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Background: Inadequate perioperative fluid therapy impairs gastrointestinal function. Studies primarily evaluating the impact of goal-directed fluid therapy on primary postoperative ileus are missing. The objective of this study was to determine whether goal-directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Methods: Randomized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Patients were assigned randomly to receive intraoperative goal-directed fluid therapy (goal-directed fluid therapy group) or fluid therapy based on traditional principles (control group). Primary postoperative ileus was the primary outcome. Results: One hundred twenty-eight patients were included and analyzed (goal-directed fluid therapy group: N = 64; control group: N = 64). The incidence of primary postoperative ileus was 22% in the goal-directed fluid therapy and 22% in the control group (relative risk, 1; 95% CI, 0.5 to 1.9; P = 1.00). Intraoperatively, patients in the goal-directed fluid therapy group received less intravenous fluids (mainly less crystalloids) but a greater volume of colloids. The increase of stroke volume and cardiac output was more pronounced and sustained in the goal-directed fluid therapy group. Length of hospital stay, 30-day postoperative morbidity, and mortality were not different. Conclusions: Intraoperative goal-directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program. Its previously demonstrated benefits might have been offset by advancements in perioperative care.

We have used admittance spectroscopy and deep-level transient spectroscopy to characterize electronic properties of Si/Si1–x–yGexCy heterostructures. Band offsets measured by admittance spectroscopy for compressively strained Si/Si1–x–yGexCy heterojunctions indicate that incorporation of C into Si1–x–yGexCy lowers both the valence- and conduction-band edges compared to those in Si1–xGex by an average of 107 ± 6 meV/% C and 75 ± 6 meV/% C, respectively. Combining these measurements indicates that the band alignment is type I for the compositions we have studied, and that these results are consistent with previously reported results on the energy band gap of Si1–x–yGexCy and with measurements of conduction band offsets in Si/Si1–yCy heterojunctions. Several electron traps were observed using deep-level transient spectroscopy on two n-type heterostructures. Despite the presence of a significant amount of nonsubstitutional C (0.29–1.6 at. %), none of the peaks appear attributable to previously reported interstitial C levels. Possible sources for these levels are discussed.

Realization of group IV heterostructure devices requires the accurate measurement of the energy band offsets in Si/Si1–xGex and Si/Si1–x–yGexCy heterojunctions. Using admittance spectroscopy, we have measured valence-band offsets in Si/Si1–xGex heterostructures and conduction-band and valence-band offsets in Si/Si1–x–yGexCy heterostructures grown by solid-source molecular-beam epitaxy. Measured Si/Si1–xGex valence-band offsets were in excellent agreement with previously reported values. For Si/Si1–x–yGexCy our measurements yielded a conduction-band offset of 100 ± 11 meV for a n-type Si/Si0.82Ge0.169C0.011 heterojunction and valence-band offsets of 118 ± 12 meV for a p-type Si/Si0.79Ge0.206C0.004 heterojunction and 223 ± 20 meV for a p-type Si/Si0.595Ge0.394C0.011 heterojunction. Comparison of our measured band offsets with previously reported measurements of energy band gaps in Si1–x–yGexCy and Si1–yCy alloy layers indicates that the band alignment is type I for the compositions we have studied and that our measured band offsets are in quantitative agreement with these previously reported results.

Introduction: While patient engagement and clinical audit are key components of successful enhanced recovery programs (ERPs), they require substantial resource allocation. The objective of this study was to assess the validity and usability of a novel mobile device application for education and self-reporting of adherence for patients undergoing bowel surgery within an established ERP. Methods: Prospectively recruited patients undergoing bowel surgery within an ERP used a novel app specifically designed to provide daily recovery milestones and record adherence to 15 different ERP processes and six patient-reported outcomes (PROs). Validity was measured by the agreement index (Cohen’s kappa coefficient for categorical, and interclass correlation coefficient (ICC) for continuous variables) between patient-reported data through the app and data recorded by a clinical auditor. Acceptability and usability of the app were measured by the System Usability Scale (SUS). Results: Forty-five patients participated in the study (mean age 61, 64% male). Overall, patients completed 159 of 179 (89%) of the available questionnaires through the app. Median time to complete a questionnaire was 2min 49s (i.q.r. 2′32″–4′36″). Substantial (kappa > 0.6) or almost perfect agreement (kappa > 0.8) and strong correlation (ICC > 0.7) between data collected through the app and by the clinical auditor was found for 14 ERP processes and four PROs. Patient-reported usability was high; mean SUS score was 87 (95% CI 83–91). Only 6 (13%) patients needed technical support to use the app. Forty (89%) patients found the app was helpful to achieve their daily goals, and 34 (76%) thought it increased their motivation to recover after surgery. Conclusions: This novel application provides a tool to record patient adherence to care processes and PROs, with high agreement with traditional clinical audit, high usability, and patient satisfaction. Future studies should investigate the use of mobile device apps as strategies to increase adherence to perioperative interventions.

Introduction: Enhanced recovery pathways (ERP) include a bundle of evidence-based preoperative, intraoperative, and postoperative interventions that together reduce morbidity and length of stay after colorectal surgery. Increased adherence with the bundle is associated with better postoperative outcomes, but adherence is lowest in the postoperative period. Identifying risk factors for lower adherence may help design quality improvement strategies. The aim of this study was to estimate the extent to which patient, procedural, and organizational factors predict adherence to postoperative ERP elements in laparoscopic colorectal surgery. Methods: Patients in an institutional ERP registry undergoing elective laparoscopic colorectal surgery between 2012 and 2014 were analyzed. The ERP included 10 postoperative ERP elements classified into 2 groups: those requiring patient participation (PP, 5 elements, including nutritional intake and mobilization) and those provided by the clinical team (CT, 5 elements, including removal of catheters and type of analgesia). The impact of baseline and intraoperative factors on adherence was estimated using stepwise linear regression. Results: A total of 223 patients were included (mean age 60, 48% male). Mean adherence was 79% to the PP bundle (range 65–93% for individual elements), and 82% for the CT bundle (range 68–98% for individual elements). The occurrence of nausea/vomiting in the first 24h was associated with lower adherence to both bundles. In the PP bundle, patients who arrived at the ward after 6p.m. had lower adherence. In the CT bundle, patients who had rectal resection had lower adherence while thoracic epidural was associated with higher adherence. Conclusions: With the exception of postoperative nausea and vomiting, predictors of adherence to ERP elements after colorectal surgery differed for elements requiring patient participation and those provided by the clinical team. Strategies to improve ERP adherence should target staff education and engagement of patients at risk for lower adherence.

Background: Prolonged postoperative ileus (PPOI) is common after colorectal surgery but has not been widely studied in the context of enhanced recovery pathways (ERPs) that include interventions aimed to accelerate gastrointestinal recovery. The aim of this study is to estimate the incidence and predictors of PPOI in the context of an ERP for colorectal surgery. Methods: We analyzed data from an institutional colorectal surgery ERP registry. Incidence of PPOI was estimated according to a definition adapted from Vather (intolerance of solid food and absence of flatus or bowel movement for ≥ 4days) and compared to other definitions in the literature. Potential risk factors for PPOI were identified from previous studies, and their predictive ability was evaluated using Bayesian model averaging (BMA). Results are presented as posterior effect probability (PEP). Evidence of association was categorized as: no evidence (PEP < 50%), weak evidence (50–75%), positive evidence (75–95%), strong evidence (95–99%), and very strong evidence (> 99%). Results: There were 323 patients analyzed (mean age 63.5years, 51% males, 74% laparoscopic, 33% rectal resection). The incidence of PPOI was 19% according to the primary definition, but varied between 11 and 59% when using other definitions. On BMA analysis, intraoperative blood loss (PEP 99%; very strong evidence), administration of any intravenous opioids in the first 48h (PEP 94%; strong evidence), postoperative epidural analgesia (PEP 56%; weak evidence), and non-compliance with intra-operative fluid management protocols (3ml/kg/h for laparoscopic and 5ml/kg/h for open; PEP 55%, weak evidence) were predictors of PPOI. Conclusions: The incidence of PPOI after colorectal surgery is high even within an established ERP and varied considerably by diagnostic criteria, highlighting the need for a consensus definition. The use of intravenous opioids is a modifiable strong predictor of PPOI within an ERP, while the role of epidural analgesia and intraoperative fluid management should be further evaluated.

Background: Increased adherence with enhanced recovery pathways (ERP) is associated with improved outcomes. However, adherence to postoperative elements that rely on patient participation remains suboptimal. Mobile device apps may improve delivery of health education material and have the potential to foster behavior change and improve patient compliance. The objective of this study was to estimate the extent to which a novel mobile device app affects adherence to an ERP for colorectal surgery in comparison to standard written education. Methods: This was a superiority, parallel-group, assessor-blind, sham-controlled randomized trial involving 97 patients undergoing colorectal resection. Participants were randomly assigned with a 1:1 ratio into one of two groups: (1) iPad including a novel mobile device app for postoperative education and self-assessment of recovery, or (2) iPad without the app. The primary outcome measure was mean adherence (%) to a bundle of five postoperative ERP elements requiring patient participation: mobilization, gastrointestinal motility stimulation, breathing exercises, and consumption of oral liquids and nutritional drinks. Results: In the intervention group, app usage was high (94% completed surveys on POD0, 82% on POD1, 72% on POD2). Mean overall adherence to the bundle on the two first postoperative days was similar between groups: 59% (95% CI 52–66%) in the intervention group and 62% (95% CI 56–68%) in the control group [Adjusted mean difference 2.4% (95% CI − 5 to 10%) p = 0.53]. Conclusions: In this randomized trial, access to a mobile health application did not improve adherence to a well-established enhanced recovery pathway in colorectal surgery patients, when compared to standard written patient education. Future research should evaluate the impact of applications integrating novel behavioral change techniques, particularly in contexts where adherence is low.