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Background: Surgical specialties represent the most competitive residency positions to obtain, and applicants for these spots may apply to increasingly more programs in an attempt to match. We describe trends in residency applications across all surgical specialties from 2017 to 2021 application cycles., Materials and Methods: This review of the 2017, 2018, 2019, 2020, and 2021 surgical residency application cycles used the American Association of Medical Colleges' Electronic Residency Application Service (ERAS) databases. Data from a total of 72,171 applicants to United States surgical residencies during the study's time period were included. The 2021 ERAS fee schedule was used to calculate the cost of applications., Results: The number of applicants across the study interval remains unchanged. Trends suggest more women and underrepresented minorities in medicine are applying to surgical residencies today compared to 5 years ago. The mean number of applications per applicant increased 32.0% from 39.3 in 2017 to 51.8 in 2021, resulting in an increased application fee cost of $329 per applicant. Mean total cost for application fees alone in 2021 were $1211 per applicant. In 2021, the cost of applying to surgical residency for all applicants was over $26 million, a nearly $8 million increase from 2017., Conclusions: There has been an increase in the number of applications per applicant in the past 5 residency application cycles. Increased applications create barriers and burdens for applicants, and residency program personnel. These rapid increases are unsustainable and require intervention, although a viable solution has yet to be elucidated., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Abstract To assess the impact of Enhanced Recovery After Surgery (ERAS) protocol in children undergoing corrective surgery for congenital scoliosis. A retrospective analysis was conducted on children undergoing surgical correction for congenital scoliosis, with participants categorized into either the ERAS group or the control group. Comparative evaluations were made across clinical, surgical, laboratory, and quality of life parameters. Following propensity score matching, 156 patients were analyzed. Within the initial 3 days following surgery, the ERAS cohort demonstrated lower pain intensity and exhibited higher daily oral intake compared to their counterparts in the control group. A mere 14.1% of patients in the ERAS group experienced a peak body temperature exceeding 38.5°, illustrating a significantly lower incidence compared to the 33.3% recorded in the control group. The ERAS cohort displayed expedited timeframes for the onset of initial bowel function and postoperative discharge when contrasted with the control group. Levels of IL-6 assessed on the third day post-surgery were markedly reduced in the ERAS group in comparison to the control group. Noteworthy is the similarity observed in postoperative hemoglobin and albumin levels measured on the first and third postoperative days between the two groups. Assessments of quality of life using SF-36 and SRS-22r questionnaires revealed comparable scores across all domains in the ERAS group when juxtaposed with the control cohort. ERAS protocol has demonstrated a capacity to bolster early perioperative recovery, alleviate postoperative stress responses, and uphold favorable quality of life outcomes in children undergoing corrective surgery for congenital scoliosis.

Abstract Background Effects of preoperative drinks on muscle metabolism are unclear despite general recommendations. The aim of the present study was therefore to compare metabolic effects of a preoperative oral nutrition drink, recommended by protocols for enhanced recovery after surgery (ERAS), compared to overnight preoperative peripheral total parenteral nutrition (PPN) on skeletal muscle metabolism in patients aimed at major gastrointestinal cancer surgery. Methods Patients were randomized, based on diagnosis and clinical characteristics, to receive either a commercial carbohydrate-rich nutrition drink (Drink); or overnight (12 h) peripheral parenteral nutrition (PPN) as study regimens; compared to isotone Ringer-acetate as Control regimen. Arterial blood- and abdominal muscle tissue specimens were collected at start of surgery. Blood chemistry included substrate- and hormone concentrations. Muscle mRNA transcript analyses were performed by microarray and evaluated for changes in gene activities by Gene Ontology algorithms. Results Patient groups were comparable in all measured preoperative assessments. The Nutrition Drink had significant metabolic alterations on muscle glucose metabolism (p

Introduction. Implementation of enhanced recovery after surgery protocol (ERAS) is becoming more and more widespread due to their effectiveness and safety. At the same time, there is a rather limited number of studies focusing on the opportunities of ERAS in the context of its association with metabolic syndrome in patients with colorectal cancer. This study represents the results of our early experience implementing elements of the ERAS program in the perioperative management of patients with colorectal cancer associated with metabolic syndrome. The aim. To conduct a comparative analysis and evaluate the results of surgical treatment using the enhanced recovery after surgery protocol in patients with colorectal cancer and accompanying metabolic syndrome. Materials and methods. This study included 106 patients with colorectal cancer and accompanying metabolic syndrome, divided into two groups: the first group with the use of elements of the ERAS protocol in colorectal surgery from 2018 – 56 patients, and the second group in which the principles of ERAS were not used (50 patients). Results. In the first group, with a statistically significant difference, a less severe pain syndrome was observed according to VAS (p

Background: Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative complications and promote earlier recovery. Although it is well established in noncardiac surgery fields, the ERAS approach has only recently been adopted in cardiac surgery. The aim of this review is to evaluate the status and implementation of ERAS protocols in patients undergoing heart valve surgery and to summarise associated clinical results. Methods: A literature search for the period January 2015 and January 2024 was performed through online databases. Clinical studies (randomised controlled trials and cohort studies) on patients undergoing heart valve surgical procedures and comparing ERAS and conventional approaches were included. The data extracted covered studies and populations characteristics, early outcomes and the features of each ERAS protocol. Results: There were 14 studies that fulfilled the final search criteria and were ultimately included in the review. Overall, 5142 patients were identified in the 14 studies, with 2501 in ERAS groups and 2641 patients who were representative of control groups. Seven experiences exclusively included patients who underwent heart valve surgery. Twelve out of fourteen protocols involved multiple interventions from the preoperative to postoperative phase, while two studies reported actions limited to intraoperative and postoperative care. We found high heterogeneity among the included protocols regarding key actions targeted for improvement and measured outcomes. All the studies showed that ERAS pathways can be safely adopted in cardiac surgery and in most of the experiences were associated with shorter mechanical ventilation time, reduced postoperative opioid use and reduced ICU and hospital stays. Conclusions: As demonstrated in noncardiac surgery, the adoption of structured ERAS protocols has the potential to improve results in patients undergoing heart valve surgery. Further evidence based on larger populations is needed, including more homogenous pathways and reporting further outcomes in terms of patient satisfaction, recovery and quality of life after surgery.

The introduction of minimally invasive surgery ushered in a new era of spine surgery by minimizing the undue iatrogenic injury, recovery time, and blood loss, among other complications, of traditional open procedures. Over time, technological advancements have further refined the care of the operative minimally invasive spine patient. Moreover, pre-, and postoperative care have also undergone significant change by way of artificial intelligence risk stratification, advanced imaging for surgical planning and patient selection, postoperative recovery pathways, and digital health solutions. Despite these advancements, challenges persist necessitating ongoing research and collaboration to further optimize patient care in minimally invasive spine surgery.

This article aims to present cryoanalgesia as an inventive strategy for pain alleviation among pediatric patients. It underlines the tremendous need to align pain management with the principles of the enhanced recovery after surgery (ERAS) approach. The aim of the study was to review the patient outcomes of nerve cryoanalgesia during surgery reported with regard to ERAS in the literature. The literature search was performed using PubMed and Embase to identify articles on the use of cryoanalgesia in children. It excluded editorials, reviews, meta-analyses, and non-English articles. The analysis focused on the study methods, data analysis, patient selection, and patient follow-up. This review includes a total of 25 articles. Three of the articles report the results of cryoanalgesia implemented in ERAS protocol in children. The research outcome indicates shortened hospital stay, potential reduction in opioid dosage, and significant progress in physical rehabilitation. This paper also describes the first intraoperative utilization of intercostal nerve cryoanalgesia during the Nuss procedure in Poland, highlighting its effectiveness in pain management. Adding the cryoanalgesia procedure to multimodal analgesia protocol may facilitate the implementation of the ERAS protocol in pediatric patients.

Abstract Background and Aims With advancements in imaging and microelectrode recording techniques, general anesthesia (GA) has emerged as an alternative option for Parkinson's disease (PD) patients undergoing subthalamic nucleus deep brain stimulation (STN‐DBS). In this study, we compared the advantages and disadvantages of using GA and local anesthesia for STN‐DBS in enhanced recovery after surgery (ERAS). Methods Surgical outcomes of STN‐DBS were evaluated using the unified PD rating scales (UPDRS). CT and magnetic resonance imaging scans are used to evaluate intracranial conditions. State‐trait anxiety inventory and hospital anxiety and depression scale are used to evaluate patients' perioperative psychology. Results Anesthesia method does not significantly impact the accuracy of microelectrode placement or the improvement of postoperative symptoms. However, the local anesthesia group had a higher incidence of intracranial air, as well as higher rates of postoperative complications such as headache, dizziness, vomiting, and delirium. GA effectively alleviated preoperative anxiety and resulted in lower levels of perioperative anxiety and psychological stress compared to local anesthesia. Additionally, the GA group had shorter surgery duration, earlier ambulation, and a shorter average hospital stay. Conclusion DBS under GA is safe and effective. Due to shorter surgical duration, reduced occurrence of perioperative complications, effective reduction of preoperative anxiety, and faster postoperative recovery, DBS under GA is better aligned with the concept of ERAS.

Background: ERAS® (Enhanced Recovery after Surgery) is an evidence-based multidisciplinary approach focusing on optimizing outcomes after surgery through structured clinical pathways. This study aimed to assess patient-reported outcome and experience measures (PROM/PREM), which are not routinely assessed after liver surgery within an ERAS® protocol. Methods: Routine outcome parameters were extracted from clinical documentation. Using qualitative content analysis, PROM and PREM were retrospectively identified in 13 case records. In a prospective survey of 10 participants, PROM was assessed at three timepoints using the EQ-5D-5L questionnaire. PREM were collected at discharge. Results: The following PROM categories occurred in the retrospective content analysis: appetite (84.6%), pain/discomfort (76.9%), mobility (69.2%), wound condition (69.2%), and weight (61.5%). The categories of continuity of care (92.0%) and information, communication, education (69.0%) emerged as PREM. Descriptive changes in health state were shown for all EQ-5D-5L dimensions and timepoints. At discharge, mobility, selfcare, usual activities, and pain/discomfort tended to be worse, whereas anxiety/depression decreased gradually from preoperatively to the 4 week follow-up. There was high satisfaction with interprofessional care services and experienced cooperation between professionals. Conclusions: PROM and PREM are helpful to incorporate patients’ perspectives after liver surgery within an ERAS® pathway and should be collected routinely in clinical practice.

The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the “Environmental context and resources” domain (57.6%, 95%CI: 49.5–65.4), e.g., lack of professionals, funding, and coordination, and the “Knowledge” domain (52.8%, 95%CI: 44.7–60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS.

Objective:The enhanced recovery after surgery protocol has been applied more frequently in cesarean surgeries, and regional anesthesia is the first choice because of its postoperative advantages. Hypotension and bradycardia are common side effects of spinal anesthesia. Bezold Jarisch reflex, which occurs by the stimulation of 5-HT3 receptors, is thought to be effective. This study was planned as a prospective randomized study to investigate the effect of ondansetron, a 5-HT3 receptor antagonist, on hemodynamics in pregnant women undergoing cesarean section under spinal anesthesia.Method:Seventy-eight pregnant women scheduled for elective cesarean section with spinal anesthesia were included in the study. Patients were randomly divided into two groups; group 1 (n=38) received ondansetron 4 mg intravenously before spinal anesthesia, and group 2 (n=40) did not receive ondansetron. Blood pressure, peak heart rate, and vasopressor requirements were evaluated in both groups.Results:The reductions in the mean arterial pressure were significantly lower in group 2 than in group 1 at 2 and 4 minutes (p

This study focuses on a correspondence between the surgeon, Fedor Krause (1857 – 1937), and the neurologist, Arthur Simons (1877 – 1942), who specialized in muscle neurology. The correspondence shows many interesting aspects of surgery at the time of World War I. It is especially remarkable that the important surgeon, August Bier (1861 – 1949), is criticized in this correspondence. One major problem of German surgery at the beginning of the 20th century was the fact that patients often were not mobilized sufficiently and instead, unnecessarily were told to stay in bed (“Bettruhe”) for many weeks, and in many cases, patients also were unnecessarily told to move as little as possible. Even giving massages was considered harmful. This is in contrast to today’s principle of early mobility (ERAS). The correspondence between these two scholars clearly indicates that these wrong principles were propagated by certain important surgeons in Germany (like August Bier) and that these principles were rather based on their personal opinions than on scientific evidence. More than 100 years ago, there were already some physicians, like Arthur Simons or Fedor Krause, who openly criticized these wrong approaches in German surgery.

Modified electroconvulsive therapy （MECT） is an improved treatment for mental disorders by delivering a proper dose of intravenous anesthetics and muscle relaxants based on traditional electroconvulsive therapy. An increasing number of patients receive MECT at a younger age. Frequent MECT may cause intense psychological stress to the patients. Enhanced recovery after surgery （ERAS） can accelerate postoperative recovery by optimizing perioperative management interventions, mitigating stress response and lowering the risk of postoperative complications. ERAS concept emphasizes multidisciplinary collaboration. In recent years,this concept has been promoted and applied in a variety of surgical procedures. However, the application of ERAS in MECT has been rarely studied. In this article, the management measures and operation procedures of ERAS in MECT were summarized, aiming to provide reference for the standardized implementation of ERAS in MECT.

Objective: Among the already difficult management of neuro-oncological patients, the elderly population remains vulnerable. Because of the pathology and the comorbidities, they present a significantly higher rate of medical issues related to surgical management. Despite this, the surgical option, if feasible, remains the gold standard in these patients, and an Enhanced Recovery After Surgery (ERAS) protocol could improve the postoperative safety of the patients. With this purpose, we prepared this study with the aim of defining the postoperative hospital length of stay (LOS), but also of evaluating the postoperative morbidity, perioperative complications, and postoperative pain scores. Methods: This was a retrospective, single-cohort study performed at an academic hospital (Department of Neurosurgery, Neurocenter of South Switzerland, Switzerland) on elderly patients who underwent craniotomy for glioblastoma. Patients were enrolled in a novel ERAS protocol from January 2022 to December 2022. Since this is a feasibility study and a direct comparison was not possible, we used a historical cohort of elderly patients who had undergone elective craniotomy surgery for glioblastoma as a control group. Results: A total of 19 patients treated in our center for glioblastoma multiforme (GBM) who were aged over 75 years were included in this study. Among those, seven were newly recruited patients included in the ERAS protocol, while the remaining twelve were part of a historical cohort of previously treated patients. From a statistical point of view, the two cohorts were comparable in terms of baseline demographics. In the follow-up, it was shown that in the ERAS group, there was a reduction in the use of opioids after the surgical procedures that could be seen at 30 days (36.2% vs. 71.7%, p < 0.001), but also at 3 months, after surgery (33.0% vs. 80.0%, p < 0.001). A significant difference has also been documented in terms of mobilization and ambulation: compared to the historical cohort, in the ERAS group, there was a higher rate of mobilization (60.0% vs. 10.0%, p < 0.001), but also of ambulation (36.1% vs. 10.0%, p < 0.001). Conclusions: The ERAS protocol for the management of glioblastoma in elderly patients seems to be an effective option for reducing LOS in the hospital, as well as for reducing the number of days spent in the ICU, improving the general recovery of the patient, and reducing the costs associated with hospitalization.

Background: Preoperative fasting and surgery cause metabolic stress, insulin resistance with ketosis, and postoperative nausea and vomiting (PONV). Oral carbohydrate loading strategy (CHO) improves outcomes in labor and general surgery. We aimed to compare the effectiveness of CHO with standard fasting in patients undergoing elective cesarean delivery (CD) under spinal anesthesia. Methods: A single-center, parallel, prospective randomized controlled trial (RCT) was conducted in a tertiary university obstetrics department at Pomeranian Medical University in Szczecin, Poland. Patients were randomly assigned (1:1 ratio) to the CHO group (oral carbohydrate 2 h before elective CD, n = 75) or the SF group (control—standard fasting, n = 73). The main outcome measures were incidence and severity of PONV at 6 and 24 h after CD, time to the first peristalsis, time to first bowel movement, and biochemical parameters indicating ketosis in mothers and their children. Results: A total of 148 adult females with singleton pregnancies undergoing elective CD under spinal anesthesia (ASA I and II) were included in the final analysis. At 24 h after CD, 8.0% from the CHO group vs. 20.55% reported three or more episodes of vomiting or dry retching as compared to patients in the SF group (p = 0.041). Preoperative CHO supplementation decreased preoperative feelings of hunger (p < 0.001) and thirst (p < 0.001). Laboratory results in the CHO group showed higher plasma pH (p = 0.001) and glucose (p < 0.001), lower F2-isoprostane in plasma (p = 0.049) and urine (p = 0.018), lower urine F2-isoprostane/creatinine ratio (p = 0.045) than in the SF group. HOMA-IR (p < 0.001) and lactate (p < 0.001) were higher in the CHO group than in the control group. Conclusions: There was no significant difference in the incidence or severity of early PONV at 6 h. The incidence of vomiting or dry retching at 24 h after cesarean delivery was lower in the CHO group as compared to standard starvation, but the combined results of PONV frequency and severity on the Wengritzky scale did not differ between the two study groups. Preoperative CHO supplementation decreased preoperative feelings of hunger and thirst, enhancing the comfort of pregnant women. Trial registration: ClinicalTrials.gov identifier: NCT04069806.

Objective: To evaluate the impact of enhanced recovery pathways (ERAS) on hospital stay and postoperative outcomes in patients undergoing minimally invasive esophagectomy in comparison to conventional pathway. Study Design: Quasi experimental study. Place and Duration of Study: Thoracic Surgery Department, Combined Military Hospital Rawalpindi Pakistan, from Jul 2018 to Mar 2020. Methodology: A total of 80 patients who underwent minimally invasive esophagectomy were divided in two groups. Group A underwent ERAS pathway and group B underwent conventional pathway. Both groups were compared for demographic characteristics, mean ICU stay, length of hospital stay, commencement of oral intake, and time of chest drain removal, readmission rates, postoperative morbidity and mortality. Results: There was no significant difference in age, gender and diagnostic indication among both groups. ERAS group was found to have shorter mean ICU stay (1.18 ± 0.55 vs 2.06 ± 1.10 days p

Postoperative cognitive dysfunction (POCD) is an event that alarms medical personnel owing to its adverse effects, including heightened morbidity and mortality rates, prolonged recovery times, and increased lengths of hospital stay and healthcare expenditure. The populations at high risk are elderly, critical patients, or complicated cases that need prolonged surgery in which the hemodynamics are not stable. Although guidelines have been established to facilitate the early diagnosis of POCD, its prevention is recommended for good patient outcomes. A preoperative assessment is a prerequisite for patient optimization before surgery. Intraoperative, enhanced-recovery protocols have been widely adopted to promote recovery following surgery. Frequent, postoperative assessments of patients’ vital signs and cognitive functions are required for early POCD detection. Patients diagnosed with POCD need regular follow-up, and proper patient counselling is paramount.

Abstract Background and Aims The shortage of beds at the maternity ward is ever increasing with an increasing trend in total birth and cesarean section deliveries thereby increasing the daily number of obstetric patients awaiting admission. This quality improvement (QI) project was conducted to mitigate the problem of bed shortage by implementing modified enhanced recovery after surgery in low‐risk cesarean section mothers. We aimed to increase the process measure of second day postoperative discharge in low‐risk cesarean section mothers admitted in the maternity ward from 0% to 25% over 2 months period. Simultaneously, the outcome measure of daily number of obstetric patients awaiting admission was assessed. Methods The study was conducted at the maternity ward, Jigme Dorji Wangchuck National Referral Hospital, Thimphu Bhutan. Fishbone analysis was used to analyze problems leading to delayed discharge. Interventions were discussed, implemented, and reviewed using Plan, Do, Study, and Act (PDSA) cycle over 8 week period from June 1 to July 31, 2021. Data were collected using the EXCEL sheet and analyzed using STATA 13. Process and outcome measures during the pre and postintervention period were analyzed. Descriptive statistics were used to express the results. Wilcoxon Signed‐Rank test was used to determine the statistical significance at p

Background: Robotic surgery and ERAS protocol care are both prominent developments and have each become global trends. However, the effects and learning curves of combining robotic surgery and ERAS care in colorectal resection have not yet been well validated. This study aimed to present our real-world experience and establish the learning curves necessary for the implementation of an ERAS program in minimally-invasive surgery for colorectal resection, while also evaluating the impact that the development of the robotic technique has on ERAS outcomes. Methods: A total of 155 patients who received elective, minimally-invasive surgery, including laparoscopic and robotic surgery for colorectal resection, with ERAS care during the period June 2019 to September 2021 were included in this retrospective analysis. Patients were divided chronologically into five groups (31 cases per quintile). Patient demographics, tumor characteristics, perioperative data, ERAS compliance, and surgical outcomes were all compared among the quintiles. Learning curves were evaluated based on ERAS compliance and optimal recovery, which are composed of an absence of major complications, postoperative length of stay (LOS) of no more than five days, and no readmission within 30 days. A multivariable logistic regression model was used to assess factors associated with postoperative LOS. Results: There were no statistically significant differences seen overall or between the quintile groups in regards to demographic and tumor characteristic parameters. A total of 79 patients (51%) received robotic surgery, with the ratio of robotic groups rising chronologically from zero in the first quintile to 90.3% in the fifth quintile (p < 0.001). The median compliance rate of total ERAS protocol was 83.3% overall, 72.2% in the first quintile and 83.3% in the 2nd–5th quintiles (p < 0.001). A total of 85 patients underwent optimal recovery after surgery, four patients in the first quintile, 11 patients in the second quintile, and 21, 24, 25 patients in the 3rd–5th quintiles respectively (p < 0.001). There were significant improvements from early to later groups upon postoperative LOS (p < 0.001). In addition, the surgical outcomes including first oral intake within 24 hours after surgery, time to first stool and early termination of intravenous fluid administration showed significant improvement among the quintiles. A multivariable logistic regression model demonstrated that robotic surgery was superior to laparoscopic surgery upon postoperative LOS (odds ratio = 5.029, 95% confidence interval [CI] = 1.321 to 19.142; p = 0.018). Conclusions: Our experience demonstrated that an effective implementation of the ERAS program in minimally-invasive colorectal surgery requires 31 patients to accomplish the higher compliance and requires more cases to reach the maturation phase for optimal recovery. We believe that developing a robotic platform would have no impact on the learning curve of ERAS implementation. Moreover, there is a beneficial effect on the postoperative length of surgery provided through the combination of ERAS care and robotic surgery for patients undergoing colorectal resection.

Aim: This manuscript provides information on the history, principles, and clinical results of Fast-track or ERAS concepts to optimize perioperative management (OPM).Methods: With the focus on elective colorectal surgery description of the OPM concept and its elements for with special attention to the prevention of infectious complications and clinical results compared to traditional care will be given using recent systematic literature reviews. Additionally, clinical results for other major abdominal procedures are given.Results: An optimized perioperative management protocol for elective colorectal resections will currently consist of 25 perioperative elements. These elements include the time from before hospital admission (patient education, screening, and treatment of possible risk factors like anemia, malnutrition, cessation of nicotine or alcohol abuse, optimizationcurrent systemic disease, physical prehabilitation, carbohydrate loading, adequate bowel preparation) to the preoperative period (shortened fasting, non-sedative premedication, prophylaxis of PONV and thromboembolic complications), intraoperative measures (systemic antibiotic prophylaxis, standardized anesthesia, normothermia and normovolemia, minimally invasive surgery, avoidance of drains and tubes) as well as postoperative actions (early oral feeding, enforced mobilization, early removal of a urinary catheter, stimulation of intestinal propulsion, control of hyperglycemia). Most of these elements are based on high-level evidence and will also have effects on the incidence of postoperative infectious complications.Conclusion: Optimized perioperative management should be mandatory for elective surgery today as it enhances postoperative patient recovery, reduces morbidity and infectious complications.

Abstract Background Cardiac surgery is becoming increasingly common in older, more vulnerable adults. A focus on timely and complete medical and functional recovery has led to the development of enhanced recovery protocols (ERPs) for a number of surgical procedures and subspecialties, including cardiac surgery (ERAS® Cardiac). An element that is often overlooked in the development and implementation of ERPs is the involvement of key stakeholder groups, including surgery patients and caregivers (e.g., family and/or friends). The aim of this study is to describe a protocol for a scoping review of cardiac patient and caregiver preferences and outcomes relevant to cardiac surgery ERPs. Methods Using Arksey and O’Malley’s et al six-stage framework for scoping review methodologies with adaptions from Levac et al. (Represent Interv: 1–18, 2012), a scoping review of existing literature describing patient- and caregiver-identified preferences and outcomes as they relate to care received in the perioperative period of cardiac surgery will be undertaken. The search for relevant articles will be conducted using electronic databases (i.e., the Cochrane Library, Medline, PsycINFO, Scopus, and Embase), as well as through a search of the grey literature (e.g., CPG Infobase, Heart and Stroke Foundation, ProQuest Theses and Dissertations, Google Advanced, and Prospero). Published and unpublished full-text articles written in English, published after the year 2000, and that relate to the research question will be included. Central to the design of this scoping review is our collaboration with two patient partners who possess lived experience as cardiac surgery patients. Discussion This review will identify strategies that can be integrated into ERPs for cardiac surgery which align with patient- and caregiver-defined values. Broadly, it is our goal to demonstrate the added value of patient engagement in research to aid in the success of system change processes.

Drug-related problems (DRPs) are common among surgical patients, especially older patients with polypharmacy and underlying diseases. DRPs can potentially lead to morbidity, mortality, and increased treatment costs. The enhanced recovery after surgery (ERAS) system has shown great advantages in managing surgical patients. Medication therapy management for surgical patients (established as “surgical pharmacy” by Guangdong Province Pharmaceutical Association (GDPA)) is an important part of the ERAS system. Improper medication therapy management can lead to serious consequences and even death. In order to reduce DRPs further, and promote the rapid recovery of surgical patients, the need for pharmacists in the ERAS program is even more pressing. However, the medication therapy management services of surgical pharmacy and how surgical pharmacists should participate in ERAS programs are still unclear worldwide. Therefore, this article reviews the main perioperative medical management strategies and precautions from several aspects, including antimicrobial agents, antithrombotic agents, pain medication, nutritional therapy, blood glucose monitoring, blood pressure treatment, fluid management, treatment of nausea and vomiting, and management of postoperative delirium. Additionally, the way surgical pharmacists participate in perioperative medication management, and the relevant medication pathways are explored for optimizing medication therapy management services within the ERAS programs. This study will greatly assist surgical pharmacists’ work, contributing to surgeons accepting that pharmacists have an important role in the multidisciplinary team, benefitting medical workers in treating, counseling, and advocating for their patients, and further improving the effectiveness, safety and economy of medication therapy for patients and promoting patient recovery.

ABSTRAK Cardiac surgery-associated acute kidney injury (CSA-AKI) merupakan komplikasi utama dari pembedahan jantung. Salah satu kondisi yang dapat menyebabkan terjadinya CSA-AKI pada pasien bedah jantung adalah ketidakstabilan kadar glukosa darah. Protokol Enhanced Recovery After Surgery (ERAS) memaparkan pentingnya glycemia control untuk mencegah komplikasi terjadinya CSA-AKI. Artikel ini merupakan studi kasus yang menggambarkan manajemen keperawatan : glycemic control untuk mencegah terjadinya CSA-AKI pada pasien bedah jantung. Setelah dilakukan intervensi keperawatan berupa glycemia control, pasien tidak mengalami CSA-AKI. Manajemen gula darah pada melalui manajemen diet dan kolaborasi manajemen insulin merupakan rekomendasi ERAS dalam mencegah CSA-AKI pada pasien pembedahan jantung. ABSTRACT Cardiac surgery-associated acute kidney injury (CSA-AKI) is a major complication of heart surgery. One of the conditions that can cause CSA-AKI in cardiac surgery patients is the instability of blood glucose levels. The Enhanced Recovery After Surgery (ERAS) protocol explains the importance of glycemic control to prevent complications from CSA-AKI. This article is a case study describing nursing management: glycemic control to prevent CSA-AKI in cardiac surgery patients. After the nursing intervention in the form of glycemia control, the patient did not experience CSA-AKI. Blood sugar management through diet management and insulin management collaboration is ERAS recommendations in preventing CSA-AKI in cardiac surgery patients.

ERAS (Enhanced Recovery After Surgery) is a multimodal approach which aims to optimize perioperative management. ERAS is a combination of changes in preoperative, intraoperative and postoperative care to reduce organ dysfunction and surgical stress response. This concept is managed by multidisciplinary teams that include various areas of expertise to minimize the patient’s surgical stress response, optimize physiological functions, and facilitate healing. In order to further increase these developments in various surgical specialties, protocols have been established on this subject and many health institutions offer their services in this way. With the use of ERAS protocols, perioperative and postoperative complications decreased, patient survival and quality of care improved, and patient satisfaction was significantly increased.

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Objective: To evaluate the effects of mosapride, a selective 5-hydroxytryptamine-4 agonist, on gastrointestinal recovery in patients undergoing open colorectal surgery. Methods: A prospectively collected database of the patients undergoing elective ‘open’ colorectal resection under enhanced recovery after surgery (ERAS) from May 2013 to April 2017 was reviewed. From April 2016, mosparide was routinely given from postoperative day 1 to discharge date. Eighty-four patients receiving mosapride were matched to 168 control patients (historical comparison with a ratio of 1:2). Surgical outcomes and postoperative gastrointestinal recovery was compared. Results: The patient characteristics were comparable except more patients in control group had perioperative administration of NSAIDs. The mosapride group had a 1.5% higher compliance rate of ERAS protocol. The control group had higher incidences of prolonged postoperative ileus (17.3% vs 7.1%; p=0.029) and prolonged postoperative ileus requiring nasogastric tube decompression (8.9% vs 3.6%; p=0.19). Overall complication, clinical intestinal transit and length of hospitalization were not significantly different between groups. However, the patients with prolonged postoperative ileus had significantly prolonged hospitalization (p

Protocol ERAS - "Enhanced Recovery after Surgery" - is a modern multidisciplinary formula of perioperative care to improve treatment outcomes. Over the past few years, many attempts have been made to implement recommendations for the management of patients in the perioperative period. They were primarily aimed at improving the results of treatment of patients undergoing surgery, and thus shorteninglength of stay in hospital, and - as a consequence - reducing the risk of developing complications and even the number of deaths. One of the first author who noticed effectiveness of multimodal treatment for a faster recovery and a shorter stay in the hospital was Professor Henrik Kehlet from the University of Copenhagen. He emphasized that in order to understand the nature of complications occurring in patients undergoing surgery, the basis of the factors responsible for the response to the surgical trauma should be known. In the late 1990s, Kehlet postulated that steps should be taken to introduce a comprehensive program including, among others: effective anesthesia, early rehabilitation of the patient, reduction of surgical stress, or quick restoration of nutrition via the gastrointestinal tract. The comprehensive perioperative care protocol for improving the treatment results requires the need for cooperation of specialists and all medical staff related to perioperative care - not only a surgeon or anesthetist, but also a physiotherapist or dietitian.

Dos grandes cambios han mejorado los resultados anestesicoquirurgicos en los últimas décadas. La cirugía mínimamente invasiva (CMI) y la atención multidisciplinaria perioperatoria incorporando la medicina basada en la evidencia.Tradicionalmente, los cirujanos, anestesiólogos y enfermeras han prestado atención a las experiencias individuales. Las vías de recuperación mejorada “ERAS” por sus siglas en ingles (Enhanced Recovery After Surgery) representan un cambio paradigmático de la atención tradicional, buscando integrar múltiples elementos individuales de la atención perioperatoria, así como el compromiso de los pacientes y cuidadores para comprender mejor el proceso de recuperación. Al aprovechar los logros alcanzados por las técnicas de CMI con las vías ERAS, el objetivo fue mejorar aún más la recuperación, disminuir las complicaciones y disminuir la variabilidad en la práctica, lo que a su vez se reflejaría en una internación más corta y con menos costos asistenciales. El desarrollo de la vía de recuperación mejorada no consiste en crear nuevas hipótesis para una mejor atención, sino más bien en la organización de la mejor evidencia científica disponible, que ayude a estandarizar la atención a través de una práctica, institución o sociedad profesional. En la siguiente revisión bibliográfica, buscamos el enfoque desde el punto de vista de la cirugía pediátrica, la cual presenta cada vez mas interés en esta modalidad de atención.

Enhanced recovery after surgery protocols have shown improved clinical outcomes after lung resection surgery, but their application after empyema surgery is still limited. We retrospectively evaluated the outcomes of an adapted enhanced recovery after surgery (ERAS) protocol for immunocompromised patients who underwent video-assisted thoracoscopic surgery (VATS) surgery for chronic empyema between December 2013 and December 2021. The patients were divided into an ERAS group and a conventional treatment group. Peri-operative data were collected and compared between the two groups. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative pain and post-operative complications (air leaks, atelectasis). A total of 86 patients, 45 in the ERAS group and 41 in the non-ERAS group, were considered. Chest tube duration (6.4 ± 2.3 vs. 13.6 ± 6.8 days) and post-operative length of stay (7.6 ± 1.6 vs. 16.9 ± 6.9 days) were significantly shorter in the ERAS group. The volume of chest drainage (103 ± 78 vs. 157 ± 89 mL/day) was significantly smaller in the ERAS group. There were no significant differences in operative time, blood loss, need for transfusion, tube reinsertion and median VAS score. The incidence of air leaks and atelectasis was significantly reduced in the ERAS group, as was the need for bronchoscopic aspiration. The application of an ERAS protocol after empyema VATS surgery for immunocompromised patients improved the surgical outcome, reducing the post-operative length of stay and rate of complications.

Enhanced recovery after surgery (ERAS) aims to improve patient outcomes by controlling specific aspects of perioperative care. The concept was introduced in 1997 by Henrik Kehlet, who suggested that while minor changes in perioperative practise have no significant impact alone, incorporating multiple changes could drastically improve outcomes. Since 1997, significant advancements have been made through the foundation of the ERAS Society, responsible for creating consensus guidelines on the implementation of enhanced recovery pathways. ERAS reduces length of stay by an average of 2.35 days and healthcare costs by $639.06 per patient, as identified in a 2020 meta-analysis of ERAS across multiple surgical subspecialties. Carbohydrate loading, bowel preparation and patient education in the pre-operative phase, goal-directed fluid therapy in the intra-operative phase, and early mobilisation and enteral nutrition in the post-operative phase are some of the interventions that are commonly implemented in ERAS protocols. While many specialties have been quick to incorporate ERAS, uptake has been slow in the transplantation field, leading to a scarcity of literature. Recent studies reported a 47% reduction in length of hospital stay (LOS) in liver transplantation patients treated with ERAS, while progress in kidney transplantation focuses on pain management and its incorporation into enhanced recovery protocols.

Aim of the study : An ERAS protocol provides the latest perioperative care principles, whose primary aim is to reduce complication rates, and therefore mortality. The aim of this study is to establish the progress of the ERAS pathway implementation in our gynaecology department. Material and methods : This was a retrospective analysis of two sets of 100 consecutive medical records: patients treated before (PRE-ERAS) and after (ERAS) introduction of the ERAS protocol. All patients were comparable and all underwent major gynaecological surgery. Patients as well as medical and nursing staff were informed about the proposed preparation, surgical management and postoperative routine. Results and conclusions : Patients were given supper and drank water during the night. Laparoscopic surgery was used in 44% and spinal anaesthesia was given for open surgery in 43 study patients. Use of drains was reduced only by 23%, bowel preparation by 15%. Intravenous fluid administration was reduced by 22%. Use of postoperative morphine was minimised to 12 patients. Postoperative nausea was managed with the regular use of anti-emetics. Anti-coagulation was given to 80% of the study group. Difficulties in the introduction of the ERAS protocol were due to refusal by some patients to mobilise and eat early postoperatively. Patients in the ERAS programme group were discharged earlier. Further information about the ERAS protocol in the media would facilitate patients’ education among conservative society. In order to introduce new and innovative treatment methods, one has to take into account the cultural and ideological factors, especially when patient involvement is essential.

To obtain a residency match, medical students entering emergency medicine (EM) must complete away rotations, submit a number of lengthy applications, and travel to multiple programs to interview. The expenses incurred acquiring this residency position are burdensome, but there is little specialty-specific data estimating it. We sought to quantify the actual cost spent by medical students applying to EM residency programs by surveying students as they attended a residency interview. Researchers created a 16-item survey, which asked about the time and monetary costs associated with the entire EM residency application process. Applicants chosen to interview for an EM residency position at our institution were invited to complete the survey during their interview day. In total, 66 out of a possible 81 residency applicants (an 81% response rate) completed our survey. The “average applicant” who interviewed at our residency program for the 2015-16 cycle completed 1.6 away, or “audition,” rotations, each costing an average of $1,065 to complete. This “average applicant” applied to 42.8 programs, and then attended 13.7 interviews. The cost of interviewing at our program averaged $342 and in total, an average of $8,312 would be spent in the pursuit of an EM residency. Due to multiple factors, the costs of securing an EM residency spot can be expensive. By understanding the components that are driving this trend, we hope that the academic EM community can explore avenues to help curtail these costs.

Background: Total hip arthroplasty combined with the concept of enhanced recovery is of continued worldwide interest, as it is reported to improve early functional outcome and treatment quality without increasing complications. The aim of the study was to investigate functional outcome and quality of life 4 weeks and 12 months after cementless total hip arthroplasty in combination with an enhanced recovery concept. Methods: A total of 109 patients underwent primary cementless Total Hip Arthroplasty (THA) in an enhanced recovery concept and were retrospectively analyzed. After 4 weeks and 12 months, clinical examination was analyzed regarding function, pain and satisfaction; results were evaluated using Harris Hip score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EQ-5D-5L, EQ-VAS and subjective patient-related outcome measures (PROMs). Preoperatively, HADS (Hospital Anxiety and Depression Scale) was collected. A correlation analysis of age, American Society of Anesthesiologists (ASA), HADS and comorbidities (diabetes mellitus, art. hypertension, cardiovascular disease) with WOMAC, Harris Hip score (HHS) and EQ-5D was performed. Results: Patients showed a significant improvement in Harris Hip score 4 weeks and 12 months postoperatively (p < 0.001). WOMAC total score, subscale pain, subscale stiffness and subscale function improved significantly from preoperative to 12 months postoperative (p < 0.001). EQ-5D showed a significant improvement preoperative to postoperative (p < 0.001). The influence of anxiety or depression (HADS-A or HADS-D) on functional outcome could not be determined. There was a high patient satisfaction postoperatively, and almost 100% of patients would choose enhanced recovery surgery again. Conclusion: Cementless THA with the concept of enhanced recovery improves early clinical function and quality of life. PROMs showed a continuous improvement over a follow-up of 12 months after surgery. PROMs can help patients and surgeons to modify expectations and improve patient satisfaction.

Immunonutrition (IN) appears to reduce infective complications and in-hospital length of stay (LOS) after major gastrointestinal surgery, but its use in normo-nourished patients is still controversial. The primary aim of this comparative observational study was to evaluate if pre-operative IN reduces in-hospital stay in patients undergoing laparoscopic colorectal resection for cancer under an enhanced recovery after surgery (ERAS) program. The influence of IN on time to first bowel movements, time to full oral diet tolerance, number and type of complications, reasons of prolonged LOS and readmission rate was evaluated as secondary outcome. Patients undergoing ERAS laparoscopic colorectal resection between December 2016 and December 2019 were reviewed. Patients who have received preoperative IN (group A) were compared to those receiving standard dietary advice (group B). Mean in-hospital LOS was significantly shorter in patients receiving preoperative IN than standard dietary advice (4.85 ± 2.25 days vs. 6.06 ± 3.95 days; p < 0.0492). No differences in secondary outcomes were observed. Preoperative IN associated with ERAS protocol in normo-nourished patients undergoing laparoscopic colorectal cancer resection seems to reduce LOS.

Prohibitin 2 (PHB2), an inner mitochondrial membrane (IMM) protein, has recently been identified as a novel receptor involved in parkin-mediated mitophagy. In the field of veterinary medicine, the role of PHB2 in parkin-mediated mitophagy was described, for the first time, in urothelial cells of cattle, naturally infected with bovine papillomavirus (BPV). The BPV2 and BPV13 E5 oncoprotein, responsible for abortive infections in urothelial cells, was detected by RT-PCR. Severe ultrastructural abnormalities of the inner mitochondrial membrane were detected using transmission electron microscopy. PHB2 formed a functional complex with PHB1. PHB2 was significantly overexpressed in mitochondrial fractions from urothelial mucosa samples taken from cattle harbouring BPV infection. PHB2 overexpression could be attributed to mitochondrial dysfunction, as its expression levels in the cytosolic, microsomal, and nuclear fractions were seen to be unmodified. Immunoprecipitation studies revealed the interaction between PHB2 and phosphorylated forms of both PINK1 and parkin. Furthermore, PHB2 interacted with LC3-II, a marker of autophagosomal membranes and autophagy receptors, such as p62 and optineurin. PHB2 was shown to interact with transcription factor EB (TFEB), which is activated following parkin-mediated mitophagy, and embryonic stem cell-expressed Ras (ERAS), a constitutive protein coded by ERas. Western blot analysis revealed a significant overexpression of unphosphorylated TFEB in mitochondrial and nuclear fractions from urothelial mucosa samples from cattle suffering from BPV infection. Finally, PHB2 interacted with ERAS, believed to be involved in mitophagosome maturation. Taken together, the molecular and ultrastructural findings of this study suggested that BPV infection is responsible for parkin-dependent mitophagy, in the pathway of which PHB2 plays a crucial role.

Objectives: We aimed to assess the surgical outcomes associated with the introduction of a dedicated colorectal service and newlyimplemented enhanced recovery after surgery (ERAS) programme at Logan Hospital.Methods: A prospective database was created to include all patients admitted to Logan hospital for colorectal resections after theestablishment of a dedicated colorectal service with two colorectal surgical society of Australia and New Zealand (CSSANZ) trainedcolorectal surgeons and an ERAS programme. The demographics, pathology and surgical outcomes in this patient group were comparedto a historical retrospective patient cohort from the same hospital with resections performed by general surgeons prior tothe introduction of the ERAS programme. Primary outcomes included the length of stay, readmission rate, morbidity and mortality.Results: The prospective database included patients from February to November 2015 with a minimum 30 day follow-up (n = 72).The retrospective patient cohort was from January to December 2012 (n = 68). The average length of stay (LOS) reduced from 10.85days to 5.74 days (P = 0.037). Thirty day readmission rates decreased from 7.35% to 4.17% (P = 0.485). Morbidity reduced from 41.18% to11.11% (P < 0.001). Mortality rates of 2.94% pre ERAS and nil post (P = 0.234). Demographic information, co-morbidities and pathologywere comparable.Conclusions: Our results suggest that a dedicated colorectal service with an ERAS program is able to improve surgical outcomesincluding length of stay, morbidity and mortality. This is in keeping with existing international literature.