Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach

ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of “multimodal” and “multidisciplinary” approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of “outcome” may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards “protective” techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery.

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Influence of nutritional status on postoperative outcome in patients with colorectal cancer – the emerging role of the microbiome

Innovative Surgical Sciences ◽

10.1515/iss-2017-0039 ◽

2017 ◽

Vol 3 (1) ◽

pp. 55-64 ◽

Cited By ~ 2

Author(s):

Arved Weimann

Keyword(s):

Colorectal Cancer ◽

Nutritional Status ◽

Time Window ◽

Enhanced Recovery ◽

Perioperative Complications ◽

Neoadjuvant Treatment ◽

Postoperative Outcome ◽

Nutritional Risk ◽

Term Survival ◽

Septic Complications

AbstractMany patients with colorectal cancer are overweight. Even then, nutritional status is a frequently underestimated risk factor for perioperative complications. Enhanced Recovery after Surgery is the goal for perioperative management, and preoperative nutritional risk screening should be a standard. In case of nutritional risk, perioperative nutrition therapy should be started without delay and should follow recent guideline recommendations. The preservation of the microbiome has an emerging role in preventing postoperative anastomotic leakage and septic complications. The time window for recovery after neoadjuvant treatment for rectal cancer may be used for conditioning appropriate-risk patients in a “prehabilitation” program. In order to assess metabolic recovery and the prognosis for long-term survival, C-reactive protein/albumin ratio may be a promising parameter, which has to be validated in the future. This narrative review summarizes recent strategies and guideline recommendations.

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Regurgitation under the ERAS Program: A Case Report

Clinics and Practice ◽

10.3390/clinpract11040092 ◽

2021 ◽

Vol 11 (4) ◽

pp. 775-777

Author(s):

Marta Pires ◽

Margarida Marcelino

Keyword(s):

Case Report ◽

Enhanced Recovery ◽

Elective Surgery ◽

Recovery Period ◽

Clear Fluid ◽

Anterior Rectal Resection ◽

Risk Patients ◽

History Of ◽

Induction Of Anaesthesia ◽

Positive Results

Introduction: Enhanced recovery after surgery (ERAS) is an evidence-based concept that reduces the recovery period after major abdominal surgery. Ingestion of carbohydrate solutions up until two hours before elective surgery has shown positive results. The authors present a case of regurgitation in a patient with apparently low risk for delayed gastric emptying who drank a carbohydrate solution two hours before induction of anaesthesia. Case report: An 80-year-old male patient with a relevant history of ischemic heart disease, atrial fibrillation, stage 3 chronic kidney disease and hypertension, was diagnosed with rectal cancer. He was scheduled for an anterior rectal resection hand-assisted laparoscopic surgery under the ERAS program, which included a 200 mL carbohydrate drink the night before and in the morning of the surgery, no less than two hours before the induction of anaesthesia. Immediately after loss of consciousness, there was regurgitation of a significant amount of clear fluid. Discussion: Even though ingestion of oral carbohydrate drinks is considered to be safe up to two hours before anaesthesia, further evaluation (e.g., gastric ultrasonography) may be considered in non-high-risk patients.

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The nutritional management of surgical patients: enhanced recovery after surgery

Proceedings of The Nutrition Society ◽

10.1079/pns2003299 ◽

2003 ◽

Vol 62 (4) ◽

pp. 807-811 ◽

Cited By ~ 89

Author(s):

Kenneth C. H. Fearon ◽

Rachel Luff

Keyword(s):

Enhanced Recovery ◽

Elective Surgery ◽

Rectal Surgery ◽

Oral Feeding ◽

Morbidity And Mortality ◽

Surgical Trauma ◽

Early Recovery ◽

Oral Nutrition ◽

Operative Morbidity ◽

Early Oral Feeding

Malnutrition has long been recognised as a risk factor for post-operative morbidity and mortality. Traditional metabolic and nutritional care of patients undergoing major elective surgery has emphasised pre-operative fasting and re-introduction of oral nutrition 3–5 d after surgery. Attempts to attenuate the consequent nutritional deficit and to influence post-operative morbidity and mortality have included parenteral, enteral and oral sip feeding. Recent studies have emphasised that an enhanced rate of recovery can be achieved by a multi-modal approach focused on modulating the metabolic status of the patient before (e.g. carbohydrate and fluid loading), during (e.g. epidural anaesthesia) and after (e.g. early oral feeding) surgery. Using such an approach preliminary results on patients undergoing elective colo-rectal surgery indicate a significant reduction in hospital stay (traditional care, n 48, median stay 10 d v. enhanced recovery programme, n 33, median stay 7d; P<0·01) can be achieved. Such findings emphasise the potential role of multi-modal care programmes in the promotion of early recovery from major surgical trauma.

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Prognostic Value of Biomarkers in Cardiac Allograft Vasculopathy following Heart Transplantation: A Literature Review

Cardiology ◽

10.1159/000509630 ◽

2020 ◽

Vol 145 (11) ◽

pp. 693-702

Author(s):

Shaghayegh Habibi ◽

Eiman Ghaffarpasand ◽

Fahimehalsadat Shojaei ◽

Mahda Alihashemi ◽

Farima Kahe ◽

...

Keyword(s):

Vascular Wall ◽

Cardiac Allograft Vasculopathy ◽

Cardiac Allograft ◽

Future Research ◽

Cardiac Transplant ◽

Term Survival ◽

Allograft Vasculopathy ◽

Immunologic Markers ◽

Immune Mediated ◽

Risk Patients

Cardiac allograft vasculopathy (CAV), also known as cardiac transplant vasculopathy, is a major determinant of long-term survival among cardiac transplantation recipients. Histologically, CAV is featured by diffuse, concentric thickening of the vascular wall, and primarily affects large and small epicardial coronary arteries, intramyocardial arteries, and veins. Owing to graft denervation, CAV typically follows an insidious course, and patients may not experience classic angina symptoms but instead present with progressive heart failure or ventricular arrhythmias. Recent studies on biomarkers have furthered the knowledge concerning the prediction and prognosis of CAV. Given its association with metabolic, thrombotic, inflammatory, and immunologic markers, CAV is likely to represent a complex multifactorial process that involves both immune-mediated and non-immune-mediated pathways. In order to identify the high-risk patients that would benefit from early intervention, future research is warranted to examine the usefulness of a biomarker panel in CAV risk stratification.

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Transapical versus Conventional Aortic Valve Replacement�A Propensity-Matched Comparison

The Heart Surgery Forum ◽

10.1532/hsf98.20111084 ◽

2012 ◽

Vol 15 (1) ◽

pp. 4 ◽

Cited By ~ 23

Author(s):

David M. Holzhey ◽

William Shi ◽

A. Rastan ◽

Michael A. Borger ◽

Martin H�nsig ◽

...

Keyword(s):

Aortic Valve ◽

Survival Rates ◽

Long Term Results ◽

Term Survival ◽

Kaplan Meier ◽

Risk Patients ◽

Short And Long Term ◽

Good Treatment Option ◽

Matched Comparison

Introduction: The goal of this study was to compare the short- and long-term outcomes after aortic valve (AV) surgery carried out via standard sternotomy/partial sternotomy versus transapical transcatheter AV implantation (taTAVI).Patients and Methods: All 336 patients who underwent taTAVI between 2006 and 2010 were compared with 4533 patients who underwent conventional AV replacement (AVR) operations between 2001 and 2010. Using propensity score matching, we identified and consecutively compared 2 very similar groups of 167 patients each. The focus was on periprocedural complications and long-term survival.Results: The 30-day mortality rate was 10.8% and 8.4% (P = .56) for the conventional AVR patients and the TAVI patients, respectively. The percentages of postoperative pacemaker implantations (15.0% versus 6.0%, P = .017) and cases of renal failure requiring dialysis (25.7% versus 12.6%, P = .004) were higher in the TAVI group. Kaplan-Meier curves diverged after half a year in favor of conventional surgery. The estimated 3-year survival rates were 53.5% � 5.7% (TAVI) and 66.7% � 0.2% (conventional AVR).Conclusion: Our study shows that even with all the latest successes in catheter-based AV implantation, the conventional surgical approach is still a very good treatment option with excellent long-term results, even for older, high-risk patients.

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Identification of novel autophagy-related lncRNAs associated with a poor prognosis of colon adenocarcinoma through bioinformatics analysis

Scientific Reports ◽

10.1038/s41598-021-87540-0 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Dejun Wu ◽

Zhenhua Yin ◽

Yisheng Ji ◽

Lin Li ◽

Yunxin Li ◽

...

Keyword(s):

High Risk ◽

Poor Prognosis ◽

Notch Pathway ◽

Colon Adenocarcinoma ◽

High Risk Group ◽

The Cancer Genome Atlas ◽

Future Research ◽

Risk Patients ◽

Cancer Genome Atlas ◽

Immune Score

AbstractLncRNAs play a pivotal role in tumorigenesis and development. However, the potential involvement of lncRNAs in colon adenocarcinoma (COAD) needs to be further explored. All the data used in this study were obtained from The Cancer Genome Atlas database, and all analyses were conducted using R software. Basing on the seven prognosis-related lncRNAs finally selected, we developed a prognosis-predicting model with powerful effectiveness (training cohort, 1 year: AUC = 0.70, 95% Cl = 0.57–0.78; 3 years: AUC = 0.71, 95% Cl = 0.6–0.8; 5 years: AUC = 0.76, 95% Cl = 0.66–0.87; validation cohort, 1 year: AUC = 0.70, 95% Cl = 0.58–0.8; 3 years: AUC = 0.73, 95% Cl = 0.63–0.82; 5 years: AUC = 0.68, 95% Cl = 0.5–0.85). The VEGF and Notch pathway were analyzed through GSEA analysis, and low immune and stromal scores were found in high-risk patients (immune score, cor = − 0.15, P < 0.001; stromal score, cor = − 0.18, P < 0.001) , which may partially explain the poor prognosis of patients in the high-risk group. We screened lncRNAs that are significantly associated with the survival of patients with COAD and possibly participate in autophagy regulation. This study may provide direction for future research.

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“Enhanced recovery after surgery – ERAS in elective craniotomies-a non-randomized controlled trial”

BMC Neurology ◽

10.1186/s12883-021-02150-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Anirudh Elayat ◽

Sritam S. Jena ◽

Sukdev Nayak ◽

R. N. Sahu ◽

Swagata Tripathy

Keyword(s):

Randomized Controlled Trial ◽

Glycemic Control ◽

Hospital Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Controlled Trial ◽

Early Recovery ◽

Randomized Controlled ◽

Pain Scores ◽

High Dependency

Abstract Background Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care bundle aimed at the early recovery of patients. Well accepted in gastric and pelvic surgeries, there is minimal evidence in neurosurgery and neurocritical care barring spinal surgeries. We wished to compare the length of intensive care unit (ICU) or high dependency unit (HDU) stay of patients undergoing elective craniotomy for supratentorial neurosurgery: ERAS protocol versus routine care. The secondary objective was to compare the postoperative pain scores, opioid use, glycemic control, and the duration of postoperative hospital stay between the two groups. Methods In this pragmatic non-randomized controlled trial (CTRI/2017/07/015451), consenting adult patients scheduled for elective supratentorial intracranial tumor excision were enrolled prospectively after institutional ethical clearance and consent. Elements-of-care in the ERAS group were- Preoperative –family education, complex-carbohydrate drink, flupiritine; Intraoperative – scalp blocks, limited opioids, rigorous fluid and temperature regulation; Postoperative- flupiritine, early mobilization, removal of catheters, and initiation of feeds. Apart from these, all perioperative protocols and management strategies were similar between groups. The two groups were compared with regards to the length of ICU stay, pain scores in ICU, opioid requirement, glycemic control, and hospital stay duration. The decision for discharge from ICU and hospital, data collection, and analysis was by independent assessors blind to the patient group. Results Seventy patients were enrolled. Baseline demographics – age, sex, tumor volume, and comorbidities were comparable between the groups. The proportion of patients staying in the ICU for less than 48 h after surgery, the cumulative insulin requirement, and the episodes of VAS scores > 4 in the first 48 h after surgery was significantly less in the ERAS group – 40.6% vs. 65.7%, 0.6 (±2.5) units vs. 3.6 (±8.1) units, and one vs. ten episodes (p = 0.04, 0.001, 0.004 respectively). The total hospital stay was similar in both groups. Conclusion The study demonstrated a significant reduction in the proportion of patients requiring ICU/ HDU stay > 48 h. Better pain and glycemic control in the postoperative period may have contributed to a decreased stay. More extensive randomized studies may be designed to confirm these results. Trial registration Clinical Trial Registry of India (CTRI/2018/04/013247), registered retrospectively on April 2018.

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Morbidity and Mortality of Carotid Endarterectomy under Local Anesthesia: A Retrospective Study

Neurosurgery ◽

10.1227/00006123-198810000-00007 ◽

1988 ◽

Vol 23 (4) ◽

pp. 445-450 ◽

Cited By ~ 17

Author(s):

Mario Zuccarello ◽

Hwa-shain Yeh ◽

John M. Tew

Keyword(s):

Retrospective Study ◽

High Risk ◽

Carotid Endarterectomy ◽

Local Anesthesia ◽

Perioperative Complications ◽

Minor Stroke ◽

Perioperative Mortality ◽

Occlusive Vascular Disease ◽

Risk Patients ◽

Ischemic Attack

Abstract It has been shown that carotid endarterectomy reduces the incidence of stroke in patients with symptomatic extracranial occlusive vascular disease in the absence of major perioperative complications such as stroke or death. We present a retrospective study of 106 carotid endarterectomies performed under local anesthesia in 100 patients in whom transient ischemic attack (TIA) or minor stroke had occurred. Nonfatal stroke occurred in 2%, and TIA occurred in 1%. There was no perioperative mortality. Our study suggests that, under local anesthesia, even high risk patients can be operated safely and the majority of carotid endarterectomies can be performed without the use of an indwelling shunt. Meticulous surgical technique is of great importance for achieving low perioperative complications.

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Identifying High-Risk Patients Before Head and Neck Oncologic Surgery

Survey of Anesthesiology ◽

10.1097/00132586-199402000-00039 ◽

1994 ◽

Vol 38 (1) ◽

pp. 33???34

Author(s):

BRIAN T. PELCZAR ◽

HARRISON G. WEED ◽

DAVID E. SCHULLER ◽

DONN C. YOUNG ◽

THOMAS E. REILLEY

Keyword(s):

High Risk ◽

Head And Neck ◽

Oncologic Surgery ◽

High Risk Patients ◽

Risk Patients

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Achieving ‘Marginal Gains’ to Optimise Outcomes in Resectable Pancreatic Cancer

Cancers ◽

10.3390/cancers13071669 ◽

2021 ◽

Vol 13 (7) ◽

pp. 1669

Author(s):

Sarah Powell-Brett ◽

Rupaly Pande ◽

Keith J. Roberts

Keyword(s):

Pancreatic Cancer ◽

Enhanced Recovery ◽

Perioperative Complications ◽

Evidence Base ◽

Modern Medicine ◽

Preoperative Biliary Drainage ◽

Resectable Pancreatic Cancer ◽

Exocrine Insufficiency ◽

Pancreatic Exocrine ◽

Considerable Benefit

Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.

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