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The revolutionary concept of enhanced recovery after surgery (ERAS), recognized and proven in colonic surgery, soon caught on as an attractive proposition that translated into better and faster patient recovery after various types of surgery. As an evolving concept, it is being widely accepted, with various surgical specialties suitably adapting the guidelines for use in the perioperative setting. Identification and mitigation of risk factors in special groups of patients such as patients presenting for emergency surgery, those in the extremes of age and weight, and those with various comorbidities require additional care and investigations. The use of ERAS in emergency setting has been remarkably difficult to implement, owing to a short preoperative period, altered physiology, and unexpected postoperative outcomes. There is reluctance in the application of ERAS in emergency due to difficulty in implementing all its components, especially the preoperative components. The rapid advancements in technology and increased availability of point of care diagnostics, such as ultrasound and intraoperative electroencephalogram, and the increasing number of anesthesiologists getting trained in their usage are important factors that are positively influencing perioperative patient care in the last decade. This has led to significant developments in noninvasive and rapid methods of monitoring hemodynamics and postoperative care. This review aims to highlight the influence of newer perioperative practices that are already included or are likely to have positive impact when included in an ERAS program and provide comprehensive review on the application of ERAS in emergency setting and in various surgical specialties.

Metaplastic breast carcinoma (MBC) is a rare malignant neoplasm of the breast which is highly aggressive and is known for its early recurrence and poor prognosis. Concurrent detection of a MBC and tuberculosis of the axillary lymph node is a rarity. To the best of our knowledge, there is no such case report in the literature. A 35-year-old premenopausal woman was diagnosed as a case of left carcinoma breast with a left axillary lymph node. Core-needle biopsy of the breast was suggestive of squamous cell carcinoma. The patient underwent modified radical mastectomy with a latissimus dorsi myocutaneous flap. The postoperative biopsy of the breast and axilla revealed MBC and tuberculous lymphadenitis of the axillary lymph node. The patient received antitubercular therapy and radiotherapy, followed by chemotherapy and had no recurrence on follow-up. This case report emphasizes that metaplastic carcinoma breast can coexist with tuberculous axillary lymphadenopathy.

Primary malignant tumors of the spine are rare and most commonly occur in lumbar and thoracic vertebrae. We report a rare case of retroperitoneal chondrosarcoma of L3 that was managed with sagittal en bloc spondylectomy following chemoradiation. A 26-year-old woman was evaluated for abdominal pain with contrast-enhanced computed tomography of the abdomen and pelvis, which revealed a soft tissue retroperitoneal mass arising from L3. She underwent laparotomy and biopsy, which revealed chondrosarcoma, and she received chemoradiation over a period of 28 weeks 6 days. After repeat imaging, she underwent single-stage combined approach sagittal en bloc spondylectomy of retroperitoneal chondrosarcoma of L3 with right nephrectomy and spine reconstruction. At 3-year follow-up, there was no evidence of recurrence on contrast-enhanced computed tomography of the abdomen and pelvis. She demonstrated no gait abnormality or spinal deformity. Sagittal en bloc spondylectomy is a preferred surgical approach for eccentrically placed spinal tumors that offers better oncological and functional outcomes. [ABSTRACT FROM AUTHOR]

Medical sciences and technology have grown exponentially over the past many decades. The doubling time of medical knowledge and technology has shortened from 50 years in the 1950s to just 73 days in 2020. The field of surgical oncology has progressed from open surgery to minimally invasive surgery (MIS). The revolutionary robotic technology has disrupted the space of MIS, with the added promise of better postoperative recovery and improved functional outcomes. This is largely due to reduced pain, fewer infections, lesser blood loss, shorter hospital stay, less scarring, and faster return to normal activities. It is noteworthy that better functional outcomes have been achieved without compromising the oncological principles, as endorsed by multiple studies that have demonstrated the safety, feasibility, and potential short-term advantages of the robotic platforms in surgical oncology. Although robotic surgeries are well established in high-income countries, their use in the low- and middle-income countries (LMICs) is scarce. Overwhelming issues pertaining to cancer care in the LMICs are advanced-stage presentation, barriers of affordability and access, and heterogeneity in the quality of cancer care, among others; hence, advancing the scope of robotics seems to be a low priority. Further, in LMICs, robotic surgeries are invariably offered to affluent populations, further perpetuating the vicious cycle of socioeconomic divide. There are several other challenges to implementing robotic platforms in the LMICs. We attempt to explore the potential solutions and strategies that can be adopted and adapted to overcome these challenges. [ABSTRACT FROM AUTHOR]

Introduction: Malnutrition leads to poor outcomes in surgical patients, leading to negative impact during the postoperative period. Nutrition Risk Screening (NRS) 2002 and Subjective Global Assessment (SGA) are novel tools to assess nutrition risk which have the potential to predict the postoperative complications in surgical patients. Aim: This study was carried out to determine the efficiency of the NRS 2002 and SGA in predicting postoperative complications. Materials and Methods: A prospective cohort study was conducted to assess the nutritional risk of patients aged 18 years and above who underwent elective abdominal surgery. NRS 2002 and SGA were used for nutritional screening. Univariate analysis was carried out to determine the relative risk (RR) of complications for each variable. Receiver operating characteristic (ROC) and area under curve (AUC) were plotted for NRS 2002 and SGA to identify the score for the former and grade for the latter that predicted complications postoperatively. The correlation of malnutrition with surgical outcomes was performed to determine their association. Results: A total of 320 patients were included in the study. Among the patients who underwent elective abdominal surgeries, 39.4% of the total number developed postoperative complications. The most prevalent were Grade 2 complications, which accounted for 69.1% of all such events. Postoperative complications were recorded in 75.5% of the patients identified as at risk by NRS 2002, with a RR of 5.3 (95% confidence interval [CI]: 3.7–7.6; P < 0.001). Complications were found among 68.3% of those who were malnourished by SGA, with a RR of 4.2 (95% CI: 3.0–6.0; P < 0.001). The ROC curve for NRS 2002 to determine the complications had an AUC of 0.80. A score of 3 was the optimal cutoff of NRS 2002 for predicting complications with a maximum sensitivity of 93.6%. Similarly, the ROC curve for SGA grades to determine complications had an AUC of 0.79. Grade B was the best cutoff, with a sensitivity of 77.0%. Conclusion: Patients with NRS 2002 scores higher than or equal to 3 and SGA Grades B and above had a higher incidence of postoperative complications in patients undergoing elective abdominal surgeries. Hence, NRS 2002 and SGA are reliable nutrition risk assessment tools for predicting postoperative outcomes. [ABSTRACT FROM AUTHOR]