Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Multimodal perioperative care plus immunonutrition versus traditional care in total hip arthroplasty: a randomized pilot study [Fast track rehabilitation in colonic surgery: results of a prospective trial]. A systematic review of enhanced recovery protocols in colorectal surgery. Chewing Xylitol Gum could Accelerate Bowel motility Recovery after Elective Open Proctectomy for Rectal Cancer. Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Preoperative Education in Cholecystectomy in the Context of a Multimodal Protocol of Perioperative Care: A Randomized, Controlled Trial Urethral catheter‐less robotic‐assisted radical prostatectomy Recovery after open and laparoscopic right hemicolectomy: a comparison. Benefits of post-operative oral protein supplementation in gastrointestinal surgery patients: A systematic review of clinical trials. Prehabilitation with Whey Protein Supplementation on Perioperative Functional Exercise Capacity in Patients Undergoing Colorectal Resection for Cancer: A Pilot Double-Blinded Randomized Placebo-Controlled Trial. Observation of clinical efficacy of application of enhanced recovery after surgery in perioperative period on esophageal carcinoma patients. EnROL: A multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before. Can Medical Hypnosis Accelerate Post-Surgical Wound Healing? Results of a Clinical Trial Fast‐track surgery: the next revolution in surgical care following laparoscopy Implementation of evidence-based practices for surgical site infection prophylaxis: results of a pre- and postintervention study. Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study. Preoperative albumin and surgical site identify surgical risk for major postoperative complications. Proactive care of older people undergoing surgery ('POPS'): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Systemic perioperative prophylaxis in elective oncological colorectal surgery: cefotetan versus clindamicin plus aztreonam. [Tolerance of accelerated postoperative rehabilitation following intestinal resections]. Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. Immunologic Response After Laparoscopic Colon Cancer Operation Within an Enhanced Recovery Program Pre-operative evaluation of adults undergoing elective noncardiac surgery: Updated guideline from the European Society of Anaesthesiology. An Increase in Compliance With the Surgical Care Improvement Project Measures Does Not Prevent Surgical Site Infection in Colorectal Surgery 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 Early enteral feeding in intestinal anastomosis. Prospective comparison of perioperative antibiotic management protocols in oncological head and neck surgery. Predicting the unpredictable: comparing readmitted versus non-readmitted colorectal surgery patients. The effects of intravenous fluids temperature on perioperative hemodynamic situation, post-operative shivering, and recovery in orthopaedic surgery. Fast track rehabilitation programme enhances functional recovery after laparoscopic colonic resection. Safety of deliberate intraoperative and postoperative hypothermia for patients undergoing coronary artery surgery: a randomized trial. Enhanced recovery in major colorectal surgery: safety and efficacy in an unselected surgical population at a UK district general hospital. Enteral feeding during operative procedures in thermal injuries. Effect of preparatory information prior to elective total hip replacement on post-operative physical coping outcomes. Multiple-injection thoracic paravertebral block as an alternative to general anaesthesia for elective breast surgeries: A randomised controlled trial A Prospective Cohort Study of Emergence Agitation in the Pediatric Postanesthesia Care Unit [Value of laparoscopic surgery in elective colorectal surgery with "fast-track"-rehabilitation]. Fast-Track Surgery Improves Postoperative Clinical Recovery and Immunity After Elective Surgery for Colorectal Carcinoma: Randomized Controlled Clinical Trial Is chemical antithrombotic prophylaxis effective in elective thoracolumbar spine surgery? Results of a systematic review A clinical pathway to accelerate recovery after colonic resection. The effectiveness of a storybook in lessening anxiety in children undergoing tonsillectomy and adenoidectomy in northern ireland Utility of a perioperative nutritional intervention on postoperative outcomes in high-risk head & neck cancer patients. Comparison of effects of epidural bupivacaine and intravenous meperidine analgesia on patient recovery following elective abdominal aortic surgery Impact of multicomponent, nonpharmacologic interventions on perioperative cortisol and melatonin levels and postoperative delirium in elderly oral cancer patients. The future of fast‐track surgery Effect of laryngeal mask airway on esophageal motility during general anesthesia. Multimodal Perioperative Rehabilitation for Colonic Surgery in the Elderly Cost-effectiveness of Enhanced Recovery Versus Conventional Perioperative Management for Colorectal Surgery Unplanned perioperative hypothermia and agreement between oral, temporal artery, and bladder temperatures in adult major surgery patients.
Background This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery , and to provide grade d recommendations for items for an evidence d-based enhanced recovery protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omized controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( evidence grade : high or moderate ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , European Society for Clinical Nutrition and Metabolism ( ESPEN ) and International Association for Surgical Metabolism and Nutrition ( IASMEN ) present a comprehensive evidence -based consensus review of perioperative care for rectal surgery Background This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery Background Multimodal protocol s of perioperative care may enhance postoperative recovery . However , limited information is available on preoperative immune and carbohydrate (CHO)-enriched drinks in patients undergoing hip arthroplasty . We aim ed to investigate the effect of a multimodal protocol ( ACERTO protocol ) plus preoperative immune nutrition on the length of stay ( LOS ) and the postoperative acute phase response of patients undergoing total hip arthroplasty . Methods Thirty-two patients ( mean age , 58 years ; range , 26–85 years ; 16 males ) were r and omized to receive either the  ACERTO protocol  ( n = 15 , ACERTO Group ) , which consisted of 6 h preoperative fasting for solids , an oral drink ( 200 mL of 12.5 % maltodextrin ) up to 2 h before induction of anesthesia , restricted intravenous fluids ( only 1000 mL of crystalloid fluid after surgery ) and preoperative immune nutrition ( 600 mL/day of Impact - Nestlé , Brazil ) for five days prior to surgery , or traditional care ( n = 17 ; control group ) , which consisted of 6–8 h preoperative fasting , intravenous hydration until the 1st postoperative day and no preoperative immune supplementation . The main endpoint was LOS . C-reactive protein ( CRP ) was the secondary endpoint and was assessed during induction of anesthesia and on postoperative day 2 . Results Neither deaths nor postoperative complications occurred . The median LOS was 3 ( 2–5 ) days in the ACERTO group and 6 ( 3–8 ) days in controls ( P < 0.01 ) . Postoperative CRP was higher in the control group ( P < 0.01 ) . Conclusion The ACERTO multimodal protocol of perioperative care plus preoperative immune nutrition may decrease LOS and postoperative CRP levels in total hip arthroplasty . Trial registration Clinical Trials : OBJECTIVE In elective large bowel surgery the incidence of general complications with st and ard perioperative care is up to 27 % . Hospital discharge occurs 10 to 15 days after a conventional or laparoscopic colonic resection . The aim of a fast track management is to reduce the number of general complications and the length of hospital stay . MATERIAL AND METHODS We prospect ively evaluated a multimodal protocol in our service utilizing a combined thoracic epidural analgesia , an early mobilization and oral nutrition to accelerate postoperative recovery after elective colonic surgery  . RESULTS One hundred thirty-two consecutive patients aged an average of 66 years ( range 22 - 88 ) were operated by laparotomy ( n = 71 ) or laparoscopy ( n = 61 ) and treated with the fast track rehabilitation protocol .  Surgical complications occurred in 15 patients ( 11 % ) , four of these had an anastomotique leakage ( 3 % ) . General complications occurred in 11 patients ( 8 % ) , the mortality was 1 % . The median length of hospital stay was four days ( range 3 - 77 ) and 14 patients ( 11 % ) had to be readmitted . CONCLUSION Application of a fast track rehabilitation protocol lowered the number of general complications and reduced the duration of hospital stay in our study INTRODUCTION Colorectal surgery has been associated with a complication rate of 15 - 20 % and mean post-operative inpatient stays of 6 - 11 days . The principles of enhanced recovery after surgery ( ERAS ) are well established and have been developed to optimise peri-operative care and facilitate discharge . The purpose of this systematic review is to present an up date d review of peri-operative care in colorectal surgery from the available evidence and ERAS group recommendations . METHODS Systematic search es of the PubMed and Embase ™ data bases and the Cochrane library were conducted . A h and search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy . RESULTS A total of 59 relevant studies were identified . These included six r and omised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria . These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates . CONCLUSIONS Review ing the data reveals that ERAS protocol s have a role in reducing post-operative morbidity and result in an accelerated recovery following colorectal surgery . Similarly , both primary and overall hospital stays are reduced significantly . However , the available evidence suggests that ERAS protocol s do not reduce hospital readmissions or mortality . These findings help to confirm that ERAS protocol s should now be implemented as the st and ard approach for peri-operative care in colorectal surgery Background A number of studies with conflicting results have evaluated the effect of chewing gum on post-operative gastrointestinal recovery in patients after major colorectal surgery . Objective The objective of the study was to study the efficacy of chewing gum in patients with rectal cancer after elective open proctectomy only . Methods A r and omized controlled clinical trial was performed . We recruited patients who would undergo elective open proctectomy for rectal cancer in Sichuan Academy of Medical Sciences and Sichuan Provincial People 's Hospital . Patients in the intervention arm received chewing gum 3 times a day postoperatively . All patients in the trial were placed on the same perioperative management and st and ardized post-operative care plans . The primary outcome was time to the first peristalsis sounds , time to first flatus and the first defecation . Results A total of 89 patients were recruited . The time to the first flatus was 42.33 ± 3.46 h in the gum group and 49.20 ± 1.42 h in the control group ( p < 0.05 ) . The time to the first defecation was significantly shorter in the gum-chewing group than in the control group ( 66.07 ± 2.36 vs. 78.37 ± 1.62 h ; p < 0.05 ) . Post-operative ileus ( POI ) was confirmed in 2 patients in the gum-chewing group and in 7 in the control group ( 7.0 % vs. 23.9 % ; p = 0.028 ) . Discussion The present study suggests that chewing gum is a method to reduce the time to first flatus , time to first defecation and POI in patients undergoing elective open proctectomy for rectal cancer Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety Background Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . Methods An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated “ high ” , “ moderate ” , “ low ” or “ very low ” . Recommendations were grade d as “ strong ” or “ weak ” . Results Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . Conclusions The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials BACKGROUND & AIMS Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . METHODS An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated " high " , " moderate " , " low " or " very low " . Recommendations were grade d as " strong " or " weak " . RESULTS Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . CONCLUSIONS The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials Abstract Background Preoperative education is a key point in multimodal protocol s of perioperative care . We investigated whether preoperative education for patients undergoing open cholecystectomy would reduce the incidence of perioperative symptoms . Methods This was a r and omized , single-blinded , clinical trial that included adult ( 18–65 years old ) c and i date s for elective open cholecystectomy . All patients took part in the ERAS/ACERTO protocol of perioperative care except that only the intervention group received preoperative education .  The main endpoints of the study were the presence and intensity of postoperative symptoms ( e.g. , nausea , vomiting , pain ) measured by a visual analogue scale , 24 h after the operation . Results A total of 74 patients ( 34 in the intervention group , 40 in the control group ) completed the study . The intervention group had significantly lower median ( interquartile range ) scores for nausea [ 0 ( 4 ) vs. 2.5 ( 5.8 ) , p = 0.04 ] and pain [ 0.2 ( 2.3 ) vs. 3.1 ( 3.45 ) , p < 0.01 ] than the controls . High well-being ( score ≥6 ) was reported by 79.4 % ( 27 patients ) of the intervention group in contrast to 57.5 % ( 23 patients ) of the controls ( p = 0.04 ) . Conclusions Preoperative education is highly effective in the context of a multimodal protocol for enhancing the recovery of patients su bmi tted to open cholecystectomy © 2 0 1 0 T H E A U T H O R S J O U R N A L C O M P I L A T I O N © 2 0 1 0 B J U I N T E R N A T I O N A L 1 2 0 1 8 Faiz O , Brown T , Colucci G , Kennedy RH . A cohort study of results following  elective colonic resection  within an enhanced recovery programme . Colorectal Dis 2009 ; 11 : 366–72 9 Lassen K , Soop M , Nygren J et al. Consensus review of optimal perioperative care in colorectal surgery . Enhanced Recovery After Surgery ( ERAS ) Group Recommendations . Arch Surg 2009 ; 144 : 961–9 10 Halaszynski TM , Juda R , Silverman DG . Optimizing postoperative outcomes with efficient preoperative assessment and management . Crit Care Med 2004 ; 32 ( Suppl . ) : S76–86 11 Guenaga KF , Matos D , Castro AA , Atallah A , Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery . Cochrane Data base Syst Rev 2005 ; ( 1 ) : CDOO1544 12 Shafii M , Murphy DM , Donovan MG , Hickey DP . Is mechanical bowel preparation necessary in patients undergoing cystectomy and urinary diversion . BJU Int 2002 ; 89 : 879–81 13 Smith AF , Pittaway AJ . Premedication for anxiety in adult day surgery : up date of Cochrane Data base Syst Rev 2000 : CD002192 . Cochrane Data base Syst Rev 2003 ; ( 1 ) : CD002192 14 Gerts WH , Pineo GF , Heit JA et al. Prevention of venous thromboembolism : the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy . Chest 2004 ; 126 : 338S–400S 15 Fearon KC , Luff R. The nutritional management of surgical patients : enhanced recovery after surgery . Proc Nutr Soc 2003 ; 62 : 807–11 16 Noblett SE , Watson DS , Huong H , Davison B , Hainsworth PJ , Horgan AF . Pre-operative oral carbohydrate loading in colorectal surgery : a r and omized controlled trial . Colorectal Dis 2006 ; 8 : 563–9 17 Wong PF , Kumar S , Bohra A et al. R and omized clinical trial of perioperative systemic warming in major elective abdominal surgery . Br J Surg 2007 ; 94 : 421–6 18 Ratnaraj J , Kabon B , Talcoff MR , Sessler DI , Kurz A. Supplemental oxygen and carbon dioxide each increase subcutaneous and intestinal intramural oxygenation . Anesth Analg 2004 ; 99 : 207–11 19 Grief R , Akça O , Horn EP , Kurz A , Sessler DI . Supplemental perioperative oxygen to reduce the incidence of surgical wound infection . Outcomes Research Group . N Engl J Med 2000 ; 342 : 161–7 20 Grief R , Laciny S , Rapf B , Hickle RS , Sessler DI . Supplemental oxygen reduces the incidence of post operative nausea and vomiting . Anesthesiology 1999 ; 91 : 1246–52 21 HTA . Full report : systematic review of the clinical effectiveness and cost effectiveness of oesophageal Doppler monitoring in critically ill and high risk surgical patients . Available at : http:// www.hta.ac.uk/project/.asp . Accessed 5 December 2009 22 Cepeda MS , Carr DB , Mir and a N , Diaz A , Silva C , Morales O. Comparison of morphine , ketorolac , and their combination for postoperative pain : results from a large , r and omised , double blind trial . Anaesthesiology 2005 ; 103 : 1225–32 23 Arumainayagam N , McGrath J , Jefferson KP , Gillatt DA . Introduction of an enhanced recovery protocol for radical cystectomy . BJU Int 2008 ; 101 : 698–701 24 Pruthi RS , Chun J , Richman M. Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan . Urology 2003 ; 62 : 661–6 25 Chang SS , Baumgartner RG , Wells N et al. Causes of increased hospital stay after radical cystectomy in a clinical pathway setting . J Urol 2002 ; 167 : 208– BACKGROUND Enhanced Recovery after Surgery ( ERAS ) programs have gained popularity with potential to accelerate recovery and reduce morbidity after colectomy . We were interested in comparing recovery after open right colectomy within an ERAS program compared with laparoscopic right colectomy in a st and ard care perioperative environment . METHODS Between October 2005 and June 2009 , prospect i ve data were collected on consecutive patients undergoing elective open right colectomy within an established ERAS setting ( OpERAS ) . Similarly , between March 2008 and June 2009 , data were collected on consecutive patients undergoing laparoscopic right hemicolectomy with conventional care ( LapCon ) . Exclusion criteria for both groups were : ASA > or= 4 , formation of a stoma , and dementia or mental illness rendering the patient unable to comply with instructions . Perioperative variables were collected . The surgical recovery score ( SRS ) was used as a vali date d means to measure convalescence on d 1 , 3 , 7 , 30 , and 60 postoperatively . RESULTS There were 74 patients in the OpERAS and 39 patients in the LapCon groups . At baseline , there were no significant demographic differences except that more patients had malignancy in OpERAS group .  Mean operating time was longer in the LapCon group . Median day stay was 4 ( 3 - 28 ) in OpERAS and 5 ( 2 - 18 ) in LapCon ( P = 0.032 ) . There was no statistical difference in the incidence of complications or the severity of complications . There were no significant differences in SRS after surgery at any time point . CONCLUSION When perioperative care is optimized , recovery after elective open right hemicolectomy is comparable with laparoscopic resection . Studies looking at the combination of laparoscopy and ERAS are warranted AIM To evaluate published trials examining oral post-operative protein supplementation in patients having undergone gastrointestinal surgery and assessment of reported results . METHODS Data base search es ( MEDLINE , BIOSIS , EMBASE , Cochrane Trials , Cinahl , and CAB ) , search es of reference lists of relevant papers , and expert referral were used to identify prospect i ve r and omized controlled clinical trials . The following terms were used to locate articles : " oral ' ' or " enteral ' ' and " postoperative care ' ' or " post-surgical ' ' and " proteins ' ' or " milk proteins ' ' or " dietary proteins ' ' or " dietary supplements ' ' or " nutritional supplements ' ' . In data bases that allowed added limitations , results were limited to clinical trials that studied humans , and publications between 1990 and 2014 . Quality of collated studies was evaluated using a qualitative assessment tool and the collective results interpreted . RESULTS Search es identified 629 papers of which , following review , 7 were deemed eligible for qualitative evaluation . Protein supplementation does not appear to affect mortality but does reduce weight loss , and improve nutritional status . Reduction in grip strength deterioration was observed in a majority of studies , and approximately half of the studies described reduced complication rates . No changes in duration of hospital stay or plasma protein levels were reported . There is evidence to suggest that protein supplementation should be routinely provided post-operatively to this population . However , despite comprehensive search es , clinical trials that varied only the amount of protein provided via oral nutritional supplements ( discrete from other nutritional components ) were not found . At present , there is some evidence to support routinely prescribed oral nutritional supplements that contain protein for gastrointestinal surgery patients in the immediate post-operative stage . CONCLUSION The optimal level of protein supplementation required to maximise recovery in gastrointestinal surgery patients is effectively unknown , and may warrant further study BACKGROUND A previous comprehensive prehabilitation program , providing nutrition counseling with whey protein supplementation , exercise , and psychological care , initiated 4 weeks before colorectal surgery for cancer , improved functional capacity before surgery and accelerated functional recovery . Those receiving st and ard of care deteriorated . The specific role of nutritional prehabilitation alone on functional recovery is unknown . OBJECTIVE This study was undertaken to estimate the impact of nutrition counseling with whey protein on preoperative functional walking capacity and recovery in patients undergoing colorectal resection for cancer . DESIGN We conducted a double-blinded r and omized controlled trial at a single university-affiliated tertiary center located in Montreal , Quebec , Canada . Colon cancer patients ( n=48 ) awaiting elective surgery for nonmetastatic disease were r and omized to receive either individualized nutrition counseling with whey protein supplementation to meet protein needs or individualized nutrition counseling with a nonnutritive placebo . Counseling and supplementation began 4 weeks before surgery and continued for 4 weeks after surgery . MAIN OUTCOME MEASURE The primary outcome was change in functional walking capacity as measured with the 6-minute walk test . The distance was recorded at baseline , the day of surgery , and 4 weeks after surgery . A change of 20 m was considered clinical ly meaningful . RESULTS The whey group experienced a mean improvement in functional walking capacity before surgery of + 20.8 m , with a st and ard deviation of 42.6 m , and the placebo group improved by + 1.2 ( 65.5 ) m ( P=0.27 ) . Four weeks after surgery , recovery rates were similar between groups ( P=0.81 ) . CONCLUSION Clinical ly meaningful improvements in functional walking capacity were achieved before surgery with whey protein supplementation . These pilot results are encouraging and justify larger-scale trials to define the specific role of nutrition prehabilitation on functional recovery after surgery PURPOSE To observe the clinical efficacy of the application of enhanced recovery after surgery ( ERAS ) in the perioperative period of esophageal carcinoma patients . METHODS A total of 114 patients who were admitted to Affiliated Hospital of Jining Medical University for surgical treatment of esophageal carcinoma between June 2012 and June 2016 were enrolled and r and omly divided into the intervention group and the regular group according to the difference of management procedures during the perioperative period . ERAS was carried out in 57 patients in the intervention group , while conventional management procedures were applied in 57 patients in the regular group . Thereafter , compared were the fluctuations in nutritional indicators and immunological indicators , postoperative complications , time to recovery of gastrointestinal function , length of stay ( LOS ) in hospital and cost of patients between the two groups . RESULTS Seven days post-operation in the intervention group , the evaluation indexes of nutrition status , including total protein ( TP ) , albumin ( ALB ) , prealbumin ( PA ) and transferrin ( TF ) , and of immunological functions , including immunoglobulin G ( IgG ) , immunoglobulin A ( IgA ) , immunoglobulin M ( IgM ) and total blood lymphocyte count ( TLC ) , were significantly higher than those in the regular group . As for postoperative complications , the incidence rate of the intervention group was remarkably lower than that of the regular group ; the recovery time of gastrointestinal function in the intervention group was shorter than that in the regular group ; the LOS in the intervention group was also shorter than that in the regular group ; the in-hospital cost in the intervention group was also lower than that in the regular group . All differences above were statistically significant ( p<0.05 ) . CONCLUSION During the perioperative period of esophageal carcinoma patients , ERAS should be fully applied to sustain the good status , and promote the recovery of immunological functions and gastrointestinal functions ; at the same time , ERAS also reduces the incidence rate of postoperative complications , LOS and in-hospital cost , and we maintain that ERAS should be performed in clinical practice Background During the last two decades the use of laparoscopic resection and a multimodal approach known as an enhanced recovery programme , have been major changes in colorectal perioperative care . Clinical outcome improves using laparoscopic surgery to resect colorectal cancer but until recently no multicentre trial evidence had been reported regarding whether the benefits of laparoscopy still exist when open surgery is optimized within an enhanced recovery programme . The EnROL trial ( Enhanced Recovery Open versus Laparoscopic ) examines the hypothesis that laparoscopic surgery within an enhanced recovery programme will provide superior postoperative outcomes when compared to conventional open resection of colorectal cancer within the same programme . Methods / design EnROL is a phase III , multicentre , r and omised trial of laparoscopic versus open resection of colon and rectal cancer with blinding of patients and outcome observers to the treatment allocation for the first 7 days post-operatively , or until discharge if earlier . 202 patients will be recruited at approximately 12 UK hospitals and r and omised using minimization at a central computer system in a 1:1 ratio . Recruiting surgeons will previously have performed > 100 laparoscopic colorectal resections  and > 50  open total mesorectal excisions to minimize conversion . Eligible patients are those suitable for elective resection using either technique . Excluded patients include : those with acute intestinal obstruction and patients in whom conversion from laparoscopic to open procedure is likely . The primary outcome is physical fatigue as measured by the physical fatigue domain of the multidimensional fatigue inventory 20 ( MFI-20 ) with secondary outcomes including postoperative hospital stay ; complications ; reoperation and readmission ; quality of life indicators ; cosmetic assessment s ; st and ardized performance indicators ; health economic analysis ; the other four domains of the MFI-20 . Pathological assessment of surgical quality will also be undertaken and compliance with the enhanced recovery programme will be recorded for all patients . Discussion Should this trial demonstrate that laparoscopic surgery confers a significant clinical and /or health economic benefit this will further support the transition to this type of surgery , with implication s for the training of surgeons and re source allocation . Trial registration IS RCT N48516968 IMPORTANCE The effect of surgeons ' disrupted sleep on patient outcomes is not clearly defined . OBJECTIVE To assess if surgeons operating the night before have more complications of elective surgery performed the next day . DESIGN , SETTING , AND PARTICIPANTS Population -based , matched , retrospective cohort study using administrative health care data bases in Ontario , Canada ( 2012 population , 13,505,900 ) . Participants were 2078 patients who underwent elective laparoscopic cholecystectomies performed by surgeons who operated the night before , matched with 4 other elective laparoscopic cholecystectomy recipients ( n = 8312 ) . EXPOSURE In total , 94,183 eligible elective laparoscopic cholecystectomies were performed between 2004 and 2011 . Of these surgeries , there were 2078 procedures in which 331 different surgeons across 102 community hospitals had operated between midnight and 7 am the night before . Each " at-risk " surgery was r and omly matched with 4 other elective laparoscopic cholecystectomies ( n = 8312 ) performed by the same surgeon , who had no evidence of having operated the night before . MAIN OUTCOMES AND MEASURES The primary outcome was conversion from a laparoscopic cholecystectomy to open cholecystectomy . Secondary outcomes included evidence of iatrogenic injuries or death . Risks were quantified using generalized estimating equations . RESULTS No significant association was found in conversion rates to open operations between surgeons when they operated the night before compared with when they did not operate the previous night ( 46/2031 [ 2.2 % ] vs 157/8124 [ 1.9 % ] ; adjusted odds ratio [ OR ] , 1.18 ; 95 % CI , 0.85 - 1.64 ) . There was no association between operating the night before vs not operating the night before , and risk of iatrogenic injuries ( 14/2031 [ 0.7 % ] vs 72/8124 [ 0.9 % ] ; adjusted OR , 0.77 ; 95 % CI , 0.43 - 1.37 ) or death ( ≤5/2031 [ ≤0.2 % ] vs 7/8124 [ 0.1 % ] ) . CONCLUSIONS AND RELEVANCE No significant association was found between operating the night before and not operating the previous night for conversion to open cholecystectomy , risk of iatrogenic complications , or death for elective daytime cholecystectomy . These findings do not support safety concerns related to surgeons operating the night before performing elective surgery Abstract Although medical hypnosis has a long history of myriad functional applications ( pain reduction , procedural preparation etc . ) , it has been little tested for site-specific effects on physical healing per se . In this r and omized controlled trial , we compared the relative efficacy of an adjunctive hypnotic intervention , supportive attention , and usual care only on early post-surgical wound healing . Eighteen healthy women presenting consecutively for medically recommended reduction mammaplasty at an ambulatory surgery practice underwent the same surgical protocol and postoperative care  following preoperative r and omization ( n = 6 each ) to one of the three treatment conditions : usual care , 8 adjunctive supportive attention sessions , or 8 adjunctive hypnosis sessions targeting accelerated wound healing . The primary outcome data of interest were objective , observational measures of incision healing made at 1,7 weeks postoperatively by medical staff blind to the participants ' group assignments . Data included clinical exams and digitized photographs that were scored using a wound assessment inventory ( WAI ) . Secondary outcome measures included the participants ' subjectively rated pain , perceived incision healing ( VAS Scales ) , and baseline and post-surgical functional health status ( SF-36 ) . Analysis of variance showed the hypnosis group 's objective ly observed wound healing to be significantly greater than the other two groups ' , p < .001 , through 7 postoperative weeks ; st and ard care controls showed the smallest degree of healing . In addition , at both the 1 and 7 week post-surgical observation intervals , one-way analyses showed the hypnosis group to be significantly more healed than the usual care controls , p < 0 . 02 . The mean scores of the subjective assessment s of postoperative pain , incision healing and functional recovery trended similarly . Results of this preliminary trial indicate that use of a targeted hypnotic intervention can accelerate postoperative wound healing and suggest that further tests of using hypnosis to augment physical healing are warranted Fast-track surgery , also named enhanced recovery after surgery ( ERAS ) , is in my opinion the most important innovation after the advent of laparoscopy ( in the 1990s ) in the field of  colorectal surgery  ( as in other fields of surgery ) . It is defined as a multimodal pathway aim ing to reduce surgical stress by using pain-free procedures with less organ dysfunction , less morbidity and better recovery . ERAS has been popularized by Henrik Kehlet and his team since the early 2000s [ 1 ] and has rapidly gained popularity around the world because of its remarkable benefits and safety . The concept of ERAS is to make use of the improvement of anaesthetic and analgesic techniques , the development of minimally invasive surgery and evidence -based perioperative care . It involves a number of items , beginning from the first medical visit before surgery to discharge . The items are all evidence based being derived from r and omized controlled trials or meta-analyses . The reader can find the references related to the ERAS items in the valuable consensus review published by the European ERAS group [ 2 ] and the paper of Kehlet and Wilmore [ 3 ] . Through this pathway , the patient can benefit from the best available evidence in anaesthesia , analgesia , perioperative fluid management , surgical procedures , nutrition and ambulation . I will focus in this editorial on the role of ERAS in colorectal surgery , but readers should be aware that ERAS has been applied and vali date d in other abdominal procedures , and in urology , gynaecology , vascular sugery , endocrine surgery , orthopaedic surgery , etc . [ 3 ] . The numerous items or components ( Figure 1 ) involve the preoperative , intra-operative and postoperative periods , necessitating close collaboration between surgeons ( no bowel preparation , no routine nasogastric tube , minimally invasive surgery , no routine abdominal drainage and early postoperative diet ) , anaesthesiologists ( fasting duration of two hours for liquids and six hours for solids , carbohydrate loading , no routine preoperative sedation , avoiding long-acting opioids , epidural analgesia , preventing postoperative nausea and vomiting , preventing intra-operative hypothermia , perioperative fluid restriction and postoperative analgesia ) and nurses and physiotherapists ( early nutrition and mobilisation ) . Several r and omized trials and four meta-analyses [ 4–7 ] have demonstrated the safety and efficacy of ERAS , not only in reducing total length of hospital stay and morbidity , but also in improving patient satisfaction when compared with conventional care . The metaanalyses included both r and omized and non-r and omized studies , the most recent and the largest [ 6 ] showing a reduction of 2.5 days in total hospital stay and significantly less morbidity ( OR 0.54 [ 0.45–0.69 ] ) in favour of the ERAS group , with no difference in readmission rate . A recent meta- analysis focusing on major colorectal surgery demonstrated that the ERAS programme can reduce morbidity by up to 50 % [ 7 ] . ERAS raises three questions . ( i ) What is the respective role of each ERAS item ? ( ii ) Does the ERAS protocol increase the workload of ward nursing staff ? ( iii ) How should this new paradigm be implemented ? Several anaesthesiologists are reluctant to use epidural analgesia in daily practice , mainly when patients are undergoing laparoscopic surgery . Epidural analgesia ( well known to be associated with less pain ) during laparoscopic surgery has been assessed in meta-analyses and r and omized trials but the conclusions are not concordant [ 8,9 ] . In my own daily practice , epidural analgesia is safe and efficacious in relieving pain and allowing early oral intake and mobilization , but it is obvious that its proper role in the ERAS protocol compared with other analgesic regimens such as non-opioid multimodal analgesia , local anaesthesia and continuous wound perfusion , in the era of laparoscopic surgery needs further evaluation . The roleof laparoscopyhas also been debated [ 10 ] . Two small r and omized trials have shown conflicting results [ 11,12 ] , but a recent large r and omized trial [ 13 ] involving four arms ( laparoscopy with ERAS vs laparoscopy with conventional care , vs open surgery with ERAS vs open surgery with conventional care ) has demonstrated a shorter hospital stay after laparoscopic colonic surgery with ERAS , the other outcomes being similar . The conclusion of the authors was that ‘ the most optimal perioperative treatment for patients requiring segmental colectomy for coloncancer is laparoscopic resection embedded in an ERAS program ’ , suggesting that laparoscopic surgery is an important component of ERAS . The same team has performed a futher multivariate linear regression analysis on the same data and showed that the components significantly associated with a successful ERAS programme were laparoscopic surgery , normal diet at postoperative days one , two and three and enforced mobilization at postoperative days one , two and three ( Vlug M , personal communication ) . There is a feeling that the ERAS programme could increase the workload of nursing staff . The nursing BACKGROUND Although evidence -based guidelines for best practice s pertaining to surgical site infection ( SSI ) prophylaxis exist , the feasibility of implementing such practice s remains to be demonstrated outside of a controlled clinical trial . This study was design ed to assess the safety and feasibility of implementing evidence -based care practice s to prevent SSIs . STUDY DESIGN A prospect i ve , double-cohort ( pre- and postintervention ) trial in elective , general surgery patients was conducted . All patients undergoing elective , major colorectal or hepatobiliary operations were enrolled . Postintervention cohort patients were exposed to new strategies to improve antibiotic administration times , perioperative normothermia rates , and  perioperative glucose control .  They were compared with the preintervention cohort , which received st and ard practice at the time . Outcomes evaluated include timing of antibiotic administration , perioperative temperatures , and postoperative glucose levels . SSI rates between cohorts were also compared . RESULTS A total of 208 patients were enrolled . The proportion of patients receiving their preoperative antibiotics within 60 minutes improved from 5.9 % to 92.6 % ( p < 0.001 ) ; perioperative normothermia rates improved from 60.5 % to 97.6 % ( p < 0.001 ) between cohorts . There was no improvement in rates of hyperglycemia . SSI rates improved but did not reach statistical significance ( 14.3 % versus 8.7 % ; p = 0.21 ) . CONCLUSIONS Implementation of evidence -based care practice s to prevent SSI is both safe and practical outside the setting of a r and omized , controlled trial . Sustained compliance remains to be demonstrated , although practice audits at our institution suggest ongoing success is possible OBJECTIVE A minimal extracorporeal circulation ( MECC ) circuit integrates the advances in cardiopulmonary bypass ( CPB ) technology into a single circuit and is associated with improved short-term outcome . The aim of this study was to prospect ively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures . DESIGN Prospect i ve r and omized study . SETTING All patients scheduled for elective coronary artery surgery were evaluated , excluding those considered particularly high risk for fast-track failure . The fast-track protocol included careful preoperative patient selection , a fast-track anesthetic technique based on minimal administration of fentanyl , surgery at normothermia , early postoperative extubation in the cardiac recovery unit , and admission to the cardiothoracic ward within the first 24 hours postoperatively . PARTICIPANTS One hundred twenty patients were assigned r and omly into 2 groups ( 60 in each group ) . INTERVENTIONS Group A included patients who were operated on using the MECC circuit , whereas patients in Group B underwent surgery on conventional CPB . MEASUREMENTS AND MAIN RESULTS Incidence of fast-track recovery was significantly higher in patients undergoing MECC ( 25 % v 6.7 % , p = 0.006 ) . MECC also was recognized as a strong independent predictor of early recovery , with an odds ratio of 3.8 ( p = 0.011 ) . Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion , duration of inotropic support , need for an intra-aortic balloon pump , and development of postoperative atrial fibrillation and renal failure . CONCLUSIONS MECC promotes successful early recovery after elective coronary revascularization procedures , even in a nondedicated cardiac intensive care unit setting BACKGROUND Although malnutrition contributes to morbidity , studies of pre- and postoperative nutrition often include well-nourished patients unlikely to benefit from therapy and usually do not stratify by the site of surgical pathology . This study evaluates whether perceived preoperative markers of nutritional status recorded in charts correlates with postoperative complications and re source use in patients who receive no preoperative nutrition support  and reinterprets the results of several conflicting r and omized , prospect i ve studies in this context . METHODS This is a retrospective cohort study of 526 surgical patients who had preoperative serum albumin levels measured and were undergoing elective esophageal , gastric , pancreaticoduodenal , or colon surgery between 1992 and 1996 who could have received preoperative nutrition but did not .  RESULTS Most medical records contained inadequate analysis of preoperative nutritional status , but preoperative albumin correlated inversely with complications , length of stay , postoperative stay , intensive care unit ( ICU ) stay , mortality , and resumption of oral intake .  Patients undergoing esophageal or pancreatic procedures sustained a significantly higher complication rate at most albumin levels , whereas colonic surgery result ed in lower complication rates at the same albumin levels . Re source use ( eg , length of stay and ICU stay ) related to these complication rates ; esophageal and pancreatic procedures used the most re sources and colon procedures used the fewest at most albumin levels . This lack of appreciation for nutritional risk and operative site can explain discrepancies in outcome noted in several r and omized , prospect i ve nutritional studies and must be applied to the design and implementation of new studies . CONCLUSIONS Elective , non-emergent esophageal and pancreatic procedures performed in patients who could have had surgery delayed for preoperative nutrition , but did not , result in higher risk than colon surgery at any given level of serum albumin below 3.25 g/dL. Patient population s in trials should be stratified by operative site and by markers of nutritional status . Degree of hypoalbuminemia and other potential markers of nutritional status may explain many of the discrepancies between trials of nutrition support . Preexisting hypoalbuminemia in patients undergoing elective surgery remains underappreciated , unrecognized , and untreated in many hospitalized patients BACKGROUND older people undergoing elective surgery have significant post-operative problems prolonging hospitalisation . OBJECTIVE to design , embed , and evaluate an evidence -based comprehensive geriatric assessment ( CGA ) service for at-risk older patients undergoing elective surgery . SETTING urban teaching hospital . SUBJECTS elective surgical patients aged 65 + . INTERVENTION multidisciplinary preoperative CGA service with post-operative follow-through ( proactive care of older people undergoing surgery [ ' POPS ' ] ) . METHODS observational cohort study and multilevel surveys ( development and modelling phase ) . Prospect i ve ' before and after ' comparison ( exploratory evaluation ) . RESULTS findings from the development phase showed high levels of preoperative co-morbidity , no multidisciplinary preoperative input , and multiple potentially preventable post-operative problems delaying discharge in older elective surgery patients . Comparison of 2 cohorts of elective orthopaedic patients ( pre-POPS vs POPS , N = 54 ) showed the POPS group had fewer post-operative medical complications including pneumonia ( 20 % vs 4 % [ p = 0.008 ] ) and delirium ( 19 % vs 6 % [ p = 0.036 ] ) , and significant improvements in areas reflecting multidisciplinary practice including pressure sores ( 19 % vs 4 % [ p = 0.028 ] ) , poor pain control ( 30 % vs 2 % [ p<0.001 ] ) , delayed mobilisation ( 28 % vs 9 % [ p = 0.012 ] ) and inappropriate catheter use ( 20 % vs 7 % [ p = 0.046 ] ) . Length of stay was reduced by 4.5 days . There were fewer delayed discharges relating to medical complications ( 37 % vs 13 % ) or waits for OT assessment or equipment ( 20 % vs 4 % ) . CONCLUSION a proactive evidence -based CGA service for at-risk older elective surgical patients was developed according to MRC framework for complex interventions . Pre/post comparison in elective orthopaedic patients showed improved ( within method ological limitations ) post-operative outcomes indicative of better clinical effectiveness and efficiency , and contributed to the service obtaining mainstream funding . Informed by the present study , a r and omised controlled trial is ongoing A prospect i ve r and omized study was performed with 65 patients undergoing elective surgery for colorectal cancer , to evaluate the prophylactic effect of two different parenteral antibiotic regimens . All patients underwent rigorous mechanical cleansing of the bowel ( enemas , laxatives ) , received low-residue diet 3 days pre-operatively , and were given oral metronidazole ( 250 mg ) five times a day for 3 days preoperatively . They were divided into two groups comparable in age , nutritional status and operative procedure . The patients in group A ( 36 ) received 2 g i.v . of cefotetan at induction of anaesthesia and two other administrations every 12 h. Patients in group B ( 29 ) were given clindamicin ( 600 mg , i.v . ) at induction of anaesthesia plus aztreonam ( 1 g , i.v . ) ; two other doses of the same combined antibiotics were administered every 8 h. Five patients were excluded from the study because they underwent Miles procedure ; two others because they underwent explorative laparotomy only . The overall incidence of post-operative septic complications was 6.9 % ( 4/58 ) . No significant differences were found in terms of the rate of surgical infections : 3.1 in group A ( 1/32 ) and 0 % in group B. Urinary tract infections ( 1 case ) and respiratory tract infections ( 2 cases ) were observed only in group B : the rate was found to be 11.5 % ( 3/26 ) ; two anastomotic leakages were observed in group A ( 6.25 % ) and one in group B ( 3.8 % ) . These data suggest that cefotetan appears to be as effective as clindamicin plus aztreonam in prophylaxis against infection in elective colorectal surgery INTRODUCTION Modern procedures in peri-operative care arising from evidence -based medicine improve postoperative results . Their acceptance is however not a common clinical practice at most surgical centers . AIM The aim of our study was to design a protocol and introduce it into the praxis . The subject of announcement is tolerance of protocol in our conditions . PATIENTS AND METHOD Prospect i ve r and omized study included patients who were operated on ( open bowel resection ) at Department of Surgery in period 4/2005 - 12/2007 . They were r and omized in fast track group ( n=53 ) and non-fast track group ( n=52 ) .  Protocol with accelerated recovery was used in the fast track group ( FTG ) and we used traditional approach in the not-fast track ( non-FTG ) . Results were statistically evaluated , 2 patients ( FTG ) were excluded from analysis for protocol failure ( protocol was non kept by anesthesiologist in 1 patient and by the nurse in the second patient ) . Protocol and informed consent form was approved by the Hospital Ethics Committee . RESULTS Both groups did not differ in age , diagnosis and length of surgery . Analgesia was controlled significantly better in FTG ; similarly oral intake tolerance was higher in this group ( day of surgery -- mean value 634 ml versus 304 ml ) . Restoration of bowel functions was also faster in interventional group ( mean time 2.1 versus 3.9 days ) . Frequency of postoperative complications was lower and hospital stay was shorter ( median 7.0 versus 9.0 days , p < 0.001 ) . CONCLUSION Design ed fast track protocol of postoperative recovery could be introduced in clinical praxis in terms of study . Patients ' tolerance was very good . Application of accelerated recovery procedures is possible in our conditions but it means primarily to overcome worse tolerance of attending personnel Background In Denmark , approximately 12,000 hip and knee arthroplasties were performed in 2006 , and the hospital costs were close to US$ 110,000,000 . In a r and omized clinical trial , we have recently demonstrated the efficacy of accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty compared to current intervention under ideal circumstances . We do not , however , know whether these results could be reached under usual circumstances of healthcare practice . We therefore investigated whether length of stay after implementation of accelerated perioperative care and rehabilitation after hip and knee arthroplasty could be reduced in a normal healthcare setting , and how the achieved results matched those observed during the r and omized clinical trial . Methods An effectiveness study as a before-after trial was undertaken in which all elective primary total hip and total knee arthroplasty patients were divided into a before-implementation group receiving the current perioperative procedure , and an after-implementation group receiving the new accelerated perioperative care and rehabilitation procedures as provided by a new multi-disciplinary organization . We used the Breakthrough Series Collaborative Model for implementation . The primary outcome measure was in hospital length of stay ( LOS ) , and the secondary outcome measure was adverse effects within 3 months postoperatively .  Results We included a total of 247 patients .  Mean LOS was significantly ( P < 0.001 ) reduced by 4.4 ( 95 % CI 3.8–5.0 ) days after implementation of the accelerated intervention , from 8.8 ( SD 3.0 ) days before implementation to 4.3 ( SD 1.8 ) days after implementation . No significant differences in adverse effects were observed . LOS in this effectiveness study was significantly lower than LOS reported in the efficacy study . Conclusion Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty was successfully and effectively implemented . Results obtained during usual hospital circumstances matched the results achieved under ideal circumstances in this group of patients 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 Objective It has been demonstrated that colon operation combined with fast-track ( FT ) surgery and laparoscopic technique can shorten the length of hospital stay , accelerate recovery of intestinal function , and reduce the occurrence of post-operative complications . However , there are no reports regarding the combined effects of FT colon operation and laparoscopic technique on humoral inflammatory cellular immunity . Methods This was a prospect i ve , controlled study . One hundred sixty-three colon cancer patients underwent the traditional protocol and open operation ( traditional open group , n = 42 ) , the traditional protocol and laparoscopic operation ( traditional laparoscopic group , n = 40 ) , the FT protocol and open operation ( FT open group , n = 41 ) , or the FT protocol and laparoscopic operation ( FT laparoscopic group , n = 40 ) .  Blood sample s were taken prior to operation as well as on days 1 , 3 , and 5 after operation . The number of lymphocyte sub population s was determined by flow cytometry , and serum interleukin-6 and C-reactive protein levels were measured . Post-operative hospital stay , post-operative morbidity , readmission rate , and in-hospital mortality were recorded . Results Compared with open operation , laparoscopic colon operation effectively inhibited the release of post-operative inflammatory factors and yielded good protection via post-operative cell immunity . FT surgery had a better protective role with respect to the post-operative immune system compared with traditional peri-operative care . Inflammatory reactions , based on interleukin-6 and C-reactive protein levels , were less intense following FT laparoscopic operation compared to FT open operation ; however , there were no differences in specific immunity ( CD3 + and CD4 + counts , and the CD4+/CD8 + ratio ) during these two types of surgical procedures . Post-operative hospital stay in patients r and omized to the FT laparoscopic group was significantly shorter than in the other three treatment groups ( P < 0.01 ) . Post-operative complications in patients who underwent FT laparoscopic treatment were less than in the other three treatment groups ( P < 0.05 ) . There were no significant differences between the four treatment groups regarding readmission rate and in-hospital mortality . Conclusions The laparoscopic technique and FT surgery rehabilitation program effectively inhibited release of post-operative inflammatory factors with a reduction in peri-operative trauma and stress , which together played a protective role on the post-operative immune system . Combining two treatment measures during colon operation produced better protective effects via the immune system . The beneficial clinical effects support that the better-preserved post-operative immune system may also contribute to the improvement of post-operative results in FT laparoscopic patients : The purpose of this up date of the European Society of Anaesthesiology ( ESA ) guidelines on the pre-operative evaluation of the adult undergoing noncardiac surgery is to present recommendations based on the available relevant clinical evidence . Well performed r and omised studies on the topic are limited and therefore many recommendations rely to a large extent on expert opinion and may need to be adapted specifically to the healthcare systems of individual countries . This article aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthesiologists all over Europe to integrate - wherever possible - this knowledge into daily patient care . The Guidelines Committee of the ESA formed a task force comprising members of the previous task force , members of ESA scientific subcommittees and an open call for volunteers was made to all individual active members of the ESA and national societies . Electronic data bases were search ed from July 2010 ( end of the literature search of the previous ESA guidelines on pre-operative evaluation ) to May 2016 without language restrictions . A total of 34 066 abtracts were screened from which 2536 were included for further analysis . Relevant systematic review s with meta-analyses , r and omised controlled trials , cohort studies , case-control studies and cross-sectional surveys were selected . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) system was used to assess the level of evidence and to grade recommendations . The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members , individual or national ( thus including most European national anaesthesia societies ) . Comments were collated and the guidelines amended as appropriate . When the final draft was complete , the Guidelines Committee and ESA Board ratified the guidelines PURPOSE : The primary goal of the Surgical Care Improvement Project is to improve quality of care by implementing evidence -based health care practice s that prevent surgical complications . This study was design ed to test the hypothesis that an increase in compliance with quality process measures decreases the rate of surgical site infections in patients undergoing colorectal surgeries . METHODS : A multidisciplinary task force implemented and monitored compliance with individual quality measures in patients undergoing elective colorectal resections at a tertiary institution . Individual compliance rates and infections were collected prospect ively and review ed monthly . For data analysis , patients were assigned to 2 consecutive 14-month periods : period A ( April 1 , 2006 to May 31 , 2007 ) and period B ( June 1 , 2007 to July 31 , 2008 ) . Comparisons between periods were performed to determine the association of compliance with process measures and outcomes in infections . RESULTS : A total of 491 consecutive patients were treated during the study periods ( period A : n = 238 ; period B : n = 253 ) . There were no statistically significant differences in patient characteristics , diagnoses , or surgical procedures between periods . Compliance with all process measures significantly increased within periods except for perioperative glucose control . Global compliance ( compliance with all measures per patient ) significantly improved from period A to B ( 40%–68 % , respectively ; P < .001 ) . In total , 99 patients ( 19 % ) developed surgical site infections ( period A , 18.9 % ; period B , 19.4 % ) . CONCLUSION : An increase in compliance with the Surgical Care Improvement Project aim ed to prevent surgical site infections does not translate into a significant reduction of surgical site infections in patients undergoing colorectal resections 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 BACKGROUND Routine practice after major GI surgery has been to keep patient nil per oral till the return of bowel sound with a belief that this will prevent post operative nausea and vomiting and protect the anastomotic site where as the trend has been changing to encourage enteral feeding as soon as possible as various studies has shown early enteral feeding to be beneficial in terms of nutritional , immunological aspect and for faster recovery of patient . METHODS Patients undergoing major elective GI surgery in department of Surgery , Kathm and u Medical college Teaching Hospital who were given early enteral feeding ( within 24 hrs of operation ) were studied prospect ively and were compared retrospectively with historical control who underwent similar procedure . RESULTS Early enteral feeding in patient undergoing major G.I surgery showed early return of bowel movement , decreased ICU and hospital stay with a significant reduction in postoperative cost . CONCLUSIONS Early enteral feeding promotes faster recovery while reducing hospital stay and treatment cost in patient undergoing major GI surgery 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 To evaluate  readmissions  to determine predictors and patterns of readmission . METHODS Prospect i ve data base review identified readmitted and non-readmitted patients after colorectal surgery .  Variables for the index and readmission episode were examined . RESULTS A total of 212 readmissions and 3,292 nonreadmissions were analyzed . The majority was elective . Readmitted patients were older ( P = .003 ) , had more comorbidities ( P < .0001 ) , longer operative times ( P < .0001 ) , length of stay ( P < .0001 ) , and higher costs ( P = .002 ) . At the time of discharge , more readmitted patients required temporary nursing ( P < .0001 ) . Independent readmission predictors were higher American Society of Anesthesiologists score , previous abdominal operation , intensive care unit stay , and dysmotility/constipation surgery . At the time of readmission , 29.2 % required reoperation . More than half had an open procedure initially ( 55.2 % ) . After initial open procedures , reoperative time ( P = .05 ) and LOS were longer ( P = .028 ) , and more patients required temporary nursing care at the time of discharge ( P = .046 ) . Readmissions caused an additional mean hospital cost of $ 12,670.89 . CONCLUSIONS Readmitted patients have distinct demographic and outcomes variables . As most were elective cases , stratifying patients preoperatively may enable perioperative planning for this higher risk group 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 BACKGROUND / AIMS Fast track ( IT ) rehabilitation programmes have demonstrated advantages over traditional perioperative care after open colonic surgery ; however . their contribution in recovery after laparoscopic colonic surgery is not clearly defined . This study was conducted to estimate the value of FT rehabilitation programme in laparoscopic colonic resections . METHODOLOGY This is a r and omized prospect i ve controlled clinical trial . Ninety-nine consecutive patients underwent elective laparoscopic colonic resection between February 2008 and March 2009 . Forty-nine patients received FT multimodal rehabilitation programme as FT group and 50 patients underwent traditional perioperative care as non-FT group . Postoperative hospital stay , return of gastrointestinal function , postoperative complications were recorded . RESULTS Postoperative hospital stay was shorter in the FT group , a median duration of 4.0 days versus 5.0 days in the non-FT group ( p<0.01 ) . Gastrointestinal functional recovery occurred 1 day earlier in FT group ( passage of flatus after 2.0 days vs. 3.0 days , p<0.01 ) . There were no significant differences in complications within 30 postoperative days ( 12 % in FT group vs. 20 % in non-FT group , p=0.295 ) . CONCLUSIONS When applied after laparoscopic colonic surgery , FT rehabilitation programme is feasible , safe and may lead to accelerated functional recovery and reductions in postoperative hospital stay BACKGROUND Hypothermia in the perioperative period is associated with adverse effects , particularly bleeding . Before termination of cardiopulmonary bypass , rewarming times and perfusion temperatures are often increased to avoid post-cardiopulmonary bypass hypothermia and the presumed complications . This practice may , however , also have adverse effects , particularly cerebral hyperthermia . We present safety outcomes from a trial in which patients undergoing coronary artery surgery were r and omly assigned to normothermia or hypothermia for the entire surgical procedure . METHODS Consenting patients over the age of 60 years presenting for a first , elective coronary artery surgery with cardiopulmonary bypass were r and omly assigned to having their nasopharyngeal temperature maintained at either 37 degrees C ( group N ; 73 patients ) or 34 degrees C ( group H ; 71 patients ) throughout the intraoperative period , with no rewarming before arrival in the intensive care unit . All received tranexamic acid . RESULTS There was no clinical ly important difference in intraoperative blood product or inotrope use . Temperatures on arrival in the intensive care unit were 36.7 degrees C + /- 0.38 degrees C and 34.3 degrees C + /- 0.38 degrees C in groups N and H , respectively . Blood loss during the first 12 postoperative hours was 596 + /- 356 mL in group N and 666 + /- 405 mL in group H ( mean difference + /- 95 % confidence interval , 70 + /- 126 mL ; P = .28 ) . There was no significant difference in blood product utilization , intubation time , time in the hospital , myocardial infa rct ion , or mortality . The mean time in the intensive care unit was 8.4 hours less in the hypothermic group ( P = .02 ) . CONCLUSIONS Our data support the safety of perioperative mild hypothermia in patients undergoing elective nonreoperative coronary artery surgery with cardiopulmonary bypass . These findings suggest that complete rewarming after hypothermic cardiopulmonary bypass is not necessary in all cases BACKGROUND Enhanced Recovery Programmes ( ERPs ) have been shown to benefit recovery following major surgery in selected centres and patient groups , but their wider applicability requires continued evaluation . The aims of this study were to assess the outcomes of the first 400 consecutive , non-selected patients , undergoing major elective colorectal surgery within an Enhanced Recovery programme at a UK District General hospital and to examine the effects of patient risk factors and operative approach on outcomes . METHODS Since September 2005 all patients undergoing major elective colon and rectal surgery at our hospital have been treated within an ERP and their data recorded prospect ively on a data base . Safety and efficacy outcomes for the first 400 patients were compared using SPSS v14.0 with both a retrospective , pre-ERP group ; and according to patient risk factors and operative approaches . RESULTS Median length of stays ( LOS ) reduced from 9 days ( IQR 7 - 11 ) to 6 days ( IQR 5 - 10 ) after introduction of the ERP ( p < 0.001 ) . No statistically significant differences in LOS were observed between elderly ( ≥80 years ) and younger patients or between different BMI groups . American Society of Anesthesiologists ( ASA ) grade 3 patients demonstrated significantly longer median LOS than those with ASA grade s 1 and 2 . Patients undergoing laparoscopic surgery  had median LOS of 6 days ( IQR 4 - 8 ) compared to 7 days ( IQR 5 - 10 ) for open procedures ( p < 0.001 ) . No differences in morbidity or mortality were observed between the groups . CONCLUSIONS Unselected application of an ERP in our unit has been associated with reductions in post-operative LOS . The ERP was safe and effective when applied to all our study patients independent of age and BMI . Despite LOS being longer in ASA grade 3 patients , application of the ERP to this higher risk group was not associated with significantly increased morbidity or mortality . Laparoscopic surgery result ed in additional modest reductions in LOS compared to open surgery within the ERP Multiple surgical procedures necessitated by thermal trauma traditionally require withholding nutritional support during the perioperative period . Significant caloric deficits develop with subsequent catabolism of body tissues to provide energy and amino acids for the synthesis of protein . Eighty patients , matched for age and total body surface area burn , were enrolled in a study to evaluate the safety and efficacy of providing enteral support throughout operative procedures . All patients had duodenal feeding tubes placed under fluoroscopy and were provided with isonitrogenous nutritional support calculated to meet measured energy needs ( indirect calorimetry ) . Forty patients received enteral support throughout 161 surgical procedures , and 40 had enteral support withheld during 129 procedures . Age , incidence of inhalation injury , percentage of total body surface area , and postburn day of admission were similar in both groups .  Nutritional parameters , calorie counts , and infectious complications were recorded during the first 4 weeks after burn . No patient in either group experienced aspiration . The unfed group demonstrated a significant caloric deficit ( p < 0.006 ) and increased incidence of wound infection ( p < 0.02 ) and required more albumin supplementation to maintain serum levels at a minimum of 2.5 gm/dl ( p < 0.04 ) . Enteral nutrition can be provided safely during the perioperative period and provides the additional benefits of reducing caloric deficits , wound infections , and exogenous albumin supplementation The aim of the study was to evaluate the effect of preparatory information on a patient 's post-operative physical coping outcomes  following a Total Hip Replacement ( THR ) . The research design was quasi-experimental . Eighty-two healthy individuals , scheduled for an elective THR were used and selected using non-r and om techniques , and placed into one of two groups on an alternating basis . The subjects in the experimental group were given procedural , sensory and coping information relating to the whole surgical procedure of a THR . In addition , written information was provided for each experimental subject to support the verbal information . Subjects in the control group only received the advice and support that would routinely be given to THR patients by ward , medical and nursing staff . The study measured a number of physical outcomes using a " Physical Indicators of Coping Question naire " developed to measure physiological and physical outcomes post-operatively . In addition , a Linear Analogue Coping Scale was developed to assess a patient 's personal perception of their overall coping ability with the THR . The study demonstrated that preparatory information , given pre-operatively , post-operatively and pre-discharge had positive effects on the physical recovery and coping outcomes measured . Subjects in the experimental group had significantly less post-operative intramuscular analgesia , mobilized sooner with a Zimmer frame and walking sticks and lastly , their length of stay was on average , 2 days less than the control group . The Linear Analogue Coping Scale demonstrated that patients in the experimental group did perceive they were coping more effectively post-operatively . Preparatory information of various types and in different forms appear to have positive effects on the ability of patients to cope with and recover physically from a THR in the immediate post-operative period Background : General anaesthesia is currently the conventional technique used for surgical treatment of breast lump . Paravertebral block ( PVB ) has been used for unilateral procedures such as thoracotomy , breast surgery , chest wall trauma , hernia repair or renal surgery . Methods : We compared unilateral thoracic PVB with general anaesthesia ( GA ) in 60 consenting ASA physical status I and II female patients of 18–65 years age , scheduled for unilateral breast surgery . Patients were r and omly assigned into two groups , P ( n=30 ) or G ( n=30 ) , to receive either PVB or GA , respectively . Results : The average time to first post-operative analgesic requirement at visual analogue scale score≥4 ( primary endpoint ) was significantly longer in group P ( 303.97±76.08 min ) than in group G ( 131.33±21.36 min ) , P<0.001 . Total rescue analgesic ( Inj . Tramadol ) requirements in the first 24 h were 105.17±20.46 mg in group P as compared with 176.67±52.08 mg in group G ( P<0.001 ) . Significant post-operative nausea and vomiting requiring treatment occurred in three ( 10.34 % ) patients of the PVB group and eight ( 26.67 % ) patients in the GA group . Conclusion : The present study concludes that unilateral PVB is more efficacious in terms of prolonging post-operative analgesia and reducing morbidities in patients undergoing elective unilateral breast surgery Emergence agitation ( EA ) is a postanesthetic problem that interferes with a child ’s recovery and presents a challenge in terms of assessment and management . In this prospect i ve cohort study , we sought to determine the incidence of EA , evaluate factors associated with and predictive of EA , and describe associated outcomes in healthy children . Children aged 3–7 yr who were undergoing general anesthesia for elective outpatient procedures were included . All perioperative care was documented , and postoperative behaviors in the postanesthesia care unit were recorded . Parents completed the Behavioral Style Question naire for 3- to 7-yr-olds . Five-hundred-twenty-one children were studied , of whom 96 ( 18 % )  had EA . Agitation lasted up to 45 min in some cases ( range , 3–45 min ; mean , 14 ± 11 min ) , required pharmacologic intervention in 52 % of children , and was associated with a prolonged postanesthesia care unit stay ( 117 ± 66 min versus 101 ± 61 min for nonagitated children ; P = 0.02 ) . Ten factors were found to be associated with EA , including age , previous surgery , adaptability , ophthalmology and otorhinolaryngology procedures , sevoflurane , isoflurane , sevoflurane/isoflurane , analgesics , and time to awakening . Of these , otorhinolaryngology procedures , time to awakening , and isoflurane were shown to be independent risk factors . IMPLICATION S : Children may become agitated after general anesthesia . This study describes several factors that may increase the risk for agitation . These data are important in planning anesthesia care for young children INTRODUCTION Laparoscopic ( LAP ) versus open ( CON ) colonic resection with traditional perioperative care has some short term benefits postoperatively regarding functional recovery . Whether these benefits may also occur when all patients are treated with multimodal " fast-track"-rehabilitation programs is question able . METHODS Patients undergoing elective left sided colonic surgery were prospect ively non r and omised observed . The " fast-track " program included patient information , thoracic peridural analgesia , forced mobilisation and oral intake , and stress reduction . Endpoints were duration of postoperative ileus and hospital stay , general- and local complication , and pulmonary function . RESULTS 147 consecutive patients were operated on , 47 open and 100 laparoscopically . The time until oral intake was completed seemed to be shorter in the LAP-group ( p=0.07 ) followed by a shorter hospital stay ( p<0.01 ) . The pulmonary function was postoperatively improved in the LAP-group compared to the CON-group ( p<0,01 ) . General complications ( LAP 9 % vs. CON 17 % ) were non significantly increased in the CON-group . Local complications increased in the CON-group ( LAP 13 % vs. CON 28 % , p<0,05 ) . CONCLUSION Even with perioperative " fast-track"-rehabilitation programs short term advantages were found in laparoscopic compared with open colonic surgery in a non r and omised population . The clinical relevance should be examined in controlled r and omised trials Background Few clinical studies or r and omized clinical trial results have reported the impact of fast-track surgery on human immunity . This study aim ed to investigate the clinical and immune impact of fast-track surgery in colorectal cancer patients undergoing elective open surgery . Methods A controlled r and omized clinical trial was conducted from November 2008 to January 2009 with a 1-month postdischarge follow-up . A total of 70 patients with colorectal carcinoma requiring colorectal resection were r and omized into two groups : a fast-track group ( 35 cases ) and a conventional care group ( 35 cases ) . All included patients underwent elective open colorectal resection with combined tracheal intubation and general anesthesia .  Clinical parameters and markers of immune function were evaluated in both groups postoperatively . Results In all , 62 patients completed the study : 32 in the fast-track group and 30 in the conventional care group . Our findings revealed a significantly shorter postoperative hospital stay and faster return of gastrointestinal function in patients undergoing fast-track rehabilitation . In addition , we found a quicker response of white blood cells in the fast-track group than in the conventional care group . We also found that blood levels of globulin , immunoglobulin G , and complement 4 on postoperative day 3 were higher in the fast-track group than in the conventional care group . Conclusions Fast-track surgery accelerates clinical recovery and improves postoperative immunity after elective open surgery for colorectal carcinoma 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 OBJECTIVE To investigate the feasibility of a 48-hour postoperative stay program after colonic resection . SUMMARY BACKGROUND DATA Postoperative hospital stay after colonic resection is usually 6 to 12 days , with a complication rate of 10 % to 20 % . Limiting factors for early recovery include stress-induced organ dysfunction , paralytic ileus , pain , and fatigue . It has been hypothesized that an accelerated multimodal rehabilitation program with optimal pain relief , stress reduction with regional anesthesia , early enteral nutrition , and early mobilization may enhance recovery and reduce the complication rate . METHODS Sixty consecutive patients undergoing elective colonic resection  were prospect ively studied using a well-defined postoperative care program including continuous thoracic epidural analgesia and enforced early mobilization and enteral nutrition , and a planned 48-hour postoperative hospital stay . Postoperative follow-up was scheduled at 8 and 30 days . RESULTS Median age was 74 years , with 20 patients in ASA group III-IV . Normal gastrointestinal function ( defecation ) occurred within 48 hours in 57 patients , and the median hospital stay was 2 days , with 32 patients staying 2 days after surgery . There were no cardiopulmonary complications . The readmission rate was 15 % , including two patients with anastomotic dehiscence ( one treated conservatively , one with colostomy ) ; other readmissions required only short-term observation . CONCLUSION A multimodal rehabilitation program may significantly reduce the postoperative hospital stay in high-risk patients undergoing colonic resection . Such a program may also reduce postoperative ileus and cardiopulmonary complications . These results may have important implication s for the care of patients after colonic surgery and in the future assessment of open versus laparoscopic colonic resection Aim : This study aim ed to assess the effectiveness of a storybook , entitled , The Tale of Woody ’s Tonsils , written by Anne Marie Tunney , on reducing the level of anxiety of children aged 5–11 years who were undergoing tonsillectomy and adenoidectomy in one hospital in Northern Irel and . Background / Literature Review : Psychological preparation of children for surgery impacts coping . There is evidence , in both adult and pediatric studies , that effective psychological preparation for a surgical procedure has an impact on the individuals ’ coping ability with reduced levels of anxiety leading to better post-operative outcome , faster recovery and a reduction in long term sequelae associated with admission to hospital . A storybook , as a method of preparation , has been recommended by a number of research ers but the effectiveness of this in reducing anxiety has not yet been investigated in the UK . Previous studies have mainly used only one research instrument for anxiety measurement and child self-report is not a commonly used feature of such research . Design and Methodology : A quasi-experimental study involving 80 children was conducted using a repeated measures design . Children attending a pre- assessment clinic were r and omly allocated to either an experimental group ( received the storybook ) or a control group ( did not get the storybook ) . Anxiety was tested both pre- and post-intervention using a self-report Hospital Fears Rating Scale and Child Drawing : Hospital , a projective technique based on children ’s drawings . Findings : The storybook was found to be effective in reducing pre-operative anxiety and was found to be particularly effective for females and in the 7-year-old age group . Practice Implication s ; This study demonstrates the storybook ’s effectiveness for alleviating anxiety and advocates the use of child focused anxiety measurement tools . It reinforces the need for pre assessment to include exploration of anxiety triggers so that preoperative preparation and nursing care can be individualized for each child OBJECTIVES Investigate both the utility and feasibility of perioperative nutritional supplementation with an arginine-enriched immunonutrition formula to high-risk head and neck cancer surgical patients and examine its effects on acute post-operative clinical outcomes . MATERIAL S & METHODS This prospect i ve , non-r and omized , interventional cohort study compared high-risk head and neck cancer surgical patients who consumed a pre- and post-operative arginine-based nutritional supplement to those that did not . Outcome measures included post-operative complications , length of hospitalization , readmission rates and measurement of nutritional biomarkers . RESULTS 195 high-risk head and neck cancer surgical patients were enrolled . 59 % of the patients used the nutritional supplement , 41 % did not . Of the 80 patients who did not receive the immunonutrition formula , 38 ( 47.5 % ) experienced post-operative complications of all types as compared to 29 of the 115 ( 25.2 % ) patients who did consume the product ( p=0.0021 ) . Pharyngeal leaks or fistulas were the most common post-operative complications in both groups and more common in patients who did not receive supplementation ( p=0.007 ) . Length of stay was on average 2.8 days longer in patients who did not have enhanced nutrition ( p=0.02 ) , while readmission rates between the two groups were similar ( p=0.91 ) . Measurements of nutritional biomarkers were not reported secondary to low collection rates . CONCLUSION Enhanced perioperative nutrition may result in significant reductions of post-operative fistula formations and decreased length of stay in a high-risk head and neck cancer population , even in the setting of poor compliance . The potential quality improvement in both patient care and healthcare cost is both real and significant 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 OBJECTIVE To investigate the impact of multicomponent , nonpharmacologic interventions ( MNI ) on perioperative cortisol and melatonin levels , as well as postoperative delirium ( PD ) , in elderly oral cancer patients . METHODS A total of 160 elderly oral cancer patients who underwent tumor resection surgery and completed our investigation were included in this study . The cancer patients were r and omly divided into 2 groups : Group U or Group I. During the perioperative period , Group U received usual care , while Group I received MNI , which is based on usual care and aims to decrease the risk of PD . MNI focused on general geriatric approaches and supportive nursing care . On the day before surgery and the first three postoperative days , nocturnal ( 20:00 - 8:00 ) urine sample s were collected . The melatonin sulfate and cortisol levels in the urine sample s were determined . Moreover , the RASS ( Richmond Agitation Sedation Scale ) , CAM-ICU ( Confusion Assessment Method for the Intensive Care Unit ) and QoR40 ( 40-item quality of recovery score ) scores were dynamically monitored . RESULTS There were no significant differences in the general characteristics between the 2 groups . After surgery , the melatonin sulfate levels in the nocturnal urine of Group I were higher than those in Group U. The cortisol concentrations were lower in Group I compared to those in Group U. Group I achieved better postoperative RASS and QoR40 scores than Group U. Compared to Group U , Group I also experienced less PD ( incidence and duration ) . CONCLUSIONS MNI ameliorated some postoperative disturbances regarding sleep and stress , decreased the incidence of PD and improved recovery quality 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 STUDY OBJECTIVES To determine whether the Laryngeal Mask Airway ( LMA ) triggers the pharyngo-esophago-gastric reflex during general anesthesia by comparing the esophageal motility of patients with the LMA and endotracheal tube ( ETT ) in place . DESIGN R and omized clinical trial . SETTING Operating room and recovery room of a tertiary-care referral hospital . PATIENTS 50 adult ASA physical status I and II patients scheduled for elective orthopedic surgery . INTERVENTIONS All patients received a st and ardized general anesthetic technique , then were allocated r and omly to the LMA ( n = 30 ) or ETT ( n = 20 ) groups . MEASUREMENTS AND MAIN RESULTS The esophageal manometric inputs were recorded continuously using an ambulatory esophageal manometric recorder and divided into five perioperative phases ( preanesthesia , induction , surgery , LMA , or ETT rejection and arousal phase ) . The LMA or ETT was removed at the end of the surgery , when the patient was awake . An awake state was defined as the presence of the following clinical signs : swallowing , bucking , struggling , straining , and restlessness . The esophageal peristaltic wave percent and esophageal contraction frequency were significantly decreased during induction , surgery , and the LMA or ETT rejection and arousal phases compared with the preanesthetic phases in both the LMA and ETT groups . However , there were no significant group differences in any corresponding perioperative phases . CONCLUSION During the general anesthetic period before the arousal phase in this study , a LMA does not provoke significantly different esophageal peristalsis compared with an ETT . Thus , the LMA is unlikely to stimulate the pharyngo-esophago-gastric reflex during that period Background Traditional perioperative care for colonic surgery in elderly patients is associated with increased morbidity and mortality compared to that of younger patients . Although multimodal perioperative rehabilitation has evolved as a valid concept to improve postoperative outcome , its use has not yet been established for colonic surgery in the elderly . Methods Data from 24 German hospitals performing multimodal perioperative rehabilitation as the st and ard perioperative care for elderly patients who have undergone elective colonic resection  was assessed in a prospect i ve multicenter study between April 2005 and April 2007 . Results A total of 742 patients aged ≥70 were examined . Overall compliance with the multimodal care protocol decreased with increasing age . Although laparoscopic colonic surgery was performed in 39.1 % of the septuagenarians , the number decreased to 25.1 % in the very old patients . The overall complication rate was 22.9 % in the septuagenarians ( 18.1 % surgical and 11.6 % general complications ) and increased in the very old patients to 38.4 % ( 28.0 % and 23.6 % , respectively ) The overall mortality rate was 1.0 % and showed no age-specific variations . Conclusions Although the overall morbidity did increase with age , it was still less when compared to that of historical groups with traditional care . Therefore , multimodal perioperative rehabilitation should be recommended for the elderly 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 Accurate body core temperature measurement is essential in perioperative areas to quickly recognize and address abnormal temperatures . The purpose s of this prospect i ve , descriptive study were to accurately identify unplanned perioperative hypothermia ( UPH ) in 64 elective major surgery patients ; to describe factors that increased the risk of UPH ; to describe active/passive warming measures ; to describe thermal comfort in patients with and without UPH ; and to compare oral , temporal artery , and bladder temperatures . Based on bladder temperatures , 52 % of the patients had UPH in the operating room ( OR ) and 42 % on postanesthesia care unit ( PACU ) admission . The temporal artery thermometer did not detect any hypothermia . Descriptive data and Bl and -Altman plots showed lack of agreement between the temporal artery thermometer readings and those of the oral and bladder thermometers . The patient 's thermal comfort report did not accurately reflect hypothermia . Factors found to increase the risk of UPH included older age , BMI lower than 30 , and OR ambient temperature lower than 68 ° F . All but one patient had active warming in the OR ; active warming was infrequently used in the PACU . Based on our findings and findings in previous studies , we do not recommend using the temporal artery thermometer in perioperative areas . To prevent UPH , we recommend aggressive use of convective and conductive warming measures in perioperative areas and increasing OR ambient temperatures
this guideline reflects the recommendations of the group of specialists of the Brazilian College of Surgeons , the Brazilian Society of Parenteral and Enteral Nutrition and the ACERTO Project for nutritional interventions in the perioperative period of Elective General Surgery .
The prescription of these recommendations can accelerate the postoperative recovery of patients su bmi tted to elective general surgery , with decrease in morbidity , length of stay and rehospitalization , and consequently , of costs
OBJECTIVE to present recommendations based on the ACERTO Project ( Acceleration of Total Post-Operative Recovery ) and supported by evidence related to perioperative nutritional care in General Surgery elective procedures .