Objective: To study the effects of intra-abdominal pressure on the quality of recovery and innate cytokine production capacity after laparoscopic colorectal surgery within the enhanced recovery after surgery program. Background: There is increasing evidence for the safety and advantages of low-pressure pneumoperitoneum facilitated by deep neuromuscular blockade (NMB). Nonetheless, there is a weak understanding of the relationship between clinical outcomes, surgical injury, postoperative immune dysfunction, and infectious complications. Methods: Randomized controlled trial of 178 patients treated at standard-pressure pneumoperitoneum (12 mm Hg) with moderate NMB (train-of-four 1-2) or low pressure (8 mm Hg) facilitated by deep NMB (posttetanic count 1-2). The primary outcome was the quality of recovery (Quality of Recovery 40 questionnaire) on a postoperative day 1 (POD1). The primary outcome of the immune substudy (n = 100) was ex vivo tumor necrosis factor α production capacity upon endotoxin stimulation on POD1.Results: Quality of Recovery 40 score on POD1 was significantly higher at 167 versus 159 [mean difference (MD): 8.3 points; 95% confidence interval (CI): 2.5, 14.1; P = 0.005] and the decline in cytokine production capacity was significantly less for tumor necrosis factor α and interleukin-6 (MD: −172 pg/mL; 95% CI: −316, −27; P = 0.021 and MD: −1282 pg/ mL; 95% CI: −2505, −59; P = 0.040, respectively) for patients operated at low pressure. Low pressure was associated with reduced surgical site hypoxia and inflammation markers and circulating damage-associated molecular patterns, with a less impaired early postoperative ex vivo cytokine production capacity. At low pressure, patients reported lower acute pain scores and developed significantly less 30-day infectious complications. Conclusions: Low intra-abdominal pressure during laparoscopic colorectal surgery is safe, improves the postoperative quality of recovery and preserves innate immune homeostasis, and forms a valuable addition to future enhanced recovery after surgery programs.

BackgroundSufficient pain control and rapid mobilisation after VATS are important to enhance recovery and prevent complications. Thoracic epidural analgesia (TEA) is the gold standard, but failure rates of 9–30% have been described. In addition, TEA reduces patient mobilisation and bladder function. Subpleural continuous analgesia (SCA) is a regional analgesic technique that is placed under direct thoracoscopic vision and is not associated with the mentioned disadvantages of TEA. The objective of this study was to assess surgical feasibility, pain control and patient satisfaction of SCA.MethodsObservational pilot study in patients who underwent VATS pulmonary resection and received SCA (n = 23). Pain scores (numeric rating scale 0–10) and patient satisfaction (5-point Likert scale) were collected on postoperative day (POD) 0–3. Secondary outcomes were the period of urinary catheter use and period to full mobilisation.ResultsPlacement of the subpleural catheter took an average of 11 min (SD 5) and was successful in all patients. Pain scores on POD 0–3 were 1.2 (SD 1.2), 2.0 (SD 1.9), 1.7 (SD 1.5) and 1.2 (SD 1.1) respectively. On POD 0–3 at least 79% of patients were satisfied or very satisfied on pain relief and mobilisation. The duration of subpleural continuous analgesia was 4 days (IQR 3–5, range 2–11). Urinary catheters were used zero days (IQR 0–1, range 0–6) and full mobilisation was achieved on POD 2 (IQR 1–2, range 1–6).ConclusionSubpleural continuous analgesia in VATS pulmonary resection is feasible and provides adequate pain control and good patient satisfaction.Trial registrationThis pilot study was not registered in a trial register.

Background: Perioperative music can have beneficial effects on postoperative pain and perioperative opioid requirement. This study aims to assess the implementation feasibility of music in day care surgery through adherence to implementation, as well as its effects. Methods: This implementation study employed a prospective single-center study design. Perioperative music was implemented as part of standard surgical care during day care surgery procedures. The music intervention consisted of preselected playlists. Primary outcome was adherence to implementation. Barriers and attitudes towards music of patients and perioperative care providers were evaluated. Furthermore, the effects of music were assessed through a matched cohort analysis. This study was registered with the Netherlands Trial Register (NL8213). Results: From January to April 2020, a total of 109 patients received the music intervention and 97 were analyzed after matching to retrospective controls. Adherence rate to the music intervention was 92% preoperatively, 81% intraoperatively, and 86% postoperatively, with 83% of patients satisfied with the preselected music, and 93% finding music to be beneficial to surgical care. All health care providers believed perioperative music to be beneficial (63%) or were neutral (37%) towards its use. Postoperative pain was not significantly different (mean numeric rating scale 0.74; the music intervention group versus 0.68; control group, p ¼ .363). Although not statistically significant, postoperative opioid requirement in the music group was lower (30% versus 40%, p ¼ .132). Conclusion: Perioperative music implementation in day care surgery is feasible with high adherence rates, patient satisfaction levels, and positive attitudes of health care providers towards its use.