Enhanced Recovery

RCT: Avoiding Prophylactic Drain Increases Postoperative Invasive Procedures After Gastrectomy

25 Dec, 2024 | 12:47h | UTC

Background: Prophylactic abdominal drainage following gastrectomy for gastric cancer has been debated for decades. While some Enhanced Recovery After Surgery (ERAS) guidelines discourage routine drains, many surgeons still advocate their use to detect and manage intra-abdominal collections before they become severe. Previous trials were small and underpowered, thus failing to provide robust evidence regarding the real need for prophylactic drains.

Objective: To determine whether omitting a prophylactic drain in gastric cancer surgery leads to a higher likelihood of postoperative invasive procedures (reoperation or percutaneous drainage) within 30 days.

Methods: In this multicenter randomized clinical trial, 404 patients from 11 Italian centers were randomly assigned to either prophylactic drain placement or no drain at the end of subtotal or total gastrectomy. Both academic and community hospitals participated. The primary composite outcome was the rate of reoperation or percutaneous drainage within 30 postoperative days, analyzed via a modified intention-to-treat approach. Secondary endpoints included overall morbidity, anastomotic leaks, length of hospital stay, and 90-day mortality. A parallel invited commentary addressed methodological and clinical perspectives.

Results: Among the 390 patients who underwent resection, 196 had a prophylactic drain and 194 did not. By postoperative day 30, 7.7% of patients in the drain group required reoperation or percutaneous drainage, compared with 15% in the no-drain group. This statistically significant difference was driven by a higher reoperation rate in patients without drains. Both groups had similar anastomotic leak rates (approximately 4% overall). However, patients without prophylactic drains had a higher in-hospital mortality (4.6% vs 0.5%) and were more likely to require escalation of care. There were few drain-related complications, indicating a low risk associated with drain placement. Length of hospital stay and readmission rates were comparable between groups.

Conclusions: Omitting prophylactic drains in gastrectomy was associated with an increased need for postoperative invasive interventions, particularly reoperations. While prior guidelines have recommended against routine drain placement, these findings challenge that stance for total and even subtotal gastrectomies. Surgeons may wish to revisit existing protocols, especially in facilities with fewer resources or lower patient volumes, given the potential reduction in reoperation risk associated with prophylactic drainage.

Implications for Practice: Clinicians should carefully balance possible benefits (earlier detection of fluid collections and reduced reoperations) against potential drawbacks of drain usage. Routine placement may be reconsidered, at least in higher-risk cases or in institutions less equipped for complex salvage procedures.

Study Strengths and Limitations: Key strengths include its robust sample size and standardized criteria for complications. Limitations involve the unblinded nature of postoperative management and the lack of drain fluid amylase measurements to guide removal protocols. Additionally, differentiating total from subtotal gastrectomies might refine selection criteria for prophylactic drainage.

Future Research: Further studies could focus on stratified risk profiles for total vs subtotal gastrectomy and on biomarkers in drain fluid to identify subgroups most likely to benefit from prophylactic drainage.

Reference:
Weindelmayer J, Mengardo V, Ascari F, et al. Prophylactic Drain Placement and Postoperative Invasive Procedures After Gastrectomy: The Abdominal Drain After Gastrectomy (ADIGE) Randomized Clinical Trial. JAMA Surg. Published online November 27, 2024. doi: http://doi.org/10.1001/jamasurg.2024.5227

Invited Commentary: Coffey MR, Lambert KE, Strong VE. Refrain From the Drain? The ADIGE Trial Brings Gastrectomy to the Debate. JAMA Surg. Published online November 27, 2024. doi: http://doi.org/10.1001/jamasurg.2024.5228

2025 ASA Practice Advisory for the Perioperative Care of Older Adults Undergoing Inpatient Surgery

23 Dec, 2024 | 20:27h | UTC

Introduction: This summary outlines the American Society of Anesthesiologists (ASA) 2025 advisory on optimizing perioperative care for older adults (age 65 years or older) undergoing inpatient surgery. It focuses on preoperative, intraoperative, and postoperative measures to mitigate cognitive complications, especially delirium and longer-term cognitive decline, in a population that is highly vulnerable to functional deterioration and loss of independence. The recommendations are based on systematic reviews and meta-analyses, supplemented by expert consensus where evidence is limited. Although not intended as strict standards of care, these advisory statements provide practical guidance that can be adapted to local contexts and patient-specific needs.

Key Recommendations:

Expanded Preoperative Evaluation:
- Incorporate frailty assessment, cognitive screening, and psychosocial or nutritional evaluations into routine preoperative workups for older patients.
- Patients identified with frailty or cognitive deficits should receive targeted interventions, such as geriatric co-management, deprescribing when indicated, and early family education about delirium risks.
- Evidence suggests a modest decrease in postoperative delirium when such evaluations are included.
Choice of Primary Anesthetic (Neuraxial vs. General):
- Current studies do not demonstrate a clear advantage of neuraxial over general anesthesia in reducing postoperative delirium risk.
- Both approaches are acceptable; individualize decisions based on patient factors, surgical requirements, and preference-sensitive discussions.
Maintenance of General Anesthesia (Total Intravenous vs. Inhaled Agents):
- Data are inconclusive regarding delirium prevention, with no significant difference between total intravenous anesthesia (TIVA) and inhaled volatile agents.
- Some low-level evidence indicates TIVA might reduce short-term cognitive decline, but this effect is inconsistent over longer follow-up.
Dexmedetomidine for Delirium Prophylaxis:
- Moderate-level evidence supports dexmedetomidine for reducing delirium incidence in older patients, yet its use may increase bradycardia and hypotension.
- Optimal dosing and timing remain uncertain, and baseline patient vulnerability should inform decisions.
Medications with Potential Central Nervous System Effects:
- Drugs such as benzodiazepines, antipsychotics, anticholinergics, ketamine, and gabapentinoids warrant careful risk-benefit analysis.
- Current findings are inconclusive, suggesting neither a firm endorsement nor outright disapproval; preexisting conditions and polypharmacy should guide individualized treatment plans.

Conclusion: Preserving cognitive function and independence in older adults undergoing inpatient surgery is a growing priority. These recommendations highlight the importance of comprehensive preoperative screenings (frailty, cognition, and psychosocial domains), shared decision-making when choosing anesthetic techniques, and thoughtful use of pharmacologic agents. While dexmedetomidine shows promise in mitigating delirium, vigilance regarding hypotension and bradycardia is essential. Ultimately, these strategies aim to reduce anesthesia-related complications in older patients by addressing the multifaceted determinants of postoperative cognitive outcomes.

Reference: Sieber F, McIsaac DI, Deiner S, et al. 2025 American Society of Anesthesiologists Practice Advisory for Perioperative Care of Older Adults Scheduled for Inpatient Surgery. Anesthesiology. 2025;142(1):22–51. https://doi.org/10.1097/ALN.0000000000005172

RCT: Continuing Aspirin vs. Antiplatelet Cessation Before Surgery Did Not Reduce Ischemic Events in Patients With Coronary Stents Over 1 Year Post-Implantation

7 Sep, 2024 | 12:29h | UTC

Study Design and Population: This randomized controlled trial (ASSURE-DES) investigated the perioperative management of antiplatelet therapy in 926 patients with coronary drug-eluting stents (DES) undergoing low-to-intermediate-risk noncardiac surgery. The patients, at least one year post-stent implantation, were randomized to continue aspirin monotherapy or stop all antiplatelet therapy five days prior to surgery.

Main Findings: The study found no significant difference in the primary composite outcome (death, myocardial infarction, stent thrombosis, or stroke) between the aspirin monotherapy group (0.6%) and the no antiplatelet group (0.9%). However, minor bleeding was more frequent in the aspirin group (14.9% vs 10.1%, P=0.027), with no difference in major bleeding.

Implications for Practice: These results suggest that for stable patients with DES undergoing noncardiac surgery, temporarily discontinuing aspirin may be a safe option, as continuing aspirin did not reduce ischemic events but did increase minor bleeding risk. Further research is needed to assess outcomes in higher-risk surgical settings.

Reference: Kang, D.-Y. et al. (2024). Aspirin monotherapy vs no antiplatelet therapy in stable patients with coronary stents undergoing low-to-intermediate risk noncardiac surgery. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2024.08.024

News Release: SCOFF Trial Confirms Fasting Not Necessary Before Cardiac Catheterisation Procedures

7 Sep, 2024 | 10:10h | UTC

1 September 2024 – London, United Kingdom – New findings from the SCOFF trial, presented at ESC Congress 2024, suggest that fasting prior to minimally invasive cardiac catheterisation procedures under conscious sedation does not increase the risk of complications. The trial supports reconsidering current guidelines on pre-procedural fasting.

Key Points for Physicians:

– No increased complications: The SCOFF trial found no significant difference in adverse outcomes, such as aspiration pneumonia or hypoglycemia, between patients who fasted and those who ate normally before cardiac catheterisation.

– Improved patient satisfaction: Patients who did not fast reported higher satisfaction, with fewer complaints of discomfort and hunger.

– Potential guideline change: These findings, in line with previous studies like CHOW-NOW and TONIC, challenge the necessity of fasting before such procedures.

The trial’s lead investigator, Dr. David Ferreira (John Hunter Hospital, Australia), emphasized that avoiding fasting may improve patient experience without increasing risks, making it time to reconsider fasting guidelines for these procedures.

Study Overview:

– Trial design: Prospective, randomized, open-label, with blinded endpoint assessment.

– Participants: 716 patients undergoing coronary angiography, coronary intervention, or cardiac implantable electronic device procedures.

– Primary endpoint: Composite of hypotension, aspiration pneumonia, hyperglycemia, and hypoglycemia, showing a lower event rate in the non-fasting group (12.0%) compared to the fasting group (19.1%).

These results are likely to influence future clinical practice, providing greater flexibility for both patients and healthcare systems.

Source: https://www.escardio.org/The-ESC/Press-Office/Press-releases/SCOFF-trial-confirms-that-fasting-is-not-needed-before-cath-lab-procedures

Meta-Analysis: ERAS Protocols Improve Recovery and Reduce Complications After Emergency Laparotomy – Am J Surg

18 Aug, 2024 | 19:32h | UTC

Study Design and Population: This systematic review and meta-analysis assessed the effects of Enhanced Recovery After Surgery (ERAS) protocols compared to standard care (SC) in patients undergoing emergency laparotomy. The analysis included six randomized clinical trials (RCTs) with a total of 509 patients.

Main Findings: The ERAS group showed a reduction in length of hospital stay (mean difference: -2.92 days) and quicker recovery milestones, such as time to ambulation (mean difference: -1.67 days) and first bowel opening (mean difference: -1.26 days). The ERAS protocols were also associated with lower rates of pulmonary complications (odds ratio [OR]: 0.43) and surgical site infections (OR: 0.33). Mortality rates were similar between the ERAS and SC groups.

Implications for Practice: These findings suggest that ERAS protocols may enhance recovery and reduce complications in patients undergoing emergency laparotomy. Implementation of these protocols could be beneficial in emergency surgical settings, where feasible.

Reference: Amir AH, Davey MG, Donlon NE. (2024). Evaluating the Impact of Enhanced Recovery After Surgery Protocols following Emergency Laparotomy – A Systematic Review and Meta-Analysis of Randomised Clinical Trials. The American Journal of Surgery. DOI: https://doi.org/10.1016/j.amjsurg.2024.115857.

RCT: Eliminating Fasting Before Contrast-Enhanced CT in Outpatients Reduces Nausea and Vomiting Without Increasing Acute Adverse Reactions – Insights Imaging

11 Aug, 2024 | 13:41h | UTC

Study Design and Population: This single-center, randomized clinical trial was conducted in Spain with 1,103 adult outpatients undergoing non-emergency contrast-enhanced CT scans. Patients were randomized into two groups: one group fasted for at least 6 hours (control), while the other group had no food restrictions (intervention). The primary aim was to assess whether eliminating fasting affects the incidence of acute adverse reactions (AARs), such as nausea and vomiting.

Main Findings: The study found no significant difference in the overall incidence of acute adverse reactions between the fasting and non-fasting groups (3.21% vs. 2.30%; p = 0.36). However, the non-fasting group had a significantly lower incidence of nausea and vomiting (0.92% vs. 2.86%; p = 0.02). Multivariate logistic regression identified fasting, age, allergies, neurological diseases, and contrast media concentration as independent risk factors for nausea and vomiting.

Implications for Practice: The findings suggest that the traditional practice of fasting before contrast-enhanced CT scans is unnecessary and may increase the risk of nausea and vomiting. Therefore, unrestricted food intake should be allowed for most contrast-enhanced CT exams, reserving fasting only for specific imaging procedures.

Reference: Zitan Saidi et al. (2024). Fasting before contrast-enhanced CT and the incidence of acute adverse reactions: a single-center randomized clinical trial. Insights into Imaging, 15(195). DOI: 10.1186/s13244-024-01767-9.

Review | Fast track protocols and early rehabilitation after surgery in total hip arthroplasty

31 May, 2023 | 13:46h | UTC

Fast Track Protocols and Early Rehabilitation after Surgery in Total Hip Arthroplasty: A Narrative Review – Clinics and Practice

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations – Acta Orthopaedica

Enhanced recovery pathways in orthopedic surgery – Journal of Anaesthesiology Clinical Pharmacology

Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence – British Journal of Anaesthesia

SR | Same-day discharge vs. standard enhanced recovery after surgery (ERAS) protocols for major colorectal surgery

11 May, 2023 | 11:43h | UTC

Same-day discharge (SDD) vs standard enhanced recovery after surgery (ERAS) protocols for major colorectal surgery: a systematic review – International Journal of Colorectal Disease

M-A | Enhanced Recovery after Surgery in patients with peritoneal malignancies undergoing cytoreductive surgery

9 May, 2023 | 14:43h | UTC

Enhanced Recovery after Surgery (ERAS) Program for Patients with Peritoneal Surface Malignancies Undergoing Cytoreductive Surgery with or without HIPEC: A Systematic Review and a Meta-Analysis – Cancers

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced Recovery After Surgery (ERAS®) Society Recommendations — Part II: Postoperative management and special considerations

Consensus Statement | Development of an Enhanced Recovery After Surgery (ERAS) surgical safety checklist

Complete List of Enhanced Recovery After Surgery (ERAS) Society Guidelines

Top 100 Most-Cited Articles on Enhanced Recovery After Surgery: A Bibliometric Analysis and Visualized Study – Frontiers in Surgery