Protocolo de recuperación mejorada después de cirugía (ERAS) atenúa el estrés y acelera la recuperación en pacientes después de resección radical por cáncer colorrectal: Experiencia en la Clínica Universitaria Colombia / Enhanced Recovery After Surgery (ERAS) protocol attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: Experience at Clínica Universitaria Colombia

Introducción. El conjunto de estrategias de recuperación mejorada después de la cirugía (ERAS, por sus siglas en inglés) constituye un enfoque de atención multimodal y multidisciplinario, cuyo propósito es reducir el estrés perioperatorio de la cirugía, disminuir la morbilidad y acortar la estancia hospitalaria. Este estudio tuvo como objetivo describir los resultados clínicos de pacientes sometidos a cirugía por cáncer colorrectal, identificando las complicaciones principales y los factores perioperatorios relacionados con el alta temprana. Métodos. Se analizaron los pacientes consecutivos sometidos a cirugía colorrectal entre los años 2020 y 2023, todos los cuales siguieron el protocolo ERAS institucional. Se evaluaron las características clínicas, los factores perioperatorios, los desenlaces postoperatorios y la tasa global de adherencia al protocolo. Resultados. Un total de 456 pacientes fueron sometidos a cirugía colorrectal, 51% de sexo masculino, con edad media de 60 años. La mayoría de las intervenciones se realizaron por laparoscopia (78 %), con una tasa de conversión del 14,5 %. Las complicaciones postoperatorias incluyeron fuga anastomótica (4,6 %), sangrado, infección intraabdominal y obstrucción intestinal. La estancia hospitalaria promedio fue de 4 días y la mortalidad del 2,8 %. La tasa global de adherencia al protocolo ERAS fue del 84,7 %. Conclusiones. El enfoque combinado de cirugía laparoscópica y protocolo ERAS es factible, seguro y se asocia con una estancia hospitalaria más corta. La implementación y adherencia al protocolo ERAS no solo mejora los resultados postoperatorios, sino que también resalta la importancia de acceder a datos sólidos, permitiendo mejorar la atención perioperatoria local.

Introduction. The Enhanced Recovery After Surgery (ERAS) protocol is a multimodal, multidisciplinary approach to care, the purpose of which is to reduce the perioperative stress of surgery, decrease morbidity, and shorten hospital stay. This study aimed to describe the clinical outcomes of patients undergoing surgery for colorectal cancer, identifying the main complications and perioperative factors related to early discharge. Methods. Consecutive patients undergoing colorectal surgery between 2020 and 2023 were analyzed, who followed the institutional ERAS protocol. Clinical characteristics, perioperative factors, postoperative outcomes, and overall protocol adherence rate were evaluated. Results. A total of 456 patients underwent colorectal surgery, 51% male, with a mean age of 60 years. Most interventions were performed laparoscopically (78%), with a conversion rate of 14.5%. Postoperative complications included anastomotic leak (4.6%), followed by bleeding, intra-abdominal infection, and intestinal obstruction. The average hospital stay was 4 days and mortality was 2.8%. The overall adherence rate to the ERAS protocol was 84.7%. Conclusions. The combined approach of laparoscopic surgery and ERAS protocol is feasible, safe, and associated with a shorter hospital stay. Implementation and adherence to the ERAS protocol not only improves postoperative outcomes, but also highlights the importance of accessing solid data, allowing for improved local perioperative care.

Association between enhanced recovery after surgery protocol compliance and clinical complications: a cohort study

Abstract Background Enhanced Recovery After Surgery (ERAS) protocol is composed by evidence-based interventions that aim to improve recovery through a reduction in surgical stress response. Although ERAS protocols have been introduced across the globe, exhaustive implementation is not as common. We aimed to study the ERAS protocol compliance in colorectal surgery, assessing the relationship between compliance and postoperative complications. Methods A single-center cohort study was conducted. All consecutive patients admitted to elective colorectal surgery were included. We assessed study endpoints according to ERAS protocol perioperative compliance score above 75%. Our primary endpoint was a composite of postoperative events, which includes in-hospital postoperative complications and need for reoperation after 30 days and need for readmission after discharge. Secondary endpoints were surgery-to-discharge time, postoperative use of only non-opioid adjuvants and the individual components of the primary endpoint. Results A total of 224 colorectal patients were included. The primary endpoint occurred in 59.2% (n = 58) of non-compliant patients comparing to 34.1% (n = 43) in compliant patients. In univariate analysis, compliance to ERAS protocol had an inferior risk for the primary endpoint (p< 0.001). In a logistic regression model, compliance was independently associated with a reduced risk for the primary endpoint with a odds-ratio of 0.42 (95% CI 0.23-0.75, p= 0.004). Conclusion Compliance with the ERAS protocol is associated with less complications, a reduced surgery-to-discharge time and use of only non-opioid adjuvants in the postoperative period. More studies are needed to target the most appropriate compliance goal.

Compliance with Enhanced Recovery After Surgery (ERAS) protocol recommendations for bariatric surgery in an obesity treatment center

Abstract Introduction The higher risk of perioperative complications associated with obesity has made anesthesiologists increasingly concerned with the management of obese patients. Measures that improve bariatric surgery patient safety have become essential. The implementation of ERAS protocols in several surgical specialties has made it possible to achieve appropriate outcomes as to surgery safety. The aim of this study was to evaluate patient compliance with the recommendations of an ERAS protocol for Bariatric Surgery (ERABS) at a hospital specialized in obesity treatment. Methods Cross-sectional study, using a medical record database, in a hospital certified as an International Center of Excellence in Bariatric and Metabolic Surgery. The definition of the variables to be assessed was based on the most recent ERABS proposed by Thorell et al. Results were analyzed using descriptive epidemiology. Results The study evaluated all patients undergoing bariatric surgery in 2019. Mean compliance with the recommendations per participant was 42.8%, with a maximum of 55.5%, and was distributed as follows: 22.6% of compliance with preoperative recommendations, 60% to intraoperative recommendations, and 58.1% to postoperative recommendations. The anesthesiologist is the professional who provides most measures for the perioperative optimization of bariatric surgery patients. In our study we found that anesthesiologists complied with only 39.5% of ERABS recommendations. Conclusions Mean compliance with ERABS recommendations per participant was 42.8%. Considering that the study was carried out at a hospital certified as an international center of excellence, the need for introducing improvements in the care of patients to be submitted to bariatric surgery is evident.

Effectiveness of an Educational Intervention with Guidelines from the Total Acceleration of Postoperative Recovery Project (ACERTO) in Gynecology / Efetividade de uma intervenção educativa com diretrizes do projeto Aceleração da Recuperação Total Pós-operatória (ACERTO) na ginecologia

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

Resumo Objetivo Avaliar a efetividade de uma intervenção educativa entre ginecologistas de um hospital universitário a fim de capacitar o conhecimento científico das recomendações do projeto Aceleração da Recuperação Total Pós-operatória ACERTO, derivado das bases sólidas do protocolo Enhanced Recovery After Surgery (ERAS) para otimizar a assistência hospitalar de pacientes cirúrgico-ginecológicas. Métodos Intervenção educativa por meio de reuniões mensais por 3 meses, com duração de 1 hora, com aplicação de questionário objetivo com questões de conhecimentos específicos do projeto ACERTO com fases antes e depois da intervenção, para profissionais ginecologistas, após aprovação do comitê de ética em pesquisas (CEP) e assinatura do termo de consentimento livre e esclarecido (TCLE) pelos participantes. Resultados Dentre os 25 ginecologistas que aceitaram participar, a intervenção educativa se mostrou eficaz com diferença estatisticamente significante entre as fases antes e depois da intervenção para as principais recomendações do projeto ACERTO, como abreviação de jejum pré-operatório (p = 0.006), profilaxia de tromboembolismo venoso (p = 0.024), conhecimento e replicação do conhecimento do ACERTO (p = 0.006) e analgesia multimodal (p = 0.006). Conclusão Uma intervenção educativa, por meio de reuniões clínicas com exposição e discussão das recomendações do projeto ACERTO baseadas em evidências e derivadas do ERAS é eficaz para o conhecimento e possibilidade de aplicação prática de medidas como abreviação de jejum pré-operatório, analgesia multimodal e profilaxia de trombose entre ginecologistas.

Progress on the researches of acupuncture preconditioning before surgery / 中国针灸

This paper reviews the researches on acupuncture preconditioning before surgery in recent years and explores its application value from three aspects, i.e. relieving preoperative anxiety, preventing from postoperative cognitive dysfunction, and preventing from postoperative gastrointestinal dysfunction. As a relatively safe non-drug treatment, acupuncture has the underlying advantages in participating into multidisciplinary coordination in the enhanced recovery after surgery (ERAS). By building up higher-quality medical evidences and revealing the effect mechanism of acupuncture from multi-dimenisonal aspects, it is expected that acupuncture technology can be coordinated with ERAS to optimize the clinical path in the perioperative period, and boost the development of the perioperative medicine ultimately.

Enhanced recovery after surgery in transurethral surgery for benign prostatic hyperplasia / 亚洲男科学杂志(英文版)

Enhanced recovery after surgery (ERAS) measures have not been systematically applied in transurethral surgery for benign prostatic hyperplasia (BPH). This study was performed on patients with BPH who required surgical intervention. From July 2019 to June 2020, the ERAS program was applied to 248 patients, and the conventional program was applied to 238 patients. After 1 year of follow-up, the differences between the ERAS group and the conventional group were evaluated. The ERAS group had a shorter time of urinary catheterization compared with the conventional group (mean ± standard deviation [s.d.]: 1.0 ± 0.4 days vs 2.7 ± 0.8 days, P < 0.01), and the pain (mean ± s.d.) was significantly reduced through postoperative hospitalization days (PODs) 0-2 (POD 0: 1.7 ± 0.8 vs 2.4 ± 1.0, P < 0.01; POD 1: 1.6 ± 0.9 vs 3.5 ± 1.3, P < 0.01; POD 2: 1.2 ± 0.7 vs 3.0 ± 1.3, P < 0.01). No statistically significant difference was found in the rate of postoperative complications, such as postoperative bleeding (P = 0.79), urinary retention (P = 0.40), fever (P = 0.55), and readmission (P = 0.71). The hospitalization cost of the ERAS group was similar to that of the conventional group (mean ± s.d.: 16 927.8 ± 5808.1 Chinese Yuan [CNY] vs 17 044.1 ± 5830.7 CNY, P =0.85). The International Prostate Symptom Scores (IPSS) and quality of life (QoL) scores in the two groups were also similar when compared at 1 month, 3 months, 6 months, and 12 months after discharge. The ERAS program we conducted was safe, repeatable, and efficient. In conclusion, patients undergoing the ERAS program experienced less postoperative stress than those undergoing the conventional program.

Programa para mejorar la recuperación posoperatoria en intervenciones electivas de colon / A Program for Improving Postoperative Recovery in Elective Colon Surgeries

Introducción: Los programas de recuperación mejorada después de cirugía constituyen un conjunto de acciones aplicadas al paciente quirúrgico en el período perioperatorio, que se enfoca en reducir el impacto de la cirugía en la respuesta metabólica y endocrina y así lograr una recuperación más temprana de mayor calidad. Objetivo: Evaluar los resultados de la aplicación del protocolo de recuperación mejorada después de la cirugía en procedimientos quirúrgicos mayores electivos del colon. Métodos: Se realizó un estudio descriptivo longitudinal y prospectivo con 163 pacientes con indicación de intervenciones quirúrgicas mayores electivas del colon en el Hospital Clínico Quirúrgico "Hermanos Ameijeiras", durante el período 2017-2020 y se les aplicó el programa ERAS implementado. Resultados: La edad media de los pacientes fue de 65,4±13,2 años con predominio del sexo femenino (57,7 por ciento). El 78,5 por ciento de los pacientes toleraban dieta blanda y expulsaban gases o heces por el recto al segundo día de la operación. La estadía posoperatoria promedio fue de 4,9 ± 3,4 días y en pacientes sin complicaciones se redujo a 4,0±1,0 días. La mortalidad reportada fue de un 3,1 por ciento (5 casos). Se complicó el 20,2 por ciento de los pacientes. El 6,7 por ciento de los pacientes requirió reingreso durante los primeros 30 días. Conclusiones: La implementación de un programa para mejorar la recuperación posoperatoria de pacientes con intervenciones electivas de colon demuestra resultados satisfactorios y mejora los resultados históricos del Hospital Clínico Quirúrgico "Hermanos Ameijeiras", en cuanto a complicaciones, estadía y mortalidad(AU)

Introduction: Enhanced recovery after surgery (ERAS) programs are a set of actions applied to the surgical patient in the perioperative period, focusing on reducing the impact of surgery on the metabolic and endocrine response, with the aim of achieving an earlier recovery of higher quality. Objective: To evaluate the results of the application of the enhanced recovery protocol after surgery in elective major surgical procedures of the colon. Methods: A descriptive, longitudinal and prospective study was conducted with 163 patients indicated for elective major surgery of the colon at Hospital Clínico Quirúrgico "Hermanos Ameijeiras", during the period 2017-2020, and who were applied the implemented ERAS program. Results: The mean age of the patients was 65.4 ± 13.2 years, with a predominance of the female sex (57.7 percent). 78.5 the patients tolerated a soft diet and expelled gases or faces througth the rectum at two days after the operation. The average postoperative stay was 4.9 ± 3.4 days and, in patients without complications, it was reduced to 4.0 ± 1.0 days. Reported mortality was 3.1 percent (five cases). Complications occurred in 20.2 percent of the patients. 6.7 percent of patients required readmission during the first thirty days. Conclusions: The implementation of a program for improving postoperative recovery of patients with elective interventions of the colon shows satisfactory results and improves the historical results of Hospital Clínico Quirúrgico "Hermanos Ameijeiras" in terms of complications, length of stay and mortality(AU)

Mobile colposcopy by trained nurses in a cervical cancer screening programme at Battor, Ghana

Objectives: Cervical precancer screening programs are difficult to establish in low resource settings partly because of a lack of human resource. Our aiming was to overcome this challenge. We hypothesized that this could be done through task shifting to trained nurses. Design: Descriptive retrospective cross-sectional review. Setting: Training was at the Cervical Cancer Prevention and Training Center (CCPTC) and screening was carried out at the clinic and at outreaches / peripheral facilities.Participants: All women who reported to the clinic for screening or were recruited during outreaches Interventions: All 4 nurses were trained for at least 2weeks (module 1). A total of 904 women were screened by the trained nurses using the EVA system. Quality assurance was ensured. Main outcome measures: Primary screening and follow-up were carried out by the trained nurses with quality assured through image sharing and meetings with peers and experienced gynaecologists. Results: 828 women had primary screening and 76 had follow-up screening. 739 (89.3%) were screened at the clinic and 89 (10.7%) at outreaches/peripheral facilities. Of all screened, 130 (14.5%) had cervical lesions, and 25 (2.8%) were treated, 12 (48.0%) by Loop Electrosurgical Excision Procedure (LEEP) performed by a gynaecologist, 11 (44.0%) with thermal coagulation by trained nurses except one, and 2 (8.0%) with cryotherapy by trained nurses. Conclusion: We demonstrate the utility of a model where nurses trained in basic colposcopy can be used to successfully implement a cervical precancer screening and treatment program in low-resource settings

Application of enhanced recovery after surgery in perioperative management of patients with gallbladder carcinoma / 中华外科杂志

Objective: To investigate the efficacy and safety of enhanced recovery after surgery (ERAS) in perioperative management of patients with gallbladder carcinoma. Methods: The data of the patients with gallbladder carcinoma admitted at Peking Union Medical College Hospital between January 2017 and December 2021 were analyzed retrospectively. There were 69 males(42.1%) and 95 females(57.9%),with age of (64.0±10.3) years(range:37 to 89 years). Patients were divided into ERAS group(n=53) and normal group(n=111) according to whether they were treated with ERAS measures during the perioperative period.The basic characteristics of the two groups were matched by propensity score matching,and then the perioperative information was compared between the two groups. Categorical variables were presented as absolute numbers or frequencies. Differences between study groups were analyzed using χ2 test, Fisher's exact test, t-test, or Mann-Whitney U test, as appropriate. Results: Each group had 45 patients after propensity score matching with well-balanced basic characteristics. There was no difference in basic characteristics, operation time,bleeding,complication,and hospitalization expenses between two groups(all P>0.05). Compared with the normal group,time of ambulation (M(IQR)) (1(1) day vs. 2(2) days;Z=-3.839,P<0.01),postoperative anal exhaust time (2(1) days vs. 3(1) days;Z=-3.013,P=0.003),feeding time(2(1) days vs. 2(1) days;Z=-3.647,P<0.01),postoperative (5(2) days vs. 7(4) days;Z=-3.984,P<0.01) and total(8(4) days vs. 13(6) days;Z=-3.605,P<0.01) hospitalization time were shorter in ERAS group. Postoperative complications occurred in 12 patients. According to the Clavien-Dindo classification,6,4,and 2 patients were classified as grade Ⅰ,Ⅱ,and Ⅲa,respectively. Conclusion: The ERAS measures is safe and effective for perioperative management of patients with gallbladder carcinoma, enhancing patient recovery and shortening hospitalization time without increasing complication or hospitalization cost.

Minimally invasive surgery in the concept of enhanced recovery after surgery / 中华胃肠外科杂志

Enhanced recovery after surgery (ERAS) and minimally invasive surgery are two important development directions of modern surgery in the 21st century. They provide new clinical treatment methods and theoretical basis for the rapid recovery of surgical patients and more rational utilization of medical resources. They are two hot topics in clinical research and academic exchange of surgery-related subjects, and promote the rapid development and clinical application of surgery. ERAS covers a range of preoperative, intraoperative, and postoperative optimization measures, of which minimally invasive surgery is an important part of intraoperative optimization. The quality of surgery, especially minimally invasive surgery, plays a key role in postoperative recovery, which is the most important one of all ERAS measures. With good surgical quality and no postoperative complications, patients will recover quickly. Therefore, minimally invasive surgery plays a central role in the ERAS concept. The combination of ERAS with minimally invasive surgery is not only safe and feasible, but is also better than these two clinical therapies alone for postoperative recovery, and improves short-term and long-term outcome and accelerates the recovery of patients. For surgical diseases treated with minimally invasive surgery as far as possible, using the ERAS management for patients will result in reduced traumatic stress, better surgical tolerance, less postoperative pain, smaller incision, earlier ambulation, better organ function, and less morbidity of complications. In short, ERAS and minimally invasive surgery complement and promote each other. As two outstanding achievements of modern medicine, they are clinical treatments that provide sufficient theoretical basis for rapid recovery of patients and open a new chapter for the development of modern surgery.

Patient experience in the implementation of enhanced recovery after surgery strategy after radical gastric cancer surgery / 中华胃肠外科杂志

Objective: To investigate the experience of patients in the implementation of enhanced recovery after surgery (ERAS) strategy after radical gastrectomy and the factors affecting the treatment experience. Methods: A prospective cohort study was carried out. Patients who were diagnosed with gastric cancer by pathology and underwent radical gastrectomy at the Xijing Digestive Disease Hospital from December 2019 to December 2020 were consecutively enrolled. Those who received emergency surgery, residual gastric cancer surgery, preoperative neoadjuvant chemotherapy, non-curative tumor resection, intraperitoneal metastasis, or other malignant tumors were excluded. Patients' expectation and experience during implementation were investigated by questionnaires. The questionnaire included three main parts: patients' expectation for ERAS, patients' experience during the ERAS implementation, and patients' outcomes within 30 days after discharge. The items on the expectation and experience were ranked from 0 to 10 by patients, which indicated to be unsatisfied/unimportant and satisfied/important respectively. According to their attitudes towards the ERAS strategy, patients were divided into the support group and the reject group. Patients' expectation and experience of hospital stay, and the clinical outcomes within 30 days after discharge were compared between the two groups. Categorical data were reported as number with percentage and the quantitative data were reported as mean with standard deviation, or where appropriate, as the median with interquartile range (Q1, Q3). Categorical data were compared using the Chi-squared test or Fisher's exact test, where appropriate. For continuous data, Student's t test or Mann-Whitney U test were used. Complication was classified according to Clavien-Dindo classification. Results: Of the included 112 patients (88 males and 24 females), aged (57.8±10.0) years, 35 patients (31.3%) were in the support group and 77 (68.7%) in the reject group. Anxiety was detected in 56.2% (63/112) of the patients with score >8. The admission education during the ERAS implementation improved the patients' cognitions of the ERAS strategy [M(Q1, Q3) score: 8 (4, 10) vs. 2 (0, 5), Z=-7.130, P<0.001]. The expected hospital stay of patients was longer than the actual stay [7 (7, 10) days vs. 6 (6, 7) days, Z=-4.800, P<0.001]. During the ERAS implementation, patients had low score in early mobilization [3 (1, 6)] and early oral intake [5 (2.25, 8)]. Fifty-eight (51.8%) patients planned the ERAS implementation at home after discharge, while 32.1% (36/112) preferred to stay in hospital until they felt totally recovered. Compared with the reject group, the support group had shorter expected hospital stay [7 (6, 10) days vs. 10 (7, 15) days, Z=-2.607, P=0.009], and higher expected recovery-efficiency score [9 (8, 10) vs. 7(5, 9), Z=-3.078, P=0.002], lower expected less-pain score [8 (6, 10) vs. 6 (5, 9) days, Z=-1.996, P=0.046], expected faster recovery of physical strength score [8 (6, 10) vs. 6 (4, 9), Z=-2.200, P=0.028] and expected less drainage tube score [8 (8, 10) vs. 8 (5, 10), Z=-2.075, P=0.038]. Worrying about complications (49.1%) and self-recognition of not recovery (46.4%) were the major concerns when assessing the experience toward ERAS. During the follow-up, 105 patients received follow-up calls. There were 57.1% (60/105) of patients who experienced a variety of discomforts after discharge, including pain (28.6%), bloating (20.0%), nausea (12.4%), fatigue (7.6%), and fever (2.9%). Within 30 days after discharge, 6.7% (7/105) of patients developed Clavien-Dindo level I and II operation-associated complications, including poor wound healing, intestinal obstruction, intraperitoneal bleeding, and wound infection, all of which were cured by conservative treatment. There were no complications of level III or above in the whole group after surgery. Compared with the support group, more patients in the reject group reported that they had not yet achieved self-expected recovery when discharged [57.1% (44/77) vs. 22.9% (8/35), χ2=11.372, P<0.001], and expected to return to their daily lives [39.0% (30/77) vs. 8.6% (3/35), χ2=10.693, P<0.001], with statistically significant differences (all P<0.05). Only 52.4% (55/105) of patients returned home to continue rehabilitation, and the remaining patients chose to go to other hospitals to continue their hospitalization after discharge, with a median length of stay of 7 (7, 9) days. Compared with the reject group, the support group had a higher proportion of home rehabilitation [59.7% (12/33) vs. 36.4% (43/72), χ2=4.950, P=0.026], and shorter time of self-perceived postoperative full recovery [14 (10, 20) days vs. 15 (14, 20) days, Z=2.100, P=0.036], with statistically significant differences (all P<0.05). Conclusions: Although ERAS has promoted postoperative rehabilitation while ensuring surgical safety, it has not been unanimously recognized by patients. Adequate rehabilitation education, good analgesia, good physical recovery, and early removal of drainage tubes may improve the patient's experience of ERAS.

Digitalization of perioperative traumatic stress in enhanced recovery after surgery program: current application and future prospect / 中华胃肠外科杂志

Perioperative traumatic stress is a systemic nonspecific response caused by stimuli such as anesthesia, surgery, pain and anxiety, which lasts throughout the perioperative period.The continuous excessive stress response is not conducive to the postoperative rehabilitation of patients. Enhanced recovery after surgery (ERAS), a research hotspot of modern surgery, can significantly reduce perioperative pain and stress, thus promoting the rehabilitation of patients. With the progress of artificial intelligence and information technology, wearable, non-invasive, real-time heart rate variability (HRV) dynamic monitoring can effectively realize the digitalization of stress monitoring with low price, which is worthy of clinical application. Therefore, the use of HRV for digital monitoring of perioperative stress has a significant research value. Moreover, the combination of HRV and ERAS has shown its advantages and the prospect of clinical application is worthy of anticipating.

Thinking and suggestions on pathway management of perioperative enhanced recovery after surgery in gastrointestinal tumors in China / 中华胃肠外科杂志

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care program to decrease the risk of delayed hospitalization, medical complications, readmission and to improve patient short- and long-term outcomes with minimized level of surgical stress responses through multidisciplinary cooperation. Despite its huge success, the program has challenges for further optimization with a primary focus on modification according to the specific pathophysiology and perioperative management characteristics of patients with gastrointestinal tumors to improve the compliance and implementation rate of items. Patient education, prehabilitation, multimodal analgesia, precision surgery, early mobilization, early oral feeding and oral nutrition supplement (ONS) should be regarded as core terms suitable for all the patients. During the application of ERAS pathway management, it is necessary to fully understand the perioperative changes of organ function and pathophysiology, and to strictly implement the ERAS program and items based on evidence-based medicine. Moreover, the close collaboration of multidisciplinary teams is needed to improve the compliance and increase the adherence rate of ERAS protocol for patients, which emphasizes the dynamic, gap-free and whole course management that covers pre-hospital, pre-operative, intra-operative, post-operative and post-hospital periods. Concurrently, we encourage our patients and their families to participate in the whole healthcare activities. Even more concerning, it is indispensable to adjust ERAS program for special time and special patients. At present, several consensus and guidelines on the ERAS management of gastrointestinal tumor surgery have come out for clinical practice in China, which, however, still lacks a high-level evidence from more high-quality clinical trials conducted by Chinese researchers. It is urgent to carry out a series of large-scale randomized controlled studies in accordance with international standards to obtain high-level evidence-based medical evidence for clinical practice, which is problem-oriented and integrated with features of metabolism and perioperative management of gastrointestinal tumor surgery.

How to standardize the enhanced recovery after surgery in clinical practice? / 中华胃肠外科杂志

The enhanced recovery after surgery (ERAS) protocol is an evidence-based perioperative care pathway, which is to reduce the perioperative stress and metabolic variation, with the ultimate goal of improving patient recovery and outcomes. This article reviews some hot issues in the clinical practice of ERAS in China. Currently, the concept and pathways of ERAS are very consistent with China's medical reform, and the basic principle of "safety first, efficiency second" should be adhered to. In specific clinical practice, multidisciplinary cooperation, the improvement of surgical quality and the implementation of prehabilitation pathway should be advocated. In addition, the ERAS approaches should be implemented individually to avoid mechanical understanding and dogmatic implementation. The implementation of ERAS and its clinical outcome should be audited to accumulate experience, and a feedback mechanism should be established to improve the outcome continuously. In clinical practice, "fast recovery" should not be the sole purpose. For patients, the decrease in the risk of readmission rate is more important as compared to discharge rate. Additionally, the disparities between the development of ERAS clinical research in China and that in the world are also analyzed in this review. A national ERAS database should be established on the basic platform of academic groups to ensure the development of high-quality clinical research in China.

Factors influencing super-long hospital stays in patients undergoing radical gastrectomy in the age of enhanced recovery after surgery / 中华胃肠外科杂志

Objective: To obtain experience and generate suggestions for reducing average hospital stays, optimizing perioperative management of patients with gastric cancer and improving utilization of medical resources by analyzing the factors influencing super-long hospital stays in patients undergoing radical gastrectomy in the age of enhanced recovery after surgery (ERAS). Methods: This was a case-control study. Inclusion criteria: (1) pathologically diagnosed gastric adenocarcinoma; (2) radical surgery for gastric cancer; and (3) complete clinicopathologic data. Exclusion criteria: (1) history of upper abdominal surgery; (2) presence of distant metastasis of gastric cancer or other ongoing neoplastic diseases; (3) concurrent chemoradiotherapy; and (4) preoperative gastric cancer-related complications such as obstruction or perforation. The study cohort comprised 285 eligible patients with hospital stays of ≥30 days (super-long hospital stay group). Using propensity score matching in a 1:1 ratio, age, sex, medical insurance, pTNM stage, and extent of surgical resection as matching factors, 285 patients with hospital stays of < 30 days during the same period were selected as the control group (non-long hospital stay group). The primary endpoint was relationship between pre-, intra-, and post-operative characteristics and super-long hospital stays. Clavien-Dindo grade was used to classify complications. Results: Univariate analysis showed that number of comorbidities, number of preoperative consultations, preoperative consultation, inter-departmental transference, operation time, open surgery, blood loss, intensive care unit time, presence of surgical or non-surgical complications, Clavien-Dindo grade of postoperative complications, and reoperation were associated with super-long hospital stays (all P<0.05). Inter-departmental transference (OR=4.876, 95% CI: 1.500-16.731, P<0.001), preoperative consultation time ≥ 3 d (OR=1.758, 95%CI: 1.036-2.733, P=0.034), postoperative surgery-related complications (OR = 6.618, 95%CI: 2.141-20.459, P=0.01), and higher grade of complications (Clavien-Dindo Grade I: OR = 7.176, 95%CI: 1.785-28.884, P<0.001; Clavien-Dindo Grade II: OR = 18.984, 95%CI: 6.286-57.312, P<0.001; Clavien-Dindo Grade III-IV: OR=7.546, 95%CI:1.495-37.952, P=0.014) were independent risk factors for super-long hospital stays. Conclusion: Optimizing preoperative management, enhancing perioperative management, and surgical quality control can reduce the risk of prolonging average hospital stay.

Protocolos de recuperación mejorada en cirugía cardiaca. Revisión sistemática con metanálisis de ensayos clínicos aleatorizados / Improved recovery protocols in cardiac surgery: Systematic review with metaanalysis of randomized clinical trails

Introducción: Múltiples son los esfuerzos realizados para incluir los protocolos de recuperación mejorada como un indicador de calidad en la atención al paciente quirúrgico, bajo la premisa de acelerar la recuperación de los enfermos, sin que esto vaya en detrimento del proceso asistencial y obtener su alta satisfacción. Para ello se hace necesario el desarrollo de la investigación avalada por la mejor evidencia científica y práctica. Objetivo: Estimar, a través de la literatura publicada, la efectividad de la aplicación de los protocolos de recuperación precoz sobre la evolución perioperatoria de pacientes a los que se les realizan procedimientos quirúrgicos cardíacos. Método: Se incluyeron ensayos clínicos controlados y aleatorizados, publicados entre enero del año 2013 y mayo de 2020. La revisión sistemática se realizó según las recomendaciones del manual 5.1.0 para revisores de la biblioteca Cochrane. Resultados: Se analizaron 6 estudios (687 pacientes/Grupo estudio=345, Grupo Control=342). La calidad metodológica de la mayoría de las investigaciones evaluadas fue buena. Se muestra una superioridad de los protocolos, ya que se acompañan de una disminución en la incidencia de complicaciones perioperatorias (RR=0,61 [0,40, 0,93]). De forma similar se encuentran relacionados con la disminución la estadía hospitalaria (diferencia de medias, efecto aleatorio, fue de -2,98 [-3,31, -2,65]. Conclusiones: A pesar de los pocos estudios incluidos, la evidencia sugiere que estos programas mejoran la evolución perioperatoria de los pacientes(AU)

Introduction: Multiple efforts are made to include improved recovery protocols as an indicator of quality in care for surgical patients, under the premise of accelerating the recovery of patients, without this being detrimental to the care process, and thus guarantee high patient satisfaction. In view of this, the development of research supported by the best scientific and practical evidence is necessary. Objective: To estimate, through the published literature, the effectiveness of the application of early recovery protocols on the perioperative evolution of patients who undergo cardiac surgical procedures. Method: Randomized controlled clinical trials, published between January 2013 and May 2020, were included. The systematic review was carried out according to the recommendations of the Cochrane Library manual 5.1.0 for reviewers. Results: Six studies were analyzed (687 patients/study group: 345, control group: 342). The methodological quality of most of the researches assessed was good. A superiority of the protocols is shown, since they are accompanied by a decrease in the incidence of perioperative complications (RR=0.61 [0.40, 0.93]). Similarly, they are related to the decrease in hospital stay (mean difference, random effect, was -2.98 [-3.31, -2.65]). Conclusions: Despite the few studies included, the evidence suggests that these programs improve the perioperative outcome of patients(AU)

Teams, Rapid Recovery Protocols and Technology to Resume Cardiac Surgery in the COVID-19 Era

Abstract The coronavirus disease 2019 (COVID-19) pandemic brings numerous challenges to the health ecosystem, including the safe resumption of elective cardiac surgery. In the pre-pandemic period, rapid recovery protocols demonstrated, through strategies focused on the multidisciplinary approach, reduction of hospital length of stay, infection rates and, consequently, costs. Even with several studies proving the benefits of these protocols, their acceptance and implementation have been slow. It is believed that the resumption of surgeries in the current context requires the use of rapid recovery protocols combined with the use of a mobile application promoting greater engagement between patients, caregivers and care teams.

The use of dexmedetomidine in puncture techniques for degenerative diseases of the lumbar spine / Uso de dexmedetomidina em técnicas de punção para doenças degenerativas da coluna lombar / Uso de dexmedetomidina en técnicas de punción para enfermedades degenerativas de la columna lumbar

ABSTRACT Objective To analyze the results of the use of dexmedetomidine (D) in the treatment of patients with degenerative diseases of the lumbar spine using puncture techniques. Methods The study included 77 patients who underwent surgical puncture for degenerative diseases of the lumbar spine with the use of alpha-2-adrenomimetic D: percutaneous laser denervation of the facet joints (n = 46) and posterolateral transforaminal endoscopic discectomy (n = 31). We assessed: the level of sedation using the Ramsay Sedation Scale (RSS) and the Richmond Agitation Sedation Scale (RASS); intraoperative dynamics of the cardiovascular and respiratory system parameters; the level of pain syndrome according to VAS. Results A high intraoperative level of sedation was determined, with RASS -2, -3 and Ramsay III, IV; when transferring a patient to a department (in 90 minutes) this parameter was RASS 0 and Ramsay II. There were no significant changes in central hemodynamics and respiratory depression. The minimum level of pain was determined immediately after surgery, at 30 and 60 minutes after surgery, and before transfer to the department (90 minutes): 6 (4;9); 10 (8;12); 12 (9;13); 16 (13;19) respectively. The absence of the need for additional analgesia on the first postoperative day was verified. Conclusion The use of D significantly reduces the level of pain, while maintaining the necessary verbal contact with the patient, and provides the necessary neurovegetative protection without respiratory depression or lowered hemodynamic parameters during the perioperative period. Level of evidence II; Prognostic Studies - Investigating the Effect of a Patient Characteristic on Disease Outcome. Case series, retrospective study.

RESUMO Objetivo Analisar os resultados do uso de dexmedetomidina (D) no tratamento de pacientes com doenças degenerativas da coluna lombar com técnicas de punção. Métodos O estudo incluiu 77 pacientes submetidos à punção cirúrgica em doenças degenerativas da coluna lombar com o uso de um agonista alfa-2 adrenérgico: denervação percutânea das articulações facetárias com laser (n = 46) e discectomia endoscópica transforaminal posterolateral (n = 31). Foram avaliados o nível de sedação usando a Escala de Sedação de Ramsay (RSS) e a Escala de Sedação e Agitação de Richmond (RASS); a dinâmica intraoperatória dos parâmetros dos sistemas cardiovascular e respiratório; o nível de síndrome de dor de acordo com a EVA. Resultados Determinou-se um alto nível intraoperatório de sedação pela RASS (-2, -3) e pela Ramsay (III, IV). Ao transferir um paciente para outro setor (depois de 90 minutos), esse parâmetro era 0 em RASS e II em Ramsay. Não houve alterações significativas na hemodinâmica central e na depressão respiratória. O nível mínimo de dor foi determinado imediatamente após a cirurgia, 30 e 60 minutos depois da cirurgia e antes da transferência para o outro setor (90 minutos depois): 6 (4; 9); 10 (8; 12); 12 (9; 13); 16 (13; 19), respectivamente. Constatou-se que não era necessária analgesia adicional no primeiro dia pós-operatório. Conclusões O uso de D reduz significativamente o nível de dor mantendo a comunicação verbal necessária com o paciente e fornece a proteção neurovegetativa necessária sem depressão respiratória e os parâmetros hemodinâmicos reduzidos durante o período perioperatório. Nível de evidência II; Estudos prognósticos - Investigação do efeito de característica de um paciente sobre o desfecho da doença. Série de casos, Estudo retrospectivo.

RESUMEN Objetivo Analizar los resultados del uso de dexmedetomidina (D) en el tratamiento de pacientes con enfermedades degenerativas de la columna lumbar con técnicas de punción. Métodos El estudio incluyó a 77 pacientes con enfermedades degenerativas de la columna lumbar que se sometieron a punción quirúrgica mediante el uso de un agonista adrenérgico alfa-2: denervación percutánea de las articulaciones facetarias con láser (n = 46) y discectomía endoscópica transforaminal posterolateral (n = 31). Fueron evaluados el nivel de sedación mediante la Escala de Sedación de Ramsay (RSS) y la Escala de Sedación y Agitación de Richmond (RASS); la dinámica intraoperatoria de los parámetros de los sistemas cardiovascular y respiratorio; el nivel del síndrome de dolor según la EVA. Resultados Se determinó un alto nivel de sedación intraoperatoria en RASS (-2, -3) y por Ramsay (III, IV)Al transferir un paciente a otro sector (después de 90 minutos), este parámetro fue 0 en RASS y II en Ramsay. No hubo cambios significativos en la hemodinámica central y la depresión respiratoria.El nivel mínimo de dolor se determinó después de la cirugía, 30 y 60 minutos después de la cirugía y antes del traslado al otro sector (90 minutos después): 6 (4; 9); 10 (8; 12); 12 (9; 13); 16 (13; 19), respectivamente. Se verificó que no era necesaria analgesia adicional el primer día postoperatorio. Conclusiones El uso de D reduce significativamente el nivel de dolor al mismo tiempo que se mantiene la necesaria comunicación verbal con el paciente y brinda la protección neurovegetativa necesaria sin depresión respiratoria y parámetros hemodinámico reducidos durante el período perioperatorio. Nivel de evidencia II; Estudios de pronóstico: Investigación del efecto de la característica de un paciente sobre el desenlace de la enfermedad. Serie de casos, Estudio retrospectivo.

Cirugía mayor abdominal electiva sin descompresión nasogástrica y con apertura precoz de vía oral / Major Elective Abdominal Surgery without Nasogastric Decompression and with Early Opening of the Oral Route

Introducción: La descompresión con sonda nasogástrica y la vía oral cerrada por varios días, ha sido práctica común tras procedimientos quirúrgicos electivos del tracto digestivo. Los programas para mejorar la recuperación posoperatoria (Enhanced Recovery After Surgery), aconsejan cambiar esta práctica. Objetivo: Evaluar el cumplimiento y repercusión en la evolución posoperatoria de dos acciones del programa en el retiro de la sonda nasogástrica y la apertura de la vía oral el día de la intervención. Métodos: Se realizó un estudio prospectivo, en el Servicio de Cirugía General del Hospital "Hermanos Ameijeiras" de septiembre 2017 a agosto 2020. La muestra fue de 270 pacientes con intervención quirúrgica mayor electiva del colon, hígado, vía biliar o páncreas, a los que se les aplicó el programa para mejorar la recuperación posoperatoria. Resultados: En 79,6 por ciento de pacientes, la sonda nasogástrica se retiró en el quirófano tras la intervención y esto se asoció a más rápida recuperación de la función intestinal, menor estadía, complicaciones, reingresos y reintervenciones. En 60 por ciento se inició la vía oral 6 horas después de la cirugía y 79,6 por ciento toleraban dieta blanda a las 48 horas. Estos pacientes presentaron menos complicaciones y mortalidad. Conclusiones: En el contexto de un programa para mejorar la recuperación posoperatoria, tras cirugía abdominal electiva, el retiro de la sonda nasogástrica el día de la intervención, con apertura precoz de la vía oral y rápida progresión a dieta blanda, son acciones bien toleradas que repercuten positivamente en la evolución posoperatoria(AU)

Introduction: Nasogastric tube decompression, together with the oral route closed for several days, has been a common practice after elective surgical procedures of the digestive tract. Programs to improve postoperative recovery (Enhanced Recovery After Surgery) advise changing this practice. Objective: To assess compliance and impact on postoperative evolution of two program actions for nasogastric tube removal and opening of the oral route on the intervention day. Methods: A prospective study was carried out, from September 2017 to August 2020, in the general surgery service of Hermanos Ameijeiras Hospital. The sample consisted of 270 patients who underwent major elective surgery of the colon, liver, bile duct or pancreas and were applied the program to improve postoperative recovery. Results: In 79.6 percent of patients, the nasogastric tube was removed in the operating room after the intervention, a fact associated with faster recovery of intestinal function, shorter stay, as well as fewer complications, readmissions and reinterventions. In 60 percent of the patients, the oral route was started at six hours after surgery, while 79.6 percent of them tolerated a soft diet at 48 hours. These patients presented fewer complications and mortality. Conclusions: In the context of a program to improve postoperative recovery after elective abdominal surgery, nasogastric tube removal on the intervention day, with early opening of the oral route and rapid progression to a soft diet, are well-tolerated actions that have a positive effect on postoperative evolution(AU)