on esophageal carcinoma patients. Brief smoking cessation intervention in relation to breast cancer surgery: a randomized controlled trial. Intraoperative tranexamic acid use in major spine surgery in adults: a multicentre, randomized, placebo-controlled trial† Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery: A Consensus Statement of the International Society of Minimally Invasive Cardiothoracic Surgery (ISMICS) 2005 Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: Impact of measures to improve adherence. EnROL: A multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme Personalised perioperative care by e-health after intermediate-grade abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial Fast-track surgery in laparoscopic radical prostatectomy: basic principles Fluid management during video-assisted thoracoscopic surgery for lung resection: a randomized, controlled trial of effects on urinary output and postoperative renal function. Chemotherapy and targeted therapy for women with human epidermal growth factor receptor 2-negative (or unknown) advanced breast cancer: American Society of Clinical Oncology Clinical Practice Guideline. Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery: A Randomized Clinical Trial (LAFA-study) Randomized controlled trial of perioperative antimicrobial therapy based on the results of preoperative bile cultures in patients undergoing biliary reconstruction The effect of beta-blocker dosing strategy on regulation of perioperative heart rate and clinical outcomes in patients undergoing vascular surgery: a randomized comparison. Is chemical antithrombotic prophylaxis effective in elective thoracolumbar spine surgery? Results of a systematic review Comparison of effects of epidural bupivacaine and intravenous meperidine analgesia on patient recovery following elective abdominal aortic surgery Comparison of Perioperative Oral Multimodal Analgesia Versus IV PCA for Spine Surgery Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Short-term safety outcomes of mastectomy and immediate implant-based breast reconstruction with and without mesh (iBRA): a multicentre, prospective cohort study Elimination of preoperative mechanical bowel preparation in patients undergoing cystectomy and urinary diversion. Intravenous versus epidural analgesia to reduce the incidence of gastrointestinal complications after elective pancreatoduodenectomy (the PAKMAN trial, DRKS 00007784): study protocol for a randomized controlled trial Perioperative Anti-Tumor Necrosis Factor Therapy Does Not Increase the Rate of Early Postoperative Complications in Crohn’s Disease A prospective randomized controlled trial to compare Pringle maneuver, hemihepatic vascular inflow occlusion, and main portal vein inflow occlusion in partial hepatectomy. Influence of preoperative oral feeding on stress response after resection for colon cancer. Standardized perioperative care protocols and reduced length of stay after colon surgery. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. The effects of intravenous fluids temperature on perioperative hemodynamic situation, post-operative shivering, and recovery in orthopaedic 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 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 & 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 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 : Enhanced recovery after surgery was compared with traditional recovery after surgery for postmastectomy alloplastic breast reconstruction . Methods : Length of stay , emergency room visits , and complications within 30 days of surgery were compared among three groups : traditional recovery after surgery , transition ( some elements of enhanced recovery protocol , not transitioned to outpatient care ) , and enhanced recovery after surgery ( day surgery , provided with st and ardized perioperative education and multimodal analgesia ) . Prospect i ve data collection allowed quality -of-recovery assessment using a vali date d question naire for enhanced recovery/transition groups . Results were statistically analyzed ( analysis of variance/chi-square ) . Results : The traditional recovery , transition , and enhanced recovery cohorts comprised 29 , 11 , and 29 patients , respectively . No significant differences were present regarding age , smoking status , preoperative radiation , single stage direct-to-implant versus tissue exp and er , bilateral versus unilateral surgery , or immediate versus delayed reconstruction among groups . Average length of stay was 1.6 nights in both the traditional recovery and transition groups , compared with 0 nights in the enhanced recovery group ( p < 0.001 ) . Enhanced recovery patients had less severe pain ( p = 0.02 ) and nausea ( p = 0.01 ) , and better enjoyed their food ( p = 0.0002 ) and felt more rested ( p = 0.02 ) than their transition counterparts . There were no differences in the number of emergency room visits among the three groups ( p = 0.88 ) . There was no difference in the rate of hematoma ( p = 0.36 ) , infection requiring intravenous antibiotics ( p = 0.36 ) , or infection requiring explantation ( p = 0.36 ) among the three groups . Conclusion : An enhanced recovery protocol for alloplastic breast reconstruction treated patients safely , with improved patient satisfaction and same-day discharge and with no increase in complications . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , III © 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 There is increasing interest in implementing comprehensive perioperative protocol s , including preoperative optimization and education , perioperative goal -directed fluid management , and postoperative fast tracking , to enhance recovery after surgery . Data on the outcomes of these protocol s in pancreatic surgery , however , are limited . STUDY DESIGN A retrospective review of a prospect ively maintained pancreas surgery data base at a single institution from August 2012 to April 2015 was undertaken . An enhanced recovery protocol was initiated in October 2014 , and patients were divided into groups according to pre protocol or post protocol implementation . Preoperative , intraoperative , and postoperative data were tabulated . Statistical analysis was performed with Student 's t-test and Fisher 's exact tests , as well as e quality of variances where appropriate , using SAS System software ( SAS Institute ) . RESULTS Three hundred and seventy-eight patients ( 181 men , mean age 54 years , BMI 28 kg/m(2 ) ) underwent elective pancreatic surgery during the study period , 297 patients pre protocol and 81 post protocol . There were no significant differences in preoperative or intraoperative characteristics . Mean postoperative length of stay was significantly lower in the Enhanced Recovery After Surgery group ( 7.4 vs 9.2 days ; p < 0.0001 ) . Hospital costs were similarly lower in the Enhanced Recovery After Surgery group ( $ 23,307.90 vs $ 27,387.80 ; p < 0.0001 ) . Readmission ( 29 % vs 32 % ) and pancreatic fistula ( 26 % vs 28 % ) rates were similar between groups . Delayed gastric emptying was lower in the Enhanced Recovery After Surgery group ( 26 % vs 13 % ; p = 0.03 ) . CONCLUSIONS Implementation of an enhanced recovery after pancreatic surgery protocol significantly decreased length of stay and hospital cost without increasing readmission or morbidity . Despite patient complexity and the potential need for individualization of care , enhanced recovery protocol s can be valuable and effective in high-risk patient population s , including pancreatic surgery patients Coronary artery bypass grafting (CABG)-related bleeding complications and perioperative coronary events are strongly influenced by the management of antithrombotic therapy before and after CABG . Bleeding but also blood products transfusion increase the risk of death and compromise the long-term benefits of CABG.1 The use of new P2Y12 inhibitors , increasing pre-CABG percutaneous coronary interventions ( PCI ) with drug eluting stents ( DES ) requiring specific antiplatelet regimens , and advances in surgical technique has prompted the ESC Working Group on Cardiovascular Surgery and the ESC Working Group on Thrombosis to review the evidence of peri-CABG recommendations on antithrombotic management . Due to the paucity of r and omized trials , most of the evidence is still derived from observational studies and expert consensus , further reinforcing the importance of a multidisciplinary consultation for optimal decision making . # # # Benefits of preoperative aspirin Aspirin ( acetylsalicylic acid , ASA ) is recommended as secondary prevention therapy for all patients with proven coronary artery disease ( CAD ) and without contraindications . Its indication is even stronger for post-CABG patients ( recommendation IA).2 The general consensus is that ASA treatment withdrawal has ominous prognostic implication s in patients with CAD , especially in those with intracoronary stents , and should be advocated only when the bleeding risk clearly outweighs that of atherothrombotic events.3 The benefits of continuing ASA until the day of CABG ( ‘ preoperative ASA ’ ) are less clear and may explain the wide variability in the management of ASA therapy in the perioperative period and differences between guidelines endorsed by different professional and scientific societies ( Supplementary material online , Table S1 ) . This was based on the demonstration that ASA started the day before surgery was no more effective than ASA started 6 h after surgery at improving early ( 7- to 10-day ) graft patency , but was associated with increased bleeding complications.4 More recent evidence suggests , however , that ASA use within 5–7 days prior to CABG 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 Enhanced recovery after surgery ( ERAS ) pathways aim to accelerate functional return and discharge from hospital . They have proven effective in many forms of surgery , most notably colorectal . However , experience in esophagectomy has been limited . A recent study reported significant reductions in pulmonary complications , mortality , and length of stay following the introduction of an ERAS protocol alone , without the introduction of any clinical changes . We instituted a similar change 16 months ago , introducing a protocol to provide a formal framework , for our existing postoperative care . This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change . Data were collected from prospect ively maintained secure web-based multidisciplinary data bases . Complication severity was classified using the Clavien-Dindo scale . Operative mortality was defined as death within 30 days of surgery , or at any point during the same hospital admission . Lower respiratory tract infection was defined as clinical evidence of infection , with or without radiological signs . Respiratory complications included lower respiratory tract infection , pleural effusion ( irrespective of drainage ) , pulmonary collapse , and pneumothorax . Statistical analysis was performed using SPSS v21 . One hundred thirty-two patients underwent esophagectomy ( 55 protocol group ; 77 before ) . All were performed open . There were no differences between the two groups in terms of age , gender , operation , use of neoadjuvant therapy , cell type , stage , tumor site , or American Society of Anesthesiologists grade . Median length of stay was 14.0 days ( protocol ) compared with 12.0 before ( interquartile range 9 - 19 and 9.5 - 15.5 , respectively ; P = 0.073 , Mann-Whitney U-test ) . Readmission within 30 days of discharge occurred in five ( 9.26 % ) and six ( 8.19 % ; P = 1.000 , Fisher 's exact test ) . There were four in-hospital deaths ( 3.03 % ) : one ( 1.82 % ) and three ( 3.90 % ) , respectively ( P = 0.641 ) . There were no differences in the severity of complications ( P = non-significant ; Pearson 's chi-squared ) . There were no differences in the type of complications occurring in either group . The protocol was completed successfully by 26 ( 47.3 % ) . No baseline factors were predictive of this . In contrast to previous studies , we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol . Consequently , improvements in short-term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care . Consequently , we would recommend that centers introducing new ( or review ing existing ) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such st and ardized pathways AIMS Pain and anxiety are commonly reported among those undergoing orthopaedic surgery . Improvement in anxiety and pain control might be achieved by supplementing st and ard care with psychological interventions . However , the effectiveness of adjunctive psychosocial interventions in anxiety and pain control have not been addressed sufficiently by previous systematic review s in orthopaedic surgeries . The present study aim ed to assess the effectiveness of adjunctive psychosocial techniques to improve perioperative clinical care in orthopaedic surgery , to identify the most effective intervention types and to evaluate potential moderators . METHODS We will perform a systematic review and meta- analysis to address the study aims . PubMed , PsycINFO , CINAHL and ProQuest Dissertations & Theses will be search ed between 1980 and 2015 . Prospect i ve controlled clinical trials completed in adults , contrasting st and ard care and st and ard care supplemented with psychosocial methods  , will be eligible for inclusion . Effectiveness will be assessed through the outcomes of postoperative pain intensity , analgesic requirement , perioperative anxiety , quality of life and postoperative recovery . The results of a r and om-effect meta- analysis will be reported . To aid implementation of best practice , moderating effects of the type and timing of psychosocial intervention , type of surgical intervention and type of anaesthesia will be evaluated through meta-regression . Sensitivity analyses and subgroup contrasts will follow as necessary . DISCUSSION Recommendations will be made to improve medical care in orthopaedic procedures . The quality of evidence will be rated using GRADE criteria . Copyright © 2016 John Wiley & Sons , Background The enhanced recovery program ( ERP ) aims to reduce the metabolic response to surgery , hastening recovery and shortening hospital stay . Concerns exist regarding morbidity and hospital stay in elderly patients . The present study aim ed to compare the outcomes and compliance of elderly patients managed by an ERP protocol with a younger group . Methods A review was performed of a prospect i ve data base of patients undergoing colorectal resection managed under the ERP protocol between 2005 and 2010 . Patients were grouped into < 80 years and ≥80 years , and perioperative data were collated . The postoperative outcomes were compared with the goals set out by the ERP protocol . Results A total of 688 patients were included , 558 were < 80 years ( median : 66 years ; range : 17–79 years ) and 130 were ≥80 years ( median : 83 years ; range : 80–95 years ) . Some 96 % of operations were planned laparoscopically . Median total length of hospital stay was 6 days ( range : 1–108 days ) for the < 80 year group and 8 days ( range : 1–167 days ; P 0.363 ) for the elderly group , with a 30 day readmission rate of 8.6 % for the population and no significant differences between groups . The 30 day mortality was 5 % , with a significant difference between the two groups ( P < 0.0001 ) . Differences in protocol adherence were identified in the discontinuation of intravenous fluids , catheter removal , and early mobilization . Conclusions An enhanced recovery program is feasible for colorectal surgery patients ≥80 years of age , with similar compliance as the younger group to some aspects of the protocol and an acceptable readmission rate . Attention to improving compliance in the postoperative phase is necessary , particularly in such high-risk patients , as such improvement may reduce the morbidity and mortality INTRODUCTION In a majority of cases , enhanced recovery after surgery program ( ERP ) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery . The program 's preoperative , perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team . Having shown its merits in digestive surgery , ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail . The objective of this review was to evaluate the efficacy of ERP  in liver surgery . METHOD This is a systematic narrative review of the literature on the efficacy of ERP  in liver surgery by laparotomy or laparoscopy . RESULTS Notwithst and ing a number of studies ( n=30 : 5 r and omized trials , 14 cohort studies and 11 meta-analyses ) less sizable than with regard to digestive surgery in general and colorectal surgery in particular , analysis of the literature confirms that in liver surgery , ERP is associated with an overall decrease in complications by 30 to 60 % , but without improvement in the rates of hospital readmission and postoperative mortality . All of the studies report a reduction in average length of stay ( ALOS ) by 2.3 days and in functional recovery , a more objective indicator than ALOS , by 2.5 days . As of now , the economic impact of the ERP programs in liver surgery is neither positive nor negative , the above-mentioned savings being counterbalanced by heightened costs for material and equipment . Laparoscopic surgery is independently associated with better outcomes in terms of complications , functional recovery and ALOS ; that is why it is important to incorporate this surgical approach in ERP as often as possible . Given a lack of robust evidence , Prehabilitation , which is a preoperative optimization process leading to improved functional reserve , has yet to be assigned a place in ERP programs pertaining to liver surgery . Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader , a motivated multidisciplinary team , training courses and dedicated teaching sessions . CONCLUSION ERP is a care improvement process that has a major play to play in organization of liver surgery , and its large-scale application is to be recommended Abstract Immediate breast implant reconstruction has among the highest incidence of infections in plastic surgery . A literature search returned key articles that showed a significant decrease in surgical-site infections by performing nasal swab evaluation to treat methicillin-sensitive and methicillin-resistant Staphylococcus aureus before surgery with mupirocin nasal ointment and 5 days of chlorhexidine scrub to the surgical area . Additional Level 1 data supported the use of chlorhexidine-alcohol over povidone-iodine solutions for skin preparation . Intraoperative data on breast pocket irrigation showed the benefits of povidone-iodine as well as a triple antibiotic solution . Nasal swabs from 120 patients showed no methicillin-resistant S. aureus but did identify 10 patients with methicillin-sensitive S. aureus , 1 with streptococcus , and 3 with gram-negative rods , which changed perioperative antibiotic management . On the basis of the previously mentioned data , an evidence -based protocol for infection control was developed to potentially decrease infection rates . Further cost and efficacy data are warranted BACKGROUND & AIMS Evidence of the advantages of enhanced recovery after surgery ( ERAS ) protocol s following pancreaticoduodenectomy ( PD ) is limited . The aim of this study was to examine the efficiency of ERAS protocol s in patients following PD . METHODS Between June 2014 and October 2016 , patients undergoing PD were r and omly assigned to receive ERAS protocol s or st and ard care . The primary endpoint was the postoperative length of stay . Secondary endpoints included postoperative complications , postoperative quality -of-life ( QoR-40J ) , readmission , and medical cost . RESULTS Of 80 eligible patients , 74 were analyzed in intention-to-treat principles : 37 in the control group and 37 in the ERAS group . The mean length of stay in the ERAS group was significantly shorter than that in the control group ( 20.1 ± 5.4 vs 26.9 ± 13.5 days , P < 0.001 ) . The ERAS group had a significantly lower percentage of postoperative complications ( 32.4 % vs 56.8 % , P = 0.034 ) and readmissions ( 0 % vs 8.1 % , P = 0.038 ) . Quality -of-life was also significantly better in the ERAS group ( 184 ± 12.4 vs 177 ± 14.5 , P = 0.022 ) . The total medical cost was lower in the ERAS group , but not significantly ( $ 25,445 ± 5065 vs $ 28,384 ± 9999 , P = 0.085 ) . CONCLUSIONS The optimization of ERAS protocol s in patients undergoing PD  is safe and accelerates perioperative recovery and quality -of-life , thereby reducing the length of stay . Morbidity was significantly decreased in the ERAS group without compromising surgical outcome . REGISTRATION NUMBER UMIN000014068 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 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 Major colorectal surgery usually requires a hospital stay of more than 12 days . Inadequate pain management , intestinal dysfunction and immobilisation are the main factors associated with delay in recovery . The present work assesses the short and medium term results achieved by an enhanced recovery program based on previously published protocol s. Methods This prospect i ve study , performed at 12 Spanish hospitals in 2008 and 2009 , involved 300 patients . All patients underwent elective colorectal resection for cancer following an enhanced recovery program .  The main elements of this program were : preoperative advice , no colon preparation , provision of carbohydrate-rich drinks one day prior and on the morning of surgery , goal directed fluid administration , body temperature control during surgery , avoiding drainages and nasogastric tubes , early mobilisation , and the taking of oral fluids in the early postoperative period . Perioperative morbidity and mortality data were collected and the length of hospital stay and protocol compliance recorded . Results The median age of the patients was 68 years . Fifty-two % of the patients were women . The distribution of patients by ASA class was : I 10 % , II 50 % and III 40 % . Sixty-four % of interventions were laparoscopic ; 15 % required conversion to laparotomy . The majority of patients underwent sigmoidectomy or right hemicolectomy .  The overall compliance to protocol was approximately 65 % , but varied widely in its different components . The median length of postoperative hospital stay was 6 days . Some 3 % of patients were readmitted to hospital after discharge ; some 7 % required repeat surgery during their initial hospitalisation or after readmission . The most common complications were surgical ( 24 % ) , followed by septic ( 11 % ) or other medical complications ( 10 % ) . Three patients ( 1 % ) died during follow-up . Some 31 % of patients suffered symptoms that delayed their discharge , the most common being vomiting or nausea ( 12 % ) , dyspnoea ( 7 % ) and fever ( 5 % ) . Conclusion The following of this enhanced recovery program posed no risk to patients in terms of morbidity , mortality and shortened the length of their hospital stay . Overall compliance to protocol was 65 % . The following of this program was of benefit to patients and reduces costs by shortening the length of hospital stay . The implantation of such programmes is therefore highly recommended OBJECTIVE Enhanced recovery after surgery ( ERAS ) has led to a paradigm shift in various surgical specialties . Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process . Still , ERAS remains relatively new to spine surgery . The authors report their 5-year experience , focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures , including anterior lumbar interbody fusion ( ALIF ) . METHODS A multimodal ERAS protocol was applied between November 2013 and October 2018 . The authors analyze hospital stay , perioperative outcomes , readmissions , and adverse events obtained from a prospect i ve institutional registry .  Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive ( MI ) anterior or posterior fusion cases were included . Their institutional ERAS protocol contains 22 pre- , intra- , and postoperative elements , including preoperative patient counseling , MI techniques , early mobilization and oral intake , minimal postoperative restrictions , and regular audits . RESULTS A total of 2592 consecutive patients were included , with 199 ( 8 % ) undergoing fusion . The mean hospital stay was 1.1 ± 1.2 days , with 20 ( 0.8 % ) 30-day and 36 ( 1.4 % ) 60-day readmissions . Ninety-four percent of patients were discharged after a maximum 1-night hospital stay . Over the 5-year period , a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed ( p < 0.001 ) , with a concomitant decrease in adverse events in the overall cohort ( p = 0.025 ) and without increase in readmissions . For fusion procedures , the rate of 1-night hospital stays increased from 26 % to 85 % ( p < 0.001 ) . Similarly , the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days ( p < 0.001 ) , with a notable concomitant decrease in variance , result ing in an estimated reduction in nursing costs of 46.8 % . CONCLUSIONS Application of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures , including ALIF , for treatment of degenerative spine conditions was safe and effective , without increase in readmissions . The data from this large case series stress the importance of the multidisciplinary , iterative improvement process to overcome the learning curve associated with ERAS implementation , and the importance of a dedicated perioperative care team . Prospect i ve trials are needed to evaluate spinal ERAS on a higher level of evidence Background A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery ( ERAS ) programs . Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce . We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease . Methods The ERAS program was initiated in 2009 . Patients who underwent esophagectomy and were treated according to the ERAS program were included . Items of ERAS included preoperative nutrition , early extubation , early removal of nasogastric tube , and early mobilization . Primary outcome parameters were hospital stay and the incidence of postoperative complications . Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol . A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient . Results Between 2008 and August 2010 , 181 patients in our department underwent esophagectomy .  Of these , 103 patients were included in the ERAS program ( ERAS+ group ) and were compared to 78 patients who had undergone an esophagectomy in 2008 ( ERAS– group ) .  Overall hospital stay was 14 days versus 15 days ( ERAS+ and ERAS– , respectively ; p = 0.013 ) . There were no significant differences in the incidence of postoperative complications in either group . The percentage of achieved items varied between 42 and 93 % per item . Conclusions The implementation of an ERAS program in esophageal surgery was feasible and result ed in a small but significant reduction in overall hospital stay , whereas overall morbidity was not affected Aim : Enhanced recovery after surgery ( ERAS ) is a multimodal approach that aims to optimize perioperative treatment . Whether elderly patients receiving colorectal surgery can adhere to and benefit from an ERAS approach is uncertain . The aim of this study was to compare patients in different age groups participating in an ERAS program .  Method : In this sub study of a r and omized controlled trial , we analyzed the interventional ERAS arm of adult patients eligible for laparoscopic or open colorectal resection with regard to the importance of age . Patients were divided into three groups based on age : ≤65 years ( n = 79 ) , 66 - 79 years ( n = 56 ) , and ≥80 years ( n = 19 ) . The primary end point was total postoperative hospital stay ( THS ) . Secondary end points were postoperative hospital stay , postoperative complications , postoperative C-reactive protein levels , readmission rate , mortality , and patient adherence to the different  ERAS elements . All parameters and measuring the adherence to the ERAS protocol were recorded before surgery , on the day of the operation , and daily until discharge . Results : There were no significant differences in length of THS between age groups ( ≤65 years , median 5 [ range 2 - 47 ] days ; 66 - 79 years , median 5.5 [ range 2 - 36 ] days ; ≥80 years , median 7 [ range 3 - 50 ] days ; p = .53 ) . All secondary outcomes were similar between age groups . Patient adherence to the ERAS protocol was as good in the elderly as it was in the younger patients . Conclusion : Elderly patients adhered to and benefited from an ERAS program , similar to their younger counterparts BACKGROUND The aim of this trial was to compare multimodal optimization with conventional perioperative management in a consecutive series of patients undergoing gastrectomy procedures . METHODS According to r and omized controlled studies and conclusions made by meta-analyses in colorectal surgery , optimized perioperative measures were design ed and applied in gastrectomy surgery . Thirty-three patients were r and omized to the optimized group and 30 patients to a control group .  Two groups were treated in 1 center by a single surgical team in different wards . Both groups used patient-controlled intravenous analgesia for postoperative analgesia . The primary end point was length of postoperative hospital stay . Secondary outcomes included bowel function recovery after surgery , perioperative changes of inflammatory factors , glucocorticoid , insulin resistance , and body composition . Perioperative complications and adverse events were also recorded . RESULTS The groups were similar in terms of age , sex ratio , and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity ( POSSUM score ) . The optimized group was associated with a significantly shorter postoperative hospital stay compared with the conventional care group ( P < .001 ) . Duration s of urinary catheterization and abdominal drainage were also less ( P < .001 ) . The diet program in the optimization group was well tolerated and was associated with an earlier recovery of gut function ( P < .001 ) . Proinflammatory factors were less elevated and body composition was more stable in the optimized group than in controls . There were no differences in morbidity or mortality between the groups . CONCLUSIONS Optimization of care in gastrectomy can shorten postoperative hospital stay and provides multiple beneficial outcomes , including hastening the return of gut function , without increasing morbidity Background : A multidisciplinary patient care plan was developed to facilitate early discharge following autogenous breast reconstruction and included ( 1 ) preadmission patient education , ( 2 ) perioperative multimodal pain management , ( 3 ) intraoperative nerve blocks , and ( 4 ) postdischarge telephone advice . This study evaluated the success of this care plan in the first 18 months after its implementation . Methods : A retrospective cohort study of all consecutive women undergoing pedicled transverse rectus abdominis myocutaneous ( TRAM ) flap breast reconstruction ( November of 2009 to May of 2011 ) was performed . The primary outcome was time to discharge ; secondary outcomes included complications , readmission , and self-report pain at discharge . Predictors of discharge time were analyzed using stepwise multivariable regression modeling . Results : Ninety-one women ( mean age , 50.0 ± 8.5 years ) underwent pedicled TRAM flap reconstruction ( 76 percent unilateral and 81 percent delayed ) , with 77 percent receiving the intended multimodal analgesia protocol . Mean time to discharge was 38.7 ± 27.6 hours . Overall , 40 percent of patients were discharged within 24 hours , but successful early discharge increased significantly over the study period . Key predictors of shorter time to discharge were use of multimodal analgesia , lower American Society of Anesthesiologists class , and surgery more than 6 months after implementation of the care plan . Conclusions : The authors ’ initial experience has supported the safety and feasibility of expedited discharge following pedicled TRAM flap breast reconstruction , with adherence to the authors ’ care plan improving steadily over the study period . Multimodal pain management proved a key modifiable factor in facilitating early discharge . A prospect i ve study is currently underway to evaluate patient-reported quality of recovery following ambulatory surgery in this population . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , IV Pregabalin is a gamma-amino-butyric acid analog shown to be effective in several models of neuropathic pain , incisional injury , and inflammatory injury . In this review , the role of pregabalin in acute postoperative pain and in chronic pain syndromes has been discussed . Multimodal perioperative analgesia with the use of gabapentinoids has become common . Based on available evidence from r and omized controlled trials and meta- analysis , the perioperative administration of pregabalin reduces opioid consumption and opioid-related adverse effects in the first 24 h following surgery . Postoperative pain intensity is however not consistently reduced by pregabalin . Adverse effects like visual disturbance , sedation , dizziness , and headache are associated with higher doses . The advantage of the perioperative use of pregabalin is so far limited to laparoscopic , gynecological , and daycare surgeries which are not very painful . The role of the perioperative administration of pregabalin in preventing chronic pain following surgery , its efficacy in more painful surgeries and surgeries done under regional anesthesia , and the optimal dosage and duration of perioperative pregabalin need to be studied . The efficacy  of pregabalin in  chronic pain conditions like  painful diabetic neuropathy , postherpetic neuralgia , central neuropathic pain  , and fibromyalgia has been demonstrated BACKGROUND : Cyclo-oxygenase 2 inhibitors can be used for pain treatment after colorectal surgery . OBJECTIVE : The aim of this study was to investigate whether the use of etoricoxib has negative effects on the perioperative outcome in colorectal surgery . DESIGN : Complication data from an advanced medical data base system were sample d prospect ively , and patient records were review ed retrospectively . PATIENTS : All patients with elective colorectal surgery within an enhanced recovery after surgery protocol from 2008 to 2009 were selected . INTERVENTION : The nonr and omized use of perioperative etoricoxib treatment was compared with a control group . MAIN OUTCOME MEASURES : The primary outcome measured was the number of patients with postoperative complications according to the Dindo-Clavien classification . RESULTS : One hundred one patients received etoricoxib treatment , whereas 104 did not . The patient groups were very comparable . We observed a significant increase in the number of patients with postoperative complications with etoricoxib treatment ( 43 vs 30 patients ; 42.6 % vs 28.8 % , p = 0.041 ) due to an increase in patients with a major complication ( Dindo-Clavien complication grade III – V : 22.8 % vs 9.6 % , p = 0.01 ) . Patients with etoricoxib treatment and a complication needed a longer recovery period than patients with a complication in the control group ( 18 ( 17 ; 20 ) vs 14 ( 13 ; 15 ) days , p = 0.05 ) . We observed an increased level of postoperative serum creatinine with etoricoxib treatment ( 105 ( 98 ; 112 ) vs 82 ( 78 ; 85 ) , p = 0.003 ) , which was more pronounced in patients with a complication ( 141 ( 127 ; 155 ) vs 91 ( 83 ; 98 ) , p = 0.002 ; 25 vs 8 patients with serum creatinine > 100 & mgr;mol/L , p = 0.008 ) . In multivariate analysis , etoricoxib was identified as an independent risk factor for experiencing a major complication with a risk increase of approximately 2.5-fold ( p = 0.03 ) . LIMITATIONS : This study was limited by the nonr and omized use of perioperative etoricoxib and the retrospective nature of its review of patient records . CONCLUSIONS : Etoricoxib increased the number of patients with postoperative complications and should be considered carefully in colorectal surgery INTRODUCTION : No consensus exists regarding the optimal fluid ( crystalloid or colloid ) or strategy ( liberal , restricted , or goal directed ) for fluid management after colectomy . Prior assessment s have used normal saline . This is the first assessment of st and ard , goal -directed perioperative fluid management with either lactated Ringer ’s or hetastarch/lactated Ringer ’s , with use of esophageal Doppler for guidance , in laparoscopic colectomy with an enhanced recovery protocol . METHODS : A double-blinded , prospect i ve , r and omized , three-armed study with Institutional Review Board approval was used for patients undergoing laparoscopic segmental colectomy assigned to the st and ard , goal -directed/lactated Ringer ’s and goal -directed/hetastarch groups .  A st and ard anesthesia and basal fluid administration protocol was used in addition to the goal -directed strategies guided by esophageal Doppler . RESULTS : Sixty-four patients undergoing laparoscopic colectomy ( 22 st and ard , 21 goal -directed/lactated Ringer ’s , 21 goal -directed/hetastarch ) had similar operative times ( st and ard , 2.3 hours ; goal -directed/lactated Ringer ’s , 2.5 hours ; goal -directed/hetastarch , 2.3 hours ) . The lactated Ringer ’s group received the greatest amount of total and milliliters per kilogram per hour of operative fluid ( st and ard , 2,850/18 ; goal -directed/lactated Ringer ’s , 3,800/23 ; and goal -directed/hetastarch , 3,300/17 ; P < 0.05 ) . The hetastarch group had the longest stay ( st and ard , 64.9 hours ; goal -directed/lactated Ringer ’s , 71.8 hours ; goal -directed/hetastarch , 75.5 hours ; P < 0.05 ) . The st and ard group received the greatest amount of fluid during hospitalization ( st and ard , 2.5 ml/kg/h ; goal -directed/lactated Ringer ’s , 1.9 ml/kg/h ; goal -directed/hetastarch , 2.1 ml/kg/h ; P < 0.05 ) . There was one instance of operative mortality in the goal -directed/hetastarch group . CONCLUSIONS : Goal -directed fluid management with a colloid/balanced salt solution offers no advantage and is more costly . However , goal -directed , individualized intraoperative fluid management with crystalloid should be evaluated further as a component of enhanced recovery protocol s following colectomy because of reduced overall fluid administration Introduction Several studies have demonstrated that perioperative hemodynamic optimization has the ability to improve postoperative outcome in high-risk surgical patients . All of these studies aim ed at optimizing cardiac output and /or oxygen delivery in the perioperative period . We conducted a survey with the American Society of Anesthesiologists ( ASA ) and the European Society of Anaesthesiology ( ESA ) to assess current hemodynamic management practice s in patients undergoing high-risk surgery in Europe and in the United States . Methods A survey including 33 specific questions was emailed to 2,500 r and omly selected active members of the ASA and to active ESA members . Results Overall , 368 question naires were completed , 57.1 % from ASA and 42.9 % from ESA members . Cardiac output is monitored by only 34 % of ASA and ESA respondents ( P = 0.49 ) while central venous pressure is monitored by 73 % of ASA respondents and 84 % of ESA respondents ( P < 0.01 ) . Specifically , the  pulmonary artery catheter  is being used much more frequently in the US than in Europe in the setup of high-risk surgery ( 85.1 % vs. 55.3 % respectively , P < 0.001 ) . Clinical experience , blood pressure , central venous pressure , and urine output are the most widely indicators of volume expansion . Finally , 86.5 % of ASA respondents and 98.1 % of ESA respondents believe that their current hemodynamic management could be improved . Conclusions In conclusion , these results point to a considerable gap between the accumulating evidence about the benefits of perioperative hemodynamic optimization and the available technologies that may facilitate its clinical implementation , and clinical practice s in both Europe and the United States Background Enhanced recovery after surgery ( ERAS ) programs are aim ed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles . “ Early mobilization ” is one such principle , but the quality of assessment and monitoring is poor , and evidence of improved outcome is lacking . Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization . The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristb and s. Methods / design Patients undergoing elective open and laparoscopic surgery of the colon , rectum , stomach , pancreas , and liver for any indication will be included . Further inclusion criteria are age between 18 and 75 years , American Society of Anesthesiologists Physical Status class less than IV , and a signed informed consent form . Patients will be stratified into two subgroups , laparoscopic and open surgery , and will be r and omized 1:1 for automatic feedback of their step count using an activity tracker wristb and . The control group will have no automatic feedback . The sample size ( n = 30 patients in each of the four groups , overall n = 120 ) is calculated on the basis of an assumed difference in step count of 250 steps daily ( intervention group versus control group ) . The primary study endpoint is the average step count during the first 5 postoperative days ; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization ( step count ) targets , assessment of additional activity data obtained from the devices , assessment of preoperative mobility , length of hospital and intensive care unit stays , number of patients who receive physiotherapy , 30-day mortality , and overall 30-day morbidity . Discussion Early mobilization is a key element of ERAS . However , enhanced early mobilization is difficult to define , to assess objective ly , and to implement in clinical practice . Consequently , there is a discrepancy between ERAS targets and actual practice , especially in patients undergoing major visceral surgery . This study is the first r and omized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization . Trial registration Clinical Trials.gov identifier : NCT02834338 . Registered on 15 June 2016 OBJECTIVES The adequate perioperative antibiotic prophylaxis in head and neck cancer surgery is an important and easy applicable tool to decrease nosocomial morbidity and mortality by reducing the rate of infections . In the study a strictly perioperative antibiosis is compared with an extended postoperative prophylactic antibiosis . We aim to clarify the value of postoperative prophylactic antibiosis for the recovery and clinical course of patients . MATERIAL AND METHODS In this prospect i ve study 75 consecutive patients , who underwent major oncological head and neck surgery were included and divided in three groups , each containing 25 patients . The first group received peri- and postoperative antibiotic prophylaxis ( POAP ) from the day of operation until the fifth day postoperatively . The second group was treated with perioperative antibiotic prophylaxis ( PEAP ) only . The third group received perioperative antibiotic prophylaxis and increased local antiseptic care ( PAPAC ) . General anamnestic data was collected , as well as duration of hospitalisation , stay on intensive care unit , rate and type of infections , surgical closure of the tracheostomy , and postoperative blood parameters . RESULTS There were no statistically significant differences in general diseases or extent of surgery between the groups . There were statistically significant fewer patients suffering from surgical site infections in subjects with POAP ( n = 1 ) in comparison to PEAP ( n = 9 ; p = 0.011 ) and PAPAC ( n = 9 ; p = 0.011 ) . In contrast , other nosocomial infections ( pneumonia , urinary tract infection , sepsis ) did not decrease under a prolonged antibiotic prophylaxis . CONCLUSION Based on findings of the study , we recommend an extended postoperative antibiotic prophylaxis for patients undergoing major oncological head and neck surgery BACKGROUND The ERAS ( enhanced recovery after surgery ) care has been shown in r and omized clinical trials to improve outcome after colorectal surgery compared to traditional care . The impact of different levels of compliance and specific elements , particularly out with a trial setting , is poorly understood . OBJECTIVE This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection . METHODS The international , multicenter ERAS registry data , collected between November 2008 and March 2013 , was review ed . Patient demographics , disease characteristics , and perioperative ERAS protocol compliance were assessed . Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication . FINDINGS A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries .  Median length of stay for colorectal resections was 6 days , with readmissions in 216 ( 9.2 % ) , complications in 948 ( 40 % ) , and reoperation in 167 ( 7.1 % ) of 2352 patients . Laparoscopic surgery was associated with reduced complications [ odds ratio ( OR ) = 0.68 ; P < 0.001 ] and length of stay ( OR = 0.83 , P < 0.001 ) . Increasing ERAS compliance was correlated with fewer complications ( OR = 0.69 , P < 0.001 ) and shorter primary hospital admission ( OR = 0.88 , P < 0.001 ) . Shorter hospital stay was associated with preoperative carbohydrate and fluid loading ( OR = 0.89 , P = 0.001 ) , and totally intravenous anesthesia ( OR = 0.86 , P < 0.001 ) ; longer stay was associated with intraoperative epidural analgesia ( OR = 1.07 , P = 0.019 ) . Reduced postoperative complications were associated with restrictive perioperative intravenous fluids ( OR = 0.35 , P < 0.001 ) . CONCLUSIONS This analysis has demonstrated that in a large , international cohort of patients , increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome BACKGROUND : Enhanced recovery after surgery programs have been developed to improve recovery , shorten hospital stays , and reduce morbidity . OBJECTIVE : The aim of the current study was to examine the effects of the enhanced recovery program on the outcome of rectal surgery . DESIGN : A cohort of patients who underwent open rectal surgery after an enhanced recovery program was compared with a historic case-matched control group receiving conventional perioperative care . Patients were matched for type of surgery , disease , comorbidity , and demographic characteristics . Data regarding fast-track targets , length of hospital stay , mortality , complications , relaparotomies , and readmissions were collected . RESULTS : Forty-one patients in the enhanced recovery group were compared with 82 case-matched patients receiving conventional care .  The length of hospital stay ( median : 8 days vs 12 days , P < .005 ) was reduced in the enhanced recovery after surgery group . There were no significant differences in epidural use , mortality , morbidity , and readmission rates between groups . LIMITATIONS : This study performed an intention-to-treat analysis for the multimodal enhanced recovery program in rectal surgery . Specific elements of the program were not analyzed separately . The study used nonr and omly assigned historic controls for comparison . CONCLUSION : Enhanced recovery after surgery programs help to reduce the length of hospital stay after rectal surgery Introduction Recent evidence raises concern about the use of perioperative non-steroidal anti-inflammatory drug ( NSAID ) use after colorectal resection . The purpose of this retrospective cohort study was to investigate the relationship between perioperative ketorolac use and anastomotic leakage after colorectal surgery . Methods A retrospective review ( 2004–2011 ) was performed on patients who underwent elective colorectal surgery .  Univariate analysis and multivariate logistic regression were used to evaluate the association between patients who did not receive any  NSAIDs and those who received ketorolac within the first 5 days perioperatively and leak rate . Results A total of 731 patients were identified as having resection with primary anastomosis : 376 ( 51.4 % ) received no NSAIDs and 355 ( 48.6 % ) received ketorolac perioperatively within 5 days after their surgery . There were 24 ( 3.3 % ) leaks , with 12 in both the no NSAIDs ( 3.2 % ) and ketorolac ( 3.4 % ) groups , odds ratio ( OR ) 1.06 ( 0.43 , 2.62 ; p = 0.886 ) . Adjusting for smoking , steroid use , and age , there remained no significant difference between  ketorolac use and leakage , OR 1.21 ( 0.52 , 2.84 ; p = 0.660 ) . In our multivariate model , only smoking was a significant predictor of postoperative leak , OR 3.34 ( 1.30 , 8.62 ; p = 0.021 ) . Conclusions There does not appear to be a significant association between perioperative ketorolac use and anastomotic leakage after colorectal surgery . However , further prospect i ve studies are needed to confirm our findings before definitive guidelines on NSAID use perioperatively can be recommended Background Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track recovery programs . Both focus on a faster recovery and shorter hospital stay . The r and omized controlled multicenter LAFA-trial ( LAparoscopy and /or FAst track multimodal management versus st and ard care ) was conceived to determine whether laparoscopic surgery , fast track perioperative care or a combination of both is to be preferred over open surgery with st and ard care in patients having segmental colectomy for malignant disease . Methods / design The LAFA-trial is a double blinded , multicenter trial with a 2 × 2 balanced factorial design . Patients eligible for segmental colectomy for malignant colorectal disease i.e. right and left colectomy and anterior resection will be r and omized to either  open or laparoscopic colectomy  , and to either st and ard care or the fast track program . This factorial design produces four treatment groups ; open colectomy with st and ard care ( a ) , open colectomy with fast track program ( b ) , laparoscopic colectomy with st and ard care ( c ) , and laparoscopic surgery with fast track program ( d ) . Primary outcome parameter is postoperative hospital length of stay including readmission within 30 days . Secondary outcome parameters are quality of life two and four weeks after surgery , overall hospital costs , morbidity , patient satisfaction and readmission rate . Based on a mean postoperative hospital stay of 9 + /- 2.5 days a group size of 400 patients ( 100 each arm ) can reliably detect a minimum difference of 1 day between the four arms ( alfa = 0.95 , beta = 0.8 ) . With 100 patients in each arm a difference of 10 % in subscales of the Short Form 36 ( SF-36 ) question naire and social functioning can be detected . Discussion The LAFA-trial is a r and omized controlled multicenter trial that will provide evidence on the merits of fast track perioperative care and laparoscopic colorectal surgery in patients having segmental colectomy for malignant disease Background : Previous studies have noted that the use of antifibrinolytic medications can help reduce blood loss and transfusion requirements during cardiac , total joint arthroplasty , and spine surgery . Tranexamic acid ( TXA ) has been investigated in these patient groups but consensus with respect to the dosing regimen has not been achieved , especially in the pediatric scoliosis literature . The purpose of this study was to compare the effects of 2 TXA dosing regimens on reducing transfusion requirements . Methods : A retrospective chart review was performed on all idiopathic scoliosis patients undergoing posterior spinal instrumentation and fusion from 2005 to 2006 to determine total perioperative transfusion requirements . Transfusion requirements for those patients receiving either a low ( 10 mg/kg loading , 1 mg/kg/h infusion ) or high ( 20 mg/kg loading , 10 mg/kg/h infusion ) dose of TXA were compared . Results : High-dose TXA ( n = 11 ) showed a trend toward a reduction in transfusion requirements compared with the low dose ( n = 15 ) for idiopathic scoliosis patients undergoing posterior only instrumentation and fusion ( 687.9 ± 778.1 mL vs 1372.6 ± 1077.3 mL ; P = 0.07 ; 95 % confidence interval for the mean difference , −66.3 mL to 1435.7 mL ) . Although substantial , this difference was underpowered to show a difference . Conclusions : The use of the higher dose of TXA result ed in a 50 % reduction in transfusion requirements for idiopathic scoliosis patients . Given previous studies , there appears to be a dose-response effect . A prospect i ve dose-ranging study is now required to determine the optimal dose for pediatric patients with idiopathic scoliosis . Level of Evidence : III , retrospective cohort study Background Due to the strong reduction in the length of hospital stays in the last decade , the period of in-hospital postoperative care is limited . After discharge from the hospital , guidance and monitoring on recovery and resumption of ( work ) activities are usually not provided . As a consequence , return to normal activities and work after surgery is hampered , leading to a lower quality of life and higher costs due to productivity loss and increased health care consumption . Objective With this study we aim to evaluate whether an eHealth care program can improve perioperative health care in patients undergoing commonly applied abdominal surgical procedures , leading to accelerated recovery and to a reduction in costs in comparison to usual care . Methods This is a multicenter r and omized , single-blinded , controlled trial . At least 308 patients between 18 and 75 years old who are on the waiting list for a laparoscopic cholecystectomy , inguinal hernia surgery , or laparoscopic adnexal surgery for a benign indication will be included . Patients will be r and omized to an intervention or control group . The intervention group will have access to an innovative , perioperative eHealth care program . This intervention program consists of a website , mobile phone app , and activity tracker . It aims to improve patient self-management and empowerment by providing guidance to patients in the weeks before and after surgery . The control group will receive usual care and will have access to a nonintervention ( st and ard ) website consisting of the digital information brochure about the surgical procedure being performed . Patients are asked to complete question naires at 5 moments during the first 6 months after surgery . The primary outcome measure is time to return to normal activities based on a patient-specific set of 8 activities selected from the Patient-Reported Outcomes Measurement Information System ( PROMIS ) physical functioning item bank version 1.2 . Secondary outcomes include social participation , self-rated health , duration of return to work , physical activity , length of recovery , pain intensity , and patient satisfaction . In addition , an economic evaluation alongside this r and omized controlled trial will be performed from the societal and health care perspective . All statistical analyses will be conducted according to the intention-to-treat principle . Results The enrollment of patients started in September 2015 . The follow-up period will be completed in February 2017 . Data cleaning and analyses have not begun as of the time this article was su bmi tted . Conclusions We hypothesize that patients receiving the intervention program will resume their normal activities sooner than patients in the control group and costs will be lower . Clinical Trial Netherl and s Trial Registry NTC4699 ; http://www.trialregister.nl/trialreg/admin/ rct view.asp?TC=4699 ( Archived by WebCite at http://www.webcitation.org/6mcCBZmwy INTRODUCTION The present prospect i ve study compared the clinical outcomes between a multimodal analgesia group and a patient-controlled analgesia ( PCA ) group for postoperative pain control in upper extremities surgery . HYPOTHESIS Multimodal analgesia including pre-emptive analgesic can provide similar or superior analgesic effects and a lower incidence of adverse reactions than PCA following upper extremity surgery . PATIENTS AND METHODS Sixty-one patients undergoing upper extremity surgery were r and omized to 2 perioperative analgesic groups ( multimodal analgesia and PCA )  . We compared the clinical outcomes : use of additional pain rescue , opioid-related complication rate , and patient 's satisfaction between the 2 groups . RESULTS No significant differences on the resting and exercise pain scores between the two groups . Also , there were no differences regarding additional pain rescue during postoperative day ( POD ) 1 , 2 and achievement of rehabilitation protocol in both groups . However , use of additional pain rescue in PCA group was increased significantly after PCA removal . Moreover , there was significant difference in the incidence of opioid-related complications on operation day and at POD 1 . At discharge , multimodal analgesia group showed significantly greater satisfaction than PCA group . DISCUSSION Perioperative pain management following upper extremity surgery through the multimodal analgesia could be an acceptable alternative method that can provide good results BACKGROUND Preoperative patient education is an important part of the informed consent process , and a perceived lack of information can lower patient satisfaction . We sought to evaluate the effect of a web-based multimedia patient education tool on the perioperative experience of patients undergoing first-time knee arthroscopy for a meniscal tear . METHODS Adult patients undergoing knee arthroscopy for the first time for a primary diagnosis of a meniscal tear were consecutively enrolled into the study from January 2014 through June 2014 . Patients were equally r and omized to a control group , who received st and ard preoperative counseling , or the intervention group , who completed a twenty-minute web-based multimedia tutorial in addition to st and ard counseling . The web-based tutorial covered relevant anatomy , pathology , and general perioperative instructions , and it was completed prior to the preoperative visit . Patients completed surveys that evaluated their preparedness for surgery and knowledge recall at the preoperative visit , on the day of surgery , and after the first postoperative visit . RESULTS Sixty-four patients were enrolled , and fifty-five patients ( 86 % ; twenty-nine in the control group and twenty-six in the intervention group ) with complete data sets were included in the analysis . Preoperatively , the intervention group felt significantly more informed about the surgery and more clearly understood the risks and benefits of , and alternatives to , the surgery ( all p < 0.001 ) . Postoperatively , the intervention group reported being significantly more satisfied with the perioperative education that they had received and felt more informed about their surgery and rehabilitation ( p ≤ 0.05 ) . Patients in the intervention group were significantly more likely to correctly answer questions regarding their surgical details at the first postoperative visit ( p ≤ 0.03 ) . CONCLUSIONS Patients who completed the web-based tutorial had improved preoperative knowledge and preparedness as well as enhanced postoperative knowledge recall regarding their surgical procedure . The tutorial received high user satisfaction scores with low user burden scores and was an effective tool for enhancing the patients ' perioperative experience Objective : To determine the cost-effectiveness of enhanced recovery pathways ( ERPs ) versus conventional care for patients undergoing elective colorectal surgery . Background : ERPs for colorectal surgery are clinical ly effective , but their cost-effectiveness is unknown . Methods : A multi-institutional prospect i ve cohort cost-effectiveness analysis was performed . Adult patients undergoing elective colorectal resection at 2 university-affiliated institutions from October 2012 to October 2013 were enrolled . One center used an ERP , whereas the other did not . Postoperative outcomes were recorded up to 60 days . Total costs were reported in 2013 Canadian dollars . Effectiveness was measured using the SF-6D , a health utility measure vali date d for postoperative recovery . Uncertainty was expressed using bootstrapped estimates ( 10,000 repetitions ) . Results : A total of 180 patients were included  ( conventional care : n = 95 ; ERP : n = 95 ) . There were no differences in patient characteristics except for a higher proportion of laparoscopy in the ERP group . Mean length of stay was shorter in the ERP group ( 6.5 vs 9.8 days ; P = 0.017 ) , but there were no differences in complications or readmissions . Patients in the ERP group returned to work quicker and had less caregiver burden . There was no difference in quality of life between the 2 groups . The cost of the ERP program was $ 153 per patient . Overall societal costs were lower in the ERP group ( mean difference = −2985 ; 95 % confidence interval , −5753 to −373 ) . The ERP had a greater than 99 % probability of cost-effectiveness . The results were insensitive to a range of assumptions and subgroups . Conclusions : Enhanced recovery is cost-effective compared with conventional perioperative management for elective colorectal resection Background : Inadequate perioperative fluid therapy impairs gastrointestinal function . Studies primarily evaluating the impact of goal -directed fluid therapy on primary postoperative ileus are missing . The objective of this study was to determine whether goal -directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program . Methods : R and omized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program . Patients were assigned r and omly to receive intraoperative goal -directed fluid therapy ( goal -directed fluid therapy group ) or fluid therapy based on traditional principles ( control group ) .  Primary postoperative ileus was the primary outcome . Results : One hundred twenty-eight patients were included and analyzed ( goal -directed fluid therapy group : n = 64 ; control group : n = 64 ) . The incidence of primary postoperative ileus was 22 % in the goal -directed fluid therapy and 22 % in the control group ( relative risk , 1 ; 95 % CI , 0.5 to 1.9 ; P = 1.00 ) . Intraoperatively , patients in the goal -directed fluid therapy group received less intravenous fluids ( mainly less crystalloids ) but a greater volume of colloids . The increase of stroke volume and cardiac output was more pronounced and sustained in the goal -directed fluid therapy group . Length of hospital stay , 30-day postoperative morbidity , and mortality were not different . Conclusions : Intraoperative goal -directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program . Its previously demonstrated benefits might have been offset by advancements in perioperative care Introduction Perioperative goal -directed therapy ( PGDT ) may improve postoperative outcome in high-risk surgery patients but its adoption has been slow . In 2012 , we initiated a performance improvement ( PI ) project focusing on the implementation of PGDT during high-risk abdominal surgeries . The objective of the present study was to evaluate the effectiveness of this intervention . Methods This is a historical prospect i ve quality improvement study . The goal of this initiative was to st and ardize the way fluid management and hemodynamic optimization are conducted during high-risk abdominal surgery in the Departments of Anesthesiology and Surgery at the University of California Irvine . For fluid management , the protocol consisted in st and ardized baseline crystalloid administration of 3 ml/kg/hour and any additional boluses based on PGDT . The impact of the intervention was assessed on the length of stay in the hospital ( LOS ) and post-operative complications ( NSQIP data base ) . Results In the 1 year pre- and post-implementation periods , 128 and 202 patients were included . The average volume of fluid administered during the case was 9.9 ( 7.1–13.0 ) ml/kg/hour in the pre-implementation period and 6.6 ( 4.7–9.5 ) ml/kg/hour in the post-implementation period ( p < 0.01 ) . LOS decreased from 10 ( 6–16 ) days to 7 ( 5–11 ) days ( p = 0.0001 ) . Based on the multiple linear regression analysis , the estimated coefficient for intervention was 0.203 ( SE = 0.054 , p = 0.0002 ) indicating that , with the other conditions being held the same , introducing intervention reduced LOS by 18 % ( 95 % confidence interval 9–27 % ) . The incidence of NSQIP complications decreased from 39 % to 25 % ( p = 0.04 ) . Conclusion These results suggest that the implementation of a PI program focusing on the implementation of PGDT can transform fluid administration patterns and improve postoperative outcome in patients undergoing high-risk abdominal surgeries . Trial registration Clinical trials.gov NCT02057653 . Registered 17 December 2013 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 Background —Despite the accepted utility of delayed-enhancement MRI in identifying irreversible myocardial injury , no study has yet assessed its role as a viability tool exclusively in the setting of coronary artery bypass surgery ( CABG ) , and no study has repeated delayed-enhancement MRI late after revascularization . In a clinical trial in which patients underwent CABG by either the off-pump or on-pump surgical technique , we hypothesized that ( 1 ) preoperative delayed-enhancement MRI would have high diagnostic accuracy in predicting viability and ( 2 ) the occurrence of perioperative myocardial necrosis would affect late regional wall motion recovery . Methods and Results —Fifty-two patients undergoing multivessel CABG  were studied by preoperative and early ( day 6 ) and late ( 6 months ) postoperative cine MRI for global and regional functional assessment and delayed-enhancement MRI for assessment of irreversible myocardial injury . Preoperatively , 611 segments ( 21 % ) had abnormal regional function , whereas 421 segments ( 14 % ) showed evidence of hyperenhancement . At 6 months after revascularization , 57 % ( 343 of 611 ) of dysfunctional segments improved contraction by at least 1 grade . When all preoperative dysfunctional segments were analyzed , there was a strong correlation between the transmural extent of hyperenhancement and the recovery in regional function at 6 months ( P<0.001 ) . Of a total of 96 previously dysfunctional but nonenhancing or minimally hyperenhancing myocardial segments that did not improve regional function at 6 months , 35 ( 36 % ) demonstrated new perioperative hyperenhancement in the early postoperative MRI scan . Conclusions —Delayed-enhancement MRI is a powerful predictor of myocardial viability after surgery , suggesting an important role for this technique in clinical viability assessment BACKGROUND & AIMS This study review ed the case mix , clinical management , and clinical outcomes of patients undergoing colorectal resection in five European centres performing different forms of conventional or ' fast-track ' perioperative care . METHODS The perioperative care programme and surgical practice in each centre was defined . Patient data were collected by case-note review on an internet-based audit system . Case mix was determined using ASA classification and the P-POSSUM scoring system . RESULTS A total of 451 consecutive patients from units practicing either conventional ( Sweden , n=109 ; UK , n=87 ; Netherl and s , n=76 , Norway , n=61 ) or fast-track surgery ( Denmark , n=118 ) , were studied between 1998 and 2001 . Elements of perioperative practice varied widely both between units practicing ' traditional ' care and the reference ' fast-track ' unit ( Denmark ) . Based on the P-POSSUM scores , the case mix was similar between centres . There were no differences in morbidity or 30-day mortality between the different centres . The median length of stay was 2 days in Denmark and 7 - 9 days in the other centres ( P<0.05 ) . The readmission rate was 22 % in Denmark and 2 - 16 % in the other centres ( P<0.05 ) . CONCLUSION Compared with traditional care , fast-track perioperative care results in a reduced length of hospital stay but may be associated with a higher readmission rate . Morbidity and mortality appears to be similar with either approach . Prospect i ve evaluation of the potential benefits of the fast-track approach in different European centres is merited Enhanced recovery after surgery ( ERAS ) pathways have been associated with improved perioperative outcomes following several surgical procedures . Less is known , however , regarding their use following hepatic surgery INTRODUCTION Bleeding during liver surgery is often routinely controlled by the Pringle maneuver consisting in the temporary clamping of hepatic artery , portal vein , and bile duct . This study aim ed at investigating a possible influence of the Pringle maneuver on tissue hypoxia during liver resection . METHODS Twenty-five consecutive patients undergoing elective liver resection were prospect ively r and omized either to be treated with the Pringle maneuver ( Pringle group , n = 14 ) or without clamping ( Controls , n = 11 ) . Blood lactate levels , pyruvate levels , and hepatic vein oxygen saturation were monitored perioperatively . RESULTS Patients were comparable with respect to resection time , intraoperative blood loss , and duration of surgery . The Pringle maneuver induced a significant increase in arterial lactate levels during liver resection when compared to Controls ( 2.6 + /- 0.3 vs 1.8 + /- 0.2 mmol/l ; p < 0.05 ) . Further , the Pringle maneuver significantly increased hepatic venous lactate ( 3.3 + /- 0.3 vs 1.6 + /- 0.3 mmol/l ; p < 0.05 ) and lactate/pyruvate ratio in hepatic venous blood ( 43 + /- 8 vs 21 + /- 5 ; p < 0.05 ) during surgery . This was paralleled by a temporal decrease in hepatic venous oxygen saturation in the Pringle group ( 61 + /- 4 vs 73 + /- 4 % ; p < 0.05 ) . CONCLUSION Our findings demonstrate that liver metabolism and tissue oxygenation were markedly affected by occlusion of the liver hilus . Restricting the use of the Pringle maneuver to cases with severe bleeding might therefore be beneficial in patients undergoing liver resection Introduction Preventing perioperative tissue oxygen debt contributes to a better postoperative recovery . Whether the beneficial effects of fluids and inotropes during optimization of the oxygen delivery index ( DO2I ) in high-risk patients su bmi tted to major surgeries are due to fluids , to inotropes , or to the combination of the two is not known . We aim ed to investigate the effect of DO2I optimization with fluids or with fluids and dobutamine on the 60-day hospital mortality and incidence of complications . Methods A r and omized and controlled trial was performed in 50 high-risk patients ( elderly with coexistent pathologies ) undergoing major elective surgery .  Therapy consisted of pulmonary artery catheter-guided hemodynamic optimization during the operation and 24 hours postoperatively using either fluids alone ( n = 25 ) or fluids and dobutamine ( n = 25 ) , aim ing to achieve supranormal values ( DO2I > 600 ml/minute/m2 ) . Results The cardiovascular depression was an important component in the perioperative period in this group of patients . Cardiovascular complications in the postoperative period occurred significantly more frequently in the volume group ( 13/25 , 52 % ) than in the dobutamine group ( 4/25 , 16 % ) ( relative risk , 3.25 ; 95 % confidence interval , 1.22–8.60 ; P < 0.05 ) . The 60-day mortality rates were 28 % in the volume group and 8 % in the dobutamine group ( relative risk , 3.00 ; 95 % confidence interval , 0.67–13.46 ; not significant ) . Conclusion In patients with high risk of perioperative death , pulmonary artery catheter-guided hemodynamic optimization using dobutamine determines better outcomes , whereas fluids alone increase the incidence of postoperative complications Background Despite the laparoscopic approach becoming the st and ard in colorectal surgery , postoperative pain management for minimally invasive surgery is still mainly based on strategies that have been established for open surgical procedures . Patient-controlled epidural and intravenous analgesia are considered st and ard postoperative analgesia regimens in colorectal surgery . Epidural analgesia provides excellent analgesia , but is increasingly scrutinized in laparoscopic surgery since postoperative pain after the laparoscopic approach is significantly reduced . Moreover , epidural analgesia can be associated with numerous complications . Therefore , epidural analgesia is no longer recommended for the management of postoperative pain in laparoscopic colorectal surgery . Likewise , patient-controlled intravenous analgesia is subject to significant side effects . Given these important limitations of the traditional strategies for postoperative analgesia , effective and efficient alternatives in patients undergoing laparoscopic colorectal surgery are needed . Both the transversus abdominis plane block and systemically administered lidocaine have already been reported to effectively reduce pain after laparoscopic colorectal surgery . We hypothesize that the transversus abdominis plane block is superior to perioperative intravenous lidocaine . Methods / design One hundred and twenty five patients undergoing laparoscopic colorectal surgery will be included in this prospect i ve , r and omized , double-blind controlled clinical trial . Patients will be r and omly allocated to three different postoperative strategies : postoperative patient-controlled intravenous analgesia with morphine ( control group , n = 25 ) , a transversus abdominis plane block with ropivacaine 0.375 % at the end of surgery plus postoperative patient-controlled intravenous analgesia with morphine ( TAP group , n = 50 ) , or perioperative intravenous lidocaine plus postoperative patient-controlled intravenous analgesia with morphine ( LIDO group , n = 50 ) . As the primary outcome parameter , we will evaluate the opioid consumption during the first 24 postoperative hours . Secondary endpoints include the Numeric Rating Scale , time to return of intestinal function , time to mobilization , inflammatory response , incidence of postoperative nausea and vomiting , length of hospital stay and postoperative morbidity as assessed with the Clavien-Dindo classification . Discussion Recognizing the importance of a multimodal approach for perioperative pain management , we aim to investigate whether a transversus abdominis plane block delivers superior pain control in comparison to perioperative intravenous lidocaine and patient-controlled intravenous analgesia with morphine alone . Trial registration EudraCT Identifier : 2014 - 001499 - 73 ; 31 July 2014 BACKGROUND Evidence -based guidelines on optimal perioperative fluid management have not been established , and recent r and omized trials in major abdominal surgery suggest that large amounts of fluid may increase morbidity and hospital stay . However , no information is available on detailed functional outcomes or with fast-track surgery . Therefore , we investigated the effects of two regimens of intraoperative fluids with physiological recovery as the primary outcome measure after fast-track colonic surgery . METHODS In a double-blind study , 32 ASA I-III patients undergoing elective colonic surgery were r and omized to ' restrictive ' ( Group 1 ) or ' liberal ' ( Group 2 ) perioperative fluid administration .  Fluid algorithms were based on fixed rates of crystalloid infusions and a st and ardized volume of colloid .  Pulmonary function ( spirometry ) was the primary outcome measure , with secondary outcomes of exercise capacity ( submaximal exercise test ) , orthostatic tolerance , cardiovascular hormonal responses , postoperative ileus ( transit of radio-opaque markers ) , postoperative nocturnal hypoxaemia , and overall recovery within a well-defined multimodal , fast-track recovery programme . Hospital stay and complications were also noted . RESULTS ' Restrictive ' ( median 1640 ml , range 935 - 2250 ml ) compared with ' liberal ' fluid administration ( median 5050 ml , range 3563 - 8050 ml ) led to significant improvement in pulmonary function and postoperative hypoxaemia . In contrast , we found significantly reduced concentrations of cardiovascularly active hormones ( renin , aldosterone , and angiotensin II ) in Group 2 . The number of patients with complications was not significantly different between the groups [ 1 ( ' liberal ' group ) [ corrected ] vs 6 ( ' restrictive ' group ) [ corrected ] patients , P = 0.08 ] . CONCLUSIONS A ' restrictive ' [ corrected ] fluid regimen led to a transient improvement in pulmonary function and postoperative hypoxaemia but no other differences in all-over physiological recovery compared with a ' liberal ' [ corrected ] fluid regimen after fast-track colonic surgery . Since morbidity tended to be increased with the ' restrictive ' fluid regimen , future studies should focus on the effect of individualized ' goal -directed ' fluid administration strategies rather than fixed fluid amounts on postoperative outcome 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 : BACKGROUND Obesity is a growing epidemic in the United States ( US ) affecting more than 33 % of adults . We aim ed to use the World Health Organization ( WHO ) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP data base from 2005 to 2010 . STUDY DESIGN We review ed the 2005 to 2010 ACS-NSQIP data bases identifying encounters for Current Procedural Terminology ( CPT ) codes including either implant-based reconstruction ( immediate , delayed , and tissue exp and er ) or autologous reconstruction ( pedicled transverse rectus abdominis myocutaneous [ pTRAM ] , free TRAM , and latissimus dorsi flap with or without implant ) .  Patients were classified and compared based on WHO obesity criteria : nonobese ( body mass index [ BMI ] = 20 to 29.9 kg/m(2 ) ) , class I ( BMI = 30 to 34.9 kg/m(2 ) ) , class II ( BMI = 35 to 39.9 kg/m(2 ) ) , and class III ( BMI > 40 kg/m(2 ) ) . RESULTS During the study period 15,937 breast reconstructions were performed . The majority of reconstructions were immediate reconstructions ( 85.0 % ) and implant-based ( 79.1 % ) . The incidence of obesity was 27.1 % , with 16.3 % defined as class I obese , 6.9 % defined as class II obese , and 4.0 % defined as class III obese . The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions , higher American Society of Anesthesiologists ( ASA ) physical status ( p < 0.001 ) , longer operative times ( p = 0.0001 ) , and greater lengths of hospital stay ( p = 0.0001 ) . Progressively higher BMI s were associated with higher rates of complications , including wound ( p < 0.001 ) , medical ( p < 0.001 ) , infections ( p < 0.001 ) , major surgical ( p < 0.001 ) , graft and prosthesis loss ( p < 0.001 ) , and return to the operating room ( p < 0.001 ) . CONCLUSIONS This study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large , prospect i ve multicenter data set . Increasing obesity is associated with increased perioperative morbidity . Data derived from this cohort study can be used to risk-stratify patients , enhance risk counseling , and advocate for institutional reimbursement in obese patients undergoing breast reconstruction Since its introduction in the 1990s , the concept of multimodal perioperative care ( fast-track surgery , enhanced recovery programmes ) has gained widespread acceptance and is now considered as a st and ard of care . Most studies that support this approach relate to colorectal surgery , but similar data have been published across surgical specialties with major economic benefits 1–4 . The implementation process has been described in detail and is essentially based on the simple question : ‘ Why is the postoperative patient in hospital today?’1,5 . The relevant question may therefore be asked – what next ? Postoperative length of stay is often seen as the key outcome for fast-track surgery and , although this may not always be appropriate , whatever is used as a primary outcome measure must be justified adequately . It should also be emphasized that significant progress in fast-track care dem and s inclusion and implementation of all of its basic components . Many studies have not implemented the most important aspects of the care programmes that were originally described , including patient information , effective thoracic epidural analgesia with sufficient local anaesthetic that facilitates early mobilization , reduced ileus and rapid re introduction of oral feeding , or the use of non-opioid analgesia , where appropriate , in open or minimally invasive surgery . An important issue that needs to be addressed in future is detailed analysis of ‘ medical ’ versus ‘ surgical ’ morbidity6 . To improve further our underst and ing of perioperative risk , future studies must analyse how one specific complication might lead to another : for instance , whether a pneumonia or myocardial infa rct ion led to an anastomotic dehiscence ; or a wound dehiscence with reoperation led to a subsequent pneumonia , myocardial infa rct ion or thromboembolic complication6 . Initial ‘ medical ’ morbidity may depend on perioperative care principles and pre-existing comorbidity , in contrast to an initial ‘ surgical ’ complication , which may depend on surgical technique , and therefore require a different approach from fast-track methodology . How might the fast-track approach evolve further , as surgeons perform an ever-increasing number of major procedures in older patients with comorbidities , with greater risks of postoperative complications , prolonged hospital stay and death6 ? Preoperative evaluation of operative risk may not be helpful unless evidence -based perioperative interventions are available and instituted . Thus , the specific role of preoperative morbidity , such as smoking , diabetes and cardiopulmonary disease , in determining the risk of postoperative morbidity needs to be reassessed in studies with a fully implemented fast-track procedure-specific programme6 . We also need to have a second look at the relative roles of the different components of the fast-track programme ( for example type of analgesia and fluid management1,5 ) and analyse where progress can be made in order to reduce perioperative risk and morbidity , instead of focusing on length of stay as the primary outcome . The surgical stress response is proportional to the degree of insult and the main factor that contributes to postoperative organ dysfunction1,2 . Every effort should therefore be made to reduce those responses that are undesirable . Regional anaesthetic techniques have a powerful effect on the catabolic response , reducing cardiac dem and s , pain , pulmonary dysfunction and ileus .  Regional anaesthesia should be used whenever possible on a procedure-specific basis7 . Inflammatory responses contribute to pain , fatigue and organ dysfunction . They can be modified pharmacologically by preoperative glucocorticoids8 . Significant reductions in pain , nausea and vomiting , and early fatigue have been demonstrated , facilitating early recovery , so far without demonstrable side-effects . More procedure-specific and dosefinding studies are required . A single preoperative glucocorticoid dose in a larger amount than used for conventional nausea and vomiting prophylaxis might , for instance , be an important contributory factor to improving fast-track programmes in high-risk patients . Minimally invasive surgery also reduces the inflammatory response , although the contribution that this plays in the context of fast-track programmes in colonic surgery is difficult to interpret , as the care programmes used in the ‘ open ’ groups have often not been fully implemented6,9,10 . Therefore , future efforts to assess early postoperative outcome effects of minimally invasive surgery should include r and omized studies with fully implemented fasttrack programmes11 . Newer developments in minimally invasive BACKGROUND Approximately 10 % of patients who undergo surgical procedures require chronic oral anticoagulation . Physicians must balance the thromboembolic and bleeding risks to make informed decisions on whether to continue anticoagulant medication . Evidence is lacking regarding the perioperative management of novel oral anticoagulant ( NOAC ) agents . This survey aims to describe the management of perioperative NOAC use during device implantation by Canadian centres . METHODS A Web-based tool was used to survey all Canadian adult pacemaker/defibrillator implant centres . The survey collected data regarding the perioperative management of NOACs  in atrial fibrillation patients at high risk for thromboembolism who undergo device implantation . RESULTS Twenty-two centres performed approximately 14,971 device implants ; 1150 ( 8 % ) of these implants were in patients who were prescribed a NOAC . In 82 % of centres , the NOAC is discontinued in anticipation of device implantation ; 73 % of these centres do not bridge with heparin . In patients with normal renal function at high risk of thromboembolic events ( Congestive Heart Failure , Hypertension , Age , Diabetes , Stroke/Transient Ischemic Attack ; CHADS2 ≥ 2 ) , 72 % of the centres restart the NOAC within 48 hours of the procedure . For patients with abnormal renal function ( glomerular filtration rate < 80 mL/min ) , the timing of NOAC discontinuation is variable . Hematoma rates vary from 0 to 30 % . CONCLUSIONS Most Canadian centres perform device implantation with NOAC interruption without the use of bridging . The timing of stopping and restarting anticoagulation and incidence of bleeding complications is variable . These findings emphasize the need for r and omized controlled studies to guide the optimal approach to management of NOACs during device implantation Objective : A single institution retrospective analysis of 200 patients with major bile duct injuries was completed . Three patients died without surgery due to uncontrolled sepsis . One hundred seventy-five patients underwent surgical repair , with a 1.7 % postoperative mortality and a complication rate of 42.9 % . Summary Background Data : The widespread application of laparoscopic cholecystectomy ( LC ) has led to a rise in the incidence of major bile duct injuries ( BDI ) . Despite the frequency of these injuries and their complex management , the published literature contains few substantial reports regarding the perioperative management of BDI . Methods : From January 1990 to April 2003 , a prospect i ve data base of all patients with a BDI following LC  was maintained . Patients ’ charts were retrospectively review ed to analyze perioperative surgical management . Results : Over 13 years , 200 patients were treated for a major BDI following LC . Patient demographics were notable for 150 women ( 75 % ) with a mean age of 45.5 years ( median 44 years ) . One hundred eighty-eight sustained their BDI at an outside hospital . The mean interval from the time of BDI to referral was 29.1 weeks ( median 3 weeks ) . One hundred nine patients ( 58 % ) were referred within 1 month of their injury for acute complications including bile leak , biloma , or jaundice . Twenty-five patients did not undergo a surgical repair at our institution . Three patients ( 1.5 % ) died after delayed referral before an attempt at repair due to uncontrolled sepsis . Twenty-two patients , having intact biliary-enteric continuity , underwent successful balloon dilatation of an anastomotic stricture . A total of 175 patients underwent definitive biliary reconstruction , including 172 hepaticojejunostomies ( 98 % ) and 3 end-to-end repairs . There were 3 deaths in the postoperative period ( 1.7 % ) . Seventy-five patients ( 42.9 % ) sustained at least 1 postoperative complication . The most common complications were wound infection ( 8 % ) , cholangitis ( 5.7 % ) , and intraabdominal abscess/biloma ( 2.9 % ) . Minor biliary stent complications occurred in 5.7 % of patients . Early postoperative cholangiography revealed an anastomotic leak in 4.6 % of patients and extravasation at the liver dome-stent exit site in 10.3 % of patients . Postoperative interventions included percutaneous abscess drainage in 9 patients ( 5.1 % ) and new percutaneous transhepatic cholangiography and stent placement in 4 patients ( 2.3 % ) . No patient required reoperation in the postoperative period . The mean postoperative length of stay was 9.5 days ( median 9 days ) . The timing of operation ( early , intermediate , delayed ) , presenting symptoms , and history of prior repair did not affect the incidence of the most common perioperative complications or length of postoperative hospital stay . Conclusions : This series represents the largest single institution experience reporting the perioperative management of BDI following LC . Although perioperative complications are frequent , nearly all can be managed nonoperatively . Early referral to a tertiary care center with experienced hepatobiliary surgeons and skilled interventional radiologists would appear to be necessary to assure optimal results Abstract Background Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy ( CRS-HIPEC ) can prolong survival in peritoneal-based malignancies . These malignancies harbor in visceral and omental adipose tissue , and as a result , obesity may contribute to greater tumor burden . Obesity also is an independent risk factor for perioperative complications following major surgery . No studies to date have investigated the effect of elevated body mass index ( BMI ) on disease burden and perioperative outcomes in CRS-HIPEC patients . Methods Observational study of consecutive patients taken to the operating suite from 2007 to 2012 for CRS-HIPEC .  Data were review ed retrospectively , and patients for whom complete cytoreduction was not achieved and those with BMI < 18.5 were excluded . Various operative data points , including peritoneal cancer index , surgery length , and estimated blood loss , were measured prospect ively . Perioperative complications were identified and recorded . Results Complete data for review was available for 114 patients . Patients were subdivided based on BMI ( group A 18.5–24.9 , n = 43 ; group B 25–29.9 , n = 49 ; group C ≥ 30 , n = 22 ) . There was no statistically significant difference in tumor burden , operative length , probability of unresectable disease , operative blood loss , or length of stay between groups . Rates of respiratory , gastrointestinal , infectious , renal , and hematologic complications were not statistically different , with the exception of deep vein thrombosis ( A = 0 , B = 13.5 % , C = 0 ; p = 0.026 ) . Conclusions CRS-HIPEC can be safely performed in overweight and obese patients without significant increase in perioperative morbidity . Despite the limitations in physical examination and increase in visceral fat , they do not appear to present later than patients with normal BMI , nor do they have higher tumor burden Objective : A prospect i ve r and omized controlled trial ( RCT ) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer . Aims : This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT . Methods : Patients for elective resection for colorectal cancer were offered trial entry . Participants were stratified by sex and requirement for a total mesorectal excision and central ly r and omized .  Multimodal patients received intravenous fluid restriction , unrestricted oral intake with prokinetic agents , early ambulation , and fixed regimen epidural analgesia . Control patients received intravenous fluids to prevent oliguria , restricted oral intake until return of bowel motility , and weaning regimen epidural analgesia . Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets . Discharge decision was made using preagreed criteria . The primary endpoint was postoperative stay , and achievement of independence milestones . Secondary endpoints were postoperative complications , readmission rates , and mortality . Analysis was by intention to treat . Results : Seventy patients were recruited . Approximately one fourth underwent TME . Median ages were similar ( 69.3 vs. 73.0 years ) . The median stay was significantly reduced in the multimodal group ( 5 vs. 7 days ; P < 0.001 , Mann-Whitney U test ) . Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days . Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions . There were 2 deaths , both controls . Conclusions : This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery . Morbidity and mortality are not increased Introduction Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program ( ERP ) . However , the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear . The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection . Methods Prospect ively collected data entered in a registry specifically design ed for ERPs were review ed . Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements . Primary outcome was successful recovery defined as the absence of complications , discharge by postoperative day 4 and no readmission . Secondary outcomes were length of hospital stay ( LOS ) , 30-day morbidity , and severity ( Comprehensive complication index , CCI , 0–100 ) . Regression analyses were adjusted for potential confounders . Results A total of 347 patients were included in the study .  Median primary LOS was 4 days ( IQR 3–7 ) . Patients were adherent to median 18 ( IQR 16–20 ) elements . A total of 156 ( 45 % ) patients had successful recovery . Morbidity occurred in 175 ( 50 % ) patients with median CCI 8.6 ( IQR 0–22.6 ) . There was a positive association between adherence and successful recovery ( OR 1.39 for every additional element , p < 0.001 ) , LOS ( 11 % reduction for every additional element , p < 0.001 ) , 30-day postoperative morbidity ( OR 0.78 , p < 0.001 ) , and the CCI ( 17 % reduction , p < 0.001 ) . Laparoscopy ( OR 4.32 , p < 0.001 ) , early mobilization out of bed ( OR 2.25 , p = 0.021 ) , and early termination of IV fluid infusion ( OR 2.00 , p = 0.013 ) significantly predicted successful recovery . These factors were also associated with reduced morbidity and complication severity . Conclusions Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity . In an established ERP where overall adherence was high , laparoscopic approach , perioperative fluid management , and patient mobilization remain key elements associated with improved outcomes Microvascular free tissue transfer is a ubiquitous and routine method of restoring anatomic defects . There is a paucity of data regarding the role of perioperative antibiotics in free tissue transfer . We design ed a survey to explore usage patterns among microvascular surgeons and thereby define a st and ard of care . A 24- question survey regarding the  perioperative antibiotic use  in microvascular head and neck , breast , and lower extremity reconstruction was sent to all those members of the American Society for Reconstructive Microsurgery who had registered e-mail addresses ( N = 450 ) . Ninety-nine members responded . A first-generation cephalosporin is the most frequent choice of perioperative antibiotics across most categories : 93.5 % for breast , 59.2 % for head and neck , 91.1 % for nontraumatic lower extremity , and 84.9 % for traumatic noninfected lower extremity reconstruction . In penicillin-allergic patients , clindamycin is the most common choice . For traumatic lower extremity reconstruction in the presence of soft tissue infection or osteomyelitis , culture and sensitivity results determine the selection of perioperative antibiotics  in 74 % . A first-generation cephalosporin is the st and ard of care for perioperative antibiotic use in microvascular breast , head and neck , nontraumatic lower extremity , and traumatic noninfected lower extremity reconstruction . No consensus exists regarding the appropriate duration of coverage . These data may serve as a guide until a large controlled prospect i ve trial is performed and a st and ard of care is established UNLABELLED Postmastectomy pain syndrome ( PMPS ) is a neuropathic pain syndrome that might develop after breast surgery . Like many other forms of neuropathic pain , it is relatively resistant to treatment and negatively affects the quality of life . A double-blind , r and omized , placebo-controlled pilot trial was conducted to study the analgesic efficacy of perioperative administration of the N-methyl-D-aspatrate ( NMDA ) receptor antagonist amantadine in preventing PMPS after mastectomy plus axillary lymph node dissection ( ALND ) . In the study group , a regimen of 200 mg/day of amantadine was started 1 day before surgery and continued for 14 days , whereas the control group received a placebo .  Patients were required to indicate the exact location of their pain and to record its level at 1 , 3 , and 6 months after surgery . Neurologic examination and Quantitative Thermal Testing ( QTT ) were performed 1 and 6 months after surgery . On both the neurologic examination and the QTT , all patients , regardless of the perioperative intervention ( amantadine or placebo ) , presented evidence for nerve injury , manifested primarily by painful hypoesthesia ( anesthesia dolorosa ) in the axilla or inner arm . PMPS persisted for the entire duration of the study in 82 % of the patients who were available for follow-up . The average intensity of the pain was moderate in both groups and tended not to decline over time . No differences between the 2 groups in any of the outcome parameters reached statistical significance . According to the results of the present pilot study , the NMDA antagonist amantadine does not prevent the development of PMPS in patients who undergo breast surgery with ALND . PERSPECTIVE Breast surgery that involves ALND seems to uniformly cause nerve injury , which can not be prevented by the perioperative administration of 200 mg of amantadine . It is most commonly presented by painful hypoesthesia or anesthesia dolorosa in the axillary/inner arm area , which is moderate in intensity and likely to persist for at least 6 months PURPOSE To provide evidence -based recommendations to practicing oncologists , surgeons , and radiation therapy clinicians to up date the 2005 clinical practice guideline on the use of sentinel node biopsy ( SNB ) for patients with early-stage breast cancer . METHODS The American Society of Clinical Oncology convened an Up date Committee of experts in medical oncology , pathology , radiation oncology , surgical oncology , guideline implementation , and advocacy . A systematic review of the literature was conducted from February 2004 to January 2013 in Medline . Guideline recommendations were based on the review of the evidence by Up date Committee . RESULTS This guideline up date reflects changes in practice since the 2005 guideline . Nine r and omized clinical trials ( RCTs ) met systematic review criteria for clinical questions 1 and 2 ; 13 cohort studies informed clinical question 3 . RECOMMENDATIONS Women without sentinel lymph node ( SLN ) metastases should not receive axillary lymph node dissection ( ALND ) .  Women with one to two metastatic SLNs planning to undergo breast-conserving surgery with whole-breast radiotherapy should not undergo ALND ( in most cases ) . Women with SLN metastases who will undergo mastectomy should be offered ALND . These three recommendation are based on RCTs . Women with operable breast cancer and multicentric tumors , with ductal carcinoma in situ ( DCIS ) who will undergo mastectomy , who previously underwent breast and /or axillary surgery , or who received preoperative/neoadjuvant systemic therapy may be offered SNB . Women who have large or locally advanced invasive breast cancer ( tumor size T3/T4 ) , inflammatory breast cancer , or DCIS ( when breast-conserving surgery is planned ) or are pregnant should not undergo SNB . These recommendations are based on cohort studies and /or informal consensus . In some cases , up date d evidence was insufficient to up date previous recommendations Surgical stress and inflammatory response induce the release of catecholamines and PGs , which may be key factors in facilitating cancer recurrence through immunosuppression . Animal studies have suggested the efficacy of perioperative blockades of catecholamines and PGs in reducing immunosuppression . In this study , to our knowledge , we present the first report of the effects of perioperative propranolol and /or parecoxib on peripheral regulatory T cells ( Tregs ) in breast cancer patients . Patients were r and omly assigned to control , propranolol , parecoxib , and propranolol plus parecoxib  groups . We demonstrated that levels of circulating epinephrine , norepinephrine , and PGE2 increased in response to surgery . Meanwhile , peripheral FOXP3 mRNA level and Treg frequencies were elevated on postoperative day 7 . Propranolol administration , rather than parecoxib , attenuated such elevation of Tregs , indicating the critical roles for catecholamines in surgery-induced promotion of Tregs . Besides , propranolol plus parecoxib treatment demonstrated no additive or synergistic effects . Furthermore , a study of Treg activity on CD4 + T cell responses to specific tumor Ags was performed in the control and propranolol groups . Propranolol abrogated the increased Treg activity and accompanying suppression of CD4 + T cell responses after surgery . Finally , we conducted ex vivo experiments on the effects of varying concentrations of epinephrine and /or propranolol on Treg proliferation over P BMC s from breast cancer patients , to provide further direct evidence strengthening our clinical observations . Epinephrine markedly promoted Treg proliferation , whereas propranolol prevented such enhancement effect . In conclusion , our study highlights beneficial roles for propranolol in inhibiting Treg responses in vivo and in vitro , and demonstrates that propranolol could alleviate surgical stress – induced elevation of Tregs in breast cancer patients Patients who undergo major contaminated surgery of the head and neck benefit from perioperative antibiotic prophylaxis . This study was developed to determine if 5 days of antibiotic administration would be more effective than 1 day . A multi-institutional prospect i ve r and omized double-blind study was design ed . Patients who were identified as requiring pedicled flap reconstruction were potential c and i date s for the study . Later , patients were r and omly assigned to receive cefoperazone sodium for either 24 hours or 120 hours . In each case , the drug was administered intravenously , beginning 1 to 2 hours preoperatively and continued for the prescribed period . One hundred nine patients were evaluable . Fifty-three patients were assigned to 1 day of perioperative prophylaxis .  Wound Infection developed in ten patients ( 18.9 % ) . Fifty-six patients were assigned to 5 days of perioperative antibiotic prophylaxis .  Wound infection developed in 14 ( 25 % ) of these patients ( P > .05 ) . These data suggest that no beneficial effect from administration of antibiotics for longer than 24 hours postoperatively can be achieved in patients who undergo myocutaneous flap reconstruction BACKGROUND : Superior early pain control has been suggested with transversus abdominis plane blocks , but evidence -based recommendations for transversus abdominis plane blocks and their effects on patient outcomes are lacking . OBJECTIVE : The aim of this study was to determine whether transversus abdominis plane blocks improve early postoperative outcomes in patients undergoing laparoscopic colorectal resection already on an optimized enhanced recovery pathway . DESIGN : This study is based on a prospect i ve , r and omized , double-blind controlled trial . SETTING S : The trial was conducted at a tertiary referral center . PATIENTS : Patients undergoing elective laparoscopic colorectal resection were selected . INTERVENTIONS ( S ) : Patients were r and omly assigned to receive either a transversus abdominis plane block or a placebo placed intraoperatively under laparoscopic guidance . All followed a st and ardized enhanced recovery pathway . Patient demographics , perioperative procedures , and postoperative outcomes were collected . MAIN OUTCOME MEASURES : Postoperative pain and nausea/vomiting scores in the postanesthesia care unit and department , opioid use , length of stay , and 30-day readmission rates were measured . RESULTS : The trial r and omly assigned 41 patients to the transversus abdominis plane block group and 38 patients to the control group .  Demographic , clinical , and procedural data were not significantly different . In the postanesthesia care unit , the transversus abdominis plane block group had significantly lower pain scores ( p < 0.01 ) and used fewer opioids ( p < 0.01 ) than the control group ; postoperative nausea/vomiting scores were comparable ( p = 0.99 ) . The transversus abdominis plane group had significantly lower pain scores on postoperative day 1 ( p = 0.04 ) and throughout the study period ( p < 0.01 ) . There was no significant difference between groups in postoperative opioid use ( p = 0.65 ) or nausea/vomiting ( p = 0.79 ) . The length of stay ( median , 2 days experimental , 3 days control ; p = 0.50 ) and readmission rate ( 7 % experimental , 5 % control , p = 0.99 ) was similar across cohorts . LIMITATIONS : This study was conducted a single center . CONCLUSIONS : Transversus abdominis plane blocks improved immediate short-term opioid use and pain outcomes . Pain improvement was durable throughout the hospital stay . However , the blocks did not translate into less overall narcotic use , shorter length of stay , or lower readmission rates Objective Enhanced recovery after surgery ( ERAS ) integrates evidence -based interventions to reduce surgical stress and accelerate rehabilitation . Our study was to compare the short-term quality of life ( QOL ) in patients undergoing open colonic surgery using ERAS program or conventional management .  Methods A prospect i ve study of 57 patients using ERAS program and 60 patients using conventional management was conducted . The clinical characteristics of all patients were recorded . QOL was evaluated longitudinally using the question naires ( EORTC QLQ-C30 and QLQ-CR29 ) pre- and postoperatively . Generalized estimating equation was used to do the analysis in order to determine the effective impact of correlative factors on the postoperative QOL , including age , sex , BMI , ASA grade , tumor location , tumor size , pTNM stage , recovery program and length of time after surgery . Results The morbidity in ERAS and control group was 17.5 versus 26.7 % ( p = 0.235 ) . The patients in ERAS group had much faster rehabilitation and less hospital stay . In the primary statistical analysis , the scores of global QOL ( on POD3 , POD6 , POD10 , POD14 , POD21 ) , physical functioning ( on POD3 , POD6 , POD10 , POD14 , POD21 ) , role functioning ( on POD6 , POD10 , POD14 , POD21 ) , emotional functioning ( on POD3 , POD6 , POD10 , POD14 , POD21 ) , cognitive functioning ( on POD3 , POD6 ) and social functioning ( on POD3 , POD6 , POD10 , POD14 , POD21 , POD28 ) were higher in ERAS group than in control group , which suggested that the patients in ERAS group had a better life status . However , the scores of pain ( on POD10 , POD14 , POD21 ) , appetite loss ( on POD3 , POD6 ) , constipation ( on POD3 , POD6 , POD10 ) , diarrhea ( on POD3 , POD10 ) , financial difficulties ( on POD10 , POD14 , POD21 ) , perspective of future health ( on POD6 , POD10 , POD14 ) , gastrointestinal tract problems ( on POD3 , POD6 , POD10 ) and defecation problems ( on POD6 , POD10 , POD14 ) were lower in ERAS group than in control group , which revealed that the patients in ERAS group suffered less symptoms . In the further generalized estimating equation analysis , the result showed that recovery program and length of time after surgery had independently positive impact on the patient ’s postoperative QOL . ConclusionS hort-term QOL in patients undergoing colonic cancer using ERAS program was better than that using conventional management BACKGROUND AND OBJECTIVE Magnesium has antinociceptive effects in animal and human models of pain . These effects are primarily based on the regulation of calcium influx into the cell . The aim of this study was to determine whether perioperative infusion of magnesium would reduce postoperative pain and anxiety . METHODS Twenty-four patients , undergoing elective hysterectomy , received a bolus of 30 mg kg(-1 ) magnesium sulphate or the same volume of isotonic sodium chloride solution intravenously before the start of surgery and 0.5 g h(-1 ) infusion for the next 20 h. Intraoperative and postoperative analgesia were achieved with fentanyl and morphine respectively . Patients were evaluated pre- and postoperatively for anxiety . RESULTS Fentanyl consumption and total morphine requirements were significantly decreased in the magnesium group compared to the control group . Postoperative anxiety scores and sedation were similar between groups . CONCLUSIONS Continuous magnesium infusion , including the pre- , intra- , and postoperative periods reduces analgesic requirements . These results demonstrate that magnesium can be an adjuvant for perioperative analgesic management Abstract The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased . We hypothesized same-day discharge following either a unicompartmental ( UKA ) or total knee arthroplasty ( TKA ) in an unselected group of patients would not result in a higher perioperative complication rate than st and ard-length hospitalization when following a comprehensive perioperative clinical pathway , including preoperative teaching , regional anesthesia , preemptive oral analgesia , preemptive antiemetics , and a rapid rehabilitation protocol . We prospect ively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospect ively ; 25 had UKA and 86 TKA . Of the 111 patients , 104 ( 94 % , 24 with UKA and 80 with TKA ) met discharge criteria and were discharged directly to home the day of surgery . Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge . There were four ( 3.6 % ) readmissions ( all with TKA ) and one emergency room visit without readmission ( in a patient with a TKA ) within the first week after surgery , while there were four subsequent readmissions ( 3.6 % ) and one additional emergency room visit without readmission within three months of surgery , all among patients undergoing TKA . There were no deaths , cardiac events , or pulmonary complications during this study . Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization . Level of Evidence : Level IV , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence BACKGROUND AND AIMS The Enhanced Recovery after Surgery ( ERAS ) program has been proposed as a postoperative recovery-enhancing strategy . We frequently apply the Modified-ERAS program following oesophagectomy . This study aims to eluci date the impact of goal -directed fluid therapy ( GDT ) for the perioperative management of oesophageal cancer on the postoperative recovery of patients undergoing oesophagectomy . METHODS This is an interventional before-after comparative observational study conducted at Kanagawa Cancer Centre , Japan . Patients who underwent elective oesophagectomy for oesophageal cancer were recruited . Group H ( retrospectively collected ) received intraoperative and postoperative management consisting of fluid administration without haemodynamic monitoring and the M-ERAS program , while Group S prospect ively received management consisting of GDT and the M-ERAS program . The primary endpoint was the speed of gastrointestinal functional recovery , while secondary endpoints were the level of postoperative mobilisation , incidence of complications , postoperative length of hospital stay ( LOS ) , and nutritional status after discharge . RESULTS The proportion of patients who completely egested Gastrografin by postoperative day 4 , the level of postoperative mobilisation , and achievement ratio for a 100-m walk on the first postoperative attempt were significantly higher in Group S than in Group H ( P = 0.034 , P = 0.0197 , and P < 0.0001 , respectively ) . No significant differences were observed in the postoperative LOS and incidence of complications within 30 days between the groups . The serum albumin levels at 6 months after discharge was higher in Group S than in Group H ( P = 0.0002 ) . CONCLUSIONS The GDT-ERAS program enhanced postoperative gastrointestinal recovery and mobilisation , as well as postoperative nutritional status and protein synthesis . The program did not affect either postoperative LOS or the incidence of complications . TRIAL REGISTRATION UMIN registration number : UMIN000013705 , https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000015999 Objective To analyze the results after the introduction of enhanced recovery after surgery ( ERAS ) protocol s , a r and omized study was performed to compare the outcomes of laparoscopic hepatectomy under ERAS or traditional care . Methods Patients undergoing laparoscopic hepatectomy from April 2014 to October 2014 were included and r and omly divided into Control group ( CG ) and ERAS . Primary outcome was quality of life ( QoL ) and length of hospital stay ( LOS ) . Secondary endpoints were percentage readmission , mortality , duration to first flatus , complications , hospital costs , conversions and blood loss . Results Thirteen patients withdrew after r and omization . Eighty-six patients completed the study , 48 ERAS and 38 CG . Postoperative LOS was significantly reduced in ERAS [ 6 ( 4–8 ) versus 10 ( 7–15 ) days , P = 0.04 ] . First flatus occurred earlier in ERAS than CG [ 2(1–4 ) versus 3(2–5 ) days , P = 0.02 ] . The average perioperative charges were 9470 ± 1540 in CG and only 7742 ± 1200 in ERAS ( P = 0.03 ) , with no differences in readmission rate , blood loss , conversions to open surgery , mortality or surgical complications . The median AUC ( area under a curve ) of QoL was considerably improved in ERAS ( P = 0.04 ) . Conclusions This study suggests that ERAS is feasible and safe for laparoscopic hepatectomy 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 Smokers are more prone to develop postoperative complications . Smoking cessation intervention beginning 4 - 8 weeks prior to surgery improves the postoperative outcome . Cancer patients , however , often undergo surgery less than 4 weeks after diagnosis . The primary objective of this study was therefore to examine if a brief smoking cessation intervention shortly before breast cancer surgery would influence postoperative complications and smoking cessation . METHODS A r and omized controlled multicentre trial with blinded outcome assessment conducted at 3 hospitals in Denmark . One hundred and thirty patients were r and omly assigned to brief smoking intervention ( n = 65 ) or st and ard care ( n = 65 ) . The intervention followed the principles of motivational interviewing and included personalized nicotine replacement therapy aim ed at supporting smoking cessation from 2 days before to 10 days after surgery . RESULTS The overall postoperative complication rate ( including seroma requiring aspiration ) was 61 % in both groups risk ratio ( RR ) 1.00 ( 95 % CI 0.75 - 1.33 ) . The wound complication rate was 44 % versus 45 % . The effect on perioperative smoking cessation was modest , 28 % intervention versus 11 % control group patients , RR 2.49 ( 95 % CI 1.10 - 5.60 ) . There was no effect on smoking cessation at 12 months , 13 % versus 9 % . CONCLUSIONS Brief smoking intervention administered shortly before breast cancer surgery modestly increased self-reported perioperative smoking cessation without having any clinical impact on postoperative complications . The study adds to the body of evidence indicating that brief intervention has no clinical importance for surgical patients in regard to postoperative morbidity . Future studies should be design ed to determine the optimal time of smoking cessation before surgery Background Perioperative tranexamic acid ( TXA ) use can reduce bleeding and transfusion requirements in several types of surgery , but level I evidence proving its effectiveness in major spine surgery is lacking . This study was design ed to investigate the hypothesis that TXA reduces perioperative blood loss and transfusion requirements in patients undergoing major spine procedures . Methods We conducted a multicentre , prospect i ve , r and omized double-blind clinical trial , comparing TXA with placebo in posterior instrumented spine surgery .  Efficacy was determined based on the total number of blood units transfused and the perioperative blood loss . Other variables such as the characteristics of surgery , length of hospital stay , and complications were also analysed . Results Ninety-five patients undergoing posterior instrumented spine surgery ( fusion of > 3 segments ) were enrolled and r and omized : 44 received TXA ( TXA group ) and 51 received placebo ( controls ) . The groups were comparable for duration of surgery , number of levels fused , and length of hospitalization . Transfusion was not required in 48 % of subjects receiving TXA compared with 33 % of controls ( P = 0.05 ) . Mean number of blood units transfused was 0.85 in the TXA group and 1.42 with placebo ( P = 0.06 ) . TXA result ed in a significant decrease in intraoperative bleeding ( P = 0.01 ) and total bleeding ( P = 0.01 ) relative to placebo . The incidence of adverse events was similar in the two groups . Conclusions TXA did not significantly reduce transfusion requirements , but significantly reduced perioperative blood loss in adults undergoing major spinal surgery . Clinical trial registration NCT01136590 Objective This purpose of this consensus statement was to compare endoscopic vascular graft harvesting ( EVH ) with conventional open vascular harvesting ( OVH ) in adults undergoing coronary artery bypass grafting ( CABG ) surgery and to determine which result ed in improved clinical and re source outcomes . Methods Before the consensus conference , the consensus panel review ed the best available evidence , whereby systematic review s , r and omized trials , and nonr and omized trials were considered in descending order of importance . Evidence -based statements were created , and consensus processes were used to determine the ensuing statements . The AHA/ACC system was used to label the level of evidence and class of recommendation . Results The consensus panel agreed upon the following statements : 1 . EVH is recommended to reduce wound related complications when compared with OVH ( Class I , Level A ) . 2 . Based on quality of conduit harvested , either endoscopic or open vein harvest technique may be used ( Class IIa ; Level B ) . 3 . Based on major adverse cardiac events and angiographic patency at 6 months , either endoscopic or open vein harvest technique may be used ( Class IIa ; Level A ) . 4 . EVH is recommended for vein harvesting to improve patient satisfaction and postoperative pain when compared with OVH in CABG surgery ( Class I , Level A ) . 5 . EVH is recommended for vein harvesting to reduce postoperative length of stay and outpatient wound management re sources ( Class I , Level A ) . Conclusions Given these evidence -based statements , the consensus panel stated that EVH should be the st and ard of care for patients who require saphenous vein grafts for coronary revascularization ( Class I , Level B ) . Future research should address long-term safety , cost-effectiveness , and endoarterial harvest BACKGROUND Perioperative treatment of patients with colorectal cancer according to the Enhanced Recovery After Surgery ( ERAS ) protocol has proven to reduce complications and duration of stay . However , strict adherence remains a challenge and the benefits may decrease with lower adherence . In this study , we report on 8 years of adherence to the ERAS protocol and its effect on postoperative outcome in patients with colon cancer . METHODS In 2006 , the ERAS protocol was introduced for treatment of colon cancer patients in the Medical Center Alkmaar , a large teaching hospital . Patients scheduled for elective colon cancer resection were included in this study . Adherence to ERAS items was monitored and along with clinical data prospect ively gathered in a data base . In 2011 , several measures to improve adherence were implemented . RESULTS In total , 816 patients were included .  Mean adherence rate was 73 % in 2006 and 2007 , 66 % in 2008 and 2009 , 63 % in 2010 and 2011 , and 82 % in 2012 and 2013 . There was a shorter duration of stay in the years with high adherence ( 5.7 days ) compared with the years with low adherence ( 7.3 days ; P < .001 ) . The ERAS items that were the strongest predictors for a shorter duration of stay were no nasogastric tube , early mobilization , early oral nutrition , early removal of epidural , early removal of catheter , and nonopioid oral analgesia . CONCLUSION It is possible to improve adherence to the ERAS protocol and related outcomes with specific measures . Adherence to the ERAS protocol was related inversely to duration of stay . Only postoperative items of the ERAS protocol were predictive for a shorter duration of stay . Keeping adherence optimal remains an ongoing challenge that requires repeated training and dedicated personnel 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 BACKGROUND Instructing and guiding patients after surgery is essential for successful recovery . However , the time that health-care professionals can spend with their patients postoperatively has been reduced because of efficiency-driven , shortened hospital stays . We evaluated the effect of a personalised e-health-care programme on return to normal activities after surgery . METHODS A multicentre , single-blind , r and omised controlled trial was done at seven teaching hospitals in the Netherl and s. Patients aged 18 - 75 years who were scheduled for laparoscopic cholecystectomy , inguinal hernia surgery , or laparoscopic adnexal surgery for a benign indication were recruited . An independent research er r and omly allocated participants to either the intervention or control group using computer-based r and omisation lists , with stratification by sex , type of surgery , and hospital . Participants in the intervention group had access to a perioperative , personalised , e-health-care programme , which managed recovery expectations and provided postoperative guidance tailored to the patient . The control group received usual care and access to a placebo website containing st and ard general recovery advice . Participants were unaware of the study hypothesis and were asked to complete question naires at five timepoints during the 6-month period after surgery . The primary outcome was time between surgery and return to normal activities , measured using personalised patient-reported outcome measures . Intention-to-treat and per- protocol analyses were done . This trial is registered in the Netherl and s National Trial Register , number NTR4699 . FINDINGS Between Aug 24 , 2015 , and Aug 12 , 2016 , 344 participants were enrolled and r and omly allocated to either the intervention ( n=173 ) or control ( n=171 ) group . 14 participants ( 4 % ) were lost to follow-up , with 330 participants included in the primary outcome analysis . Median time until return to normal activities was 21 days ( 95 % CI 17 - 25 ) in the intervention group and 26 days ( 20 - 32 ) in the control group ( hazard ratio 1·38 , 95 % CI 1·09 - 1·73 ; p=0·007 ) . Complications did not differ between groups . INTERPRETATION A personalised e-health intervention after abdominal surgery speeds up the return to normal activities compared with usual care . Implementation of this e-health programme is recommended in patients undergoing intermediate- grade abdominal , gynaecological , or general surgical procedures . FUNDING ZonMw Fast-track surgery describes innovative treatment concepts ensuring a faster convalescence phase . The aim of this study was to allow hospital discharge 3 days after surgery without additional complications in patients receiving LRPE for localized prostate cancer . Twenty-five patients each were r and omized in the study groups to verify if a fast-track regimen could be transferred into clinical routine . The perioperative data , early complications , hospital stay as well as readmission rate were analyzed . The mean postoperative stay was 3.6 days in the fast-track group versus 6.7 days in the conventional group . The overall complications were significantly less in the fast-track procedure . The readmission rate was low and not significant . Patients receiving an LRPE benefit from a suitable fast-track concept . The postoperative hospital stay could be shortened nearly by half with a significantly decreased overall complication rate . Thus , fast-track concepts might contribute to saving re sources in the long term . However , more evidence based on larger prospect i ve trials is needed to achieve optimal quality of life for patients perioperatively BACKGROUND Increased perioperative fluid administration is an independent risk factor for lung injury after pulmonary resection . In clinical practice , fluid therapy is heavily guided by urinary output ; however , diuretic response to plasma volume expansion has been reported to be blunted during anesthesia and surgery . We therefore hypothesized that in patients undergoing video-assisted thoracoscopic surgery  , different regimens of intraoperative fluid management would not affect urinary output as would be expected in the nonsurgical scenario . Moreover , a restrictive perioperative fluid approach , as indicated in these operations , will not harm renal function . METHODS One hundred two patients undergoing video-assisted thoracoscopic surgery  were r and omly allocated to receive intraoperatively either high ( 8 mL/[kg · h ] ; n = 51 ) or low ( 2 mL/[kg · h ] ; n = 51 ) amounts of Ringer 's lactate solution . The primary end point was intraoperative urinary output . Secondary end points included postoperative creatinine serum levels and postoperative complication rate . RESULTS Demographic and surgical data were comparable between groups . Regardless of the intraoperatively fluids administered ( mean ± SD , 2131 ± 850 vs 1035 ± 652 mL in high and low groups , respectively ; P < .0001 ) , urinary output was similar ( median 300 mL ) . Perioperative creatinine serum levels decreased significantly postoperatively and were not significantly different among the groups . CONCLUSIONS In patients undergoing video-assisted thoracoscopic surgery  , intraoperative urinary output and postoperative renal function are not affected by administration of fluids in the range of 2 to 8 mL/(kg · h ) . The clinical practice of administering fluids to enhance diuresis in the perioperative period should therefore be ab and oned PURPOSE To identify optimal chemo- and targeted therapy for women with human epidermal growth factor 2 (HER2)- negative ( or unknown ) advanced breast cancer . METHODS A systematic review of r and omized evidence ( including systematic review s and meta-analyses ) from 1993 through to current was completed . Outcomes of interest included survival , progression-free survival , response , quality of life , and adverse effects . Guideline recommendations were evidence based and were agreed on by the Expert Panel via consensus . RESULTS Seventy-nine studies met the inclusion criteria , comprising 20 systematic review s and /or meta-analyses , 30 trials on first-line treatment , and 29 trials on second-line and subsequent treatment . These trials form the evidence base for the guideline recommendations . RECOMMENDATIONS Endocrine therapy is preferable to chemotherapy as first-line treatment for patients with estrogen receptor-positive metastatic breast cancer unless improvement is medically necessary ( eg , immediately life-threatening disease ) . Single agent is preferable to combination chemotherapy , and longer planned duration improves outcome but must be balanced against toxicity . There is no single optimal first-line or subsequent line chemotherapy , and choice of treatment will be determined by multiple factors including prior therapy , toxicity , performance status , comorbid conditions , and patient preference . The role of bevacizumab remains controversial . Other targeted therapies have not so far been shown to enhance chemotherapy outcome in HER2-negative breast cancer Objective : To investigate which perioperative treatment , ie , laparoscopic or open surgery combined with fast track ( FT ) or st and ard care , is the optimal approach for patients undergoing segmental resection for colon cancer . Summary Background Data : Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care , both focusing on faster recovery . Methods : In a 9-center trial , patients eligible for segmental colectomy were r and omized to laparoscopic or open colectomy , and to FT or st and ard care  , result ing in 4 treatment groups . Primary outcome was total postoperative hospital stay ( THS ) . Secondary outcomes were postoperative hospital stay ( PHS ) , morbidity , reoperation rate , readmission rate , in-hospital mortality , quality of life at 2 and 4 weeks , patient satisfaction and in-hospital costs .  Four hundred patients were required to find a minimum difference of 1 day in hospital stay . Results : Median THS in the laparoscopic/FT group was 5 ( interquar-tile range : 4–8 ) days ; open/FT 7 ( 5–11 ) days ; laparoscopic/st and ard 6 ( 4.5–9.5 ) days , and open/st and ard 7 ( 6–13 ) days ( P < 0.001 ) . Median PHS in the laparoscopic/FT group was 5 ( 4–7 ) days ; open/FT 6 ( 4.5–10 ) days ; laparoscopic/st and ard 6 ( 4–8.5 ) days and open/st and ard 7 ( 6–10.5 ) days ( P < 0.001 ) . Secondary outcomes did not differ significantly among the groups . Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity . Conclusions : Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program . If open surgery is applied , it is preferentially done in FT care . This study was registered under NTR222 ( www.trialregister.nl ) BACKGROUND The high frequency of surgical site infections ( SSIs )  after hepato-pancreato-biliary ( HPB ) surgery is a problem that needs to be addressed . This prospect i ve , r and omized , controlled study examined whether perioperative prophylactic use of antibiotics based on preoperative bile culture results in HPB surgery could decrease SSI . METHODS Participants comprised 126 patients who underwent HPB ( bile duct , gallbladder , ampullary , or pancreatic ) cancer surgery with biliary reconstruction at Hokkaido University Hospital between August 2008 and March 2013 ( UMIN Clinical Trial Registry # 00001278 ) . Before surgery , subjects were r and omly allocated to a targeted group administered antibiotics based on bile culture results or a st and ard group administered cefmetazole . The primary endpoint was SSI rates within 30 days after surgery . Secondary endpoint was SSI rates for each operative procedure . RESULTS Of the 126 patients , 124 were r and omly allocated ( targeted group , n = 62 ; st and ard group , n = 62 ) . Frequency of SSI after surgery was significantly lower in the targeted group ( 27 patients , 43.5 % ) than in the st and ard group ( 44 patients , 71.0 % ; P = 0.002 ) . Among patients who underwent pancreaticoduodenectomy and hepatectomy , SSI occurred significantly less frequently in the targeted group ( P = 0.001 and P = 0.025 , respectively ) . CONCLUSIONS This study demonstrated that preoperative bile culture-targeted administration of prophylactic antibiotics decreased SSIs following HBP surgery with biliary reconstruction The optimal dosing strategy for  perioperative beta-blockers  to safely achieve recommended target heart rates ( HRs ) by current guidelines is not well defined . An HR-titrated perioperative beta-blocker dosing regimen versus a fixed-dose regimen was assessed by clinical outcomes , postoperative heart rate , and beta-blocker-related complications .  Patients ( n = 64 ) scheduled to undergo moderate- to high-risk vascular surgery and without contraindications to beta-blockade were r and omized to either a fixed-dose or HR-titrated beta-blocker dosing schedule . Clinical outcomes and HRs were followed immediately preoperatively to 24 hr postoperatively . A difference in mean HR between the two dosing arms was significant immediately postoperatively ( 70.1 vs. 58.2 bpm for fixed dose and HR-titrated arms , respectively ; p = 0.012 ) but at no other time points . However , the HR-titrated strategy led to a significant reduction in the percentage of HR measurements > 80 bpm ( 34.5 % vs. 16.1 % , p < 0.001 ) and to a significant reduction in absolute HR change ( 17.5 vs. 22.5 bpm , p = 0.034 ) . There were no significant differences in the occurrence of asymptomatic hypotension between the two study arms , and no beta-blocker-related adverse events occurred in either study arm . An aggressive , HR-titrated perioperative beta-blocker dosing strategy was associated with more consistent maintenance of postoperative HRs within the range recommended by current guidelines and did not result in increased drug-related adverse events . The question of what is the best perioperative beta-blocker dosing regimen warrants further evaluation in a large-scale clinical trial Study design : Systematic review Study rationale and context : There is controversy regarding the efficacy and safety of chemical prophylaxis to prevent deep venous thrombosis ( DVT ) and pulmonary embolism ( PE ) in elective spinal procedures .Commonly performed elective spine surgeries done through a posterior approach have a very low associated risk of DVT/PE . The lack of consensus is due in part to a limited amount of quality evidence based literature dealing with this issue . Objective : To compare chemical prophylaxis with no chemical prophylaxis in preventing venous thromboembolism in elective thoracolumbar spine surgery . Methods : We undertook a systematic review of the literature to assess the efficacy and safety of chemical prophylaxis in preventing venous thromboembolism in elective thoracolumbar spine surgery . Pubmed , EMBASE , Cochrane , National Guideline Clearinghouse Data bases as well as bibliographies of key articles were search ed . Articles were review ed by two independently working review ers . Inclusion and exclusion criteria were set and each article was subject to a predefined quality rating scheme . Results : We identified only two articles meeting our inclusion criteria . Neither study demonstrated a significant difference between chemical prophylaxis versus no prophylaxis in preventing thromboembolic events . There was an increased incidence of perioperative bleeding with low dose Coumadin in one of the studies . Conclusion : The incidence of DVT and PE in commonly performed elective posterior spinal procedures is very low . While there is a limited amount of r and omized literature looking at this issue , the current literature does not support the routine use of chemical prophylaxis for low risk patients undergoing these procedures Background The efficacy of epidural anesthesia and analgesia in management of perioperative stress has been established . Perioperative pain management strategies decrease surgical complications and aid recovery . In this study , we aim ed to document and compare the efficacy of epidural bupivacaine and intravenous meperidine on recovery of patients with elective abdominal aortic surgery performed under general anesthesia . Material / Methods Patients undergoing elective abdominal aortic surgery between February 2009 and November 2011 were studied prospect ively . Patients were r and omized into epidural bupivacaine ( n=40 ) and intravenous meperidine ( n=40 ) groups regarding postoperative analgesia strategy . The preoperative demographic characteristics , perioperative outcomes , postoperative adverse effects of analgesia strategy , time to initiate oral intake , sedation scores , visual analogue scale results , and mobility scores were compared . Results The mean ages of the patients were 61.7±8.1 in the epidural group and 59.4±9.7 in the intravenous group ( p>0.05 ) . The preoperative demographic characteristics of the patients were comparable between the groups . There were no statistically significant differences between groups regarding anesthesia times , intubation times , intensive care unit stay , hospital length of stay , postoperative vomiting , and postoperative cardiac , renal , and cerebral complications . Postoperative nausea was more prevalent in the meperidine group ( p<0.05 ) . In the epidural group , time to begin oral intake was shorter , sedation scores and visual analogue scale results were lower , and mobility scores were higher ( p<0.05 each ) . Conclusions Epidural analgesia allowed earlier recovery compared to intravenous analgesia in patients undergoing elective abdominal aortic surgery , but did not affect postoperative outcomes and complications Study Design A preintervention and postintervention design was used to examine a total of 200 patients . Objective After successful implementation at our institution of a perioperative oral multimodal analgesia protocol in major joint arthroplasty , a modified regimen was provided to patients undergoing spine procedures . Summary of Background Data A proactive , multimodal approach is currently recommended for the management of acute postoperative pain . Inadequate postoperative analgesia can negatively influence surgical outcome and duration of rehabilitation . Routine use of intravenous patient controlled analgesia ( IV PCA ) after surgery can result in substantial functional interference , side effects , and lead to untoward events as a result of programming errors . Methods A preintervention and postintervention design was used to compare a  historical control group of spine surgery patients who received conventional IV PCA ( N=100 ) with a prospect i ve group  who received some form of perioperative oral multiodal analgesis ( N=100 ) . The new regimen included preoperative and postoperative scheduled extended-release oxycodone , gabapentin , and acetaminophen , intraoperative dolasetron and as-needed postoperative short-acting oral oxycodone . Patient surveys and chart audits were used to measure pain intensity , functional interference from pain , opioid consumption , analgesic-related side effects , and patient satisfaction over the first 24 hours postoperatively . Results Patients who received the new perioperative multimodal oral regimen had significantly less opioid consumption ( P<0.001 ) , lower ratings of Least Pain ( P<0.01 ) , and experienced less nausea ( P<.001 ) , drowsiness ( P<0.05 ) , interference with walking ( P=0.05 ) , and coughing and deep breathing ( P<0.05 ) compared with the IV PCA group . Conclusions This quality improvement study shows some safety and significant advantages of a multimodal perioperative oral analgesic regimen compared with st and ard IV PCA after spine surgery OBJECTIVES Stage III non-small cell lung cancer ( NSCLC ) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable , bulky nodal disease . This review up date s the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients . METHODS Systematic search es were conducted through MEDLINE , Embase , and the Cochrane Data base for Systematic Review up to December 2011 , focusing primarily on r and omized trials , selected meta-analyses , practice guidelines , and review s. RESULTS For individuals with stage IIIA or IIIB disease , good performance scores , and minimal weight loss , treatment with combined chemoradiotherapy results in better survival than radiotherapy alone . Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported . Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation . Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy ; however , weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate . The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery . Postoperative radiotherapy  improves local control without improving survival . CONCLUSIONS Multimodality therapy is preferable in most subsets of patients with stage III lung cancer . Variability in the patients included in r and omized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios . Future trials are needed to investigate the roles of individualized chemotherapy , surgery in particular cohorts or setting s , prophylactic cranial radiation , and adaptive radiation Summary Background Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction — breast reconstruction with implants or exp and ers at the time of mastectomy — but there is a lack of high- quality evidence to support the safety or effectiveness of the technique . We aim ed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh , to inform the feasibility of undertaking a future r and omised clinical trial comparing different breast reconstruction techniques . Methods In this prospect i ve , multicentre cohort study , we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction , with any technique , at 81 participating breast and plastic surgical units in the UK . Data about patient demographics and operative , oncological , and complication details were collected before and after surgery . Outcomes of interest were implant loss ( defined as unplanned removal of the exp and er or implant ) , infection requiring treatment with antibiotics or surgery , unplanned return to theatre , and unplanned re-admission to hospital for complications of reconstructive surgery , up to 3 months after reconstruction and assessed by clinical review or patient self-report . Follow-up is complete . The study is registered with the IS RCT N Registry , number IS RCT N37664281 . Findings Between Feb 1 , 2014 , and June 30 , 2016 , 2108 patients had 2655 mastectomies with immediate implant-based breast reconstruction at 81 units across the UK . 1650 ( 78 % ) patients had planned single-stage reconstructions ( including 12 patients who had a different technique per breast ) . 1376 ( 65 % ) patients had reconstruction with biological ( 1133 [ 54 % ] ) or synthetic ( 243 [ 12 % ] ) mesh , 181 ( 9 % ) had non-mesh submuscular or subfascial implants , 440 ( 21 % ) had dermal sling implants , 42 ( 2 % ) had pre-pectoral implants , and 79 ( 4 % ) had other or a combination of implants . 3-month outcome data were available for 2081 ( 99 % ) patients . Of these patients , 182 ( 9 % , 95 % CI 8–10 ) experienced implant loss , 372 ( 18 % , 16–20 ) required re-admission to hospital , and 370 ( 18 % , 16–20 ) required return to theatre for complications within 3 months of their initial surgery . 522 ( 25 % , 95 % CI 23–27 ) patients required treatment for an infection . The rates of all of these complications are higher than those in the National Quality St and ards ( < 5 % for re-operation , re-admission , and implant loss , and < 10 % for infection ) . Interpretation Complications after immediate implant-based breast reconstruction are higher than recommended by national st and ards . A r and omised clinical trial is needed to establish the optimal approach to immediate implant-based breast reconstruction . Funding National Institute for Health Research , Association of Breast Surgery , and British Association of Plastic , Reconstructive and Aesthetic Surgeons INTRODUCTION The utility of a preoperative mechanical bowel preparation prior to bowel surgery has recently been question ed . The purpose of this study is to compare the perioperative outcomes between patients undergoing cystectomy with urinary diversion with or without preoperative mechanical bowel preparation .  METHODS Seventy patients underwent radical cystectomy and urinary diversion between May 2008 and August 2009 for bladder cancer . The first cohort of patients ( n = 37 ) underwent cystectomy and diversion during the period May 2008-December 2008 and underwent a preoperative mechanical bowel preparation including a clear liquid diet , magnesium citrate solution , and an enema before surgery . The second cohort of patients underwent surgery  during the period of January 2009-August 2009 ( n=33 ) . These patients were given a regular diet before surgery and did not undergo a mechanical bowel preparation except for the enema before surgery was performed to decrease rectal/colonic distention . Outcome measures included gastrointestinal and overall complications , and perioperative outcomes including recovery of bowel function . RESULTS There were no differences with regard to recovery of bowel function , time to discharge , or overall complication rates between the 2 groups . More specifically , the rate of GI complications was not different in prepped patients vs. nonprepped patients ( 22 % vs. 15 % ; P = 0.494 ) . There were no occurrences of bowel anastomotic leak , fistula , abscess , peritonitis , or surgical site infection in either group . One perioperative death occurred in the nonprepped group secondary to cardiovascular complications . CONCLUSIONS Preoperative mechanical bowel preparation prior to radical cystectomy with urinary diversion does not demonstrate any significant advantage in perioperative outcomes , including gastrointestinal complications . Further studies aim ed at measuring patient satisfaction and larger r and omized trials will be beneficial in evaluating the role of mechanical bowel preparation prior to urinary diversion Background Despite substantial improvements in surgical and anesthesiological practice s leading to decreased mortality of less than 5 % at high-volume centers , pancreatic surgery is still associated with high morbidity rates of up to 50 % . Attention is increasingly directed toward the optimization of perioperative management to reduce complications and enhance postoperative recovery . Currently , two different strategies for postoperative pain management after pancreatoduodenectomy are being routinely used : patient-controlled intravenous analgesia and thoracic epidural analgesia . Evidence is lacking to assess which strategy entails fewer postoperative complications . Methods / design The PAKMAN trial is design ed as an adaptive , pragmatic , r and omized , controlled , multicenter , open-label , superiority trial with two parallel study groups . A total of 370 patients scheduled for elective pancreatoduodenectomy will be r and omized after giving written informed consent , and 278 patients are needed for analysis . Patients with chronic pancreatitis , severe chronic obstructive pulmonary disease ( COPD ) , American Society of Anesthesiologists ( ASA ) physical status classification ≥ IV , or chronic pain syndrome will be excluded . The group A intervention includes intraoperative general anesthesia and postoperative patient-controlled intravenous analgesia ; the group B intervention comprises combined intraoperative general anesthesia and epidural analgesia with postoperative epidural analgesia . The primary endpoint of this trial is a composite of the gastrointestinal complications ( delayed gastric emptying , pancreatic fistula , biliary leak , gastrointestinal bleeding , and postoperative ileus ) up to postoperative day 30 . The aim is to investigate whether the frequency of gastrointestinal complications following pancreatoduodenectomy can be reduced by 15 % using postoperative , patient-controlled intravenous analgesia compared with epidural analgesia . Discussion Several previous studies investigating the two different strategies for postoperative pain management have mainly focused on their effectiveness in pain control . However , the PAKMAN trial is the first to compare them with regard to their impact on the surgical endpoint “ postoperative gastrointestinal complications ” after pancreatoduodenectomy . Trial registration German Clinical Trials Register , Background There have been numerous studies with conflicting results regarding the use of anti-tumor necrosis factor ( TNF ) therapy and its relationship to postoperative outcome in Crohn disease . The aim of our study was to examine the rate of postoperative morbidity in patients receiving anti TNF therapy in the perioperative period . Methods All patients undergoing surgery for Crohn disease from 2005 till 2008 were abstract ed from a prospect i ve data base . Patients undergoing surgery which included a suture or staple line at risk for leaking were selected for the study . A retrospective review of medical records was performed . The study group comprised patients treated with perioperative anti TNF therapy ( defined as treatment within 8 weeks preoperatively or up to 30 days postoperatively ) . The remainder of the patients did not receive perioperative anti TNF therapy .  Patient characteristics , disease severity , medication use , operative intervention and 30-day complication were compared between the two groups . Results Three hundred and seventy patients were selected for analysis in this study , of which 119 received perioperative anti TNF therapy and 251 did not . The groups were similar in baseline characteristics , perioperative risk factors and procedures . The group who received perioperative anti TNF therapy had a more severe disease overall as measured by the American College of Gastroenterology ( ACG ) categories of disease ( 50 % severe fulminant disease in the perioperative anti-TNF therapy group versus 18 % in the group that did not receive perioperative anti-TNF therapy , p < 0.001 ) . There was no significant association of perioperative anti TNF therapy and any postoperative complications ( 27.9 % in anti-TNF group versus 30.1 % in no anti-TNF group , p = 0.63 ) nor intra-abdominal infectious complications ( 5.0 % in anti-TNF group versus 7.2 % in no anti-TNF group , p = 0.44 ) . Univariate analysis showed that the only factors associated with an increase in postoperative intra-abdominal infections were age and penetrating disease . Conclusions The use of anti-TNF therapy in the perioperative period is safe and is not associated with an increase in overall or infectious complications in Crohn disease patients undergoing surgery BACKGROUND blood loss during liver resection and the need for perioperative blood transfusions have negative impact on perioperative morbidity , mortality , and long-term outcomes . METHODS a r and omized controlled trial was performed on patients undergoing liver resection comparing hemihepatic vascular inflow occlusion , main portal vein inflow occlusion , and Pringle maneuver .  The primary endpoints were intraoperative blood loss and postoperative liver injury . The secondary outcomes were operating time , morbidity , and mortality . RESULTS a total of 180 patients were r and omized into 3 groups according to the technique used for inflow occlusion during hepatectomy : the hemihepatic vascular inflow occlusion group ( n = 60 ) , the main portal vein inflow occlusion group ( n = 60 ) , and the Pringle maneuver group ( n = 60 ) . Only 1 patient in the hemihepatic vascular occlusion group required conversion to the Pringle maneuver because of technical difficulty . The Pringle maneuver group showed a significantly shorter operating time . There were no significant differences between the 3 groups in intraoperative blood loss and perioperative mortality . The degree of postoperative liver injury and complication rates were significantly higher in the Pringle maneuver group , result ing in a significantly longer hospital stay . CONCLUSIONS all 3 vascular inflow occlusion techniques were safe and efficacious in reducing blood loss . Patients subjected to hemihepatic vascular inflow occlusion , or main portal vein inflow occlusion responded better than those with Pringle maneuver in terms of earlier recovery of postoperative liver function . As hemihepatic vascular inflow occlusion was technically easier than main portal vein inflow occlusion , it is recommended BACKGROUND / AIMS Preoperative management involves patients  fasting from midnight on the evening prior to surgery . Fasting period is often long enough to change the metabolic condition of the patient which increases perioperative stress response . That could have a detrimental effect on clinical outcome . The aim of the present study was to investigate the possible effects of carbohydrate-rich beverage on stress response after colon resection . METHODOLOGY R and omized and double blinded study included 40 patients with colon , upper rectal or rectosigmoid cancer . Investigated group received a carbohydrate-rich beverage the day before and two hours before surgery . In the control group patients were in the st and ard preoperative regime : nothing by mouth from the evening prior to operation . Peripheral blood was sample d 24h before surgery , at the day of the surgery , and 6 , 24 and 48h postoperatively . RESULTS Colonic resection in both groups caused a significant increase in serum interleukin 6 ( IL-6 ) levels 6 , 24 and 48h after the operation . Increase was more evident and statistically significant in the group with fasting protocol . More significant increase of interleukin 10 ( IL-10 ) occurred in patients who received preoperative nutrition . CONCLUSIONS Smaller increase in IL-6 and higher in IL- 10 are indicators of reduced perioperative stress BACKGROUND Recent studies have suggested that critical pathways and st and ard order sets decrease hospital length of stay and improve quality of care . A recently conducted prospect i ve , r and omized study at our institution found that patients undergoing elective colon resections had earlier return of bowel function if perioperative epidural anesthesia and analgesia were provided . All patients in the study were also placed on a st and ardized perioperative regimen . We hypothesized that the st and ardized perioperative protocol used in this study contributed to early return of bowel function and hospital discharge compared with similar patients managed off protocol . STUDY DESIGN To test this hypothesis , we performed a case-controlled study comparing the hospital courses of 36 study patients to 36 control patients undergoing colorectal surgery by the same surgeons during the same calendar year . The distribution of types of operations and anesthetic techniques was similar in both groups . RESULTS As dictated by the protocol , all study patients had their nasogastric tubes removed , were started on a low fat liquid diet , and ambulated in the first postoperative day . Nasogastric tubes were removed in control patients and study patients 2.2 + /- 0.9 ( mean value + /- SD ) and 1.0 + /- 0.0 days postoperatively , respectively . Control patients were started on an oral diet , usually clear liquids , an average of 2.9 + /- 1.1 days postoperatively , a specific liquid diet was started 1.0 day postoperatively in study patients ( p < 0.001 ) . Return of bowel function , as determined by bowel tones , flatus , and bowel movements , occurred approximately 1 day earlier in study patients . Study patients were discharged 1 day sooner than control patients . CONCLUSIONS Our results suggest that the return of bowel function and the length of stay of patients undergoing colon surgery are improved if patients are entered into a st and ardized protocol that eliminates variation in intraoperative and postoperative anesthesia and postoperative surgical care . We believe these results can be reproduced in routine clinical surgery by having a clearly outlined protocol for perioperative care similar to that used in this study OBJECTIVE The aim was to formulate practice guidelines on the management of  hyperglycemia in hospitalized patients in the non-critical care setting . PARTICIPANTS The Task Force was composed of a chair , selected by the Clinical Guidelines Subcommittee of The Endocrine Society , six additional experts , and a method ologist . EVIDENCE This evidence -based guideline was developed using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system to describe both the strength of recommendations and the quality of evidence . CONSENSUS PROCESS One group meeting , several conference calls , and e-mail communications enabled consensus . Endocrine Society members , American Diabetes Association , American Heart Association , American Association of Diabetes Educators , European Society of Endocrinology , and the Society of Hospital Medicine review ed and commented on preliminary drafts of this guideline . CONCLUSIONS Hyperglycemia is a common , serious , and costly health care problem in hospitalized patients . Observational and r and omized controlled studies indicate that improvement in glycemic control results in lower rates of hospital complications in general medicine and surgery patients . Implementing a st and ardized sc insulin order set promoting the use of scheduled basal and nutritional insulin therapy is a key intervention in the inpatient management of diabetes . We provide recommendations for practical , achievable , and safe glycemic targets and describe protocol s , procedures , and system improvements required to facilitate the achievement of glycemic goals in patients with hyperglycemia and diabetes admitted in non-critical care setting BACKGROUND Perioperative hypothermia is physiologically stressful because it elevates blood pressure , heart rate and plasma catecholamine concentration that may increase the risk of cardiac complications , bleeding , wound infection , and post-anaesthesia care unit stay . This study was design ed to evaluate the effects of warming intravenous fluids on perioperative hemodynamic situation , post-operative shivering and recovery in orthopaedic surgery patients . METHODS Perioperative pulse rate , blood pressure , intraoperative esophageal and skin temperature were measured in sixty patients undergoing orthopaedic surgery that were r and omly divided into two groups according to intraoperative IV fluids management . In 30 patients ( hypothermia group ) all IV fluids infused were at room temperature . In the other 30 patients ( normothermia group ) all IV fluids were warmed using a dry IV fluid warmer . RESULTS The core and skin temperatures of the hypothermia and normothermia groups decreased significantly between the induction of anesthesia and the end of surgery , but the drop was greater in the hypothermia group ( P < 0.005 ) . Postoperative mean arterial blood pressure ( non-invasive ) increased significantly more in the hypothermia group versus normothermia group ( p < 0.005 ) . Shivering was observed in 21 of 30 in the hypothermia group and 11 of 30 in the normothermia group ( p < 0.005 ) and recovery time was significantly lower in the normothermia group ( 36 + /- 5 vs. 26 + /- 3 min , p < 0.005 ) . CONCLUSION Intraoperative IV fluid warming reduces perioperative changes to the hemodynamic situation , post-operative shivering , and recovery time
Key recommendations support use of  opioid-sparing perioperative medications  , minimal preoperative fasting and early feeding , use of anesthetic techniques that decrease postoperative nausea and vomiting and pain , use of measures to prevent intraoperative hypothermia , and support of early mobilization after surgery .
Background : Enhanced recovery following surgery can be achieved through the introduction of evidence -based perioperative maneuvers .
This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery  and to provide evidence -based recommendations for an enhanced perioperative protocol .