Enhanced recovery after surgery (ERAS) protocol is well established in many surgical disciplines and leads to a decrease in the length of hospital stay and morbidity. Multimodal protocols have also been introduced to bariatric surgery. This review aims to evaluate the current literature on ERAS in obesity surgery and to conduct a meta-analysis of primary and secondary outcomes. MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. Key journals were hand-searched. We analysed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was the length of hospital stay; the secondary outcomes included overall morbidity, specific complications, mortality, readmissions and costs. Random effect meta-analyses were undertaken. The initial search yielded 1151 articles. Thorough evaluation resulted in 11 papers, which were analysed. The meta-analysis of the length of stay presented a significant reduction standard mean difference (Std. MD) = −2.39 (−3.89, −0.89), p = 0.002. The analysis of overall morbidity, specific complications and Clavien-Dindo classification showed no significant variations among the study groups. ERAS protocol in bariatric surgery leads to the reduction of the length of hospital stay while maintaining no or low influence on morbidity.

BackgroundAcute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.MethodsThis prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016–September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.ResultsA total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.ConclusionsThe results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

Full implementation of the ERAS protocol significantly improves short term outcomes both in comparison to the high- and low-compliant groups.

Summary Background 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov , NCT03471494 . Findings Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding National Institute for Health Research Global Health Research Unit.

Background Until recently there has been little data available about long-term outcomes of laparoscopic rectal cancer surgery. But new randomized controlled trials regarding laparoscopic colorectal surgery have been published. The aim of this study was to compare the short- and long-term oncologic outcomes of laparoscopy and open surgery for rectal cancer through a systematic review of the literature and a meta-analysis of relevant RCTs.MethodsA systematic review of Medline, Embase and the Cochrane library from January 1966 to October 2016 with a subsequent meta-analysis was performed. Only randomized controlled trials with data on circumferential resection margins were included. The primary outcome was the status of circumferential resection margins. Secondary outcomes included lymph node yield, distal resection margins, disease-free and overall survival rates for 3 and 5 years and local recurrence rates.ResultsEleven studies were evaluated, involving a total of 2018 patients in the laparoscopic group and 1526 patients in the open group. The presence of involved circumferential margins was reported in all studies. There were no statistically significant differences in the number of positive circumferential margins between the laparoscopic group and open group, RR 1.16, 95% CI 0.89–1.50 and no significant differences in involvement of distal margins (RR 1.13 95% CI 0.35–3.66), completeness of mesorectal excision (RR 1.22, 95% CI 0.82–1.82) or number of harvested lymph nodes (mean difference = −0.01, 95% CI −0.89 to 0.87). Disease-free survival rates at 3 and 5 years were not different (p = 0.26 and p = 0.71 respectively), and neither were overall survival rates (p = 0.19 and p = 0.64 respectively), nor local recurrence rates (RR 0.88, 95% CI 0.63–1.23).ConclusionsLaparoscopic surgery for rectal cancer is associated with similar short-term and long-term oncologic outcomes compared to open surgery. The oncologic quality of extracted specimens seems comparable regardless of the approach used.Electronic supplementary materialThe online version of this article (doi:10.1007/s10151-017-1662-4) contains supplementary material, which is available to authorized users.