Martin Hübner

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include:• integration of nutrition into the overall management of the patient• avoidance of long periods of preoperative fasting• re-establishment of oral feeding as early as possible after surgery• start of nutritional therapy early, as soon as a nutritional risk becomes apparent• metabolic control e.g. of blood glucose• reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function• minimized time on paralytic agents for ventilator management in the postoperative period• early mobilisation to facilitate protein synthesis and muscle functionThe guideline presents 37 recommendations for clinical practice. Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: • integration of nutrition into the overall management of the patient • avoidance of long periods of preoperative fasting • re-establishment of oral feeding as early as possible after surgery • start of nutritional therapy early, as soon as a nutritional risk becomes apparent • metabolic control e.g. of blood glucose • reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • minimized time on paralytic agents for ventilator management in the postoperative period • early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice. biomedical endpoints enteral nutrition (enteral tube feeding) enhanced recovery after surgery European Society for Clinical Nutrition and Metabolism health care economy endpoint integration of classical and patient-reported endpoints oral nutritional supplements parenteral nutrition quality of life tube feeding normal diet as offered by the catering system of a hospital including special diets period starting prior to surgery from hospital admission until discharge after surgery In order to make proper plans for the nutritional support of patients undergoing surgery, it is essential to understand the basic changes in metabolism that occur as a result of injury, and that a compromised nutritional status is a risk factor for postoperative complications. Starvation during metabolic stress from any type of injury differs from fasting under physiological conditions [[1]Soeters P. Bozzetti F. Cynober L. Elia M. Shenkin A. Sobotka L. Meta-analysis is not enough: the critical role of pathophysiology in determining optimal care in clinical nutrition.Clin Nutr. 2016; 35: 748-757Abstract Full Text Full Text PDF PubMed Google Scholar]. Surgery itself leads to inflammation corresponding with the extent of the surgical trauma, and leads to a metabolic stress response. To achieve appropriate healing and functional recovery (“restitutio ad integrum”) a metabolic response is necessary, but this requires nutritional therapy especially when the patient is malnourished and the stress/inflammatory response is prolonged. The negative effect of long term caloric and protein deficits on outcome for critically ill surgical patients has been shown again recently [[2]Yeh D.D. Fuentes E. QUrashi S.A. Cropano C. Kaafarani H. Lee J. et al.Adequate nutrition may get you home: effect of caloric/protein deficits on the discharge destination of critically ill surgical patients.J Parenter Enteral Nutr. 2016; 40: 37-44Crossref PubMed Scopus (9) Google Scholar]. The success of surgery does not depend exclusively on technical surgical skills, but also on metabolic interventional therapy, taking into account the ability of the patient to carry a metabolic load and to provide appropriate nutritional support. In patients with cancer, management during the perioperative period may be crucial for long-term outcome [3Horowitz M. Neeman E. Sharon E. Ben-Eliyahu S. Exploiting the critical perioperative period to improve long-term cancer outcomes.Nat Rev Clin Oncol. 2015; : 213-226Crossref PubMed Scopus (27) Google Scholar, 4Gustafsson U.O. Oppelstrup H. Thorell A. Nygren J. Ljungqvist O. Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study.World J Surg. 2016; 40: 1741-1747Crossref PubMed Google Scholar]. Surgery, like any injury, elicits a series of reactions including release of stress hormones and inflammatory mediators, i.e. cytokines. The cytokine response to infection and injury, the so-called “Systemic Inflammatory Response Syndrome”, has a major impact on metabolism. The syndrome causes catabolism of glycogen, fat and protein with release of glucose, free fatty acids and amino acids into the circulation, so that substrates are diverted from their normal purpose of maintaining peripheral protein (especially muscle) mass, to the tasks of healing and immune response [5Gillis C. Carli F. Promoting perioperative metabolic and nutritional care.Anesthesiology. 2015; 123: 1455-1472Crossref PubMed Google Scholar, 6Alazawi W. Pirmadid N. Lahiri R. Bhattacharya S. Inflammatory and immune responses to surgery and their clinical impact.Ann Surg. 2016; 64: 73-80Crossref Scopus (1) Google Scholar]. The consequence of protein catabolism is the loss of muscle tissue which is a short and long-term burden for functional recovery which is considered the most important target [[7]Aahlin E.K. Tranø G. Johns N. Horn A. Søreide J.A. Fearon K.C. et al.Risk factors, complications and survival after upper abdominal surgery: a prospective cohort study.BMC Surg. 2015; 15: 83Crossref PubMed Scopus (5) Google Scholar]. In order to spare protein stores, lipolysis, lipid oxidation, and decreased glucose oxidation are important survival mechanisms [[8]Soeters M.R. Soeters P.B. Schooneman M.G. Houten S.M. Rimijn J.A. Adaptive reciprocity of lipid and glucose metabolism in human short-term starvation.Am J Physiol Endocrinol Metab. 2012; 303: E1397-E1407Crossref PubMed Scopus (21) Google Scholar]. Nutritional therapy may provide the energy for optimal healing and recovery, but in the immediate postoperative phase may only minimally counteract muscle catabolism, or not at all. To restore peripheral protein mass the body needs to deal with the surgical trauma and possible infection adequately. Nutritional support/intake and physical exercise are prerequisites to rebuild peripheral protein mass/body cell mass. Patients undergoing surgery may suffer from chronic low-grade inflammation as in cancer, diabetes, renal and hepatic failure [[9]Soeters P.B. Schols A.M. Advances in understanding and assessing malnutrition.Curr Opin Clin Nutr Metab Care. 2009; 12: 487-494Crossref PubMed Scopus (0) Google Scholar]. Other non-nutritional metabolic factors interfering with an adequate immune response have to be taken into account and, whenever possible, corrected or ameliorated before surgery. These are diminished cardio-respiratory organ function, anaemia, acute and chronic intoxications (e.g. alcohol, recreational drugs), medical treatment with anti-inflammatory and cytotoxic drugs. The surgeon has to balance the extent of surgery according to nutritional state, inflammatory activity and anticipated host response. Severe pre-existing inflammation and sepsis influence healing negatively (wounds, anastomoses, immune function, etc.) but also decrease the benefit of nutritional therapy. Severely malnourished patients may exhibit an adynamic form of sepsis with hypothermia, leukopenia, somnolence, impaired wound healing and pus production, altogether leading to slow deterioration and mortality. In this situation nutritional therapy will not maintain or build up muscle mass but may restore an adequate stress response, promoting the chances of recovery. Awareness for the impaired inflammatory stress response means limiting the extent of the surgical trauma and may lead to uneventful recovery. Severely compromised patients should receive perioperative nutritional therapy of longer duration or when acute intervention is required, surgery should be limited or minimally invasive interventional techniques should be preferred to relieve infection/ischaemia. In order to optimize the mildly malnourished patient short-term (7–10 days) nutritional conditioning has to be considered. In severely malnourished patients longer periods of nutritional conditioning are necessary and this should be combined with resistance exercise. In the truly infected patient immediately dealing with the focus of sepsis (“source control”) should have priority and no major surgery should be performed (risky anastomoses, extensive dissections etc.). Definitive surgery should be performed at a later stage when sepsis has been treated adequately. In elective surgery it has been shown that measures to reduce the stress of surgery can minimize catabolism and support anabolism throughout surgical treatment and allow patients to recover substantially better and faster, even after major surgical operations. Such programmes for Fast Track surgery [[10]Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation.Br J Anaesth. 1997; 78: 606-617Crossref PubMed Google Scholar] later developed into Enhanced Recovery after Surgery (ERAS). A series of components that combine to minimize stress and to facilitate the return of function have been described: these include preoperative preparation and medication, fluid balance, anaesthesia and postoperative analgesia, pre- and postoperative nutrition, and mobilization [5Gillis C. Carli F. Promoting perioperative metabolic and nutritional care.Anesthesiology. 2015; 123: 1455-1472Crossref PubMed Google Scholar, 11Fearon K.C. Ljungqvist O. Von Meyenfeldt M. Revhaug A. Dejong C.H. Lassen K. et al.Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection.Clin Nutr. 2005; 24: 466-477Abstract Full Text Full Text PDF PubMed Scopus (533) Google Scholar, 12Ljungqvist O. ERAS-enhanced recovery after surgery: moving evidence-based perioperative care to practice.J Parenter Enteral Nutr. 2014; 38: 559-566Crossref PubMed Scopus (0) Google Scholar, 13Bakker N. Cakir H. Doodeman H.J. Houdijk A.P. Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: impact of measures to improve adherence.Surgery. 2015; 157: 1130-1136Abstract Full Text Full Text PDF PubMed Google Scholar]. The ERAS programmes have now become a standard in perioperative management that has been adopted in many countries across several surgical specialties. They were developed in colonic operations [11Fearon K.C. Ljungqvist O. Von Meyenfeldt M. Revhaug A. Dejong C.H. Lassen K. et al.Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection.Clin Nutr. 2005; 24: 466-477Abstract Full Text Full Text PDF PubMed Scopus (533) Google Scholar, 14Lassen K. Soop M. Nygren J. Cox P.B. Hendry P.O. Spies C. et al.Enhanced Recovery After Surgery (ERAS) GroupConsensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations.Arch Surg. 2009; 144: 961-969Crossref PubMed Scopus (413) Google Scholar, 15Varadhan K.K. Neal K.R. Dejong C.H. Fearon K.C. Ljungqvist O. Lobo D.N. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials.Clin Nutr. 2010; 29: 434-440Abstract Full Text Full Text PDF PubMed Scopus (366) Google Scholar, 16Greco M. Capretti G. Beretta L. Gemma M. Pecorelli N. Braga M. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials.World J Surg. 2014; 38: 1531-1541Crossref PubMed Scopus (85) Google Scholar, 17Gustafsson U.O. Scott M.J. Schwenk W. Demartines N. Roulin D. Francis N. Enhanced Recovery After Surgery Society et al.Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations.Clin Nutr. 2012; 31: 783-800Abstract Full Text Full Text PDF PubMed Scopus (166) Google Scholar] and are now being applied to all major operations. ERAS programmes have been also successful in promoting rapid “functional” recovery after gastrectomy [[18]Mortensen K. Nilsson M. Slim K. Schäfer M. Mariette C. Braga M. et al.Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.Br J Surg. 2014; 101: 1209-1229Crossref PubMed Scopus (0) Google Scholar], pancreatic resections [19Balzano G. Zerbi A. Braga M. Rocchetti S. Beneduce A.A. Di Carlo V. Fast-track recovery programme after pancreatico-duodenectomy reduces delayed gastric emptying.Br J Surg. 2008; 95: 1387-1393Crossref PubMed Scopus (132) Google Scholar, 20Braga M. Pecorelli N. Ariotti R. Capretti G. Greco M. Balzano G. et al.Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomy.World J Surg. 2014; 38: 2960-2966Crossref PubMed Scopus (11) Google Scholar], pelvic surgery [21Nygren J. Thacker J. Carli F. Fearon K.C. Norderval S. Lobo D.N. Enhanced Recovery After Surgery Society et al.Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations.Clin Nutr. 2012; 31: 801-816Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar, 22Patel H.R. Cerantola Y. Valerio M. Persson B. Jichlinski P. Ljungqvist O. et al.Enhanced recovery after surgery: are we ready, and can we afford not to implement these pathways for patients undergoing radical cystectomy?.Eur Urol. 2014; 65: 263-266Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar], hysterectomy [[23]Wijk L. Franzen K. Ljungqvist O. Nilsson K. Implementing a structured Enhanced Recovery after Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy.Acta Obstet Gynecol Scand. 2014; 93: 749-756Crossref PubMed Scopus (18) Google Scholar], gynaecologic oncology [[24]Nelson G. Altman A.D. Nick A. Meyer L.A. Ramirez P.T. Achtari C. et al.Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations – part 1.Gynecol Oncol. 2016; 140: 313-322Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar]. In times of limitations in health care economy ERAS is also a reasonable contribution for the purpose of saving resources [[25]Bond Smith G. Belgaumkar A.P. Davison B.R. Gurusamy K.S. Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery.Cochrane Database Syst Rev. 2016; 1 (CD011382): 2Google Scholar]. ERAS protocols have been also shown to be safe and beneficial in the elderly [[26]Slieker J. Frauche P. Jurt J. Addor V. Blanc C. Demartines N. et al.Enhanced recovery ERAS for elderly: a safe and beneficial pathway in colorectal surgery.Int J Colorectal Dis. 2017; 32: 215-221Crossref PubMed Scopus (0) Google Scholar]. High adherence to ERAS protocols may be associated with improved 5-year cancer specific survival after major colorectal surgery [[4]Gustafsson U.O. Oppelstrup H. Thorell A. Nygren J. Ljungqvist O. Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study.World J Surg. 2016; 40: 1741-1747Crossref PubMed Google Scholar]. As a key component of ERAS, nutritional management is an inter-professional challenge. The ERAS programmes also include a metabolic strategy to reduce perioperative stress and improve outcomes [[12]Ljungqvist O. ERAS-enhanced recovery after surgery: moving evidence-based perioperative care to practice.J Parenter Enteral Nutr. 2014; 38: 559-566Crossref PubMed Scopus (0) Google Scholar]. While early oral feeding is the preferred mode of nutrition, avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Keeping in mind that the nutritional status is a risk factor for postoperative complications, this is especially relevant for patients at nutritional risk and those undergoing upper gastrointestinal (GI) surgery. For this reason, ERAS guidelines recommend liberal subscription of oral supplements pre- and postoperatively. Equally ERAS protocols support early oral intake for the return of gut function. From a metabolic and nutritional point of view, the key aspects of perioperative care include:•integration of nutrition into the overall management of the patient•avoidance of long periods of preoperative fasting•re-establishment of oral feeding as early as possible after surgery•start of nutritional therapy early, as soon as a nutritional risk becomes apparent•metabolic control e.g. of blood glucose•reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function•minimize time on paralytic agents for ventilator management in the postoperative period•early mobilisation to facilitate protein synthesis and muscle function. Nutrition therapy. Synonym: nutritional support is defined according to the European Society for Clinical Nutrition and Metabolism (ESPEN) [27Cederholm T. Barrazoni R. Austin P. Ballmer P. Biolo G. Bischoff S.C. et al.ESPEN guidelines on definitions and terminology of clinical nutrition.Clin Nutr. 2017; 36: 49-64Abstract Full Text Full Text PDF PubMed Google Scholar, 28Cederholm T. Bosaeus I. Barazzoni R. Bauer J. Van Gossum A. Klek S. et al.Diagnostic criteria for malnutrition - an ESPEN consensus statement.Clin Nutr. 2015; 34: 335-340Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar]: Nutrition therapy is the provision of nutrition or nutrients either orally (regular diet, therapeutic diet, e.g. fortified food, oral nutritional supplements) or via enteral nutrition (EN) or parenteral nutrition (PN) to prevent or treat malnutrition. “Medical nutrition therapy is a term that encompasses oral nutritional supplements, enteral tube feeding (enteral nutrition) and parenteral nutrition” [[27]Cederholm T. Barrazoni R. Austin P. Ballmer P. Biolo G. Bischoff S.C. et al.ESPEN guidelines on definitions and terminology of clinical nutrition.Clin Nutr. 2017; 36: 49-64Abstract Full Text Full Text PDF PubMed Google Scholar]. Enteral and parenteral nutrition have traditionally been called artificial nutritional support. Nutrition therapies are individualized and targeted nutrition care measures using diet or medical nutrition therapy. Dietary advice or nutritional counselling can be part of a nutrition therapy. In the surgical patient, the indications for nutritional therapy are prevention and treatment of catabolism and malnutrition. This affects mainly the perioperative maintenance of nutritional state in order to prevent postoperative complications [[29]Chambrier C. Sztark F. Societé francophone de nutrition clinique et métabolisme (SFNEP), Societé francaise de l'anésthesie et réanimation (SFAR) French clinical guidelines on perioperative nutrition - update of the 1994 consensus conference on perioperative artificial nutrition for elective surgery in adults.J Visc Surg. 2012; 49: e325-336Crossref Google Scholar]. Therapy should start as a nutritional risk becomes apparent. Criteria for the success of the “therapeutic” indication are the so-called “outcome” parameters of mortality, morbidity, and length of hospital stay, while taking into consideration economic implications. The improvement of nutritional status and functional recovery including quality of life are most important nutritional goals in the late postoperative period. Nutrition therapy may be indicated even in patients without obvious disease-related malnutrition, if it is anticipated that the patient will be unable to eat or cannot maintain appropriate oral intake for a longer period perioperatively. In these situations, nutrition therapy may be initiated without delay. Altogether, it is strongly recommended not to wait until severe disease-related malnutrition has developed, but to start nutrition therapy early, as soon as a nutritional risk becomes apparent. Nutritional care protocols for the surgical patient must include•a detailed nutritional and medical history that includes body composition assessment•a nutrition intervention plan•an amendment of the intervention plan, where appropriate•clear and accurate documentation assessment of nutritional and clinical outcome•resistance exercise whenever possible Therefore, as a basic requirement a systematic nutritional risk screening (NRS) has to be considered in all patients on hospital admission [[30]Kondrup J. Allison S.P. Elia M. Vellas B. Plauth M. Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN) ESPEN guidelines for nutrition screening 2002.Clin Nutr. 2003; 22: 415-421Abstract Full Text Full Text PDF PubMed Scopus (1121) Google Scholar]. The items of the NRS comprise BMI <20.5 kg/m2, weight loss >5% within 3 months, diminished food intake, and severity of the disease. In older adults comprehensive geriatric assessment is necessary and should definitely include NRS [[31]Cheema F.N. Abraham N.S. Berger D.H. Albo D. Taffet G.E. Naik A.D. Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults.Ann Surg. 2011; 253: 867-874Crossref PubMed Scopus (0) Google Scholar]. In order to improve oral intake documentation of food intake is necessary and nutritional counselling should be provided as needed. Oral nutritional supplements (ONS) and EN (tube feeding) as well as PN offer the possibility to increase or to ensure nutrient intake in case of insufficient oral food intake. Assessment before surgery means risk assessment according to pathophysiology [[32]Soeters P.B. Reijven P.L. van Bokhorst-de van der Schueren M.A. Schols J.M. Halfens R.J. Meijers J.M. et al.A rational approach to nutritional assessment.Clin Nutr. 2008; 27: 706-716Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar]. Severe undernutrition has long been known to be detrimental to outcome [33Studley H.M. Percentage of weight loss – a basic indicator for surgical risk in patients with chronic peptic ulcer.JAMA. 1936; 106: 458-460Crossref Google Scholar, 34van Bokhorst-de van der Schueren M.A. van Leeuwen P.A. Sauerwein H.P. Kuik D.J. Snow G.B. Quak J.J. Assessment of malnutrition parameters in head and neck cancer and their relation to postoperative complications.Head Neck. 1997; 19: 419-425Crossref PubMed Google Scholar, 35Durkin M.T. Mercer K.G. McNulty M.F. Phipps L. Upperton J. Giles M. et al.Vascular surgical society of great britain and Ireland: contribution of malnutrition to postoperative morbidity in vascular surgical patients.Br J Surg. 1999; 86: 702Crossref PubMed Google Scholar, 36Pikul J. Sharpe M.D. Lowndes R. Ghent C.N. Degree of preoperative malnutrition is predictive of postoperative morbidity and mortality in liver transplant recipients.Transplantation. 1994; 57: 469-472Crossref PubMed Google Scholar]. Malnutrition is generally considered to be associated with starving and lack of food. Its presence in the Western world with an increasing percentage of obese people is frequently neither realized nor well understood. Disease Related Malnutrition (DRM) is more subtle than suggested by the World Health Organization (WHO) definition of undernutrition with a body mass index (BMI) < 18.5 kg/m2 (WHO) [28Cederholm T. Bosaeus I. Barazzoni R. Bauer J. Van Gossum A. Klek S. et al.Diagnostic criteria for malnutrition - an ESPEN consensus statement.Clin Nutr. 2015; 34: 335-340Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 37Valentini L. Volkert D. Schütz T. Ockenga J. Pirlich M. Druml W. et al.Suggestions for terminology in clinical nutrition.Clin Nutr ESPEN. 2014; 9: e97-e108Google Scholar]. Disease related weight loss in patients who are overweight is not necessarily associated with a low BMI. However, this weight loss results in changes in body composition with a loss of fat free mass inducing a “metabolic risk” which has to be kept in mind for patients undergoing major surgery with special regard to cancer. Additionally, chronic low-grade inflammation may be a component of malnutrition [[9]Soeters P.B. Schols A.M. Advances in understanding and assessing malnutrition.Curr Opin Clin Nutr Metab Care. 2009; 12: 487-494Crossref PubMed Scopus (0) Google Scholar]. ESPEN has recently defined diagnostic criteria for malnutrition according to two options [[28]Cederholm T. Bosaeus I. Barazzoni R. Bauer J. Van Gossum A. Klek S. et al.Diagnostic criteria for malnutrition - an ESPEN consensus statement.Clin Nutr. 2015; 34: 335-340Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar]•option 1: BMI <18.5 kg/m2•option 2: combined: weight loss >10% or >5% over 3 months and reduced BMI or a low fat free mass index (FFMI). Reduced BMI is <20 or <22 kg/m2 in patients younger and older than 70 years, respectively. Low FFMI is <15 and <17 kg/m2 in females and males, respectively. Because DRM is frequently not recognized and therefore untreated, metabolic factors will usually not be considered for the critical analysis of surgical morbidity and outcome. In traditional surgical care many retrospective and prospective studies (References in ESPEN guidelines 2006, [[38]Weimann A. Braga M. Harsanyi L. Laviano A. Ljungqvist O. Soeters P. et al.ESPEN guidelines on enteral nutrition: surgery including organ transplantation.Clin Nutr. 2006; 25: 224-244Abstract Full Text Full Text PDF PubMed Scopus (545) Google Scholar]) have shown clearly the prognostic influence of nutritional status on complications and mortality. A systematic review of ten studies revealed a validated nutritional tool a predictor for length of hospital stay in gastrointestinal cancer patients requiring surgery [[39]Gupta D. Vashi P.G. Lammersfeld C.A. Braun D.P. Role of nutritional status in predicting the length of stay in cancer: a systematic review of the epidemiological literature.Ann Nutr Metab. 2011; 59: 96-106Crossref PubMed Scopus (35) Google Scholar]. DRM is also relevant for outcome after organ transplantation (see references [[38]Weimann A. Braga M. Harsanyi L. Laviano A. Ljungqvist O. Soeters P. et al.ESPEN guidelines on enteral nutrition: surgery including organ transplantation.Clin Nutr. 2006; 25: 224-244Abstract Full Text Full Text PDF PubMed Scopus (545) Google Scholar]). Data from the European “NutritionDay” in about 15,000 patients clearly showed that “metabolic risk” is a factor for hospital mortality, with special focus on the elderly [[40]Hiesmayr M. Schindler K. Pernicka E. Schuh C. Schoeniger-Hekele A. Bauer P. et al.Decreased food intake is a risk factor for mortality in hospitalised patients: the NutritionDay survey 2006.Clin Nutr. 2009; 28: 484-491Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar]. According to the prospective data from a multicentre trial, most patients at risk will be found in hospital in the departments of surgery, oncology, geriatrics, and intensive care medicine. The univariate analysis revealed significant impact for the hospital complication rate: severity of the disease, age >70 years, surgery and cancer [[41]Sorensen J. Kondrup J. Prokopowicz J. Schiesser M. Krahenbuhl L. Meier R. et al.EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome.Clin Nutr. 2008; 27: 340-349Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar]. Bearing in mind the demographic development in the Western world, surgeons will have to deal with an increased risk of developing complications in the elderly undergoing major surgery for cancer. The metabolic risk associated with DRM can be detected easily by the “Nutritional Risk Score” [[30]Kondrup J. Allison S.P. Elia M. Vellas B. Plauth M. Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN) ESPEN guidelines for nutrition screening 2002.Clin Nutr. 2003; 22: 415-421Abstract Full Text Full Text PDF PubMed Scopus (1121) Google Scholar]. This tool has been validated prospectively in recent studies for surgical patients as well [41Sorensen J. Kondrup J. Prokopowicz J. Schiesser M. Krahenbuhl L. Meier R. et al.EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome.Clin Nutr. 2008; 27:

Abstract Background This is the fourth updated Enhanced Recovery After Surgery (ERAS ® ) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS ® protocol. Methods A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta‐analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Results All recommendations on ERAS ® protocol items are based on best available evidence; good‐quality trials; meta‐analyses of good‐quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. Conclusions The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS ® Society in this comprehensive consensus review.

Enhanced recovery after surgery (ERAS) pathways have significantly reduced complications and length of hospital stay after colorectal procedures. This multimodal concept could probably be partially applied to major urological surgery.The primary objective was to systematically assess the evidence of ERAS single items and protocols applied to cystectomy patients. The secondary objective was to address a grade of recommendation to each item, based on the evidence and, if lacking, on consensus opinion from our ERAS Society working group.A systematic literature review was performed on ERAS for cystectomy by searching EMBASE and Medline. Relevant articles were selected and quality-assessed by two independent reviewers using the GRADE approach. If no study specific to cystectomy was available for any of the 22 given items, the authors evaluated whether colorectal guidelines could be extrapolated.Overall, 804 articles were retrieved from electronic databases. Fifteen articles were included in the present systematic review and 7 of 22 ERAS items were studied. Bowel preparation did not improve outcomes. Early nasogastric tube removal reduced morbidity, bowel recovery time and length of hospital stay. Doppler-guided fluid administration allowed for reduced morbidity. A quicker bowel recovery was observed with a multimodal prevention of ileus, including gum chewing, prevention of PONV and minimally invasive surgery.ERAS has not yet been widely implemented in urology and evidence for individual interventions is limited or unavailable. The experience in other surgical disciplines encourages the development of an ERAS protocol for cystectomy.

Abstract Background Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus. Methods A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations. Results A total of 157 full texts were screened. Thirty‐seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal‐directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia. Conclusions The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.

Background & AimsA fast-track program is a multimodal approach for patients undergoing colonic surgery that combines stringent regimens of perioperative care (fluid restriction, optimized analgesia, forced mobilization, and early oral feeding) to reduce perioperative morbidity, hospital stay, and cost. We investigated the impact of a fast-track protocol on postoperative morbidity in patients after open colonic surgery.MethodsA randomized trial of patients in 4 teaching hospitals in Switzerland included 156 patients undergoing elective open colonic surgery who were assigned to either a fast-track program or standard care. The primary end point was the 30-day complication rate. Secondary end points were severity of complications, hospital stay, and compliance with the fast-track protocol.ResultsThe fast-track protocol significantly decreased the number of complications (16 of 76 in the fast-track group vs 37 of 75 in the standard care group; P = .0014), resulting in shorter hospital stays (median, 5 days; range, 2–30 vs 9 days, respectively; range, 6–30; P < .0001). There was a trend toward less severe complications in the fast-track group. A multiple logistic regression analysis revealed fluid administration greater than the restriction limits (odds ratio, 4.198; 95% confidence interval, 1.7–10.366; P = .002) and a nonfunctioning epidural analgesia (odds ratio, 3.365; 95% confidence interval, 1.367–8.283; P = .008) as independent predictors of postoperative complications.ConclusionsThe fast-track program reduces the rate of postoperative complications and length of hospital stay and should be considered as standard care. Fluid restriction and an effective epidural analgesia are the key factors that determine outcome of the fast-track program. A fast-track program is a multimodal approach for patients undergoing colonic surgery that combines stringent regimens of perioperative care (fluid restriction, optimized analgesia, forced mobilization, and early oral feeding) to reduce perioperative morbidity, hospital stay, and cost. We investigated the impact of a fast-track protocol on postoperative morbidity in patients after open colonic surgery. A randomized trial of patients in 4 teaching hospitals in Switzerland included 156 patients undergoing elective open colonic surgery who were assigned to either a fast-track program or standard care. The primary end point was the 30-day complication rate. Secondary end points were severity of complications, hospital stay, and compliance with the fast-track protocol. The fast-track protocol significantly decreased the number of complications (16 of 76 in the fast-track group vs 37 of 75 in the standard care group; P = .0014), resulting in shorter hospital stays (median, 5 days; range, 2–30 vs 9 days, respectively; range, 6–30; P < .0001). There was a trend toward less severe complications in the fast-track group. A multiple logistic regression analysis revealed fluid administration greater than the restriction limits (odds ratio, 4.198; 95% confidence interval, 1.7–10.366; P = .002) and a nonfunctioning epidural analgesia (odds ratio, 3.365; 95% confidence interval, 1.367–8.283; P = .008) as independent predictors of postoperative complications. The fast-track program reduces the rate of postoperative complications and length of hospital stay and should be considered as standard care. Fluid restriction and an effective epidural analgesia are the key factors that determine outcome of the fast-track program.

Patients undergoing major gastrointestinal surgery are at increased risk of developing complications. The use of immunonutrition (IN) in such patients is not widespread because the available data are heterogeneous, and some show contradictory results with regard to complications, mortality and length of hospital stay.Randomized controlled trials (RCTs) published between January 1985 and September 2009 that assessed the clinical impact of perioperative enteral IN in major gastrointestinal elective surgery were included in a meta-analysis.Twenty-one RCTs enrolling a total of 2730 patients were included in the meta-analysis. Twelve were considered as high-quality studies. The included studies showed significant heterogeneity with respect to patients, control groups, timing and duration of IN, which limited group analysis. IN significantly reduced overall complications when used before surgery (odds ratio (OR) 0·48, 95 per cent confidence interval (c.i.) 0·34 to 0·69), both before and after operation (OR 0·39, 0·28 to 0·54) or after surgery (OR 0·46, 0·25 to 0·84). For these three timings of IN administration, ORs of postoperative infection were 0·36 (0·24 to 0·56), 0·41 (0·28 to 0·58) and 0·53 (0·40 to 0·71) respectively. Use of IN led to a shorter hospital stay: mean difference -2·12 (95 per cent c.i. -2·97 to -1·26) days. Beneficial effects of IN were confirmed when low-quality trials were excluded. Perioperative IN had no influence on mortality (OR 0·90, 0·46 to 1·76).Perioperative enteral IN decreases morbidity and hospital stay but not mortality after major gastrointestinal surgery; its routine use can be recommended.

Enhanced recovery protocols may reduce postoperative complications and length of hospital stay. However, the implementation of these protocols requires time and financial investment. This study evaluated the cost-effectiveness of enhanced recovery implementation.The first 50 consecutive patients treated during implementation of an enhanced recovery programme were compared with 50 consecutive patients treated in the year before its introduction. The enhanced recovery protocol principally implemented preoperative counselling, reduced preoperative fasting, preoperative carbohydrate loading, avoidance of premedication, optimized fluid balance, standardized postoperative analgesia, use of a no-drain policy, as well as early nutrition and mobilization. Length of stay, readmissions and complications within 30 days were compared. A cost-minimization analysis was performed.Hospital stay was significantly shorter in the enhanced recovery group: median 7 (interquartile range 5-12) versus 10 (7-18) days (P = 0·003); two patients were readmitted in each group. The rate of severe complications was lower in the enhanced recovery group (12 versus 20 per cent), but there was no difference in overall morbidity. The mean saving per patient in the enhanced recovery group was €1651.Enhanced recovery is cost-effective, with savings evident even in the initial implementation period.

Pressurised intraperitoneal aerosol chemotherapy (PIPAC) was introduced as a new treatment for patients with peritoneal metastases in November, 2011. Reports of its feasibility, tolerance, and efficacy have encouraged centres worldwide to adopt PIPAC as a novel drug delivery technique. In this Review, we detail the technique and rationale of PIPAC and critically assess its evidence and potential indications. A systematic search was done to identify all relevant literature on PIPAC published between Jan 1, 2011, and Jan 31, 2019. A total of 106 articles or reports on PIPAC were identified, and 45 clinical studies on 1810 PIPAC procedures in 838 patients were included for analysis. Repeated PIPAC delivery was feasible in 64% of patients with few intraoperative and postoperative surgical complications (3% for each in prospective studies). Adverse events (Common Terminology Criteria for Adverse Events greater than grade 2) occurred after 12-15% of procedures, and commonly included bowel obstruction, bleeding, and abdominal pain. Repeated PIPAC did not have a negative effect on quality of life. Using PIPAC, an objective clinical response of 62-88% was reported for patients with ovarian cancer (median survival of 11-14 months), 50-91% for gastric cancer (median survival of 8-15 months), 71-86% for colorectal cancer (median survival of 16 months), and 67-75% (median survival of 27 months) for peritoneal mesothelioma. From our findings, PIPAC has been shown to be feasible and safe. Data on objective response and quality of life were encouraging. Therefore, PIPAC can be considered as a treatment option for refractory, isolated peritoneal metastasis of various origins. However, its use in further indications needs to be validated by prospective studies.

In Brief Objective: To compare epidural analgesia (EDA) to patient-controlled opioid-based analgesia (PCA) in patients undergoing laparoscopic colorectal surgery. Background: EDA is mainstay of multimodal pain management within enhanced recovery pathways [enhanced recovery after surgery (ERAS)]. For laparoscopic colorectal resections, the benefit of epidurals remains debated. Some consider EDA as useful, whereas others perceive epidurals as unnecessary or even deleterious. Methods: A total of 128 patients undergoing elective laparoscopic colorectal resections were enrolled in a randomized clinical trial comparing EDA versus PCA. Primary end point was medical recovery. Overall complications, hospital stay, perioperative vasopressor requirements, and postoperative pain scores were secondary outcome measures. Analysis was performed according to the intention-to-treat principle. Results: Final analysis included 65 EDA patients and 57 PCA patients. Both groups were similar regarding baseline characteristics. Medical recovery required a median of 5 days (interquartile range [IQR], 3–7.5 days) in EDA patients and 4 days (IQR, 3–6 days) in the PCA group (P = 0.082). PCA patients had significantly less overall complications [19 (33%) vs 35 (54%); P = 0.029] but a similar hospital stay [5 days (IQR, 4–8 days) vs 7 days (IQR, 4.5–12 days); P = 0.434]. Significantly more EDA patients needed vasopressor treatment perioperatively (90% vs 74%, P = 0.018), the day of surgery (27% vs 4%, P < 0.001), and on postoperative day 1 (29% vs 4%, P < 0.001), whereas no difference in postoperative pain scores was noted. Conclusions: Epidurals seem to slow down recovery after laparoscopic colorectal resections without adding obvious benefits. EDA can therefore not be recommended as part of ERAS pathways in laparoscopic colorectal surgery. A total of 128 patients undergoing elective laparoscopic colorectal resections were randomized to epidural analgesia (EDA) versus patient-controlled opioid-based analgesia (PCA). Medical recovery and high-dependency stay were longer in EDA patients, but hospital stay was similar. Thirty percent of EDA patients needed transitory vasopressor treatment. There was no difference in postoperative pain scores.

Abstract Background Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a minimally invasive approach under investigation as a novel treatment for patients with peritoneal carcinomatosis of various origins. The aim was to review the available evidence on mechanisms, clinical effects and risks. Methods This was a systematic review of the literature on pressurized intraperitoneal chemotherapy published between January 2000 and October 2016. All types of scientific report were included. Results Twenty-nine relevant papers were identified; 16 were preclinical studies and 13 were clinical reports. The overall quality of the clinical studies was modest; five studies were prospective and there was no randomized trial. Preclinical data suggested better distribution and higher tissue concentrations of chemotherapy agents in PIPAC compared with conventional intraperitoneal chemotherapy by lavage. Regarding technical feasibility, laparoscopic access and repeatability rates were 83–100 and 38–82 per cent. Surgery-related complications occurred in up to 12 per cent. Postoperative morbidity was low (Common Terminology Criteria for Adverse Events grade 3–5 events reported in 0–37 per cent), and hospital stay was about 3 days. No negative impact on quality of life was reported. Histological response rates for therapy-resistant carcinomatosis of ovarian, colorectal and gastric origin were 62–88, 71–86 and 70–100 per cent respectively. Conclusion PIPAC is feasible, safe and well tolerated. Preliminary good response rates call for prospective analysis of oncological efficacy.

Peritoneal surface malignancies comprise a heterogeneous group of primary tumours, including peritoneal mesothelioma, and peritoneal metastases of other tumours, including ovarian, gastric, colorectal, appendicular or pancreatic cancers. The pathophysiology of peritoneal malignancy is complex and not fully understood. The two main hypotheses are the transformation of mesothelial cells (peritoneal primary tumour) and shedding of cells from a primary tumour with implantation of cells in the peritoneal cavity (peritoneal metastasis). Diagnosis is challenging and often requires modern imaging and interventional techniques, including surgical exploration. In the past decade, new treatments and multimodal strategies helped to improve patient survival and quality of life and the premise that peritoneal malignancies are fatal diseases has been dismissed as management strategies, including complete cytoreductive surgery embedded in perioperative systemic chemotherapy, can provide cure in selected patients. Furthermore, intraperitoneal chemotherapy has become an important part of combination treatments. Improving locoregional treatment delivery to enhance penetration to tumour nodules and reduce systemic uptake is one of the most active research areas. The current main challenges involve not only offering the best treatment option and developing intraperitoneal therapies that are equivalent to current systemic therapies but also defining the optimal treatment sequence according to primary tumour, disease extent and patient preferences. New imaging modalities, less invasive surgery, nanomedicines and targeted therapies are the basis for a new era of intraperitoneal therapy and are beginning to show encouraging outcomes.

Background. Surgical stress during major surgery may be related to adverse clinical outcomes and early quantification of stress response would be useful to allow prompt interventions. The aim of this study was to evaluate the acute phase protein albumin in the context of the postoperative stress response. Methods. This prospective pilot study included 70 patients undergoing frequent abdominal procedures of different magnitude. Albumin (Alb) and C-reactive protein (CRP) levels were measured once daily starting the day before surgery until postoperative day (POD) 5. Maximal Alb decrease (Alb Δ min) was correlated with clinical parameters of surgical stress, postoperative complications, and length of stay. Results. Albumin values dropped immediately after surgery by about 10 g/L (42.2 ± 4.5 g/L preoperatively versus 33.8 ± 5.3 g/L at day 1, P < 0.001). Alb Δ min was correlated with operation length (Pearson ρ = 0.470, P < 0.001), estimated blood loss (ρ = 0.605, P < 0.001), and maximal CRP values (ρ = 0.391, P = 0.002). Alb Δ min levels were significantly higher in patients having complications (10.0 ± 5.4 versus 6.1 ± 5.2, P = 0.005) and a longer hospital stay (ρ = 0.285, P < 0.020). Conclusion. Early postoperative albumin drop appeared to reflect the magnitude of surgical trauma and was correlated with adverse clinical outcomes. Its promising role as early marker for stress response deserves further prospective evaluation.

Objective: To determine the role of the surgeon in the occurrence of surgical site infection (SSI) following colon surgery, with respect to his or her adherence to guidelines and his or her experience.Design, Setting, and Patients: Prospective cohort study of 2393 patients who underwent colon surgery performed by 31 surgeons in 9 secondary and tertiary care public Swiss hospitals, recruited from a surveillance program for SSI between March 1, 1998, and December 31, 2008, and followed up for 1 month after their operation.Main Outcome Measures: Risk factors for SSI were identified in univariate and multivariate analyses that included the patients' and procedures' characteristics, the hospitals, and the surgeons as candidate covariates.Correlations were sought between surgeons' individual adjusted risks, their self-reported adherence to guidelines, and the delay since their board certification.Results: A total of 428 SSIs (17.9%) were identified, with hospital rates varying from 4.0% to 25.2% and individual surgeon rates varying from 3.7% to 36.1%.Fea-tures of the patients and procedures associated with SSI in univariate analyses were male sex, age, American Society of Anesthesiologists score, contamination class, operation duration, and emergency procedure.Correctly timed antibiotic prophylaxis and laparoscopic approach were protective.Multivariate analyses adjusting for these features and for the hospitals found 4 surgeons with higher risk of SSI (odds ratio [OR]=2.37,95% confidence interval [CI], 1.51-3.70;OR = 2.19, 95% CI, 1.41-3.39;OR=2.15, 95% CI, 1.02-4.53;and OR=1.97, 95% CI, 1.18-3.30)and 2 surgeons with lower risk of SSI (OR=0.43,95% CI, 0.19-0.94;and OR=0.19, 95% CI, 0.04-0.81).No correlation was found between surgeons' individual adjusted risks and their adherence to guidelines or their experience. Conclusion:For reasons beyond adherence to guidelines or experience, the surgeon may constitute an independent risk factor for SSI after colon surgery.

Enhanced recovery after surgery (ERAS) for radical cystectomy seems logical, but our study has shown a paucity in the level of clinical evidence. As part of the ERAS Society, we welcome global collaboration to collect evidence that will improve patient outcomes.

BackgroundEnhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management.MethodsThe core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.ResultsResponse rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma.ConclusionThe present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.

Background: Adequate selection of patients with peritoneal metastasis (PM) for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains critical for successful long-term outcomes. Factors reflecting tumor biology are currently poorly represented in the selection process. The prognostic relevance of RAS/RAF mutations in patients with PM remains unclear. Methods: Survival data of patients with colorectal PM operated in 6 European tertiary centers were retrospectively collected and predictive factors for survival identified by Cox regression analyses. A simple point-based risk score was developed to allow patient selection and outcome prediction. Results: Data of 524 patients with a median age of 59 years and a median peritoneal cancer index of 7 (interquartile range: 3–12) were collected. A complete resection was possible in 505 patients; overall morbidity and 90-day mortality were 50.9% and 2.1%, respectively. PCI [hazard ratio (HR): 1.08], N1 stage (HR: 2.15), N2 stage (HR: 2.57), G3 stage (HR: 1.80) as well as KRAS (HR: 1.46) and BRAF (HR: 3.97) mutations were found to significantly impair survival after CRS/HIPEC on multivariate analyses. Mutations of RAS/RAF impaired survival independently of targeted treatment against EGFR. Consequently, a simple point-based risk score termed BIOSCOPE (BIOlogical Score of COlorectal PEritoneal metastasis) based on PCI, N-, G-, and RAS/RAF status was developed, which showed good discrimination [development area under the curve (AUC) = 0.72, validation AUC = 0.70], calibration ( P = 0.401) and allowed categorization of patients into 4 groups with strongly divergent survival outcomes. Conclusion: RAS/RAF mutations impair survival after CRS/HIPEC. The novel BIOSCOPE score reflects tumor biology, adequately stratifies long-term outcomes, and improves patient assessment and selection.

Enhanced recovery after surgery (ERAS) programmes have been shown to decrease complications and hospital stay. The cost-effectiveness of such programmes has been demonstrated for colorectal surgery. This study aimed to assess the economic outcomes of a standard ERAS programme for pancreaticoduodenectomy.ERAS for pancreaticoduodenectomy was implemented in October 2012. All consecutive patients who underwent pancreaticoduodenectomy until October 2014 were recorded. This group was compared in terms of costs with a cohort of consecutive patients who underwent pancreaticoduodenectomy between January 2010 and October 2012, before ERAS implementation. Preoperative, intraoperative and postoperative real costs were collected for each patient via the hospital administration. A bootstrap independent t test was used for comparison. ERAS-specific costs were integrated into the model.The groups were well matched in terms of demographic and surgical details. The overall complication rate was 68 per cent (50 of 74 patients) and 82 per cent (71 of 87 patients) in the ERAS and pre-ERAS groups respectively (P = 0·046). Median hospital stay was lower in the ERAS group (15 versus 19 days; P = 0·029). ERAS-specific costs were €922 per patient. Mean total costs were €56 083 per patient in the ERAS group and €63 821 per patient in the pre-ERAS group (P = 0·273). The mean intensive care unit (ICU) and intermediate care costs were €9139 and €13 793 per patient for the ERAS and pre-ERAS groups respectively (P = 0·151).ERAS implementation for pancreaticoduodenectomy did not increase the costs in this cohort. Savings were noted in anaesthesia/operating room, medication and laboratory costs. Fewer patients in the ERAS group required an ICU stay.

Enhanced recovery protocols have been proven to decrease complications and hospital stay following elective colorectal surgery. However, these principles have not yet been reported for urgent surgery procedures. We aimed to assess our initial experience with urgent colectomies performed within an established enhanced recovery pathway.In a prospective cohort study, all patients undergoing colonic resection between April 2012 and March 2013 were treated according to a standardized enhanced recovery protocol. Urgent surgeries were compared with the elective procedures with regards to baseline characteristics, compliance with enhanced recovery items, and clinical outcome.Patients (N = 28) requiring urgent colonic resection were included and compared with patients undergoing elective colectomy (N = 63). Overall compliance with the protocol was 57% for the urgent compared with 77% for the elective procedures (p = 0.006). The pre-operative compliance was 64 versus 96% (p < 0.001), the intra-operative compliance was 77 versus 86% (p = 0.145), and the post-operative compliance was 49 versus 67% (p = 0.015), for the urgent and elective resections, respectively. Overall, 18 urgent patients (64%) and 32 elective patients (51%) developed postoperative complications (p = 0.261). Median postoperative length of stay was 8 days in the urgent setting compared with 5 days in the elective setting (p = 0.006).Many of the intra-operative and post-operative enhanced recovery items can also be applied to urgent colectomy, entailing outcomes that approach the results achieved in the elective setting.

Purpose To assess the impact of delay from diagnosis to curative surgery on survival in patients with non-metastatic colon cancer. Methods National Cancer database (NCDB) analysis (2004–2013) including all consecutive patients diagnosed with stage I-III colon cancer and treated with primary elective curative surgery. Short and long delays were defined as lower and upper quartiles of time from diagnosis to treatment, respectively. Age-, sex-, race-, tumor stage and location-, adjuvant treatment-, comorbidity- and socioeconomic factors-adjusted overall survival (OS) was compared between the two groups (short vs. long delay). A multivariable Cox regression model was used to identify the independent impact of each factor on OS. Results Time to treatment was <16 days in the short delay group (31,171 patients) and ≥37 days in the long delay group (29,617 patients). OS was 75.4 vs. 71.9% at 5 years and 56.6 vs. 49.7% at 10 years in short and long delay groups, respectively (both p < 0.0001). Besides demographic (comorbidities, advanced age) and pathological factors (transverse and right-vs. left-sided location, advanced tumor stage, poor differentiation, positive microscopic margins), treatment delay had a significant impact on OS (HR 1.06, 95% CI 1.05–1.07 per 14 day-delay) upon multivariable analysis. The adjusted hazard ratio for death increased continuously with delay times of longer than 30 days, to become significant after a delay of 40 days. Conclusion This analysis using a national cancer database revealed a significant impact on OS when surgeries for resectable colon cancer were delayed beyond 40 days from time of diagnosis.

Background Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new drug delivery method offered in selected patients suffering from non-resectable peritoneal carcinomatosis (PC). As reported experience is still limited, we conducted a survey among active PIPAC centers aiming to report their technical approach and clinical findings. Methods An online survey was sent to active PIPAC centers worldwide. The questionnaire consisted of 34 closed questions and was conducted over a period of 3 months beginning in March 2017. Results Nine out of 15 contacted centers completed the questionnaire totaling 832 PIPAC procedures in 349 patients. Most common indications for PIPAC were PC from gastric, ovarian and colorectal origin. The mean time between each PIPAC procedure was 6–8 weeks. Seven of nine (77.8%) centers evaluate the PCI at every PIPAC procedure. At least four tissue samples for histopathology analysis were retrieved in 5 (55.6%). All centers (100%) use the same chemotherapy protocol: oxaliplatin at a dosage of 92mg/m2 for PC of colorectal origin and a combination of cisplatin and doxorubicin at a dosage of 7.5mg/m2 and 1.5mg/m2, respectively, for other types of PC. Eight centers (88.9%) perform routine radiological evaluation before first PIPAC and after third PIPAC. Conclusion These data confirm that PIPAC procedures are homogeneously performed in established centers. Standardization of the procedure will facilitate future international multicenter prospective clinical trials.

BackgroundEnhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations.MethodsThe core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.ResultsResponse rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma.ConclusionThe present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.

This is a short overview of the principles of a novel development in surgery called enhanced recovery after surgery (ERAS) programs. This is an evidence-based approach to perioperative care that has shown to reduce complications and recovery time by 30-50%. The main mechanism is reduction of the stress reactions to the operation. These principles have been shown to be particularly well suited for the compromised patient and hence very good for the elderly people who often have co-morbidities and run a higher risk of complications.

Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.Twelve components of preoperative care were considered. Consensus was reached after three rounds.These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

Postoperative ileus (POI) is a frequent complication after abdominal surgery; nonetheless, it remains poorly defined. Our aim was to achieve an international consensus among leading colorectal surgeons on definition, prevention, and treatment of POI. Thirty-five experts from five continents participated in a three-round Delphi process. Round 1 contained open-ended questions on POI and postoperative nausea and vomiting (PONV). Round 2 included closed-ended questions. Round 3 measured agreement on a 5-point Likert scale. Consensus was defined when items were rated as agree or strongly agree by at least 70 % of the experts. Experts reached following consensus: POI is a temporary inhibition (86 %) of gastrointestinal motility after surgical intervention due to non-mechanical causes (89 %) and prevents sufficient oral intake (96 %). Abdominal distension/tenderness are the most relevant clinical signs (71 %). Nasogastric tube placement is not mandatory (78 %) but can be removed without previous clamping (81 %)/gastrointestinal contrast study (100 %). Preventive measures are recommended to decrease the risk of POI (96 %): narcotic sparing analgesia (89 %) and fluid optimization (74 %). Treatment of POI should include stimulation of ambulation (96 %) and stop of opioids (74 %). Total parenteral nutrition is recommended from the 7th day without sufficient oral intake (81 %). There was no consensus on the ranking of POI’s symptoms, on the imaging modality of choice for the diagnosis of POI, neither on the difference between POI and PONV. This Delphi study achieved consensus on the definition, relevant clinical signs, prevention, treatment, and supportive care of POI. Areas of non-consensus were identified (necessity and modality of radiologic imaging to establish the diagnosis, difference between POI and PONV), giving opportunity for further research.

Crohn's disease is an incurable and frequently progressive entity with major impact on affected patients. Up to half of patients require surgery in the first 10 years after diagnosis and over 75% of operated patients require at least one further surgery within lifetime. In order to minimize surgical risk, modifiable risk factors such as nutritional status need to be optimized. This systematic review on preoperative nutritional support in adult Crohn's patients between 1997 and 2017 aimed to provide an overview on target populations, screening modalities, routes of administration, and expected benefits. Pertinent study characteristics (prospective vs. retrospective, sample size, control group, limitations) were defined a priori. Twenty-nine studies were retained, of which 14 original studies (9 retrospective, 4 prospective, and 1 randomized controlled trial) and 15 reviews. Study heterogeneity was high regarding nutritional regimens and outcome, and meta-analysis could not be performed. Most studies were conducted without matched control group and thus provide modest level of evidence. Consistently, malnutrition was found to be a major risk factor for postoperative complications, and both enteral and parenteral routes were efficient in decreasing postoperative morbidity. Current guidelines for nutrition in general surgery apply also to Crohn's patients. The route of administration should be chosen according to disease presentation and patients' condition. Further studies are needed to strengthen the evidence.

<h3>Objective</h3> To test postoperative serum albumin drop (ΔAlb) as a marker of surgical stress response and early predictor of clinical outcomes. <h3>Design</h3> Prospective cohort study (NCT02356484). Albumin was prospectively measured in 138 patients undergoing major abdominal surgery. Blood samples were collected before surgery and on postoperative days 0, 1 2 and 3. ΔAlb was compared to the modified estimation of physiologic ability and surgical stress (mE-PASS) score and correlated to the performances of C reactive protein (CRP), procalcitonin (PCT) and lactate (LCT). Postoperative outcomes were postoperative complications according to Clavien classification and Comprehensive Complication Index (CCI), and length of hospital stay (LoS). <h3>Setting</h3> Department of abdominal surgery in a European tertiary centre. <h3>Participants</h3> Adult patients undergoing elective major abdominal surgery, with anticipated duration ≥2 hours. Patients on immunosuppressive or antibiotic treatments before surgery were excluded. <h3>Results</h3> The level of serum albumin rapidly dropped after surgery. ΔAlb correlated to the mE-PASS score (r=0.275, p=0.01) and to CRP increase (r=0.536, p&lt;0.001). ΔAlb also correlated to overall complications (r=0.485, p&lt;0.001), CCI (r=0.383, p&lt;0.001) and LoS (r=0.468, p&lt;0.001). A ΔAlb ≥10 g/L yielded a sensitivity of 77.1% and a specificity of 67.2% (AUC: 78.3%) to predict complications. Patients with ΔAlb ≥10 g/L on POD 1 showed a threefold increased risk of overall postoperative complications. <h3>Conclusions</h3> Early postoperative decrease of serum albumin correlated with the extent of surgery, its metabolic response and with adverse outcomes such as complications and length of stay. A decreased concentration of serum albumin ≥10 g/L on POD 1 was associated with a threefold increased risk of overall postoperative complications and may thus be used to identify patients at risk.

Enhanced recovery after surgery (ERAS) protocols advocate no nasogastric tubes after colorectal surgery, but postoperative ileus (POI) remains a challenging clinical reality. The aim of this study was to assess incidence and risk factors of POI.This retrospective analysis included all consecutive colorectal surgical procedures since May 2011 until November 2014. Uni- and multivariate risk factors for POI were identified by multiple logistic regression and functional and surgical outcomes assessed.The study cohort consisted of 513 consecutive colorectal ERAS patients. One hundred twenty-eight patients (24.7%) needed postoperative reinsertion of nasogastric tube at the 3.9 ± 2.9 postoperative day. Multivariate analysis retained the American Society of Anesthesiologists group 3-4 (odds ratio (OR) 1.3; 95% CI 1-1.8, p = 0.043) and duration of surgery of >3 h (OR 1.3; 95% CI 1-1.7, p = 0.047) as independent risk factors for POI. Minimally invasive surgery (OR 0.6; 95% CI 0.5-0.8, p ≤ 0.001) and overall compliance of >70% to the ERAS protocol (OR 0.7; 95% CI 0.6-1, p = 0.031) represented independent protective factors. POI was associated with respiratory (23 vs. 5%, p ≤ 0.001) and cardiovascular (16 vs. 3%, p ≤ 0.001) complications.POI was frequent in the present study. Overall compliance to the ERAS protocol and minimally invasive surgery helped to prevent POI, which was significantly correlated with medical complications.

Background Enhanced recovery after surgery (ERAS) guidelines for colorectal surgery suggest routine transurethral bladder drainage with early removal to prevent urinary tract infection (UTI). The aim of this study was to identify risk factors for urinary retention (UR). Methods This retrospective analysis included all colorectal patients since ERAS implementation in May 2011-November 2014. From the prospective ERAS database, over 100 items related to demographics, surgery, compliance, and outcome were analyzed. Risk factors for UR were identified by multiple logistic regressions; then, UR was correlated to functional outcomes and UTI and acute kidney injury rates. Results The study cohort consisted of 513 consecutive patients. Of these, 73 patients (14%) presented with UR. Multivariate analysis identified male gender (odds ratio 1.4; 95% CI, 1-1.8; P = 0.045) and postoperative thoracic epidural analgesia (EDA; odds ratio 2.6; 95% CI, 1.6-4.3; P ≤ 0.001) as independent risk factors for postoperative UR. Functional recovery was impeded in patients with UR, who were less mobile (mobilization day 1 >4 h: 57% versus 70%, P = 0.024) and gained more weight (2.8 ± 2.5 kg versus 1.6 ±3 kg on day 1, P = 0.001) due to fluid overload. Furthermore, patients with urinary catheters reported more pain (visual analog scales day 3: 3.1 ± 2.5 versus 2.2 ± 2.4, P = 0.002) and depended longer on intravenous fluid administration (termination of intravenous fluids later than day 1: 53% versus 39%, P = 0.021). Ten of 73 patients (14%) developed UTI in patients with UR and 42 of 440 (10%) in patients without UR (P = 0.276). Six of 73 patients (8%) developed acute kidney injury in patients with UR and 36 of 440 (8%) in patients without UR (P = 0.991). Conclusions Male gender and EDA were independent risk factors for postoperative UR which appeared to be a significant impediment for functional recovery.

The importance of nursing for surgical patients has been frequently underestimated. The success of enhanced recovery programs after surgery (ERAS) depends on preferably complete fulfillment of the protocol and nurses are an important part of it. Due to the additional nursing action required, such protocols are suspected to increase the nursing workload. The aim of the present study was to observe and measure objectively nursing workload before, during and after systematic implementation of a comprehensive enhanced recovery pathway in colorectal surgery.The program ERAS was introduced systematically in our tertiary academic centre 2011, since then our experience is based on more than 1500 ERAS patients. Nursing workload was prospectively assessed for all patients on a routine basis by means of a standardized and validated point system (PRN). In a retrospective cohort study, we compared nursing workload based on prospective data before, during and after ERAS implementation and correlated nursing workload to the compliance with the ERAS protocol.The study cohort included 50 patients before ERAS implementation (2010) and 69 (2011) and 148 (2012) consecutive patients after implementation; the baseline characteristics of the 3 groups were similar. Mean PRN values were 61.2 ± 19.7 per day in 2010 and decreased to 52.3 ± 13.7 (P = 0.005) and 51.6 ± 18.6 (P < 0.002) in 2011 and 2012, respectively. Increasing compliance with the ERAS protocol was significantly correlated to decreasing nursing workload (ρ = -0.42; P < 0.001).Nursing workload is--against a common belief--decreased by systematic implementation of enhance recovery protocol. The higher the compliance with the pathway, the lower the burden for the nurses!

Introduction Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) has been introduced as novel treatment for peritoneal carcinomatosis. Only proper patient selection, stringent safety protocol and careful surgery allow for a secure procedure. We hereby report the essentials for safe implementation. Methods All consecutive procedures within 20 months after PIPAC implementation were analyzed with regards to practical and surgical aspects. Special emphasis was laid on modifications of technique and safety measures during the implementation process with systematic use of a dedicated checklist. Further, surgical difficulty was documented by use of a visual analogue scale (VAS). Results 127 PIPAC procedures were performed in 58 patients from January 2015 until October 2016. 81% of patients had at least one previous laparotomy. Median operation time was 91 min (87–103) for the first 20 cases, 93 min (IQR 88–107) for PIPAC21-50, and 103 min (IQR 91–121) for the following 77 procedures. Primary and secondary non-access occurred in 3 patients (2%), all of them having prior hyperthermic intraperitoneal chemotherapy (HIPEC). Using open Hasson technique, one single bowel lesion occurred, which was the only intraoperative complication. One 5 mm and another 10/12 mm trocar were used in 88% of procedures while additional trocars were needed in 12%. No leak of cytostatics was observed and no procedure needed to be stopped. VAS for overall difficulty of the procedure was 3 ± 2.4, and 3 ± 2.9 and 3 ± 2.5, respectively, for abdominal access and intraoperative staging. Conclusions With standardized surgical approach and dedicated safety checklist, PIPAC can be safely introduced in clinical routine with minimal learning curve.

Enhanced recovery after surgery (ERAS) programs have been shown to ease the postoperative recovery and improve clinical outcomes for various surgery types. ERAS cost-effectiveness was demonstrated for colorectal surgery but not for liver surgery. The present study aim was to analyze the implementation costs and benefits of a specific ERAS program in liver surgery.A dedicated ERAS protocol for liver surgery was implemented in our department in July 2013. The subsequent year all consecutive patients undergoing liver surgery were treated according to this protocol (ERAS group). They were compared in terms of real in-hospital costs with a patient series before ERAS implementation (pre-ERAS group). Mean costs per patient were compared with a bootstrap T test. A cost-minimization analysis was performed.Seventy-four ERAS patients were compared with 100 pre-ERAS patients. There were no significant pre- and intraoperative differences between the two groups, except for the laparoscopy number (n = 18 ERAS, n = 9 pre-ERAS, p = 0.010). Overall postoperative complications were observed in 36 (49 %) and 64 patients (64 %) in the ERAS and pre-ERAS groups, respectively (p = 0.046). The median length of stay was significantly shorter for the ERAS group (8 vs. 10 days, p = 0.006). The total mean costs per patient were €38,726 and €42,356 for ERAS and pre-ERAS (p = 0.467). The cost-minimization analysis showed a total mean cost reduction of €3080 per patient after ERAS implementation.ERAS implementation for liver surgery induced a non-significant decrease in cost compared to standard care. Significant decreased complication rate and hospital stay were observed in the ERAS group.

Abstract Background The success of enhanced recovery (ERAS) pathways depends on the actual application of the intended protocol (adherence), but its full implementation remains challenging. In order to potentially streamline the pathway, it is indispensable to know the impact of individual items and the entire protocol on clinical outcomes. Methods Retrospective analysis including all consecutive colorectal ERAS patients since implementation (May 2011) until February 2014; demographics, adherence and outcomes were retrieved from a prospectively maintained database. Primary outcome was the impact of individual item and of the entire protocol on complications (overall and major) and length of hospital stay. Statistical analysis included logistic multivariate regression and adjustment for confounding factors. Results There were 328 patients with complete data sets analyzed. A minimally invasive approach [odd ratio (OR) 0.62; confidence interval (CI) 0.4–0.9] was significantly associated with less overall complications. In contrast, the use of prophylactic nasogastric tubes (OR 3.18; CI 1.4–7.4), prophylactic abdominal and pelvic drains (OR 1.96; 1.2–3.2) and intraoperative thoracic epidural analgesia (OR 1.76; CI 1.3–2.4) were associated with more overall complications. Minimal invasive approach was further associated with reduced hospital stay (OR 0.5; CI 0.4–0.7) and less major complications (OR 0.58; CI 0.4–0.8). Higher adherence to the entire ERAS protocol was associated with significantly less complications ( P &lt; 0.001) and shorter hospital stay ( P &lt; 0.001). Conclusions Minimally invasive surgery was the single most important component of the ERAS pathway while nasogastric tubes, drains and epidurals should be avoided. Overall, increasing adherence with the protocol was associated with better outcomes and should be the goal.

Enhanced Recovery After Surgery (ERAS) is widely accepted in current surgical practice due to its positive impact on patient outcomes. The successful implementation of ERAS is challenging and compliance with protocols varies widely. Continual staff education is essential for successful ERAS programmes. Teaching modalities exist, but there remains no agreement regarding the optimal training curriculum or how its effectiveness is assessed. We aimed to draw consensus from an expert panel regarding the successful training and implementation of ERAS.A modified Delphi technique was used; three rounds of questionnaires were sent to 58 selected international experts from 11 countries across multiple ERAS specialities and multidisciplinary teams (MDT) between January 2016 and February 2017. We interrogated opinion regarding four topics: (1) the components of a training curriculum and the structure of training courses; (2) the optimal framework for successful implementation and audit of ERAS including a guide for data collection; (3) a framework to assess the effectiveness of training; (4) criteria to define ERAS training centres of excellence.An ERAS training course must cover the evidence-based principles of ERAS with team-oriented training. Successful implementation requires strong leadership, an ERAS facilitator and an effective MDT. Effectiveness of training can be measured by improved compliance. A training centre of excellence should show a willingness to teach and demonstrable team working.We propose an international expert consensus providing an ERAS training curriculum, a framework for successful implementation, methods for assessing effectiveness of training and a definition of ERAS training centres of excellence.

Enhanced recovery after surgery (ERAS) protocols for elective colorectal surgery reduce the intensity of postoperative complications, hospital stays and costs. Improvements in clinical outcome are directly proportional to the adherence to the recommended pathway (compliance). The aim of the present study was to analyze reasons for the non-compliance of colorectal surgeries with the ERAS protocol.A consecutive cohort of patients undergoing elective colorectal surgery was prospectively analyzed with regards to the surgery's compliance with the ERAS protocol. The reason for every single protocol deviation was documented and the decision was categorized based on whether it was medically justified or not.During the 8-month study period, 76 patients were included. The overall compliance with 22 ERAS items was 76% (96% in the preoperative, 82% in the perioperative, and 63% in the postoperative period). The decision to deviate from the clinical pathway was mainly a medical decision, while patients and nurses were responsible in 26 and 14% of the cases, respectively. However, reasons for non-compliance were medically justified in 78% of the study participants.'Non-compliance' with the ERAS protocol was observed mostly in the postoperative period. Most deviations from the pathway were decided by doctors and in a majority of cases it appeared that they were due to a medical necessity rather than non-compliance. However, almost a quarter of deviations that were absolutely required are still amenable to improvement.

Background. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) has been introduced as a novel repeatable treatment for peritoneal carcinomatosis. The available evidence from the pioneer center suggests good tolerance and high response rates, but independent confirmation is needed. A single-center cohort was analyzed one year after implementation for feasibility and safety. Methods. PIPAC was started in January 2015, and every patient was entered into a prospective database. This retrospective analysis included all consecutive patients operated until April 2016 with emphasis on surgical feasibility and early postoperative outcomes. Results. Forty-two patients (M : F = 8 : 34, median age 66 (59-73) years) with 91 PIPAC procedures in total (4×: 1, 3×: 17, 2×: 12, and 1×: 12) were analyzed. Abdominal accessibility rate was 95% (42/44); laparoscopic access was not feasible in 2 patients with previous HIPEC. Median initial peritoneal carcinomatosis index (PCI) was 10 (IQR 5-17). Median operation time was 94 min (89-108) with no learning curve observed. One PIPAC application was postponed due to intraoperative intestinal lesion. Overall morbidity was 9% with 7 minor complications (Clavien I-II) and one PIPAC-unrelated postoperative mortality. Median postoperative hospital stay was 3 days (2-3). Conclusion. Repetitive PIPAC is feasible in most patients with refractory carcinomatosis of various origins. Intraoperative complications and postoperative morbidity rates were low. This encourages prospective studies assessing oncological efficacy.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a new drug delivery method used in patients with peritoneal cancer (PC) of primary or secondary origin. Intraperitoneal use of oxaliplatin raises concerns about toxicity, especially abdominal pain. The objective of this study was to assess the tolerance of PIPAC with oxaliplatin (PIPAC-Ox) in a large cohort of patients and to identify the risk factors for high grade toxicity, discontinuation of treatment and impaired survival.This retrospective cohort study included all consecutive patients treated with PIPAC-Ox (92 mg/m2) in five centers specialized in the treatment of PC. The procedure was repeated every 6 weeks. Outcomes of interest were Common Terminology Criteria for Adverse Events (CTCAE), symptoms and survival (Kaplan-Meier). Univariate risk factors were included in a multinominal regression model to control for bias.Overall, 251 PIPAC-Ox treatments were performed in 101 patients (45 female) having unresectable PC of various origins: 66 colorectal, 15 gastric, 5 ovarian, 3 mesothelioma, 2 pseudomyxoma, 10 other malignancies (biliary, pancreatic, endocrine) respectively. The median PCI was 19 (IQR: 10-28). Postoperative abdominal pain was present in 23 patients. Out of the 9 patients with grade 3 abdominal pain, only 3 needed a change of PIPAC drug. CTCAE 4.0 toxicity grade 4 or higher was encountered in 16(15.9%) patients. The patients had a mean of 2.5 procedures/patient (SD = 1.5). 50 subjects presented with symptom improvement.Oxaliplatin-based PIPAC appears to be a safe treatment that offers good symptom control and promising survival for patients with advanced peritoneal disease.

Enhanced recovery after surgery (ERAS) programs has shown clinical benefits in gynecologic surgery. The aim of the present study was to compare costs before and after implementation of an ERAS program for gynecologic surgery.Retrospective study comparing perioperative costs between consecutive patient groups undergoing gynecologic surgery (benign, staging or debulking) (I, 2012-13) prior, (II) immediately after, and (III, 2014-16) the three years after ERAS implementation. Preoperative, intraoperative, and postoperative real costs were collected for each patient via hospital administration. A bootstrap independent t-test was used for comparison.Demographics and preoperative characteristics were similar between group I (n = 42), II (n = 51), and III (ERAS I; n = 122, II; n = 134, III; n = 90). Average ERAS-specific costs were $687 per patient. Total mean individual costs per patient were $13'329 (95% confidence interval (CI): 11'301-15'213) and $17'710 (95% CI: 14'452-21'605) in the ERAS and pre-ERAS groups respectively, resulting in net savings of $4'381 (95% CI: 549-8'752, p = 0.043) in favour of ERAS group. Cost savings were explained by lower pre- and postoperative costs (difference: $5'011 95% CI: 1'587-8'998, p = 0.019). Total costs continued to decrease by $2'520 (mean: $15'190, 95% CI: 13'791-16'631) in year 1, by $3'077 (mean: $14'633, 95% CI: 13'378-16'250) and $5'070 (mean: $12'640, 95% CI: 11'460-14'015) (p = 0.03) respectively, in year 2 and 3 after implementation.Based on real costs and including specific costs due to ERAS implementation, ERAS program in gynecologic surgery induced significant decrease of overall costs by $4'381 per patient. Total costs continued to decrease in the three years after implementation.

Multimodal treatment, including systemic treatment and surgery, improved the prognosis of peritoneal metastasis (PM). Despite all efforts, recurrence rates remain high, and little data are available about clinical behavior or molecular patterns of PM in comparison to hematogenous metastasis. Here, we aimed to analyze recurrence patterns after multimodal treatment for PM from colorectal cancer.Patients with colorectal PM undergoing multimodal treatment including systemic chemotherapy and cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) between 2005 and 2017 at 4 centers were analyzed retrospectively.A total of 505 patients undergoing CRS/HIPEC were analyzed. Of the patients, 82.1% received preoperative chemotherapy. Median peritoneal cancer index was 6 (interquartile range = 3-11). Median disease-free and overall survival was 12 (95% confidence interval [CI] = 11 to 14) months and 51 (95% CI = 43 to 62) months, respectively. Disease recurred in 361 (71.5%) patients, presenting as isolated peritoneal recurrence in 24.6%, isolated hematogenous recurrence in 28.3%, and mixed recurrence in 13.9% of patients. Recurrence to the peritoneum was associated with an impaired time from recurrence to death of 21 (95% CI = 18 to 31) months for isolated peritoneal and 22 (95% CI = 16 to 30) months for mixed recurrence, compared with 43 (95% CI = 31 to >121) months for hematogenous recurrence (hazard ratio [HR] = 1.79, 95% CI = 1.27 to 2.53; P = .001; and HR = 2.44, 95% CI = 1.61 to 3.79; P < .001). On multiple logistic regression analysis, RAS mutational status (odds ratio [OR] = 2.42, 95% CI = 1.11 to 5.47; P = .03) and positive nodal stage of the primary (OR = 3.88, 95% CI = 1.40 to 11.86; P = .01) were identified as predictive factors for peritoneal recurrence.This study highlights the heterogeneity of peritoneal metastasis in patients with colorectal cancer. Recurrent peritoneal metastasis after radical treatment represents a more aggressive subset of metastatic colorectal cancer.

Safe implementation and thorough evaluation of new treatments require prospective data monitoring and standardization of treatments. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a promising alternative for the treatment of patients with peritoneal disease with an increasing number of suggested drug regimens. The aim was to reach expert consensus on current PIPAC treatment protocols and to define the most important research topics.The expert panel included the most active PIPAC centers, organizers of PIPAC courses and principal investigators of prospective studies on PIPAC. A comprehensive literature review served as base for a two-day hybrid consensus meeting which was accompanied by a modified three-round Delphi process. Consensus bar was set at 70% for combined (strong and weak) positive or negative votes according to GRADE. Research questions were prioritized from 0 to 10 (highest importance).Twenty-two out of 26 invited experts completed the entire consensus process. Consensus was reached for 10/10 final questions. The combination of doxorubicin (2.1 mg/m2) and cisplatin (10.5 mg/m2) was endorsed by 20/22 experts (90.9%). 16/22 (72.7%) supported oxaliplatin at 120 with potential reduction to 90 mg/m2 (frail patients), and 77.2% suggested PIPAC-Ox in combination with 5-FU. Mitomycin-C and Nab-paclitaxel were favoured as alternative regimens. The most important research questions concerned PIPAC conditions (n=3), standard (n=4) and alternative regimens (n=5) and efficacy of PIPAC treatment (n=2); 8/14 were given a priority of ≥8/10.The current consensus should help to limit heterogeneity of treatment protocols but underlines the utmost importance of further research.

Abstract Background Chronic neuropathy after hernia repair is a neglected problem as very few patients are referred for surgical treatment. The aim of the present study was to assess the outcome of standardized surgical revision for neuropathic pain after hernia repair. Methods In a prospective cohort study we evaluated all patients admitted to our tertiary referral center for surgical treatment of persistent neuropathic pain after primary herniorrhaphy between 2001 and 2006. Diagnosis of neuropathic pain was based on clinical findings and a positive Tinel’s sign. Postoperative pain was evaluated by a visual analogue scale (VAS) and a pain questionnaire up to 12 months after revision surgery. Results Forty‐three consecutive patients (39 male, median age 35 years) underwent surgical revision, mesh removal, and radical neurectomy. The median operative time was 58 min (range: 45–95 min) . Histological examination revealed nerve entrapment, complete transection, or traumatic neuroma in all patients. The ilioinguinal nerve was affected in 35 patients (81%); the iliohypogastric nerve, in 10 patients (23%). Overall pain (median VAS) decreased permanently after surgery within a follow‐up period of 12 months (preoperative 74 [range: 53–87] months versus 0 [range: 0–34] months; p &lt; 0.0001). Conclusions The results of this cohort study suggest that surgical mesh removal with ilioinguinal and iliohypogastric neurectomy is a successful treatment in patients with neuropathic pain after hernia repair.

Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown. Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice. Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.

To evaluate the impact of preoperative immunonutrition (IN) on postoperative morbidity in patients at risk of malnutrition undergoing major gastrointestinal (GI) surgery.The combination of malnutrition and major GI surgery entails high morbidity. The Nutritional Risk Score (NRS) reliably identifies patients who need preoperative nutrition; the optimal nutritional formula for these patients still needs to be defined. In all, 152 patients with a NRS≥3 and undergoing elective major GI surgery were randomized between IN or isocaloric-isonitrogenous nutrition (ICN) given for 5 days preoperatively. Patients and caregivers were blinded for the allocated intervention. Thirty days complication rate was the primary endpoint. Infections, length of hospital stay and compliance were considered as secondary outcomes.Overall, 145 patients were available for analysis; the 73 patients in the IN group matched well with the 72 ICN patients with regards to patient's and surgical characteristics. In all, 39 IN and 33 ICN patients experienced a total of 48 and 50 postoperative complications, respectively (P=0.723). Both groups did not differ significantly concerning infectious (13 vs 9) complications. Independent risk factors for overall complications were malignant disease (odds ratio (OR)=4.304; confidence interval (CI) 1.317-14.002) and operative time (OR=1.004; CI 1.000-1.008).In patients at nutritional risk, complications, infections and hospital stay after major GI surgery were comparable regardless of preoperative supplementation with IN or ICN.

Preoperative nutrition has been shown to reduce morbidity after major gastrointestinal (GI) surgery in selected patients at risk. In a randomized trial performed recently (NCT00512213), almost half of the patients, however, did not consume the recommended dose of nutritional intervention. The present study aimed to identify the risk factors for noncompliance. Demographic (n=5) and nutritional (n=21) parameters for this retrospective analysis were obtained from a prospectively maintained database. The outcome of interest was compliance with the allocated intervention (ingestion of ⩾11/15 preoperative oral nutritional supplement units). Uni- and multivariate analyses of potential risk factors for noncompliance were performed. The final analysis included 141 patients with complete data sets for the purpose of the study. Fifty-nine patients (42%) were considered noncompliant. Univariate analysis identified low C-reactive protein levels (P=0.015), decreased recent food intake (P=0.032) and, as a trend, low hemoglobin (P=0.065) and low pre-albumin (P=0.056) levels as risk factors for decreased compliance. However, none of them was retained as an independent risk factor after multivariate analysis. Interestingly, 17 potential explanatory parameters, such as upper GI cancer, weight loss, reduced appetite or co-morbidities, did not show any significant correlation with reduced intake of nutritional supplements. Reduced compliance with preoperative nutritional interventions remains a major issue because the expected benefit depends on the actual intake. Seemingly, obvious reasons could not be retained as valid explanations. Compliance seems thus to be primarily a question of will and information; the importance of nutritional supplementation needs to be emphasized by specific patients’ education.

Lower endoscopy (LE) is the standard diagnostic modality for lower gastrointestinal bleeding (LGIB). Conversely, computed tomographic angiography (CTA) offers an immediate non-invasive diagnosis visualizing the entire gastrointestinal tract. The aim of this study was to compare these 2 modalities with regards to diagnostic value and bleeding control.Tertiary center retrospective analysis of consecutive patients admitted for LGIB between 2006 and 2012. Comparison of patients with LE vs. CTA as first exam, respectively, with emphasis on diagnostic accuracy and bleeding control.Final analysis included 183 patients; 122 (66.7%) had LE first, while 32 (17.5%) had CTA; 29 (15.8%) had neither of both exams. Median time to CTA was shorter compared to LE (3 (IQR = 8.2) vs. 22 (IQR = 36.9) hours, P < 0.001). Active bleeding was identified in 31% with CTA vs. 15% with LE (P = 0.031); a non-actively bleeding source was found by CTA and LE in 22 vs. 31%, respectively (P = 0.305). Bleeding control required endoscopy in 19%, surgery in 14% and embolization in 1.6%, while 66% were treated conservatively. Post-interventional bleeding was mostly controlled by endoscopic therapy (57%). 80% of patients with active bleeding on CTA required surgery.Post-interventional LGIB was effectively addressed by LE. For other causes of LGIB, CTA was efficient, and more available than colonoscopy. Treatment was conservative for most patients. In case of active bleeding, CTA could localize the bleeding source and predict the need for surgery.

Background . Peritoneal cancer treatment aims to prolong survival, but preserving Quality of Life (QoL) under treatment is also a priority. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel minimally invasive repeatable treatment modality. The aim of the present study was to assess QoL in our cohort of PIPAC patients. Methods . Analysis of all consecutive patients included from the start of PIPAC program (January 2015). QoL (0–100: optimal) and symptoms (no symptom: 0–100) were measured prospectively before and after every PIPAC procedure using EORTC QLQ-C30. Results . Forty-two patients (M : F = 8 : 34, median age 66 (59–73) years) had 91 PIPAC procedures in total (1 : 4x, 17 : 3x, 12 : 2x, and 12 : 1x). Before first PIPAC, baseline QoL was measured as median of <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M1"><mml:mn fontstyle="italic">66</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">2.64</mml:mn></mml:math>. Prominent complaints were fatigue (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M2"><mml:mn fontstyle="italic">32</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">4.3</mml:mn></mml:math>) and digestive symptoms as diarrhea (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M3"><mml:mn fontstyle="italic">17</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">3.75</mml:mn></mml:math>), constipation (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M4"><mml:mn fontstyle="italic">17</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">4.13</mml:mn></mml:math>), and nausea (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M5"><mml:mn fontstyle="italic">7</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">2.54</mml:mn></mml:math>). Overall Quality of Life was <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M6"><mml:mn fontstyle="italic">64</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">3.75</mml:mn></mml:math> after PIPAC#1 (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M7"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn fontstyle="italic">0.57</mml:mn></mml:math>), <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M8"><mml:mn fontstyle="italic">61</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">4.76</mml:mn></mml:math> after PIPAC#2 (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M9"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn fontstyle="italic">0.89</mml:mn></mml:math>), and <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M10"><mml:mn fontstyle="italic">70</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">6.67</mml:mn></mml:math> after PIPAC#3 (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M11"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn fontstyle="italic">0.58</mml:mn></mml:math>). Fatigue symptom score was <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M12"><mml:mn fontstyle="italic">44</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">4.86</mml:mn></mml:math> after PIPAC#1 and <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M13"><mml:mn fontstyle="italic">47</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">6.69</mml:mn></mml:math> and <mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M14"><mml:mn fontstyle="italic">34</mml:mn><mml:mo>±</mml:mo><mml:mn fontstyle="italic">7.85</mml:mn></mml:math> after second and third applications, respectively (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M15"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn fontstyle="italic">0.40</mml:mn></mml:math>). Diarrhea (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M16"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn fontstyle="italic">0.31</mml:mn></mml:math>), constipation (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M17"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn fontstyle="italic">0.76</mml:mn></mml:math>), and nausea (<mml:math xmlns:mml="http://www.w3.org/1998/Math/MathML" id="M18"><mml:mi>p</mml:mi><mml:mo>=</mml:mo><mml:mn fontstyle="italic">0.66</mml:mn></mml:math>) did not change significantly under PIPAC treatment. Conclusion . PIPAC treatment of peritoneal carcinomatosis had no negative impact on patients’ overall QoL and its components or on main symptoms. This study was registered online on Research Registry (UIN: 1608).

Enhanced Recovery After Surgery (ERAS) guidelines advocate early postoperative mobilisation to counteract catabolic changes due to immobilisation and maintain muscle strength. The present study aimed to assess compliance to postoperative mobilisation according to ERAS recommendations. This is a retrospective cohort study on consecutive colorectal surgical procedures treated within an established ERAS protocol within a single center between May 2011 and May 2017. Demographics, surgical details, ERAS related items and surgical outcome were prospectively assessed in a dedicated database and compared between ambulant patients (at least 6 h out of bed at postoperative day (POD) 1) vs. patients not meeting the target (delayed mobilisation). Risk factors for decreased postoperative mobilisation were identified through multivariable logistic regression. 1170 patients were retained. 676 patients (58%) did not mobilise as recommended by ERAS protocol at POD1. Emergency operation (Odds Ratio (OR) 0.40; 95% Confidence Interval (CI) 0.18–0.91, p = 0.028), age > 70 years (OR 0.69; 95% CI 0.47–1.00, p = 0.050) and intraoperative total fluids > 2000 mL (OR 0.59; 95% CI 0.37–0.93, p = 0.025) were independent risk factors for delayed mobilisation. Patients with delayed mobilisation had significantly more overall (Clavien grade IV) (55% vs. 29%, p=<0.001), major (Clavien grade IIIb-V) (16% vs. 7%, p=<0.001) and respiratory (12% vs. 4%, p=<0.001) complications, as well as longer length of stay (12 ± 14 vs. 6±7days, p=<0.001). More than half of patients did not mobilise as recommended by ERAS guidelines. Emergency surgery, advanced age and fluid overload were independent risk factors for delayed mobilisation, which was associated with increased postoperative complications.

Abstract Background Major surgery is a term frequently used but poorly defined. The aim of the present study was to reach a consensus in the definition of major surgery within a panel of expert surgeons from the European Surgical Association (ESA). Methods A 3‐round Delphi process was performed. All ESA members were invited to participate in the expert panel. In round 1, experts were inquired by open‐ and closed‐ended questions on potential criteria to define major surgery. Results were analyzed and presented back anonymously to the panel within next rounds. Closed‐ended questions in round 2 and 3 were either binary or statements to be rated on a Likert scale ranging from 1 (strong disagreement) to 5 (strong agreement). Participants were sent 3 reminders at 2‐week intervals for each round. 70% of agreement was considered to indicate consensus. Results Out of 305 ESA members, 67 (22%) answered all the 3 rounds. Significant comorbidities were the only preoperative factor retained to define major surgery (78%). Vascular clampage or organ ischemia (92%), high intraoperative blood loss (90%), high noradrenalin requirements (77%), long operative time (73%) and perioperative blood transfusion (70%) were procedure‐related factors that reached consensus. Regarding postoperative factors, systemic inflammatory response (76%) and the need for intensive or intermediate care (88%) reached consensus. Consequences of major surgery were high morbidity (&gt;30% overall) and mortality (&gt;2%). Conclusion ESA experts defined major surgery according to extent and complexity of the procedure, its pathophysiological consequences and consecutive clinical outcomes.

Background In the early phase of the Covid-19 pandemic, mainly data related to the burden of care required by infected patients were reported. The aim of this study was to illustrate the timeline of actions taken and to measure and analyze their impact on surgical patients. Method This is a retrospective review of actions to limit Covid-19 spread and their impact on surgical activity in a Swiss tertiary referral center. Data on patient care, human resources and hospital logistics were collected. Impact on surgical activity was measured by comparing 6-week periods before and after the first measures were taken. Results After the first Swiss Covid-19 case appeared on February 25, progressively restrictive measures were taken over a period of 23 days. Covid-19 positive inpatients increased from 5 to 131, and ICU patients from 2 to 31, between days 10 and 30, respectively, without ever overloading resources. A 43% decrease of elective visceral surgical procedures was observed after Covid-19 (295 vs 165, p<0.01), while the urgent operations (all specialties) decreased by 39% (1476 vs 897, p<0.01). Fifty-two and 38 major oncological surgeries were performed, respectively, representing a 27% decrease (p = 0.316). Outpatient consultations dropped by 59%, from 728 to 296 (p<0.01). Conclusion While allowing for maximal care of Covid-19 patients during the pandemic, the shift of resources limited the access to elective surgical care, with less impact on cancer care.

Background PIPAC is a new treatment modality for peritoneal cancer which has been practiced and evaluated until very recently by few academic centers in a highly standardized manner. Encouraging oncological outcomes and the safety profile have led to widespread adoption. The aim of this study was to assess current PIPAC practice in terms of technique, treatment and safety protocol, and indications. Methods A standardized survey with 82 closed-ended questions was sent online to active PIPAC centers which were identified by help of PIPAC training centers and the regional distributors of the PIPAC-specific nebulizer. The survey inquired about center demographics (n = 8), technique (n = 34), treatment and safety protocol (n = 34), and indications (n = 6). Results Overall, 62 out of 66 contacted PIPAC centers answered the survey (response rate 93%). 27 centers had performed >60 PIPAC procedures. A consensus higher than 70% was reached for 37 items (50%), and higher than 80% for 28 items (37.8%). The topics with the highest degree of consensus were safety and installation issues (93.5% and 80.65%) while chemotherapy and response evaluation were the least consensual topics (63.7 and 59.6%). The attitudes were not influenced by volume, PIPAC starting year, type of activity, or presence of peritoneal metastases program. Conclusion Homogeneous treatment standards of new techniques are important to guarantee safe implementation and practice but also to allow comparison between cohorts and multi-center analysis of merged data including registries. Efforts to avoid diversification of PIPAC practice include regular update of the PIPAC training curriculum, targeted research and a consensus statement.

Hyperthermic intraperitoneal chemotherapy (HIPEC) is performed with a wide variation in methodology, drugs, and other elements vital to the procedure. Adoption of a limited number of regimens could increase the collective experience of peritoneal oncologists, make comparison between studies more meaningful, and lead to a greater acceptance of results from randomized trials. This study aimed to determine the possibility of standardizing HIPEC methodology and regimens and to identify the best method of performing such a standardization. A critical review of preclinical and clinical studies evaluating the pharmacokinetic aspects of different HIPEC drugs and drug regimens, the impact of hyperthermia, and the efficacy of various HIPEC regimens as well as studies comparing different regimens was performed. The preclinical and clinical data were limited, and studies comparing different regimens were scarce. Many of the regimens were neither supported by preclinical rationale or data nor validated by a dose-escalating formal phase 1 trial. All the regimens were based on pharmacokinetic data and did not take chemosensitivity of peritoneal metastases into account. Personalized medicine approaches such as patient-derived tumor organoids could offer a solution to this problem, although clinical validation is likely to be challenging. Apart from randomized trials, more translational research and phases 1 and 2 studies are needed. While waiting for better preclinical and clinical evidence, the best way to minimize heterogeneity is by an expert consensus that aims to identify and define a limited number of regimens for each indication and primary site. The choice of regimen then can be tailored to the patient profile and its expected toxicity and the methodology according regional factors.

Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is increasingly used to treat patients with peritoneal cancer. A recent survey demonstrated considerable diversification of current practice of PIPAC raising issues of concern also regarding safety and efficacy. The study aim was to reach consensus on best practice of PIPAC treatment.Current practice was critically discussed during an expert meeting and the available evidence was scrutinized to elaborate a 33-item closed-ended questionnaire. All active PIPAC centers were then invited to participate in an online two-round Delphi process with 3 reminders at least. Consensus was defined a priori as >70% agreement for a minimal response rate of 70%.Forty-nine out of 57 invited PIPAC centers participated in Delphi 1 and 2 (86%). Overall, there was agreement for 21/33 items. Consensus was reached for important aspects like advanced OR ventilation system (91.8%), remote monitoring (95.9%), use of the PRGS (85.7%) and use of a safety checklist (98%). The drug regimens oxaliplatin (87.8%) and cisplatin/doxorubicin (81.6%) were both confirmed by the expert panel. Important controversies included number and location of Biopsies during repeated PIPAC and the combination of PIPAC with additional surgical procedures.This consensus statement aims to allow for safe and efficacious PIPAC treatment and to facilitate multi-center analyses of the results. Additional preclinical and clinical studies are needed to resolve the remaining controversies.

Enhanced Recovery After Surgery (ERAS) guidelines and the World Health Organization Surgical Safety Checklist (SSC) are 2 well-established tools for optimizing patient outcomes perioperatively.To integrate the 2 tools to facilitate key perioperative decision-making.Snowball sampling recruited international ERAS users from multiple clinical specialties. A 3-round modified Delphi consensus model was used to evaluate 27 colorectal or gynecologic oncology ERAS recommendations for appropriateness to include in an ERAS SSC. Items attaining potential consensus (65%-69% agreement) or consensus (≥70% agreement) were used to develop ERAS-specific SSC prompts. These proposed prompts were evaluated in a second round by the panelists with regard to inclusion, modification, or exclusion. A final round of interactive discussion using quantitative consensus and qualitative comments was used to produce an ERAS-specific SSC. The panel of ERAS experts included surgeons, anesthesiologists, and nurses within diverse practice settings from 19 countries. Final analysis was conducted in May 2022.Round 1 was completed by 105 experts from 18 countries. Eleven ERAS components met criteria for development into an SSC prompt. Round 2 was completed by 88 experts. There was universal consensus (≥70% agreement) to include all 37 proposed prompts within the 3-part ERAS-specific SSC (used prior to induction of anesthesia, skin incision, and leaving the operating theater). A third round of qualitative comment review and expert discussion was used to produce a final ERAS-specific SSC that expands on the current WHO SSC to include discussion of analgesia strategies, nausea prevention, appropriate fasting, fluid management, anesthetic protocols, appropriate skin preparation, deep vein thrombosis prophylaxis, hypothermia prevention, use of foley catheters, and surgical access. The final products of this work included an ERAS-specific SSC ready for implementation and a set of recommendations to integrate ERAS elements into existing SSCs.The SSC could be modified to align with ERAS recommendations for patients undergoing major surgery within an ERAS protocol. The stakeholder- and expert-generated ERAS SSC could be adopted directly, or the recommendations for modification could be applied to an existing institutional SSC to facilitate implementation.

This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care.Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL.Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process.These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.

Ovarian pseudomyxoma peritonei (OPMP) are rare, without well-defined therapeutic guidelines. We aimed to evaluate cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) to treat OPMP.Patients from the French National Network for Rare Peritoneal Tumors (RENAPE) database with proven OPMP treated by CRS/HIPEC and with histologically normal appendix and digestive endoscopy were retrospectively included. Clinical and follow-up data were collected. Histopathological and immunohistochemical features were reviewed.Fifteen patients with a median age of 56 years were included. The median Peritoneal Cancer Index was 16. Following CRS, the completeness of cytoreduction (CC) score was CC-0 for 9/15 (60%) patients, CC-1 for 5/15 (33.3%) patients, and CC-2 for 1/15 (6.7%) patients. The median tumor size was 22.5 cm. After pathological review and immunohistochemical studies, tumors were classified as Group 1 (mucinous ovarian epithelial neoplasms) in 3/15 (20%) patients; Group 2 (mucinous neoplasm in ovarian teratoma) in 4/15 (26.7%) patients; Group 3 (mucinous neoplasm probably arising in ovarian teratoma) in 5/15 (33.3%) patients; and Group 4 (non-specific group) in 3/15 (20%) patients. Peritoneal lesions were OPMP pM1a/acellular, pM1b/grade 1 (hypocellular) and pM1b/grade 3 (signet-ring cells) in 13/15 (86.7%), 1/15 (6.7%) and 1/15 (6.7%) patients, respectively. Disease-free survival analysis showed a difference (p = 0.0463) between OPMP with teratoma/likely-teratoma origin (groups 2 and 3; 100% at 1, 5, and 10 years), and other groups (groups 1 and 4; 100%, 66.6%, and 50% at 1, 5, and 10 years, respectively).These results suggested that a primary therapeutic strategy using complete CRS/HIPEC for patients with OPMP led to favorable long-term outcomes.

Abstract Background Many instruments are used for laparoscopic dissection, including monopolar electrosurgery scissors (MES), electrothermal bipolar vessel sealers (BVS) and ultrasonically coagulating shears (UCS). These three devices were compared with regard to dissection time, blood loss, safety and costs. Methods Sixty-one consecutive patients undergoing laparoscopic left-sided colectomy were randomized to MES, BVS or UCS. The primary endpoint was dissection time. Results Patient and operation characteristics did not differ between the groups. Median dissection time was significantly shorter with BVS (105 min) and UCS (90 min) than with MES (137 min) (P &amp;lt; 0·001). With BVS and UCS, significantly fewer additional clips were required (MES 9 versus BVS 0 versus UCS 3; P &amp;lt; 0·001) and there was a trend towards lower blood loss (125 versus 50 versus 50 ml respectively; P = 0·223) and a reduced volume of suction fluid (425 versus 80 versus 110 ml; P = 0·058). Overall satisfaction was similar for the three instruments. Dissection with BVS and UCS was significantly cheaper than with MES, assuming a centre volume of 200 cases per year (P = 0·009). Conclusion BVS and UCS shorten dissection time in laparoscopic left-sided colectomy and are cost-effective compared with MES. Registration number: NCT00517608 (http://www.clinicaltrials.com).

Abstract Background The present study was designed to evaluate surgeons’ strategies and adherence to preventive measures against surgical site infections (SSIs). Materials and methods All surgeons participating in a prospective Swiss multicentric surveillance program for SSIs received a questionnaire developed from the 2008 National (United Kingdom) Institute for Health and Clinical Excellence (NICE) clinical guidelines on prevention and treatment of SSIs. We focused on perioperative management and surgical technique in hernia surgery, cholecystectomy, appendectomy, and colon surgery (COL). Results Forty‐five of 50 surgeons contacted (90%) responded. Smoking cessation and nutritional screening are regularly propagated by 1/3 and 1/2 of surgeons, respectively. Thirty‐eight percent practice bowel preparation before COL. Preoperative hair removal is routinely (90%) performed in the operating room with electric clippers. About 50% administer antibiotic prophylaxis within 30 min before incision. Intra‐abdominal drains are common after COL (43%). Two thirds of respondents apply nonocclusive wound dressings that are manipulated after hand disinfection (87%). Dressings are usually changed on postoperative day (POD) 2 (75%), and wounds remain undressed on POD 2–3 or 4–5 (36% each). Conclusions Surgeons’ strategies to prevent SSIs still differ widely. The adherence to the current NICE guidelines is low for many procedures regardless of the available level of evidence. Further research should provide convincing data in order to justify standardization of perioperative management.

BACKGROUND: Surgical decision making and the use of neoadjuvant therapy in the management of solid presacral tumors rely greatly on an accurate preoperative diagnosis. The utility of preoperative biopsy has been questioned because of potential complications and the increasing accuracy of modern imaging. OBJECTIVE: The aim of this study was to analyze biopsy-related morbidity and to compare the accuracy of imaging versus biopsy in making a preoperative diagnosis. DESIGN: This study is a retrospective review of all patients who underwent biopsy of presacral tumors at Mayo Clinic Rochester between 1990 and 2010. The demographics, pathology, complications of biopsy, and imaging were reviewed. Biopsy results and radiologic findings were matched with the final pathology and analyzed. SETTINGS: This study was conducted at a tertiary care center. PATIENTS: Adult patients with solid presacral tumors who underwent preoperative biopsy were evaluated. MAIN OUTCOME MEASURES: The primary outcomes measured were the biopsy-related complications and the accuracy of preoperative imaging and biopsy in comparison with final pathology. RESULTS: Seventy-six biopsies were performed in 73 patients. Fifty-six patients underwent percutaneous biopsies, 14 underwent open biopsies, and 3 underwent both. Biopsy-specific complications included 2 hematomas (1 open, 1 percutaneous). Preoperative biopsy correlated with the postoperative pathologic diagnosis in 63 patients (91%). Of the 6 solid presacral tumors diagnosed incorrectly on biopsy, 1 was falsely reported as benign. Sensitivity, specificity, and positive and negative predictive values of biopsy to detect malignant disease was 96%, 100%, 100%, and 98%. Ten of 35 patients (29%) with a definitive imaging diagnosis were given incorrect diagnoses. Sensitivity, specificity, and positive and negative predictive values of imaging to diagnose malignant disease was 83%, 81%, 83%, and 81%. LIMITATIONS: This investigation was designed as a retrospective study. CONCLUSION: Preoperative biopsy of presacral tumors is safe and highly concordant with postoperative pathology in comparison with imaging. Given the significant differences in therapeutic approach for benign versus malignant solid presacral tumors, as well as the current limitations of imaging, a percutaneous preoperative biopsy should be obtained to guide management decisions.

Incarcerated hernias represent about 5-15 % of all operated hernias. Tension-free mesh is the preferred technique for elective surgery due to low recurrence rates. There is however currently no consensus on the use of mesh for the treatment of incarcerated hernias, especially in case of bowel resection.The aims of this study were (i) to report our current practice for the treatment of incarcerated hernias, (ii) to identify risk factors for postoperative complications, and (iii) to assess the safety of mesh placement in potentially infected surgical fields.This retrospective study included 166 consecutive patients who underwent emergency surgery for incarcerated hernia between January 2007 and January 2012 in two university hospitals. Demographics, surgical details, and short-term outcome were collected. Univariate analysis was employed to identify risk factors for overall, infectious, and major complications.Eighty-four patients (50.6 %) presented inguinal hernias, 43 femoral (25.9 %), 37 umbilical hernias (22.3 %), and 2 mixed hernias (1.2 %), respectively. Mesh was placed in 64 patients (38.5 %), including 5 patients with concomitant bowel resection. Overall morbidity occurred in 56 patients (32.7 %), and 8 patients (4.8 %) developed surgical site infections (SSI). Univariate risk factors for overall complications were ASA grade 3/4 (P = 0.03), diabetes (P = 0.05), cardiopathy (P = 0.001), aspirin use (P = 0.023), and bowel resection (P = 0.001) which was also the only identified risk factor for SSI (P = 0.03). In multivariate analysis, only bowel incarceration was associated with a higher rate of major morbidity (OR = 14.04; P = 0.01).Morbidity after surgery for incarcerated hernia remains high and depends on comorbidities and surgical presentation. The use of mesh could become current practice even in case of bowel resection.

BACKGROUND: Intrathecal analgesia and avoidance of perioperative fluid overload are key items within enhanced recovery pathways. Potential side effects include hypotension and renal dysfunction. STUDY DESIGN: From January 2010 until May 2010, all patients undergoing colorectal surgery within enhanced recovery pathways were included in this retrospective cohort study and were analyzed by intrathecal analgesia (IT) vs none (noIT). Primary outcomes measures were systolic and diastolic blood pressure, mean arterial pressure, and heart rate for 48 hours after surgery. Renal function was assessed by urine output and creatinine values. RESULTS: One hundred and sixty-three consecutive colorectal patients (127 IT and 36 noIT) were included in the analysis. Both patient groups showed low blood pressure values within the first 4 to 12 hours and a steady increase thereafter before return to baseline values after about 24 hours. Systolic and diastolic blood pressure and mean arterial pressure were significantly lower until 16 hours after surgery in patients having IT compared with the noIT group. Low urine output (<0.5 mL/kg/h) was reported in 11% vs 29% (IT vs noIT; p = 0.010) intraoperatively, 20% vs 11% (p = 0.387), 33% vs 22% (p = 0.304), and 31% vs 21% (p = 0.478) for postanesthesia care unit and postoperative days 1 and 2, respectively. Only 3 of 127 (2.4%) IT and 1 of 36 (2.8%) noIT patients had a transitory creatinine increase >50%; no patients required dialysis. CONCLUSIONS: Postoperative hypotension affects approximately 10% of patients within an enhanced recovery pathway and is slightly more pronounced in patients with IT. Hemodynamic depression persists for <20 hours after surgery; it has no measurable negative impact and therefore cannot justify detrimental postoperative fluid overload.

Despite progress in multidisciplinary treatment of esophageal cancer, oncologic esophagectomy is still the cornerstone of therapeutic strategies. Several scoring systems are used to predict postoperative morbidity, but in most cases they identify nonmodifiable parameters. The aim of this study was to identify potentially modifiable risk factors associated with complications after oncologic esophagectomy.All consecutive patients with complete data sets undergoing oncologic esophagectomy in our department during 2001-2011 were included in this study. As potentially modifiable risk factors we assessed nutritional status depicted by body mass index (BMI) and preoperative serum albumin levels, excessive alcohol consumption, and active smoking. Postoperative complications were graded according to a validated 5-grade system. Univariate and multivariate analyses were used to identify preoperative risk factors associated with the occurrence and severity of complications.Our series included 93 patients. Overall morbidity rate was 81 % (n = 75), with 56 % (n = 52) minor complications and 18 % (n = 17) major complications. Active smoking and excessive alcohol consumption were associated with the occurrence of severe complications, whereas BMI and low preoperative albumin levels were not. The simultaneous presence of two or more of these risk factors significantly increased the risk of postoperative complications.A combination of malnutrition, active smoking and alcohol consumption were found to have a negative impact on postoperative morbidity rates. Therefore, preoperative smoking and alcohol cessation counseling and monitoring and improving the nutritional status are strongly recommended.

The existence of enhanced recovery specific guidelines (ERAS) is not enough to change patient management practice since many barriers exist to successful ERAS implementation. The present survey aimed to analyse motivations for implementation as well as encountered difficulties and challenges. Further, relevance and importance of perioperative care items and postoperative recovery targets were assessed.A multicentre qualitative study was conducted between August and December 2016 among surgeons, anaesthesiologists and nurses from implemented ERAS centres in Switzerland (n = 16) and Sweden (n = 14). An online survey (31 closed questions) was sent by email, with reminders at 4, 8 and 12 weeks.Seventy-seven out of 146 experts completed the survey (response rate 52.7%). Main motivations to implement ERAS were the expectation to reduce complications (91%), higher patient satisfaction (73%) and shorter hospital stay (62%). The application of ERAS program represented major changes in clinical practice for 57% of participants without significant differences between various specialities (surgeons: 63%, nurses: 63%, anaesthesiologists: 36%, p = 0.185). The most important barriers for straightforward implementation were time restraints (69%), opposing colleagues (68%) and logistical reasons (66%). The 3 most frequently cited patient-related barriers to adopt ERAS were opposing personality (52%), co-morbidities (49%) and language barriers (31%).Implementing ERAS care into practice was challenging and required important changes in clinical practice for all involved specialities. Main reasons for implementation were the expectation to reduce complications and hospital stay with improved patients' satisfaction. Main barriers were time restraints, reluctance to change and logistics.

Enhanced recovery after surgery (ERAS) and minimally invasive surgery are both in the limelight due to their potential positive effects on surgical outcome. Large randomized trials and meta-analyses validated the use of both, laparoscopy and ERAS protocol, as individual measures. A synergistic effect of both entities might contribute to even better outcomes. This review hence assessed the literature upon up-to-date studies combining both methods.

Tense communication and disruptive behaviors during surgery have often been attributed to surgeons' personality or hierarchies, while situational triggers for tense communication were neglected. Goals of this study were to assess situational triggers of tense communication in the operating room and to assess its impact on collaboration quality within the surgical team.The prospective observational study was performed in two university hospitals in Europe. Trained external observers assessed communication in 137 elective abdominal operations led by 30 different main surgeons. Objective observations were related to perceived collaboration quality by all members of the surgical team. A total of 340 tense communication episodes were observed (= 0.57 per hour); mean tensions in surgeries with tensions was 1.21 per hour. Individual surgeons accounted for 24% of the variation in tensions, while situational aspects accounted for 76% of variation. A total of 72% of tensions were triggered by coordination problems; 21.2% by task-related problems and 9.1% by other issues. More tensions were related to lower perceived teamwork quality for all team members except main surgeons. Coordination-triggered tensions significantly lowered teamwork quality for second surgeons, scrub technicians and circulators.Although individual surgeons differ in their tense communication, situational aspects during the operation had a much more important influence on the occurrence of tensions, mostly triggered by coordination problems. Because tensions negatively impact team collaboration, surgical teams may profit from improving collaboration, for instance through training, or through reflexivity.

Background PIPAC is a novel mode of intraperitoneal drug delivery for patients with peritoneal cancer (PC). PIPAC is a safe treatment with promising oncological results. Therefore, a structured training program is needed to maintain high standards and to guarantee safe implementation. Methods An international panel of PIPAC experts created by means of a consensus meeting a structured 2-day training course including essential theoretical content and practical exercises. For every module, learning objectives were defined and structured presentations were elaborated. This structured PIPAC training program was then tested in five courses. Results The panel consisted of 12 experts from 11 different centres totalling a cumulative experience of 23 PIPAC courses and 1880 PIPAC procedures. The final program was approved by all members of the panel and includes 12 theoretical units (45 min each) and 6 practical units including dry-lab and live surgeries. The panel finalized and approved 21 structured presentations including the latest evidence on PIPAC and covering all mandatory topics. These were organized in 8 modules with clear learning objectives to be tested by 12 multiple-choice questions. Lastly, a structured quantifiable (Likert scale 1–5) course evaluation was created. The new course was successfully tested in five courses with 85 participants. Mean overall satisfaction with the content was rated at 4.79 (±0.5) with at 4.71 (±0.5) and at 4.61 (±0.7), respectively for course length and the balance between theory and practice. Conclusions The proposed PIPAC training program contains essential theoretical background and practical training enabling the participants to safely implement PIPAC.

<h2>Abstract</h2> Pseudomyxoma Peritonei (PMP) and Peritoneal Mesothelioma (PM) are both rare peritoneal malignancies. Currently, affected patients may be treated with Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy offering long-term survival or even cure in selected patients. However, many issues regarding the optimal treatment strategy are currently under debate. To aid physicians involved in the treatment of these patients in clinical decision making, the PSOGI executive committee proposed to create a consensus statement on PMP and PM. This manuscript describes the methodology of the consensus process. The Delphi technique is a reliable method for attaining consensus on a topic that lacks scientific evidence through multiple voting rounds which feeds back responses to the participants in between rounds. The GRADE system provides a structured framework for presenting and grading the available evidence. Separate questionnaires were created for PMP and PM and sent during two voting rounds to 80 and 38 experts, respectively. A consensus threshold of 51.0% was chosen. After the second round, consensus was reached on 92.9%–100.0% of the questions. The results were presented and discussed in the plenary session at the PSOGI 2018 international meeting in Paris. A third round for the remaining issues is currently in progress. In conclusion, using the Delphi technique and GRADE methodology, consensus was reached in many issues regarding the treatment of PM and PMP amongst an international panel of experts. The main results will be published in the near future.

Abstract Background Postoperative complications are frequent after gastrointestinal surgery and early prediction remains an unmet need. Serum albumin shows a rapid decrease after surgery, and this decline (ΔAlb) may reflect the intensity of the surgical stress response and thereby be a predictor of postoperative complications. This study aimed to comprehensively review the available data on ΔAlb in gastrointestinal surgery. Methods PRISMA guidelines were followed to conduct a systematic review of the literature in MEDLINE and Embase. Studies assessing the role of ΔAlb to predict complications after gastrointestinal surgery were included. Results A total of 1256 articles were screened, and 16 studies were included in the final analysis: 7 prospective and 9 retrospective trials. Sensitivity of ΔAlb to predict postoperative complications ranged from 63 to 84%, whereas specificity ranged from 61 to 86%. Nine out of the 16 included studies established a threshold of ΔAlb to predict morbidity (range: 5–11 g/l or 14–27%). Conclusion ΔAlb appeared as a valuable and promising biomarker to anticipate complications after gastrointestinal surgery. Future efforts are needed to determine whether and how ΔAlb may be integrated in clinical practice to guide clinicians in the perioperative management of patients.

This retrospective observational study aimed to evaluate whether preoperative sarcopenia, assessed by CT imaging, was associated with postoperative clinical outcomes and overall survival in patients that underwent liver resections. Patients operated on between January 2014 and February 2020 were included. The skeletal muscle index (SMI) was measured at the level of the third lumbar vertebra on preoperative CT scans. Preoperative sarcopenia was defined based on pre-established SMI cut-off values. The outcomes were postoperative morbidity, length of hospital stay (LOS), and overall survival. Among 355 patients, 212 (59.7%) had preoperative sarcopenia. Patients with sarcopenia were significantly older (63.5 years) and had significantly lower BMIs (23.9 kg/m2) than patients without sarcopenia (59.3 years, p < 0.01, and 27.7 kg/m2, p < 0.01, respectively). There was no difference in LOS (8 vs. 8 days, p = 0.75), and the major complication rates were comparable between the two groups (11.2% vs. 11.3%, p = 1.00). The median overall survival times were comparable between patients with sarcopenia and those without sarcopenia (15 vs. 16 months, p = 0.87). Based on CT assessment alone, preoperative sarcopenia appeared to have no impact on postoperative clinical outcomes or overall survival in patients that underwent liver resections. Future efforts should also consider muscle strength and physical performance, in addition to imaging, for preoperative risk stratification.

Post-transplant lymphoproliferative disease (PTLD) is a serious and potentially life-threatening complication after solid organ transplantation. Here, we report our first experience with the use of PET/CT (positron emission tomography combined with computed tomogram) for the management of patients with PTLD after liver transplantation. Four patients with histologically proven PTLD were analyzed. Conventional work-up included physical examination and head-to-pelvis CT. PET/CT was used in one patient for initial staging and in all patients for follow-up. PET/CT positive findings underwent biopsy. Information provided by PET/CT resulted in a change of medical management in three of the four patients. Conventional work-up missed residual disease after surgery in one and failed to detect a tumor relapse in another patient. However, one patient disclosed a false positive PET/CT finding in the lungs. In conclusion, PET/CT may be a useful tool for staging and therapy monitoring of PTLD after liver transplantation.

There is strong evidence for the beneficial effects of perioperative nutrition in patients undergoing major surgery. We aimed to evaluate implementation of current guidelines in Switzerland and Austria. A survey was conducted in 173 Swiss and Austrian surgical departments. We inquired about nutritional screening, perioperative nutrition and estimated clinical significance. The overall response rate was 55%, having 69% (54/78) responders in Switzerland and 44% (42/95) in Austria. Most centres were aware of reduced complications (80%) and shorter hospital stay (59%). However, only 20% of them implemented routine nutritional screening. Non-compliance was because of financial (49%) and logistic restrictions (33%). Screening was mainly performed in the outpatient's clinic (52%) or during admission (54%). The nutritional risk score was applied by 14% only; instead, various clinical (78%) and laboratory parameters (56%) were used. Indication for perioperative nutrition was based on preoperative screening in 49%. Although 23% used preoperative nutrition, 68% applied nutritional support pre- and postoperatively. Preoperative nutritional treatment ranged from 3 days (33%), to 5 (31%) and even 7 days (20%). Although malnutrition is a well-recognised risk factor for poor post-operative outcome, surgeons remain reluctant to implement routine screening and nutritional support according to evidence-based guidelines.

The nutritional risk score is a recommended screening tool for malnutrition. While a nutritional risk score of 3 or greater predicts adverse outcomes after digestive surgery, to our knowledge its predictive value for morbidity after urological interventions is unknown. We determined whether urological patients at nutritional risk are at higher risk for complications after major surgery than patients not at nutritional risk.We performed a prospective observational study in consecutive patients undergoing major surgery. A priori sample calculation resulted in a study cohort of 220 patients. Interim analysis was planned after 110 patients. The nutritional risk score was assessed preoperatively by a specialized study nurse. Nutritional care was standardized in all patients. Postoperative complications were defined previously using the standardized Dindo-Clavien classification. The primary end point was 30-day morbidity. Univariate and multivariate analysis was performed to identify predictors of complications.The study was discontinued due to significant results after interim analysis. A total of 125 patients were included in analysis from June 2011 to June 2012 and 15 were excluded because of incomplete data. Of 51 patients at nutritional risk 38 (74%) presented with at least 1 complication compared to 28 of 59 controls (47%). Patients at nutritional risk were at threefold risk for complications on univariate and multivariate analysis (OR 3.3, 95% CI 1.3-8.0). Cystectomy was the only other predictor of morbidity (OR 10, 95% CI 2-48).Patients at nutritional risk are more prone to complications after major urological procedures. Whether this increased morbidity can be reversed by perioperative nutritional support should be studied.

Enhanced recovery pathways have been shown to improve short-term outcomes after colorectal surgery. Occurrence of complications can lead to prolonged length of stay (LOS). The goal of this study was to examine whether shorter time to occurrence of complications was associated with a shorter hospital LOS in rectal cancer patients undergoing minimally invasive surgery, taking into account the perioperative pathway.This retrospective study included consecutive patients undergoing rectal cancer resection from 2005 to 2011 at a single institution. Enhanced recovery pathway was introduced in 2009. Complications and date of occurrence were reviewed. The impact of perioperative care modalities and comorbidities was evaluated using competing risk models with occurrence of complications and LOS as time-dependent outcomes measured as time from surgery.A total of 346 patients were included in the analysis with 78 patients treated with enhanced recovery pathway, and 268 with established care. The overall complication rate was 22.3% (77 patients with ileus, wound infection, leak, abscess, small bowel obstruction, reoperation for bleeding, and renal failure). Median time to occurrence of a complication was 3 days post operation. The time to complication diagnosis was associated with shorter time to discharge after the advent of the complication (hazard ratio = 0.84; 95% CI, 0.73-0.96; p = 0.01). Enhanced recovery pathway was associated with a shorter LOS for patients without complications compared with the established pathway (hazard ratio = 2.81; 95% CI, 2.09-3.78; p < 0.001) after adjusting for comorbidities in a competing risk model.Early diagnosis of postoperative complications is associated with a shorter LOS after rectal cancer surgery. Enhanced recovery pathway can facilitate a faster recovery in the presence of comorbidities.

Nanoparticles hold considerable promise for aerosol-based intraperitoneal delivery in patients with carcinomatosis. Recently, results from preclinical and early clinical trials suggested that albumin-bound paclitaxel (ABP, Abraxane™) may result in superior efficacy in the treatment of peritoneal metastases (PM) compared to the standard solvent-based paclitaxel formulation (Taxol™). Here, we propose a phase I study of pressurized intraperitoneal aerosol chemotherapy (PIPAC) using ABP in patients with upper Gastrointestinal, breast, or ovarian cancer.Eligible patients with advanced, biopsy-proven PM from ovarian, breast, gastric, hepatobiliary, or pancreatic origin will undergo three PIPAC treatments using ABP with a 4-week interval. The dose of ABP will be escalated from 35 to 140 mg/m² using a Bayesian approach until the maximally tolerated dose is determined. The primary end point is dose-limiting toxicity. Secondary analyses include surgical morbidity, non-access rate, pharmacokinetic and pharmacodynamic analyses, quality of life, and exploratory circulating biomarker analyses.ABP holds considerable promise for intraperitoneal aerosol delivery. The aim of this study is to determine the dose level for future randomized phase II trials using ABP in PIPAC therapy.This trial is registered as EudraCT: 2017-001688-20 and Clinicaltrials.gov: NCT03304210.

Background: Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel mode of intraperitoneal (IP) drug delivery claiming high IP tissue concentrations with low systemic uptake. The aim was to study inflammatory response and systemic toxicity after PIPAC. Methods: Retrospective monocentric analysis of a consecutive cohort of PIPAC patients between January 2015 and April 2016. Detailed hematological and biochemical analysis was performed the day before surgery and once daily until discharge. Comparative statistics were performed using Mann-Whitney U test and Wilcoxon signed ranked test. Results: Fourty-two consecutive patients underwent a total of 91 PIPAC procedures. Twenty patients received oxaliplatin and 22 cisplatin+doxorubicin (37 vs. 54 procedures). Creatinine, AST and ALT were not significantly altered after PIPAC (p=0.095, p= p=0.153 and p=0.351) and not different between oxaliplatin and cisplatin+doxorubicin regimens (p=0.371, p=0.251 and p=0.288). C-reactive protein (CRP) and procalcitonin (PCT) increased on post-operative day (POD) 2: ∆max 29±5 mg/L (p<0.001) and ∆max 0.05±0.01 μg/L (p=0.005), respectively. Leucocytes increased at POD 1: ∆max 2.2±0.3 G/L (p<0.001). Albumin decreased at POD 2: ∆max -6.0±0.5 g/L (p<0.001). CRP increase correlated positively with Peritoneal Cancer Index (tumor load) (ρ =0.521, p<0.001). Conclusion: PIPAC was followed by a modest and transitory inflammatory response that was commensurate to the disease extent. No hematological, renal or hepatic toxicity was observed even after repetitive administration.

Enhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes.Retrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification.A total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I-V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001).Compliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

A curative approach in patients with oligometastatic colorectal cancer can achieve "better than expected" long-term survival and provides the rationale for an extensive surgical approach in case of metastases limited in number and to one or a few organs [1].

BackgroundAnastomotic leak remains a common and potentially deleterious complication after esophagectomy. Preoperative embolization of the left gastric artery and splenic artery (PAE) has been suggested to lower anastomotic leak rates. We present the results of our 5-year experience with this technique.MethodsAll patients undergoing PAE before esophagectomy since introduction of this technique in 2004 were compared in a 1:2 matched-pair analysis with patients without PAE. Matching criteria were type of anastomosis, neoadjuvant treatment, comorbidity, and age. Data were derived from a retrospective chart review from 2000 to 2006 that was perpetuated as a prospective database up to date. Outcome measures were anastomotic leak, overall complications, and hospital stay.ResultsBetween 2000 and 2009, 102 patients underwent esophagectomy for cancer in our institution with an overall leak rate of 19% and a mortality of 8%. All 19 patients having PAE since 2004 were successfully matched 1:2 to 38 control patients without PAE; both groups were similar regarding demographics and operation characteristics. Two PAE (11%) and 8 control patients (21%) had an anastomotic leak, but the difference was statistically not significant (p = 0.469). Overall and major complication rates for PAE and control group were 89% versus 79% (p = 0.469) and 37% versus 34% (p = 1.000), respectively. Median intensive care unit and hospital stay were 3 versus 3 days (p = 1.000) and 22 versus 17 days (p = 0.321), respectively.ConclusionsIn our experience, PAE has no significant impact on complications and anastomotic leak in particular after esophagectomy. Anastomotic leak remains a common and potentially deleterious complication after esophagectomy. Preoperative embolization of the left gastric artery and splenic artery (PAE) has been suggested to lower anastomotic leak rates. We present the results of our 5-year experience with this technique. All patients undergoing PAE before esophagectomy since introduction of this technique in 2004 were compared in a 1:2 matched-pair analysis with patients without PAE. Matching criteria were type of anastomosis, neoadjuvant treatment, comorbidity, and age. Data were derived from a retrospective chart review from 2000 to 2006 that was perpetuated as a prospective database up to date. Outcome measures were anastomotic leak, overall complications, and hospital stay. Between 2000 and 2009, 102 patients underwent esophagectomy for cancer in our institution with an overall leak rate of 19% and a mortality of 8%. All 19 patients having PAE since 2004 were successfully matched 1:2 to 38 control patients without PAE; both groups were similar regarding demographics and operation characteristics. Two PAE (11%) and 8 control patients (21%) had an anastomotic leak, but the difference was statistically not significant (p = 0.469). Overall and major complication rates for PAE and control group were 89% versus 79% (p = 0.469) and 37% versus 34% (p = 1.000), respectively. Median intensive care unit and hospital stay were 3 versus 3 days (p = 1.000) and 22 versus 17 days (p = 0.321), respectively. In our experience, PAE has no significant impact on complications and anastomotic leak in particular after esophagectomy.

Abstract Background Enhanced recovery after surgery (ERAS) reduces complications and hospital stay in colorectal surgery. Thereafter, ERAS principles were extended to liver surgery. Previous implementation of an ERAS program in colorectal surgery may influence patients undergoing liver surgery in a non‐ERAS setting, on the same ward. This study aimed to test this hypothesis. Methods Retrospective analysis based on prospective data of the adherence to the institutional ERAS‐liver protocol (compliance) in three cohorts of consecutive patients undergoing elective liver surgery, between June 2010 and July 2014: before any ERAS implementation (pre‐ERAS n = 50), after implementation of ERAS in colorectal (intermediate n = 50), and after implementation of ERAS in liver surgery (ERAS‐liver n = 74). Outcomes were functional recovery, postoperative complications, hospital stay, and readmissions. Results The three groups were comparable for demographics; laparoscopy was more frequent in ERAS‐liver ( p = 0.009). Compliance with the enhanced recovery protocol increased along the three periods (pre‐ERAS, intermediate, and ERAS‐liver), regardless of the perioperative phase (pre‐, intra‐, or postoperative). ERAS‐liver group displayed the highest overall compliance rate with 73.8 %, compared to 39.9 and 57.4 % for pre‐ERAS and intermediate groups ( p = 0.072/0.056). Overall complications were unchanged ( p = 0.185), whereas intermediate and ERAS‐liver groups showed decreased major complications ( p = 0.034). Consistently, hospital stay was reduced by 2 days ( p = 0.005) without increased readmissions ( p = 0.158). Conclusions The previous implementation of an ERAS protocol in colorectal surgery may induce a positive impact on patients undergoing non‐ERAS‐liver surgery on the same ward. These results suggest that ERAS is safely applicable in liver surgery and associated with benefits.

Background The morbidity associated with liver surgery remained substantially high despite considerable surgical and anesthetic improvements. The unmet need of accurate biomarkers to predict postoperative complications is widely accepted. Aims This pilot study aimed to assess serum albumin as a surrogate marker of surgical stress and to test its potential predictive role for postoperative complications. Methods This retrospective pilot study included 106 patients who underwent liver surgery between 2010 and 2014. Serum albumin levels were measured pre- and post-operatively. Maximal albumin decrease (AlbΔmin) was correlated with complications. Results Serum albumin rapidly dropped after surgery. AlbΔmin was significantly increased in patients with complications (14.5 ± 6.0 g/L vs. 10.3 ± 7.2, p = 0.009). On multivariate analysis, ASA III/IV (p = 0.016) and AlbΔmin (p = 0.037) were the only predictors of overall complications. Conclusion Early postoperative drop of serum albumin reflects the intensity of the surgical stress and may predict complications after liver surgery. Serum albumin is a biomarker displaying precious features and deserving further prospective investigations.

Abstract Aim The present study aimed to compare functional recovery and surgical outcomes after left and right colectomies. Method Consecutive elective left and right colon resections for benign and malignant indications, performed between 2011 and 2016 and recorded in a prospectively maintained enhanced recovery database, were analysed. Demographic and surgical items, as well as functional recovery and 30‐day complications, were compared between left‐sided and right‐sided colectomies. Multivariable analysis was performed to identify risk factors for postoperative ileus ( POI ). Results In total, 1001 left and 1041 right colectomies were comparable regarding demographic factors; only body mass index ( BMI) was higher in patients undergoing left‐sided resections (&gt; 30 kg/m 2 : 33% vs 27%, P = 0.004). Malignancy (29% vs 67%, P &lt; 0.001) and Crohn's disease (1% vs 31%, P &lt; 0.001) were preponderant in right colectomies, whereas diverticular disease (68% vs 1%, P &lt; 0.001) was the most common indication for left colectomy. Compliance with the enhanced recovery pathway ( ERP ) was comparable. While the minimally invasive approach was the preferred approach for both sides (61% vs 64%, P = 0.158), left colectomies took longer (180 ± 80 min vs 150 ± 70 min, P &lt; 0.001), needed more perioperative fluids (3.1 ± 1.4 l vs 2.7 ± 1.5 l, P &lt; 0.001) and resulted in greater postoperative weight gain (3.9 ± 6.5 kg vs 2.6 ± 6 kg, P = 0.025). Crohn's disease ( OR = 2.64, 95% CI: 1.27–5.46) and fluid overload ( OR = 2.02, 95% CI: 1.06–3.82) were independent risk factors for POI . Conclusion Despite equal ERP compliance, postoperative ileus was higher after right‐sided colectomies. This finding was associated with Crohn's disease and fluid overload.

BACKGROUND: Postoperative ileus remains an issue after colorectal surgery delaying recovery and increasing the length of hospital stay and costs. OBJECTIVE: The purpose of this study was to analyze the impact of perioperative fluid management on ileus occurrence after colorectal surgery within a fully implemented enhanced recovery pathway. DESIGN: This was a retrospective cohort study of a prospectively maintained institutional database. SETTINGS: The study was conducted at a tertiary academic facility with fully implemented standardized enhanced recovery pathway over the entire study period. PATIENTS: All of the consecutive elective major colorectal resections for benign or malign indications between 2011 and 2016 were included. MAIN OUTCOME MEASURES: Postoperative ileus was defined as the need for nasogastric tube reinsertion. Perioperative fluid management and surgical outcome were compared between patients presenting with ileus and those without. Potential risk factors for ileus were identified through multinomial logistic regression. RESULTS: Postoperative ileus occurred in 377 (9%) of 4205 included patients at day 4 (interquartile range, 2–5 d). Intraoperatively, ileus patients received 3.2 ± 2.6 L of fluids, whereas the remaining patients received 2.5 ± 1.7 L ( p &lt; 0.001). Weight gain was 3.8 ± 7.1 kg in ileus patients versus 3.0 ± 6.6 kg ( p = 0.272) in the remaining patients at postoperative day 1, 4.4 ± 6.5 kg versus 3.1 ± 7.0 kg ( p = 0.028) at postoperative day 2, and 1.8 ± 6.0 kg versus 0.0 ± 6.0 kg at discharge ( p = 0.002). The multivariable model including all significant ( p &lt; 0.05) demographic, fluid management–related, and surgical parameters retained postoperative day 0 fluids of &gt;3 L (OR = 1.65 (95% CI, 1.13–2.41); p = 0.009), postoperative day 2 weight gain of &gt;2.5 kg (OR = 1.49 (95% CI, 1.01–2.21); p = 0.048), and occurrence of postoperative complications (OR = 2.00 (95% CI, 1.39–2.90); p &lt; 0.001) as independent risk factors for ileus. LIMITATIONS: This study was limited by its retrospective design. Fluid management depends on patient-, disease-, and surgery-related factors and cannot be generalized and extrapolated. CONCLUSIONS: Fluid overload and occurrence of postoperative complications were independent risk factors for postoperative ileus. This calls for action to keep perioperative fluids below suggested thresholds. See Video Abstract at http://links.lww.com/DCR/B54. ASOCIACIÓN POTENCIAL ENTRE EL MANEJO DEL LÍQUIDO PERIOPERATORIO Y EL SUCESO DE ÍLEO POSTOPERATORIO ANTECEDENTES: El íleo postoperatorio sigue siendo un problema después de una cirugía colorrectal que retrasa la recuperación y aumenta la duración de la estancia hospitalaria y los costos. OBJETIVO: Analizar el impacto del manejo del líquido perioperatorio en la incidencia de íleo después de la cirugía colorrectal dentro de una vía de recuperación mejorada totalmente implementada. DISEÑO: Estudio de cohorte retrospectivo de una base de datos institucional mantenida prospectivamente. MARCO: Centro académico terciario con una ruta de recuperación mejorada estandarizada completamente implementada durante todo el período del estudio. PACIENTES: Se incluyeron todas las resecciones colorrectales mayores electivas consecutivas para indicaciones benignas o malignas entre 2011 y 2016. MEDIDAS DE RESULTADOS PRINCIPALES: El íleo postoperatorio se definió como la necesidad de reinserción de la sonda nasogástrica. El manejo del líquido perioperatorio y el resultado quirúrgico se compararon entre los pacientes con íleo y los que no. Los posibles factores de riesgo para el íleo se identificaron mediante regresión logística multinominal. RESULTADOS: El íleo postoperatorio se ocurrió en 377 (9%) de los 4205 pacientes incluidos al cuarto día (RIC 2-5). Intraoperatoriamente, los pacientes con íleo recibieron 3.2 ± 2.6 L de líquidos, mientras que los pacientes restantes recibieron 2.5 ± 1.7 L ( p &lt; 0.001). El aumento de peso fue de 3.8 ± 7.1 kg en pacientes con íleo versus 3 ± 6.6 kg ( p = 0.272) en los pacientes restantes en el día postoperatorio 1, 4.4 ± 6.5 kg vs. 3.1 ± 7 kg ( p = 0.028) en el día postoperatorio 2 y 1.8 ± 6 kg versus a 0 ± 6 kg al tiempo de alta hospitalaria ( p = 0.002). El modelo multivariable que incluye todos los parámetros demográficos, del manejo de líquidos y quirúrgicos significativos ( p &lt;0.05) mantuvo líquidos del día 0 después de la operación de&gt; 3L (proporción de probabilidad 1.65, intervalo de confianza del 95% 1.13-2.41, p = 0.009), ganancia de peso de &gt; 2.5 kg en el dia postoperatorio 2 (proporción de probabilidad 1.49, 95% intervalo de confianza 1.01-2.21, p = 0.048) y aparición de complicaciones postoperatorias (proporción de probabilidad 2, 95% intervalo de confianza 1.39-2.9, p &lt;0.001) como factores de riesgo independientes para íleo. LIMITACIONES: Diseño retrospectivo. El manejo de líquidos depende de factores relacionados con el paciente, la enfermedad y la cirugía, y no puede generalizarse ni extrapolarse. CONCLUSIONES: La sobrecarga de líquidos y la aparición de complicaciones postoperatorias fueron factores de riesgo independientes para el íleo postoperatorio. Esto requiere medidas para mantener los líquidos perioperatorios por debajo de los umbrales sugeridos. Vea el Video del Resumen en http://links.lww.com/DCR/B54.

Sarcopenia is a surrogate marker for malnutrition and frailty, which has been linked to higher complication rates and prolonged length of stay (LOS) after surgery. The study aim was to assess the correlation between computed tomography (CT)-based sarcopenia and short-term clinical outcomes after oncologic colon surgery.This retrospective study included consecutive patients operated between May 2014 and December 2019. Three radiological indices of sarcopenia were measured at the level of the third lumbar vertebra on preoperative CT scans: skeletal muscle area (SMA), skeletal muscle index (SMI) (both markers of muscle quantity), and skeletal muscle radiation attenuation (SMRA) (marker of muscle quality). Patients with major complications (grade ≥ 3b according to the Clavien classification) were compared with those without. Statistical correlation between sarcopenia indices, LOS, and comprehensive complication index (CCI) was tested with the Pearson correlation coefficient.A total of 325 patients were included. Mean age was 67 years [standard deviation (SD) 14.3], mean body mass index was 26.0 kg/m2 (SD 5.3), and 193 (59%) were male. Fifty patients (15.4%) had major complications, while 275 (84.6%) did not. Patients with major complications had more open surgery (52 vs. 21%, P < 0.01), intraoperative blood loss (257 vs. 102 mL, P = 0.035), and intraoperative complications (22 vs. 9%, P = 0.012). Patients with major complications had significantly increased CCI scores (53 vs. 6, P < 0.01), reoperations (74 vs. 0%, P < 0.01), and LOS (33 vs. 7, P < 0.01). SMA and SMI were comparable between both groups (126.0 vs. 125.2 cm2 , P = 0.974, and 43.4 vs. 44.3 cm2 /m2 , P = 0.636, respectively), while SMRA was significantly lower in patients with major complications (33.6 vs. 37.3 HU, P = 0.018). A lower SMRA was correlated with prolonged LOS (r = -0.207, P < 0.01) and higher CCI (r = -0.144, P < 0.01), while the other sarcopenia indices had no influence on surgical outcomes.Muscle quality (SMRA) as a specific sarcopenia marker was lower in patients with major complications and seems to prevail over muscle quantity (SMA and SMI) in the prediction of adverse outcomes after oncologic colon surgery.

Background and Objective Key factors of Fast Track (FT) programs are fluid restriction and epidural analgesia (EDA). We aimed to challenge the preconception that the combination of fluid restriction and EDA might induce hypotension and renal dysfunction. Methods A recent randomized trial (NCT00556790) showed reduced complications after colectomy in FT patients compared with standard care (SC). Patients with an effective EDA were compared with regard to hemodynamics and renal function. Results 61/76 FT patients and 59/75 patients in the SC group had an effective EDA. Both groups were comparable regarding demographics and surgery-related characteristics. FT patients received significantly less i.v. fluids intraoperatively (1900 mL [range 1100–4100] versus 2900 mL [1600–5900], P < 0.0001) and postoperatively (700 mL [400–1500] versus 2300 mL [1800–3800], P < 0.0001). Intraoperatively, 30 FT compared with 19 SC patients needed colloids or vasopressors, but this was statistically not significant (P = 0.066). Postoperative requirements were low in both groups (3 versus 5 patients; P = 0.487). Pre- and postoperative values for creatinine, hematocrit, sodium, and potassium were similar, and no patient developed renal dysfunction in either group. Only one of 82 patients having an EDA without a bladder catheter had urinary retention. Overall, FT patients had fewer postoperative complications (6 versus 20 patients; P = 0.002) and a shorter median hospital stay (5 [2–30] versus 9 d [6-30]; P< 0.0001) compared with the SC group. Conclusions Fluid restriction and EDA in FT programs are not associated with clinically relevant hemodynamic instability or renal dysfunction. Key factors of Fast Track (FT) programs are fluid restriction and epidural analgesia (EDA). We aimed to challenge the preconception that the combination of fluid restriction and EDA might induce hypotension and renal dysfunction. A recent randomized trial (NCT00556790) showed reduced complications after colectomy in FT patients compared with standard care (SC). Patients with an effective EDA were compared with regard to hemodynamics and renal function. 61/76 FT patients and 59/75 patients in the SC group had an effective EDA. Both groups were comparable regarding demographics and surgery-related characteristics. FT patients received significantly less i.v. fluids intraoperatively (1900 mL [range 1100–4100] versus 2900 mL [1600–5900], P < 0.0001) and postoperatively (700 mL [400–1500] versus 2300 mL [1800–3800], P < 0.0001). Intraoperatively, 30 FT compared with 19 SC patients needed colloids or vasopressors, but this was statistically not significant (P = 0.066). Postoperative requirements were low in both groups (3 versus 5 patients; P = 0.487). Pre- and postoperative values for creatinine, hematocrit, sodium, and potassium were similar, and no patient developed renal dysfunction in either group. Only one of 82 patients having an EDA without a bladder catheter had urinary retention. Overall, FT patients had fewer postoperative complications (6 versus 20 patients; P = 0.002) and a shorter median hospital stay (5 [2–30] versus 9 d [6-30]; P< 0.0001) compared with the SC group. Fluid restriction and EDA in FT programs are not associated with clinically relevant hemodynamic instability or renal dysfunction.

Cysts of parathyroid origin are sometimes encountered and can easily be mistaken as thyroidal cysts. Functional parathyroid cysts, with symptoms and signs of hyperparathyroidism, are rare and may be a diagnostic challenge to clinicians. We report here on three cases of functional parathyroid cysts that illustrate diagnosis difficulties related to unusual clinical presentations in three Caucasian women, including negative parathyroid scintigraphy.Patient 1, an 87-year-old Caucasian woman presented with confusion and dysphagia. She had hypercalcemia and elevated parathyroid hormone levels suggesting primary hyperparathyroidism. Parathyroid scintigraphy did not reveal any focal uptake, but a computed tomography scan of her neck identified a large cyst in the upper right thyroid region. At cervicotomy, a parathyroid cystic adenoma was removed. Patient 2, a 31-year-old Caucasian woman was investigated after a hypertensive crisis related to primary hyperparathyroidism. Cervical ultrasound identified a large cystic lesion in the lower left thyroid lobe that was removed by minimally invasive cervicotomy. Patient 3, a 34-year-old Caucasian woman presented with an indolent growing mass of the neck and a past medical history of kidney stones. Primary hyperparathyroidism was diagnosed. Ultrasound showed a cystic mass, but parathyroid scintigraphy was negative. Cervical exploration revealed a large cystic adenoma, containing high parathyroid hormone levels.Diagnosis of functional parathyroid cysts can be challenging due to various clinical presentations and negative parathyroid scintigraphy. Surgery, but not fine-needle sclerotherapy, appears to be the safest treatment option. Despite its rarity, differential diagnosis of cystic lesion of the neck should include primary hyperparathyroidism due to functional parathyroid cysts.

Background Surgical site infections (SSIs) are the most frequent complication after colorectal surgery and have a major impact on length of stay and costs. Aim To analyse the incidence, timing, and treatment of SSIs within 30 days after colonic surgery. Methods This was a quality improvement project through retrospective analysis of consecutive colonic surgeries between February 2012 and October 2017 at Lausanne University Hospital (CHUV). SSIs were prospectively assessed by an independent national surveillance programme (www.swissnoso.ch) up to 30 postoperative days. Treatment strategies including drainage of infection (direct wound opening or percutaneous) and surgical management were reviewed. Findings The study cohort included 1263 patients with 532 procedures (42%) performed as emergencies. SSIs were observed in 271 patients (21%), occurring at median postoperative day (POD) 9 (interquartile range (IQR): 4–16). Specifically, 53 (4%) were superficial incisional, 65 (5%) deep incisional, and 153 (12%) organ space infections (anastomotic insufficiency included). Superficial incisional SSI occurred at a median of POD 10.5 (IQR: 7–15), deep incisional at a median of POD 10 (8–15) and organ space at a median of POD 8 (5–11). Diagnosis was performed post discharge in 64 cases (24%). Whereas 47% of organ space infections were detected by POD 7, this rate was only 26% for superficial and deep incisional infections (P = 0.003). Surgical management was necessary in 133 cases (49%), and the remaining cases were managed by drainage without general anaesthesia (138 cases, 51%). Conclusion Organ space infections occurred early in the postoperative course, whereas incisional infections were mostly detected post discharge over the entire 30-day observation period, emphasizing the importance of proper follow-up using a systematic, complete and independent surveillance programme.

&lt;b&gt;&lt;i&gt;Background:&lt;/i&gt;&lt;/b&gt; Mobilization after surgery is recommended to reduce the risk of adverse effects and to improve recovery. The aim of this study was to examine the associations between perioperative physical activity and postoperative outcomes in colorectal surgery. &lt;b&gt;&lt;i&gt;Methods:&lt;/i&gt;&lt;/b&gt; The daily number of footsteps was recorded from preoperative day 5 to postoperative day 3 in a prospective cohort of patients using wrist accelerometers. Timed Up and Go Test (TUGT), 6 Min Walking Test (6MWT), and peak expiratory flow (PEF) were assessed preoperatively. ROC curves were used to assess the performance of physical activity as a diagnostic test of complications and prolonged length of stay (LOS) of more than 5 days. &lt;b&gt;&lt;i&gt;Results:&lt;/i&gt;&lt;/b&gt; A total of 50 patients were included. Patients with complications were significantly older (67 years) than those without complications (53 years, &lt;i&gt;p&lt;/i&gt; = 0.020). PEF was significantly lower in the group with complications (mean flow 294.3 vs. 363.6 L/min, &lt;i&gt;p&lt;/i&gt; = 0.038) while there was no difference between groups for the other two tests (TUGT and 6MWT). The tests had no capacity to discriminate the occurrence of complications and prolonged LOS, except the 6MWT for LOS (AUC = 0.746, &lt;i&gt;p&lt;/i&gt; = 0.004, 95% CI: 0.604–0.889). There was no difference in the mean number of preoperative footsteps, but patients with complications walked significantly less postoperatively (mean daily footsteps 1,101 vs. 1,243, &lt;i&gt;p&lt;/i&gt; = 0.018). &lt;b&gt;&lt;i&gt;Conclusions:&lt;/i&gt;&lt;/b&gt;&lt;i&gt;&lt;/i&gt;Colorectal surgery patients with complications were elderly, had decreased PEF, and walked less postoperatively. The 6MWT could be used preoperatively to discriminate patients with potentially increased LOS and foster mobilisation strategies.

Operations require collaboration between surgeons, anaesthetia professionals, and nurses. The aim of this study was to determine whether intraoperative briefings influence patient outcomes.In a before-and-after controlled trial (9 months baseline; 9 months intervention), intraoperative briefings were introduced in four general surgery centres between 2015 and 2018. During the operation, the responsible surgeon (most senior surgeon present) briefed the surgical team using the StOP? protocol about: progress of the operation (Status), next steps (Objectives), possible problems (Problems), and encouraged asking questions (?). Differences between baseline and intervention were analysed regarding surgical-site infections (primary outcome), mortality, unplanned reoperations, and duration of hospital stay (secondary outcomes), using inverse probability of treatment (IPT) weighting based on propensity scores.In total, 8256 patients underwent surgery in the study. Endpoint data were available for 7745 patients (93.8 per cent). IPT-weighted and adjusted intention-to-treat analyses showed no differences in surgical-site infections between baseline and intervention (9.8 versus 9.6 per cent respectively; adjusted difference (AD) -0.15 (95 per cent c.i. -1.45 to 1.14) per cent; odds ratio (OR) 0.92, 95 per cent c.i. 0.83 to 1.15; P = 0.797), but there were reductions in mortality (1.6 versus 1.1 per cent; AD -0.54 (-1.04 to -0.03) per cent; OR 0.60, 0.39 to 0.92; P = 0.018), unplanned reoperations (6.4 versus 4.8 per cent; AD -1.66 (-2.69 to -0.62) per cent; OR 0.72, 0.59 to 0.89; P = 0.002), and fewer prolonged hospital stays (21.6 versus 19.8 per cent; AD -1.82 (-3.48 to -0.15) per cent; OR 0.87, 0.77 to 0.98; P = 0.024).Short intraoperative briefings improve patient outcomes and should be performed routinely.Outcomes of surgery depend on patient characteristics and surgeon expertise, but also on teamwork, notably communication. The present study introduces the StOP? protocol, in which the surgeon informs the team about the current status (St), objectives regarding next steps (O), and potential problems (P), and encourages the team to ask questions and raise concerns (?). The results suggest an effect of the StOP? intervention on patient mortality, risk of unplanned reoperation, and duration of hospital stay, but not on surgical-site infections. The study is promising regarding the effect of structured intraoperative communication on important patient outcomes. The study compared patient outcomes at baseline and after implementation of the StOP? protocol, which enhances exchange of structured information within the interdisciplinary surgical team during the course of the operation. The intention-to-treat analyses in this multicentre before-and-after study of 8256 patients undergoing general surgery showed no differences between baseline and intervention for surgical-site infections, but revealed reduced mortality and unplanned reoperations, and fewer prolonged hospital stays during the intervention period.

The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.