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Da Vinci robot-assisted pancreaticoduodenectomy offers advantages, including minimal invasiveness, precise, and safe procedures. This study aimed to investigate the clinical effectiveness of implementing enhanced recovery after surgery (ERAS) concepts in Da Vinci robot-assisted pancreaticoduodenectomy. A retrospective analysis was conducted on clinical data from 62 patients who underwent Da Vinci robot-assisted pancreaticoduodenectomy between January 2018 and December 2022. Among these patients, 30 were managed with ERAS principles, while 32 were managed using traditional perioperative management protocols. Surgical time, intraoperative blood loss, postoperative oral intake time, time to return of bowel function, time to ambulation, visual analog scale (VAS) pain scores, fluid replacement volume, length of hospital stay, total hospital expenses, complications, and patient satisfaction were recorded and compared between the two groups. Postoperative follow-up included assessment of postoperative functional scores, reoperation rates, SF-36 quality of life scores, and survival rates. The average follow-up time was 35.6 months (range: 12-56 months). There were no statistically significant differences in general characteristics, including age, surgical time, intraoperative blood loss, and preoperative medical history between the two groups (P > 0.05). Compared to the control group, the intervention group had an earlier postoperative oral intake time, faster return of bowel function, rapid ambulation, and shorter hospital stays (P < 0.05). The intervention group also had lower postoperative VAS scores, lower fluid replacement volume, lower total hospital expenses, and a lower rate of complications (P < 0.05). Patient satisfaction was higher in the intervention group (P < 0.05). There were no statistically significant differences between the two groups in two-year functional scores, reoperation rates, quality of life scores, and survival rates (P > 0.05). Implementing ERAS principles in Da Vinci robot-assisted pancreaticoduodenectomy substantially expedited postoperative recovery, lowered pain scores, and diminished complications. However, there were no notable differences in long-term outcomes between the two groups.

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Purpose: Laparoscopic right hemicolectomy is the standard surgical approach for treatment of right-sided colonic neoplasms. Although performed within a strict Enhanced Recovery After Surgery (ERAS) program, patients still develop postoperative ileus. The aim of this study was to describe the factors responsible for postoperative ileus after right hemicolectomy in a patient population with over 80% ERAS adherence. Methods: In this retrospective study, we analyzed 499 consecutive patients undergoing elective right-sided colectomy for neoplastic disease in a single high-volume center. All patients followed an updated ERAS program. Results: The overall median ERAS adherence was 80%. Patients with ≥ 80% adherence (n = 271) were included in further analysis. Their median ERAS adherence was 88.9% (interquartile range, 80-90; range, 80-100). Twenty-four of 271 patients (8.9%) developed postoperative ileus. A univariate regression analysis revealed carcinoma situated in the transverse colon, duration of operation over 200 minutes, and opiate consumption over 10 mg on the second postoperative day (POD) to be associated with a significantly higher risk of postoperative ileus. Multivariate regression analysis revealed that duration of surgery over 200 minutes (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.0-5.8; P = 0.045) and opiate consumption over 10 mg on POD 2 (OR, 4.8; 95% CI, 1.6-14.3; P = 0.005) independently predict a higher risk for postoperative ileus. The median length of hospital stay was significantly longer in patients with postoperative ileus (8 days vs. 3 days, P < 0.001). None of the 271 patients died during a 30-day follow-up. Conclusion: Long duration of surgery, even minor postoperative opiate use, predict a higher risk for postoperative ileus in strictly ERAS-adherent patients undergoing laparoscopic right hemicolectomy.

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Awake surgery has been applied for various surgical procedures with positive outcomes; however, in neurosurgery, the technique has traditionally been reserved for cranial surgery. Awake surgery for the spine (ASFS) is an alternative to general anesthesia (GA). As early studies report promising results, ASFS is progressively gaining more interest from spine surgeons. The history defining the range of adverse events facing patients undergoing GA has been well described. Adverse reactions resulting from GA can include postoperative nausea and vomiting, hemodynamic instability and cardiac complications, acute kidney injury or renal insufficiency, atelectasis, pulmonary emboli, postoperative cognitive dysfunction, or malignant hyperthermia and other direct drug reactions. For this reason, many high-risk populations who have typically been poor candidates under classifications for GA could benefit from the many advantages of ASFS. This narrative review will discuss the significant historical components related to ASFS, pertinent mechanisms of action, protocol overview, and the current trajectory of spine surgery with ASFS.

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Microsurgical breast reconstruction after mastectomy is emerging as the standard of care for patients with breast cancer. The enhanced recovery after surgery (ERAS) pathway in abdominal-based free flap breast reconstruction is in its early stage of development and lacks established consensus or guidelines. In the multidisciplinary ERAS team, the anesthesia sub-team is responsible for the provision of several core elements in the ERAS pathway including anesthetic protocol optimization, perioperative fluid management and homeostasis regulation, normothermia maintenance, perioperative analgesia, and postoperative nausea and vomiting prophylaxis. Here, we summarized the state-of-the-art in anesthetic practice for the patients undergoing abdominal-based free flap breast reconstruction within an ERAS framework, and also introduced the perioperative strategy for this surgical population based on the ERAS pathway in our center, aiming to improve free flap outcome and patient satisfaction, and accelerating their recovery following surgery.

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BACKGROUND: Advances in minimally invasive surgery and the development of Enhanced Recovery After Surgery (ERAS) have favored the spread of day-surgery programs. Even though Vaginal natural orifice transvaginal endoscopic surgery (vNOTES) is accepted as an innovative treatment for benign ovarian cysts that is rapidly gaining recognition worldwide, the safety and feasibility of same-day surgery (SDS) have yet to be established. OBJECTIVE: This study aimed to evaluate the safety and feasibility of day surgery compared to inpatient surgery of patients undergoing vNOTES for benign ovarian cysts by determining perioperative outcomes. MATERIALS AND METHODS: The study consisted of 213 patients who underwent vNOTES for ovarian cystectomy at a single institution from January 2020 to November 2022. Based on the hospital stay, patients were classified into the same-day surgery group (SDSG) and the inpatient surgery group (ISG); after data processing and screening considering the balance of the two groups, SDSG has 83 samples(n = 83), and ISG has 113 samples(n = 113). The patient's demographic characteristics and follow-up data were collected during the perioperative period by doctors and nurses for medical tracking and analysis purposes and 1-month postoperatively by doctors in charge of their operation. Independent sample t-tests were performed to verify if there was any major difference between these two groups for continuous data like age, BMI, and cyst diameter, and Pearson's chi-squared tests were used to test whether there was a major difference between these two groups for categorical data like cyst count, abdominal surgery history and whether their cyst is bilateral ovarian cysts or not. The association between exhaust time and postoperative characteristics and the association between levels of pain and postoperative characteristics were further analyzed to unveil the confounding factors contributing to the same-day discharge method's quick recovery nature. RESULTS: Upon performing propensity score matching, 196 patients were finally enrolled in this study for the matched comparison, including 83(42.3%) patients in the SDSG and 113(57.7%) patients in the ISG. There was no statistical difference between the two groups in terms of duration of operation (85.0 ± 41.5 min vs. 80.5 ± 33.5 min), estimated blood loss (27.7 ± 28.0 ml vs. 36.3 ± 33.2 ml), preoperative hemoglobin levels (128.8 ± 13.2 g/L vs. 128.6 ± 14.0 g/L), postoperative hemoglobin difference at 24 h (16.5 ± 15.4 g/L vs. 19.3 ± 9.1 g/L), pelvic adhesions (42 (50.6%) vs. 47 (41.6%)), and postoperative complications (7(8.4%) vs. 4(3.5%)). The SDSG group showed less time of feeding/off-bed/exhaust/urination after surgery, shorter hospitalization duration, a lower postoperative 6-hour pain score, and a lower incidence of analgesic drug use. Multiple linear regression analysis showed that advancing the time of postoperative off-bed activity and feeding reduced the postoperative exhaust time by 0.34 (95% CI: 0.185-0.496, 0.34 h, p < 0.001) and 0.299(95% CI: 0.158-0.443, 0.229 h, p = 0.036) hours. In addition, Ordinal logistic regression revealed a correlation between pain scores and bilaterality of cyst, increasing about 25.98 times the risk of pain levels when ovarian cysts are bilateral (OR: 26.98, 95% CI: 1.071-679.859, P = 0.045). CONCLUSION: In this pilot study, same-day discharge after vaginal natural orifice transvaginal endoscopic ovarian cystectomy is safe and feasible. The vNOTES for ovarian cystectomy combined with the same-day discharge shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and lower the use incidence of analgesic drugs.

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OBJECTIVE: Enhanced recovery after surgery (ERAS) pathways are evidence-based practices that minimize perioperative physiologic stress, reducing postoperative complications and recovery time. This study assessed the Canadian application of, and adherence to, ERAS recommendations during minimally invasive gynaecologic surgery, and identified barriers to ERAS uptake. METHODS: A self-administered cross-sectional survey was distributed to obstetrics and gynaecology residents, fellows, and attendings through three national listservs from February 2021 to January 2022. The survey assessed 14 perioperative components per the AAGL (American Association of Gynecologic Laparoscopists) ERAS consensus guidelines. Two study groups were defined-participants with vs. without an established ERAS program-and comparison analyses as well as inferential statistical tests were performed. RESULTS: 158 responses were analyzed. 41.9% of respondents work in a centre with an ERAS program. Adherence to ERAS recommendations was high with engaging patients in the operative processes, changing equipment after a contaminated procedure, discontinuing urinary catheters, and initiating early postoperative mobilization. ERAS programing enhanced adherence to preoperative carbohydrate loading, intraoperative fluid management, normothermia, and bowel regimen adjuncts (P < 0.05). Despite ERAS programming, adherence to some recommendations-preoperative fasting, comorbidity optimisation-remained low. Most respondents felt that ERAS is safe (98%) and improves outcomes (82%). CONCLUSION: While the implementation of formal ERAS pathways differs between provinces and hospitals, practitioners across Canada engage in various ERAS components. ERAS program sites had higher adherence to some perioperative recommendations; however, some high-level evidence recommendations still have national adherence gaps. Targeted research around low-adherence components would help identify and address barriers to optimize surgical care.

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INTRODUCTION: Enhanced recovery after surgery (ERAS) is an established pathway to improve short-term outcomes in colorectal surgery. It is unclear whether the efficacy, feasibility, and safety of the ERAS protocol are similar in older and younger patients. The study examined adherence to the ERAS protocol and identified factors leading to deviations in older patients. MATERIALS AND METHODS: Patients undergoing colorectal resection were prospectively included in the ERAS protocol between 2019 and 2022. The cohort was stratified according to age and ERAS adherence score. The patients were compared regarding clinical short-term follow-up (30 days). Univariate and multivariate analyses were performed using the statistical program R (version 4.1.2). RESULTS: During the study period, 414 patients were recruited, including 132 patients (31.9 %) aged ≥75 years. The cohort of older adults showed significantly higher American Society of Anesthesiologists (ASA) scores III/IV (57.8 % vs. 81.8 %; p < 0.001) and more frequently malignant diseases (45.9 % vs. 64.1 %; p < 0.001), but a lower body mass index (26.7 vs. 24.4; p < 0.001). Furthermore, older adults achieved significantly lower adherence to the ERAS protocol in the postoperative phase (84.6 % vs. 80.1 %; p = 0.003) and experienced a longer median length of hospital stay (6 vs. 8 days; p < 0.001). The differences identified were increased change of body weight on postoperative day 1, delayed removal of a urinary catheter, and shorter duration of mobilization on postoperative days 2 and 3 (p < 0.05). However, in the multivariate analysis, emergency and open surgery as well as severe complications, but not age, were elicited as independent predictive factors for lower adherence to the ERAS protocol postoperatively. DISCUSSION: Adherence to the postoperative ERAS requirements appears to be lower in older patients, although age alone was not an independent factor in our multivariate analysis and therefore not responsible for a lower adherence to the postoperative ERAS protocol after colorectal resection. This difference underlines the importance of interdisciplinary teamwork in daily practice to achieve optimal postoperative results, especially in older adults.

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BACKGROUND: The aim of this study was to evaluate the effectiveness and safety of TJ-100 TSUMURA Daikenchuto (DKT) Extract Granules in preventing post-hepatectomy digestive symptoms and the effects on small intestinal mucosal atrophy. METHODS: Eligible patients were randomly assigned to the DKT therapy and usual care groups in a 1:1 ratio. The DKT therapy group was administered DKT for 14 days after surgery or until the day of discharge if the patient left the hospital before 14 days, and the usual care group did not receive DKT. We used the numeric rating scale to measure abdominal pain and bloating after surgery and compared the results between the two groups to determine the efficiency of DKT. We also evaluated postoperative small intestinal mucosal atrophy using diamine oxidase (DAO) and glucagon-like peptide-2 (GLP-2) activities in the serum, and postoperative complications. RESULTS: No adverse effects were observed in the DKT group. No significant difference was observed in the area under the curve for postoperative abdominal pain or bloating throughout the study period. No differences were observed in DAO2, GLP2, and other nutrition assessment indicators. Four postoperative infections were observed in three patients (two with intra-abdominal surgical site infections [SSIs] and two with pneumonia). All cases of infection occurred in the control group. CONCLUSIONS: Although DKT did not significantly improve postoperative symptoms, such as abdominal pain or bloating, it is widely used in Japan to improve bowel movement and is safely prescribed for patients undergoing hepatectomy with a tendency toward less postoperative infection.

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OBJECTIVE: To evaluate the efficacy and safety of Wuda Granule (WDG) on recovery of gastrointestinal function after laparoscopic bowel resection in the setting of enhanced recovery after surgery (ERAS)-based perioperative care. METHODS: A total of 108 patients aged 18 years or older undergoing laparoscopic bowel resection with a surgical duration of 2 to 4.5 h were randomly assigned (1:1) to receive either WDG or placebo (10 g/bag) twice a day from postoperative days 1-3, combining with ERAS-based perioperative care. The primary outcome was time to first defecation. Secondary outcomes were time to first flatus, time to first tolerance of liquid or semi-liquid food, gastrointestinal-related symptoms and length of stay. Subgroup analysis of the primary outcome according to sex, age, tumor site, surgical time, histories of underlying disease or history of abdominal surgery was undertaken. Adverse events were observed and recorded. RESULTS: A total of 107 patients [53 in the WDG group and 54 in the placebo group; 61.7 ± 12.1 years; 50 males (46.7%)] were included in the intention-to-treat analysis. The patients in the WDG group had a significantly shorter time to first defecation and flatus [between-group difference -11.01 h (95% CI -20.75 to -1.28 h), P=0.012 for defecation; -5.41 h (-11.10 to 0.27 h), P=0.040 for flatus] than the placebo group. Moreover, the extent of improvement in postoperative gastrointestinal-related symptoms in the WDG group was significantly better than that in the placebo group (P<0.05). Subgroup analyses revealed that the benefits of WDG were significantly superior in patients who were male, or under 60 years old, or surgical time less than 3 h, or having no history of basic disease or no history of abdominal surgery. There were no serious adverse events. CONCLUSION: The addition of WDG to an ERAS postoperative care may be a viable strategy to enhance gastrointestinal function recovery after laparoscopic bowel resection surgery. (Registry No. ChiCTR2100046242).

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The concept of enhanced recovery after surgery (ERAS) has been practiced for decades and has been implemented in numerous surgical specialties. ERAS is a global surgical quality improvement initiative, and it is an element in the field of perioperative care. ERAS had shown significant clinical outcomes, patient-reported satisfaction, and improvements in medical service cost. ERAS has been developed for specific surgical procedures, but with the fast progress of newly introduced surgical procedures, the original ERAS have been developed and modified. Recently appearing Topics and future research trends encompass ERAS protocols for other types of surgery and the enhancement of perioperative status, including but not limited to pediatric surgery, laparoscopic and robotic assisted surgery, bariatric surgery, thoracic surgery, and renal transplantation. The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative, operative, and post-operative pathways. ERAS costs are higher than traditional care, but the patient's clinical outcome and satisfaction are higher. ERAS is in progress in the fields of anesthetic tasks, pediatric surgery, and organ transplantation. Although ERAS has shown significant clinical outcomes, there are needs to modify the protocol for specific cases, hospital facilities, resources, and nurses training on elements of ERAS. Several challenges and limitations exist in the implementation of ERAS that deserve consideration, it includes: Frailty, maximizing nutrition, prehabilitation, treating preoperative anemia, and enhancing ERAS adoption globally are all included.

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BACKGROUND: The optimal length of epidural use following open pancreaticoduodenectomy has not been defined. The aim of this study was to investigate whether the length of patient-controlled epidural analgesia affected pain and ability to mobilise on epidural termination following open pancreaticoduodenectomy in the context of enhanced recovery after surgery. METHODS: A retrospective single-centre cohort analysis was performed between November 2015 and December 2021 on patients who underwent open pancreaticoduodenectomy. As part of a continual review process of the enhanced recovery after surgery protocol, patient-controlled epidural analgesia duration changed allowing stratification of patients into either three- or five-day patient-controlled epidural analgesia groups. RESULTS: Of the 196 patients identified, 157 were included with 80 (50.9%) and 77 (49.1%) allocated to the three-day and five-day patient-controlled epidural analgesia groups, respectively. Patient-controlled epidural analgesia termination on postoperative day 3 was associated with transiently higher pain and less mobilisation, although no greater rescue analgesia requirement. Conversely, longer patient-controlled epidural analgesia usage following open pancreaticoduodenectomy was associated with less pain and greater mobilisation in the immediate postoperative period. CONCLUSIONS: Earlier patient-controlled epidural analgesia termination transiently leads to increased pain and decreased mobilisation following open pancreaticoduodenectomy. Ensuring appropriate analgesia requirements or longer patient-controlled epidural analgesia usage should be considered to avoid patient discomfort and enhance recovery.

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PURPOSE: Muscular deficits as part of severe osteoarthritis of the hip may persist for up to two years following total hip arthroplasty (THA). No study has evaluated the mid-term benefit of a modified enhanced-recovery-after-surgery (ERAS) concept on muscular strength of the hip in detail thus far. We (1) investigated if a modified ERAS-concept for primary THA improves the mid-term rehabilitation of muscular strength and (2) compared the clinical outcome using validated clinical scores. METHODS: In a prospective, single-blinded, randomized controlled trial we compared patients receiving primary THA with a modified ERAS concept (n = 12, ERAS-group) and such receiving conventional THA (n = 12, non-ERAS) at three months and one year postoperatively. For assessment of isokinetic muscular strength, a Biodex-Dynamometer was used (peak-torque, total-work, power). The clinical outcome was evaluated by using clinical scores (Patient-Related-Outcome-Measures (PROMs), WOMAC-index (Western-Ontario-and-McMaster-Universities-Osteoarthritis-Index), HHS (Harris-Hip-Score) and EQ-5D-3L-score. RESULTS: Three-months postoperatively, isokinetic strength (peak-torque, total-work, power) and active range of motion was significantly better in the modified ERAS group. One year postoperatively, the total work for flexion was significantly higher than in the Non-ERAS group, whilst peak-torque and power did not show significant differences. Evaluation of clinical scores revealed excellent results at both time points in both groups. However, we could not detect any significant differences between both groups in respect of the clinical outcome. CONCLUSION: With regard to muscular strength, this study supports the implementation of an ERAS concept for primary THA. The combination with a modified ERAS concept lead to faster rehabilitation for up to one-year postoperatively, reflected by significant higher muscular strength (peak-torque, total-work, power). Possibly, because common scores are not sensitive enough, the results are not reflected in the clinical outcome. Further larger randomized controlled trials are necessary for long-term evaluation.

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BACKGROUND: There is still some room for optimizing ambulatory pediatric surgical procedures, and the preoperative and postoperative management quality for pediatric patients needs to be improved. AIM: To discuss the safety and feasibility of the enhanced recovery after surgery (ERAS)-based management model for ambulatory pediatric surgical procedures. METHODS: We selected 320 pediatric patients undergoing ambulatory surgery from June 2023 to January 2024 at The First People's Hospital of Liangshan Yi Autonomous Prefecture. Of these, 220 received ERAS-based management (research group) and 100 received routine management (control group). General information, postoperative ambulation activities, surgical outcomes (operation time, postoperative gastrointestinal ventilation time, and hospital stay), postoperative pain visual analogue scale, postoperative complications (incision infection, abdominal distension, fever, nausea, and vomiting), and family satisfaction were compared. RESULTS: The general information of the research group (sex, age, disease type, single parent, family history, etc.) was comparable to that of the control group (P > 0.05), but the rate of postoperative (2 h, 4 h, and 6 h after surgery) ambulation activities was statistically higher (P < 0.01), and operation time, postoperative gastrointestinal ventilation time, and hospital stay were markedly shorter (P < 0.05). The research group had lower visual analogue scale scores (P < 0.01) at 12 h and 24 h after surgery and a lower incidence of total postoperative complications than the control group (P = 0.001). The research group had higher family satisfaction than the control group (P = 0.007). CONCLUSION: The ERAS-based management model was safe and feasible in ambulatory pediatric surgical procedures and worthy of clinical promotion.

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BACKGROUND: Gastric cancer-related morbidity and mortality rates are high in China. Patients who have undergone gastric cancer surgery should receive six cycles of chemotherapy according to their condition. During this period, intestinal obstruction is likely to occur. Electrolyte balance disorders, peritonitis, intestinal necrosis, and even hypovolemic shock and septic shock can seriously affect the physical and mental recovery of patients and threaten their health and quality of life (QoL). AIM: To quantitatively explore the effects of enhanced recovery after surgery (ERAS)-based nursing on anxiety, depression, and QoL of elderly patients with postoperative intestinal obstruction after gastric cancer. METHODS: The clinical data of 129 older patients with intestinal obstruction after gastric cancer surgery who were treated and cared for in our hospital between January 2019 and December 2021 were examined retrospectively. Nine patients dropped out because of transfer, relocation, or death. According to the order of admissions, the patients were categorized into either a comparison group or an observation group according to the random number table, with 60 cases in each group. RESULTS: After nursing care, the observation group required significantly less time to eat for the first time, recover bowel sounds, pass gas, and defecate than the comparison group (P < 0.05). No significant difference was noted in nutrition-related indicators between the two groups before care. Before care, the Symptom Check List-90 scores between the two groups were comparable, whereas anxiety, depression, paranoia, fear, hostility, obsession, somatization, interpersonal sensitivity, and psychotic scores were significantly lower in the observation group after care (P < 0.05). The QoL scores between the two groups before care did not differ significantly. After care, the physical, social, physiological, and emotional function scores; mental health score; vitality score; and general health score were significantly higher in the observation group, whereas the somatic pain score was significantly lower in the observation group (P < 0.05). CONCLUSION: ERAS-based nursing combined with conventional nursing interventions can effectively improve patient's QoL, negative emotions, and nutritional status; accelerate the time to first ventilation; and promote intestinal function recovery in elderly patients with postoperative intestinal obstruction after gastric cancer surgery.

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OBJECTIVE: To investigate the effects of enhanced recovery after surgery (ERAS) on the perioperative healing and stress response in patients with hip fractures. METHODS: A retrospective analysis was conducted on the medical records of 86 patients with hip fractures admitted to the Affiliated Hospital of Southwest Medical University between January 2022 and August 2023. Among them, 48 patients in the research group received ERAS, while 38 patients in the control group received conventional nursing. Hip joint function, pain levels, stress response, fracture healing time, incidence of complications, and nursing satisfaction were compared between the two groups. RESULTS: After nursing, the Harris scores notably increased in both groups, with the research group showing notably higher scores compared to the control group (P<0.05). The levels of cortisol and epinephrine, as well as the visual analog scale scores significantly decreased in both groups, with the research group showing significantly lower levels (P<0.05). In addition, the research group experienced significantly shorter fracture healing time (P<0.05), higher nursing satisfaction (P=0.014), and lower incidence of complications (P=0.028). Logistic regression analysis revealed that age, underlying diseases, nursing method, emotional disorders, and timing of surgery were independent factors influencing the post-nursing outcomes. CONCLUSION: The ERAS mode can effectively alleviate pain, improve hip joint function, reduce fracture healing time and complications, mitigate stress response, and accelerate postoperative recovery in patients with hip fractures. It is worthy of application and promotion in clinical practice.

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Introduction: Enhanced Recovery After Surgery (ERAS) protocols represent a paradigm shift in perioperative care, aim to optimize patient outcomes and accelerate recovery. This manual presents findings from implementing the INCREASE study, a bicentric prospective randomized controlled trial focusing on ERAS in minimally invasive heart valve surgery. Methods: Utilizing the Consolidated Framework for Implementation Research (CFIR) and the Template for Intervention Description and Replication (TIDieR), the study examined contextual factors, intervention components, and implementation strategies. Results: Key findings from the CFIR analysis revealed critical domains influencing implementation success. These included innovation characteristics, external and internal settings, and individual dynamics. The study showcased ERAS's adaptability to diverse healthcare systems, emphasizing its potential for successful integration across varying contexts. Furthermore, the importance of interprofessional collaboration emerged as a foundation of practical implementation, fostering teamwork, communication, and patient-centered care. Utilizing the TIDieR framework, this manual comprehensively describes ERAS intervention components, detailing preoperative counseling, intraoperative management, and postoperative care strategies. The manual underscored the importance of tailored, patient-centered approaches, highlighting the role of an academic ERAS nurse, early mobilization, and psychosomatic interventions in promoting optimal recovery outcomes. Discussion: In conclusion, the INCREASE study provided valuable insights for creating an implementation manual for ERAS in cardiac surgery, emphasizing adaptability, collaboration, and ongoing evaluation as key drivers of successful implementation. These findings have broad implications for improving patient care outcomes and advancing perioperative practices in cardiac surgery settings.

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OBJECTIVE: This enhanced recovery programme (ERP) aimed to achieve early recovery for patients undergoing major surgery. Results of a standardised ERP protocol for open infrarenal abdominal aortic aneurysm (AAA) repair within a hub and spoke regional network are presented. METHODS: In this monocentric prospective study (January 2004 - December 2021), consecutive AAAs (≥ 55 mm) were included in the ERP (patient discharge on post-operative day [POD] 4). The four phases of the ERP were pre-admission, pre-operative, intra-operative, and post-operative. Exclusion criteria were BMI > 35 kg/m2, functional capacity < 4 MET, previous aortic or abdominal surgery, and life expectancy < 5 years. Transperitoneal surgery was undertaken with routine AAA resection, graft interposition, and closure. RESULTS: Consecutive patients (n = 778) were enrolled into the study (mean age 72.3 ± 3.2 years; n = 712 men); 160 (20.5%) were treated in spoke hospitals. Median follow up was 78 (IQR 28, 128) months; median length of stay, procedure time, and blood loss were 4 days (IQR 3, 5), 190 min (IQR 170, 225), and 564 mL (IQR 300, 600). Infrarenal clamping and tube graft configuration were used in 96.5% (n = 751) and 72.5% (n = 564) of patients; 30 day mortality and complication rates were 0.4% (n = 3) and 9.2% (n = 72). Discharge after POD 4 occurred in 15.0%, and most significant predictors for discharge after POD 4 were haemotransfusion, re-intervention, and ileus over 3 days. Overall survival was: 98.2% at 1 year, 85.0% at 5 years, and 59.9% at 10 years. Freedom from re-intervention was 97.9% at 1 year, 94.1% at 5 years, and 86.8% at 10 years. Short and long term outcomes were comparable between hub and spoke hospitals. CONCLUSION: The ERP protocol was associated with low short and long term mortality and complication rates. Future studies should apply the ERP protocol to other vascular centres.

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Objective: For elective cesarean section patients with gestational diabetes mellitus (GDM), there is a lack of evidence-based research on the use of enhanced recovery after surgery (ERAS). This study aims to compare the ERAS after-surgery protocol and traditional perioperative management. Research design and methods: In this retrospective cohort study, singleton pregnancies with good glucose control GDM, delivered by elective cesarean sections under intravertebral anesthesia at least 37 weeks from January 1 to December 31, 2022, were collected at the Third Affiliated Hospital of Sun Yat-sen University. We divided all enrolled pregnant women and newborns into an ERAS group and a control group (the traditional perioperative management group) based on their adherence to the ERAS protocol. The primary outcome was the preoperative blood glucose level, with an increase of more than 1 mmol/L indicating clinical significance when compared to the control group. The secondary outcome was centered around an adverse composite outcome that affected both mothers and newborns. Results: We collected a total of 161 cases, with 82 in the ERAS group and 79 in the control group. Although the mean preoperative blood glucose level in the ERAS group was significantly higher than in the control group (5.01 ± 1.06 mmol/L vs. 4.45 ± 0.90 mmol/L, p<0.001), the primary outcome revealed that the mean glycemic difference between the groups was 0.47 mmol/L (95% CI 0.15-0.80 mmol/L), which was below the clinically significant difference of 1 mmol/L. For the secondary outcomes, the ERAS group had an 86% lower risk of a composite adverse outcome compared to the control group. This included a 73% lower risk of perioperative maternal hypoglycemia and a 92% lower rate of neonatal hypoglycemia, all adjusted by age, hypertensive disorder of pregnancy, BMI, gestational weeks, primigravidae, primary pregnancy, GDM, surgery duration, and fasting glucose. Conclusion: Implementing a low-dose carbohydrate ERAS in pregnant women with GDM prior to elective cesarean section, compared to traditional perioperative management, does not lead to clinically significant maternal glucose increases and thus glucose-related maternal or neonatal perioperative complications.

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INTRODUCTION: Variability in implementation of enhanced recovery protocols (ERPs) often reduces the effects of an intervention on clinical outcomes. This study aimed to evaluate hospital-level implementation fidelity to a pediatric gastrointestinal surgery ERP by assessing site-specific implementation materials. METHODS: This document analysis study operationalized implementation fidelity as adherence to the creation of specified materials at each study site. During the 12-mo implementation phase within the stepped-wedge cluster randomized control trial, ENhanced Recovery In CHildren Undergoing Surgery, study sites were provided with materials (e.g., order sets), access to peer-counseling, and given key ERP elements spanning multiple phases of care. Sixteen of the 18 total study sites submitted implementation materials, including 14 anesthesia protocols, 11 order sets, and 16 sets of patient/family education materials. These materials were assessed and graded for fidelity using prespecified criteria. Hospital-level fidelity scores could range from 0 to a maximum score of 18, and were categorized as either high or low, based on whether the score was above or below/equal to the median. Descriptive statistics and Wilcoxon rank sum test were used for analysis. RESULTS: The overall hospital-level median fidelity score for inclusion of ERP elements in the implementation materials was 10.5. The median score was 12.8 at nine high-fidelity sites and was 5.6 at nine low-fidelity sites (P < 0.01). Higher adherence was noted for avoiding prolonged fasting (n = 16/18 hospitals; 89%) and preventing nausea and vomiting (n = 16/18 hospitals; 89%) in anesthesia protocols and/or order sets. Lower adherence was noted for incorporation of minimally invasive surgical techniques (n = 2/18 hospitals, 11%) and of preoperative optimization of medical comorbidities (n = 0/18 hospitals, 0%) in implementation materials. CONCLUSIONS: Despite substantial resources to promote ERP elements, there was wide variation in fidelity for incorporating ERPs into implementation materials among hospital sites. Development of high-fidelity implementation materials for complex ERPs for gastrointestinal surgery in children may require longer than 12 months. Additional implementation strategies, resources, and modification of implementation-focused materials may be needed.