Publications by authors named "Olle Ljungqvist"

151 Publications

Prehabilitation, enhanced recovery after surgery, or both? A narrative review.

Br J Anaesth 2022 Jan 7. Epub 2022 Jan 7.

Department of Anesthesia, McGill University Health Center, Montreal, QC, Canada.

This narrative review presents a biological rationale and evidence to describe how the preoperative condition of the patient contributes to postoperative morbidity. Any preoperative condition that prevents a patient from tolerating the physiological stress of surgery (e.g. poor cardiopulmonary reserve, sarcopaenia), impairs the stress response (e.g. malnutrition, frailty), and/or augments the catabolic response to stress (e.g. insulin resistance) is a risk factor for poor surgical outcomes. Prehabilitation interventions that include exercise, nutrition, and psychosocial components can be applied before surgery to strengthen physiological reserve and enhance functional capacity, which, in turn, supports recovery through attaining surgical resilience. Prehabilitation complements Enhanced Recovery After Surgery (ERAS) care to achieve optimal patient outcomes because recovery is not a passive process and it begins preoperatively.
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http://dx.doi.org/10.1016/j.bja.2021.12.007DOI Listing
January 2022

Patients' perspectives of prehabilitation as an extension of Enhanced Recovery After Surgery protocols.

Can J Surg 2021 Nov-Dec;64(6):E578-E587. Epub 2021 Nov 2.

From the Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Gillis); the Patient and Community Engagement Research program, University of Calgary, Calgary, Alta. (Gill); the Department of Medicine, University of Alberta, Edmonton, Alta. (Gramlich); the Faculty of Kinesiology, University of Calgary, Calgary, Alta. (Culos-Reed); the Departments of Oncology and of Obstetrics and Gynaecology, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Nelson); the Department of Surgery, School of Health and Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden (Ljungqvist); the Department of Anesthesia, McGill University Health Centre, Montréal, Que. (Carli); and the Department of Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Calgary, Alta. (Fenton).

Background: Enhanced Recovery After Surgery (ERAS) and prehabilitation programs are evidence-based and patient-focused, yet meaningful patient input could further enhance these interventions to produce superior patient outcomes and patient experiences. We conducted a qualitative study with patients who had undergone colorectal surgery under ERAS care to determine how they prepared for surgery, their views on prehabilitation and how prehabilitation could be delivered to best meet patient needs.

Methods: We conducted semistructured interviews with adult patients who had undergone colorectal surgery under ERAS care within 3 months after surgery. Patients were enrolled between April 2018 and June 2019 through purposive sampling from 1 hospital in Alberta. The interview transcripts were analyzed independently by a researcher and a trained patient-researcher using inductive thematic analysis.

Results: Twenty patients were interviewed. Three main themes were identified. First, waiting for surgery: patients described fear, anxiety, isolation and deterioration of their mental and physical states as they waited passively for surgery. Second, preparing would have been better than just waiting: patients perceived that a prehabilitation program could prepare them for their operation if it addressed their emotional and physical needs, provided personalized support, offered home strategies, involved family and included surgical expectations (both what to expect and what is expected of them). Third, partnering with patients: preoperative preparation should occur on a continuum that meets patients where they are at and in a partnership that respects patients' expertise and desired level of engagement.

Conclusion: We identified several patient priorities for the preoperative period. Integrating these priorities within ERAS and prehabilitative programs could improve patient satisfaction, experiences and outcomes. Actively engaging patients in their care might alleviate some of the anxiety and fear associated with waiting passively for surgery.
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http://dx.doi.org/10.1503/cjs.014420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8565881PMC
November 2021

Bowel Preparation for Colorectal Surgery: Have All Questions Been Answered?

JAMA Surg 2022 Jan;157(1):41-42

Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals Trust and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom.

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http://dx.doi.org/10.1001/jamasurg.2021.5273DOI Listing
January 2022

Supervised Immediate Postoperative Mobilization After Elective Colorectal Surgery: A Feasibility Study.

World J Surg 2022 Jan 19;46(1):34-42. Epub 2021 Oct 19.

Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.

Background: Early mobilization is a significant part of the ERAS Society guidelines, in which patients are recommended to spend 2 h out of bed on the day of surgery. However, it is not yet known how early patients can safely be mobilized after completion of colorectal surgery. The aim of this study was to evaluate the feasibility, and safety of providing almost immediate structured supervised mobilization starting 30 min post-surgery at the postoperative anesthesia care unit (PACU), and to describe reactions to this approach.

Methods: This feasibility study includes 42 patients aged ≥18 years who received elective colorectal surgery at Örebro University Hospital. They underwent a structured mobilization performed by a specialized physiotherapist using a modified Surgical ICU Optimal Mobilization Score (SOMS). SOMS determines the level of mobilization at four levels from no activity to ambulating. Mobilization was considered successful at SOMS ≥ 2, corresponding to sitting on the edge of the bed as a proxy of sitting in a chair due to lack of space.

Results: In all, 71% (n = 30) of the patients reached their highest level of mobilization between the second and third hour of arrival in the PACU. Before discharge to the ward, 43% (n = 18) could stand at the edge of the bed and 38% (n = 16) could ambulate. Symptoms that delayed advancement of mobilization were pain, somnolence, hypotension, nausea, and patient refusal. No serious adverse events occurred.

Conclusions: Supervised mobilization is feasible and can safely be initiated in the immediate postoperative care after colorectal surgery. Trial registration Clinical trials.gov identifier: NTC03357497.
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http://dx.doi.org/10.1007/s00268-021-06347-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8677683PMC
January 2022

Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery.

World J Surg 2022 Jan 19;46(1):19-33. Epub 2021 Oct 19.

Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.

Background: We aimed to determine the prevalence, risk factors, and outcomes of acute kidney injury (AKI) within an ERAS program for colorectal surgery (CRS).

Methods: This is a retrospective case-control study conducted from March 2016 to September 2018 at a single tertiary hospital in Singapore. All adult patients requiring CRS within our ERAS program were considered eligible. Exclusions were stage 5 chronic kidney disease or patients requiring a synchronous liver resection. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Secondary outcomes included mortality, major complications, and hospital length of stay. Patient, surgical, and anaesthesia-related data were analysed to determine factors associated with AKI.

Results: A total of 575 patients were eligible for the study. Twenty patients were excluded from the study leaving 555 patients for analysis. Mean age was 67.8 (SD 11.4) years. Seventy-four patients met the criteria for AKI (13.4%: stage 1-11.2%, stage 2-2.0%, stage 3-0.2%). One patient required renal replacement therapy (RRT). Patients with AKI had a longer length of stay (median [IQR], 11.0 [5.0-17.0] days vs 6.0 [4.0-8.0] days; P < .001), more major complications (OR, 6.55; 95% CI, 3.00-14.35, P < .001), and a trend towards higher mortality at one year (OR, 1.44; 95% CI 0.48-4.30; p = 0.511. After multivariable regression analysis, factors associated with AKI were preoperative creatinine (OR, 1.01 per 10 µmol/l; 95% CI, 1.03-1.22; P = 0.01), robotic surgery vs open surgery (OR, 0.15; 95% CI, 0.06-0.39; P < 0.001), anaesthesia duration (OR, 1.38 per hour; 95% CI, 1.22-1.55; P < 0.001), and major complications (OR, 5.55; 95% CI, 2.63-11.70; P < 0.001).

Conclusions: Within the present cohort, the implementation of an ERAS program for CRS was associated with a low prevalence of moderate to severe AKI despite a balanced intravenous fluid regimen. Patients having open surgery, longer procedures, and major complications are at increased risk of AKI.
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http://dx.doi.org/10.1007/s00268-021-06343-6DOI Listing
January 2022

Perioperative Opioids-Reclaiming Lost Ground.

JAMA Surg 2021 11;156(11):997-998

Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom.

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http://dx.doi.org/10.1001/jamasurg.2021.2858DOI Listing
November 2021

From clinical guidelines to practice: The nutrition elements for enhancing recovery after colorectal surgery.

Nutr Clin Pract 2021 Aug 2. Epub 2021 Aug 2.

Department of Anesthesia, McGill University Health Center, Montreal, Quebec, Canada.

The Enhanced Recovery After Surgery (ERAS) Care System improves patient outcomes. The ERAS Protocol describes multimodal, evidence-based processes that are bundled into >20 care elements, and the ERAS Implementation Program provides strategies to guide the successful adoption of the care elements. Although formal training is essential to implement ERAS correctly, with this article we aim to bridge the gap between the nutritionally relevant care elements of the protocol and their implementation for colorectal surgery. This article also describes how dietitians can support optimal patient outcomes by playing an active role in implementing, monitoring, and evaluating ERAS practices.
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http://dx.doi.org/10.1002/ncp.10751DOI Listing
August 2021

Dehydration and loss of appetite: Key nutrition features in older people receiving home health care.

Nutrition 2021 Nov-Dec;91-92:111385. Epub 2021 Jun 6.

Department of Surgery, School of Medical Sciences, Örebro University, Örebro, Sweden.

Objectives: The aim was to describe a population of older people in home health care based on what is probably a novel theoretical model, previously published, and to analyze longitudinal changes in different dimensions of nutritional status.

Methods: This explorative and longitudinal study examines nutritional status based on four domains in the novel theoretical model: health and somatic disorders; cognitive, affective, and sensory function; physical function and capacity; and food and nutrition. Inclusion criteria were age ≥65 y and need of home health care for more than three months. A total of 69 men and women were enrolled in the study. Participants' nutritional status was studied at baseline and regularly during the following three years.

Results: At baseline, 44% (n = 27) reported one or more severe symptoms and 83% had polypharmacy (≥5 prescribed medications). The prevalence of malnutrition, sarcopenia, frailty, and dehydration at baseline were, respectively, 83% (n = 35), 44% (n = 24), 34% (n = 18), and 45% (n = 25). Participants that died during the 3-y follow-up (n = 14) differed from survivors in the following aspects: more reduced appetite, lower quality of life, worse cognitive function, lower physical activity, and less intake of dietary fiber and water. Dehydration at baseline was associated with lower function in several domains and with general decline over time.

Conclusions: Most participants had poor nutritional status. Dehydration and reduced appetite were important indicators of worsening nutritional and overall status and mortality.
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http://dx.doi.org/10.1016/j.nut.2021.111385DOI Listing
December 2021

ESPEN practical guideline: Clinical nutrition in surgery.

Clin Nutr 2021 07 19;40(7):4745-4761. Epub 2021 Apr 19.

Institute for Nutrition Research, Rabin Medical Center, Beilison Hospital, Petah Tikva, Israel.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.
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http://dx.doi.org/10.1016/j.clnu.2021.03.031DOI Listing
July 2021

The effect of glucose control in liver surgery on glucose kinetics and insulin resistance.

Clin Nutr 2021 07 3;40(7):4526-4534. Epub 2021 Jun 3.

Dept of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden. Electronic address:

Background & Aims: Clinical outcome is negatively correlated to postoperative insulin resistance and hyperglycemia. The magnitude of insulin resistance can be modulated by glucose control, preoperative nutrition, adequate pain management and minimal invasive surgery. Effects of glucose control on perioperative glucose kinetics in liver surgery is less studied.

Methods: 18 patients scheduled for open hepatectomy were studied per protocol in this prospective, randomized study. In the treatment group (n = 9), insulin was administered intravenously to keep arterial blood glucose between 6 and 8 mmol/l during surgery. The control group (n = 9) received insulin if blood glucose >11.5 mmol/l. Insulin sensitivity was measured by an insulin clamp on the day before surgery and immediately postoperatively. Glucose kinetics were assessed during the clamp and surgery.

Results: Mean intraoperative glucose was 7.0 mM (SD 0.7) vs 9.1 mM (SD 1.9) in the insulin and control group respectively (p < 0.001; ANOVA). Insulin sensitivity decreased in both groups but significantly (p = 0.03, ANOVA) more in the control group (M value: 4.6 (4.4-6.8) to 2.1 (1.2-2.6) and 4.6 (4.1-5.0) to 0.6 (0.1-1.8) mg/kg/min in the treatment and control group respectively). Endogenous glucose production (EGP) increased and glucose disposal (WGD) decreased significantly between the pre- and post-operative clamps in both groups, with no significant difference between the groups. Intraoperative kinetics demonstrated that glucose control decreased EGP (p = 0.02) while WGD remained unchanged (p = 0.67).

Conclusion: Glucose control reduces postoperative insulin resistance in liver surgery. EGP increases and WGD is diminished immediately postoperatively. Insulin seems to modulate both reactions, but mostly the WGD is affected. Intraoperative EGP decreased while WGD remained unaltered.

Registration Number Of Clinical Trial: ANZCTR 12614000278639.
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http://dx.doi.org/10.1016/j.clnu.2021.05.017DOI Listing
July 2021

Preoperative nutrition care in Enhanced Recovery After Surgery programs: are we missing an opportunity?

Curr Opin Clin Nutr Metab Care 2021 09;24(5):453-463

School of Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.

Purpose Of Review: A key component of Enhanced Recovery After Surgery (ERAS) is the integration of nutrition care elements into the surgical pathway, recognizing that preoperative nutrition status affects outcomes of surgery and must be optimized for recovery. We reviewed the preoperative nutrition care recommendations included in ERAS Society guidelines for adults undergoing major surgery and their implementation.

Recent Findings: All ERAS Society guidelines reviewed recommend preoperative patient education to describe the procedures and expectations of surgery; however, only one guideline specifies inclusion of routine nutrition education before surgery. All guidelines included a recommendation for at least one of the following nutrition care elements: nutrition risk screening, nutrition assessment, and nutrition intervention. However, the impact of preoperative nutrition care could not be evaluated because it was rarely reported in recent literature for most surgical disciplines. A small number of studies reported on the preoperative nutrition care elements within their ERAS programs and found a positive impact of ERAS implementation on nutrition care practices, including increased rates of nutrition risk screening.

Summary: There is an opportunity to improve the reporting of preoperative nutrition care elements within ERAS programs, which will enhance our understanding of how nutrition care elements influence patient outcomes and experiences.
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http://dx.doi.org/10.1097/MCO.0000000000000779DOI Listing
September 2021

Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review.

JAMA Surg 2021 08;156(8):775-784

Department of Visceral Surgery, University Hospital Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland.

Importance: Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion.

Observations: Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS.

Conclusions And Relevance: To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.
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http://dx.doi.org/10.1001/jamasurg.2021.0586DOI Listing
August 2021

Short-term outcome in robotic vs laparoscopic and open rectal tumor surgery within an ERAS protocol: a retrospective cohort study from the Swedish ERAS database.

Surg Endosc 2021 Apr 15. Epub 2021 Apr 15.

Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institutet, 18288, Stockholm, Danderyd, Sweden.

Background: Advantages of robotic technique over laparoscopic technique in rectal tumor surgery have yet to be proven. Large multicenter, register-based cohort studies within an optimized perioperative care protocol are lacking. The aim of this retrospective cohort study was to compare short-term outcomes in robotic, laparoscopic and open rectal tumor resections, while also determining compliance to the enhanced recovery after surgery (ERAS)®Society Guidelines.

Methods: All patients scheduled for rectal tumor resection and consecutively recorded in the Swedish part of the international ERAS® Interactive Audit System between January 1, 2010 to February 27, 2020, were included (N = 3125). Primary outcomes were postoperative complications and length of stay (LOS) and secondary outcomes compliance to the ERAS protocol, conversion to open surgery, symptoms delaying discharge and reoperations. Uni- and multivariate comparisons were used.

Results: Robotic surgery (N = 827) had a similar rate of postoperative complications (Clavien-Dindo grades 1-5), 35.9% compared to open surgery (N = 1429) 40.9% (OR 1.15, 95% CI (0.93, 1.41)) and laparoscopic surgery (N = 869) 31.2% (OR 0.88, 95% CI (0.71, 1.08)). LOS was longer in the open group, median 9 days (IRR 1.35, 95% CI (1.27, 1.44)) and laparoscopic group, 7 days (IRR 1.14, 95% CI (1.07, 1.21)) compared to the robotic group, 6 days. Pre- and intraoperative compliance to the ERAS protocol were similar between groups.

Conclusions: In this multicenter cohort study, robotic surgery was associated with shorter LOS compared to both laparoscopic and open surgery and had lower conversion rates vs laparoscopic surgery. The rate of complications was similar between groups.
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http://dx.doi.org/10.1007/s00464-021-08486-yDOI Listing
April 2021

Validity of Routinely Collected Swedish Data in the International Enhanced Recovery After Surgery (ERAS) Database.

World J Surg 2021 06 7;45(6):1622-1629. Epub 2021 Apr 7.

Division of Surgery, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, 18288, Danderyd, Stockholm, Sweden.

Background: This study aims to assess patient coverage, validity and data quality in the Swedish part of the International Enhanced Recovery After Surgery (ERAS) Interactive Audit System (EIAS).

Method: All Swedish ERAS centers that recorded colorectal surgery data in EIAS between January 1, 2017, and December 31, 2017, were included (N = 12). Information registered in EIAS was compared with data from electronic medical records at each hospital to assess the overall coverage of EIAS. Twenty random-selected patients from each of the contributing centers were assessed for accuracy for a set of clinically relevant variables. All patients admitted to the contributing centers were included for the assessment of rate of missing on a selection of key clinical variables.

Results: Eight hospitals provided complete information for the evaluation, while four hospitals only allowed assessment of coverage and missing data. The eight hospitals had an overall coverage of 98.8% in EIAS (n = 1301) and the four 86.7% (n = 811). The average agreement for the assessed postoperative outcome variables was 96.5%. The accuracy was excellent for 'length of hospital stay,' 'reoperation,' and 'any complications,' but lower for other types of complications. Only a few variables had more than 5% missing data, and missingness was associated with hospital type and size.

Conclusion: This validation of the Swedish part of the international ERAS database suggests high patient coverage in EIAS and high agreement and limited missingness in clinically relevant variables. This validation approach or a modified version can be used for continued validation of the International ERAS database.
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http://dx.doi.org/10.1007/s00268-021-06094-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093151PMC
June 2021

Risk Factors for Anastomotic Leakage in Patients with Rectal Tumors Undergoing Anterior Resection within an ERAS Protocol: Results from the Swedish ERAS Database.

World J Surg 2021 06 17;45(6):1630-1641. Epub 2021 Mar 17.

Department of Clinical Sciences, Division of Surgery, Danderyd Hospital, Karolinska Institute, Stockholm, Sweden.

Background: Research on risk factors for anastomotic leakage (AL) alone within an Enhanced Recovery After Surgery (ERAS) protocol has not yet been conducted. The aim of this study was to identify risk factors for AL and study short-term outcome after AL in patients operated with anterior resection (AR).

Methods: All prospectively and consecutively recorded patients operated with AR in the Swedish part of the international ERAS® Interactive Audit System (EIAS) between January 2010 and February 2020 were included. The cohort was evaluated regarding risk factors for AL and short-term outcomes, including uni- and multivariate analysis. Pre-, intra- and postoperative compliance to ERAS®Society guidelines was calculated and evaluated.

Results: Altogether 1900 patients were included, 155 (8.2%) with AL and 1745 without AL. Male gender, obesity, peritoneal contamination, year of surgery 2016-2020, duration of primary surgery and age remained significant predictors for AL in multivariate analysis. There was no significant difference in overall pre- and intraoperative compliance to ERAS®Society guidelines between groups. Only preadmission patient education remained as a significant ERAS variable associated with less AL. AL was associated with longer length of stay (LOS), higher morbidity rate and higher rate of reoperations.

Conclusion: Male gender, obesity, peritoneal contamination, duration of surgery, surgery later in study period, age and preadmission patient education were associated with AL in patients operated on with AR. Overall pre- and intraoperative compliance to the ERAS protocol was high in both groups and not associated with AL.
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http://dx.doi.org/10.1007/s00268-021-06054-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093169PMC
June 2021

Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization.

World J Surg 2021 05 6;45(5):1272-1290. Epub 2021 Mar 6.

Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, 19104, USA.

Background: Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

Methods: Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

Results: Twelve components of preoperative care were considered. Consensus was reached after three rounds.

Conclusions: These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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http://dx.doi.org/10.1007/s00268-021-05994-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026421PMC
May 2021

Consensus statement for perioperative care in lumbar spinal fusion: Enhanced Recovery After Surgery (ERAS®) Society recommendations.

Spine J 2021 05 12;21(5):729-752. Epub 2021 Jan 12.

Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, the Netherlands.

Background: Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care have led to improvements in outcomes in numerous surgical areas, through multimodal optimization of patient pathway, reduction of complications, improved patient experience and reduction in the length of stay. ERAS represent a relatively new paradigm in spine surgery.

Purpose: This multidisciplinary consensus review summarizes the literature and proposes recommendations for the perioperative care of patients undergoing lumbar fusion surgery with an ERAS program.

Study Design: This is a review article.

Methods: Under the impetus of the ERAS® society, a multidisciplinary guideline development group was constituted by bringing together international experts involved in the practice of ERAS and spine surgery. This group identified 22 ERAS items for lumbar fusion. A systematic search in the English language was performed in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. Systematic reviews, randomized controlled trials, and cohort studies were included, and the evidence was graded according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Consensus recommendation was reached by the group after a critical appraisal of the literature.

Results: Two hundred fifty-six articles were included to develop the consensus statements for 22 ERAS items; one ERAS item (prehabilitation) was excluded from the final summary due to very poor quality and conflicting evidence in lumbar spinal fusion. From these remaining 21 ERAS items, 28 recommendations were included. All recommendations on ERAS protocol items are based on the best available evidence. These included nine preoperative, eleven intraoperative, and six postoperative recommendations. They span topics from preoperative patient education and nutritional evaluation, intraoperative anesthetic and surgical techniques, and postoperative multimodal analgesic strategies. The level of evidence for the use of each recommendation is presented.

Conclusion: Based on the best evidence available for each ERAS item within the multidisciplinary perioperative care pathways, the ERAS® Society presents this comprehensive consensus review for perioperative care in lumbar fusion.
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http://dx.doi.org/10.1016/j.spinee.2021.01.001DOI Listing
May 2021

Preoperative Fasting Practices Across Three Anesthesia Societies: Survey of Practitioners.

JMIR Perioper Med 2020 Jan 28;3(1):e15905. Epub 2020 Jan 28.

Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia.

Background: Pulmonary aspiration of gastric contents is recognized as a complication of anesthesia. To minimize that risk, anesthesiologists advised fasting for solid foods and liquids for an often prolonged period of time. However, 30 years ago, evidence was promulgated that fasting for clear liquids was unnecessary to ensure an empty stomach. Despite a strong evidence base and the knowledge that fasting may be physiologically harmful and unpleasant for patients, the adoption of society guidelines recommending short fasting periods for clear fluids into clinical practice is uncertain.

Objective: This study aimed to determine the current practices of anesthetists with respect to fasting guidelines.

Methods: An electronic internet survey was distributed to anesthetists in Canada (CAN), Australia and New Zealand (ANZ), and Europe (EUR) during April 2014 to February 2015. The anesthetists were asked about fasting guidelines, their recommendations to patients for the consumption of clear fluids and solid foods, and the reasons and consequences if these guidelines were not followed.

Results: A total of 971 anesthetists completed the survey (CAN, n=679; ANZ, n=185; and EUR, n=107). Although 85.0% (818/962) of these participants claimed that their advice to patients followed current society guidelines, approximately 50.4% (476/945) enforced strict fasting and did not allow clear fluids after midnight. The primary reasons given were with regard to problems with a variable operating room schedule (255/476, 53.6%) and safety issues surrounding the implementation of clear fluid drinking guidelines (182/476, 38.2%).

Conclusions: Many anesthetists continue to follow outdated practices. The current interest in further liberalizing preoperative fluid intake will require more change in anesthesia culture.
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http://dx.doi.org/10.2196/15905DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709845PMC
January 2020

No association between preoperative impaired glucose control and postoperative adverse events following hip fracture surgery - A single-centre observational cohort study.

Clin Nutr 2021 03 27;40(3):1348-1354. Epub 2020 Aug 27.

Department of Emergency Surgery and Trauma, Karolinska University Hospital, Sweden; Department of Clinical Science, Intervention and Technology, (CLINTEC), Karolinska Institutet, Stockholm, Sweden.

Rationale: Observational studies have shown an association between hyperglycaemia and increased complications in orthopaedic patients. The aim of the study was to investigate if impaired preoperative glycaemic control, reflected by elevated HbA1c, was associated with adverse postoperative events in hip fracture patients.

Methods: 160 patients (116 women and 44 men; age 80 ± 10 and BMI 24 ± 4; mean ± SD) with hip fractures were included in a prospective observational cohort study. The patients were divided into two groups, normal glycaemic control (NGC) and impaired glycaemic control (IGC) HbA1c ≥ 42 mmol/mol. The patients were also characterized according to BMI and nutritional status using MNA-SF (Minimal Nutritional Assessment Short Form). Complications within 30 days of surgery were classified according to Clavien-Dindo and 1-year mortality was compared between the groups.

Results: Out of 160 patients, 18 had diabetes and 4 more had likely occult diabetes (HbA1c ≥ 48). Impaired glycaemic control (IGC) was seen in 29 patients (18.1%) and normal glycaemic control (NGC) in 131 (81.9%). In patients with NGC and IGC, no postoperative complications (Clavien-Dindo Grade 0) were seen in 64/131 vs. 14/29 (48.9 vs. 48.3%), Grade 1-3a in 54/131 vs. 14/29 (41.2 vs. 48.3%) and Grade 3b-5 in 13/131 vs. 1/29 (9.9 vs. 3.4%) respectively, p = NS. There were no differences in 30-day complications (p = 0.55) or 1-year mortality (p = 0.35) between the groups.

Conclusion: Elevated HbA1c at admission is not associated with increased complications or mortality after hip fracture surgery.
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http://dx.doi.org/10.1016/j.clnu.2020.08.023DOI Listing
March 2021

The Post COVID-19 Surgical Backlog: Now is the Time to Implement Enhanced Recovery After Surgery (ERAS).

World J Surg 2020 10 14;44(10):3197-3198. Epub 2020 Aug 14.

Department of Visceral Surgery, University Hospital CHUV and University of Lausanne, Lausanne, Switzerland.

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http://dx.doi.org/10.1007/s00268-020-05734-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7427753PMC
October 2020

Effects of beta-blocker therapy on mortality after elective colon cancer surgery: a Swedish nationwide cohort study.

BMJ Open 2020 07 7;10(7):e036164. Epub 2020 Jul 7.

School of Health and Medical Sciences, Örebro University, Örebro, Sweden

Objective: Colon cancer surgery remains associated with substantial postoperative morbidity and mortality despite advances in surgical techniques and care. The trauma of surgery triggers adrenergic hyperactivation which drives adverse stress responses. We hypothesised that outcome benefits are gained by reducing the effects of hyperadrenergic activity with beta-blocker therapy in patients undergoing colon cancer surgery. This study aims to test this hypothesis.

Design: Retrospective cohort study.

Setting And Participants: This is a nationwide study which includes all adult patients undergoing elective colon cancer surgery in Sweden over 10 years. Patient data were collected from the Swedish Colorectal Cancer Registry. The national drugs registry was used to obtain information about beta-blocker use. Patients were subdivided into exposed and unexposed groups. The association between beta-blockade, short-term and long-term mortality was evaluated using Poisson regression, Kaplan-Meier curves and Cox regression.

Primary And Secondary Outcomes: Primary outcome of interest was 1-year all-cause mortality. Secondary outcomes included 90-day all-cause and 5-year cancer-specific mortality.

Results: The study included 22 337 patients of whom 36.1% were prescribed preoperative beta-blockers. Survival was higher in patients on beta-blockers up to 1 year after surgery despite this group being significantly older and of higher comorbidity. Regression analysis demonstrated significant reductions in 90-day deaths (IRR 0.29, 95% CI 0.24 to 0.35, p<0.001) and a 43% risk reduction in 1-year all-cause mortality (adjusted HR 0.57, 95% CI 0.52 to 0.63, p<0.001) in beta-blocked patients. In addition, cancer-specific mortality up to 5 years after surgery was reduced in beta-blocked patients (adjusted HR 0.80, 95% CI 0.73 to 0.88, p<0.001).

Conclusion: Preoperative beta-blockade is associated with significant reductions in postoperative short-term and long-term mortality following elective colon cancer surgery. Its potential prophylactic effect warrants further interventional studies to determine whether beta-blockade can be used as a way of improving outcomes for this patient group.
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http://dx.doi.org/10.1136/bmjopen-2019-036164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342478PMC
July 2020

The History of ERAS (Enhanced Recovery After Surgery) Society and its development in Latin America.

Rev Col Bras Cir 2020 Jun 3;47:e20202525. Epub 2020 Jun 3.

Professor of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences Department of Surgery Örebro University, Örebro, Sweden.

The shortage of hospital beds and changes in the payment model have promoted an increased attention and financing of programs that focus on perioperative care efficiency in. Latin America. In this paper, Enhanced Recovery After Surgery (ERAS) programs developed by the ERAS® Society will be discussed. The implementation and use of ERAS®Society Guidelines consistently demonstrated a reduction in postoperative complications, hospital stay and costs. In the current paper, the definition of ERAS programs, their core elements, and the results of their implementation and regional developments are presented with special focus on Latin America.
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http://dx.doi.org/10.1590/0100-6991e-20202525DOI Listing
June 2020

Editorial: Glucose metabolism in infancy, obesity and pre and post-surgery.

Curr Opin Clin Nutr Metab Care 2020 07 20;23(4):253-254. Epub 2020 May 20.

Professor of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden.

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http://dx.doi.org/10.1097/MCO.0000000000000664DOI Listing
July 2020

Perioperative nutrition: Recommendations from the ESPEN expert group.

Clin Nutr 2020 11 18;39(11):3211-3227. Epub 2020 Apr 18.

Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Straße 141, 04129, Leipzig, Germany.

Background & Aims: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients.

Methods: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art.

Results: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer.

Conclusions: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.
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http://dx.doi.org/10.1016/j.clnu.2020.03.038DOI Listing
November 2020

Towards optimal nutritional care for all: A multi-disciplinary patient centred approach to a complex challenge.

Clin Nutr 2020 05 31;39(5):1309-1314. Epub 2020 Mar 31.

School of Health and Medical Sciences, Department of Surgery, Örebro University, Sweden. Electronic address:

Ten years ago, European health care professional societies, health associations and members of the European Parliament convened in Brussels to discuss the necessary and urgent actions needed to improve access, initiation and follow up nutritional care for European citizens. As a response to this, in 2014 the Optimal Nutritional Care for All (ONCA) campaign was launched under the leadership of the European Nutritional for Health Alliance and its members. As of today this campaign has been rolled out in 18 European countries, whereby national multi-disciplinary platforms including patient groups work together to implement national nutritional care programs and develop good practices in care, research, education in order to increase awareness on malnutrition and improve nutritional care. This article describes the making of and evolution of the ONCA campaign, the outcomes and impact created, as well as opportunities to accelerate implementation of personalized nutritional care for all European citizens.
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http://dx.doi.org/10.1016/j.clnu.2020.03.020DOI Listing
May 2020

Enhanced recovery programs in gastrointestinal surgery: Actions to promote optimal perioperative nutritional and metabolic care.

Clin Nutr 2020 07 25;39(7):2014-2024. Epub 2019 Oct 25.

Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.

The enhanced recovery after surgery (ERAS) pathway is an evidence-based approach to the use of care elements along the patient perioperative pathway. All care elements that may impact on clinically relevant outcomes have been considered and reviewed. The combined ERAS actions allow a quicker return to bowel function, oral feeding, nutritional and metabolic equilibrium, normal activity and ultimately to achieve better outcomes. Because of the multi factorial approach and the commitment of all the professionals caring for the patient, it is necessary to have the engagement of all disciplines, such as surgery, anesthesiology, clinical nutrition, nursing, physiatry, involved. ERAS is a dynamic process and new evidence are constantly integrated into the program. The primary endpoint of this review is to give updated information on the key ERAS actions to achieve optimal perioperative nutritional and metabolic care.
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http://dx.doi.org/10.1016/j.clnu.2019.10.023DOI Listing
July 2020

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

Acta Orthop 2020 02 30;91(1):3-19. Epub 2019 Oct 30.

Örebro University, Örebro, Sweden.

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.
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http://dx.doi.org/10.1080/17453674.2019.1683790DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006728PMC
February 2020

Authors' Reply: Compliance with the ERAS Protocol and 3-Year Survival After Laparoscopic Surgery for Nonmetastatic Colorectal Cancer.

World J Surg 2020 01;44(1):314-315

Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.

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http://dx.doi.org/10.1007/s00268-019-05168-8DOI Listing
January 2020

Prognostic Value of P-POSSUM and Osteopenia for Predicting Mortality After Emergency Laparotomy in Geriatric Patients.

Bull Emerg Trauma 2019 Jul;7(3):223-231

Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Orebro University, Orebro, Sweden.

Objective: To evaluate the Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in comparison with other risk factors for mortality including osteopenia as an indicator for frailty in geriatric patients subjected to emergency laparotomy.

Methods: All geriatric patients (≥65 years) undergoing emergency laparotomy at a single university hospital between 1/2015 and 12/2016 were included in this cohort study. Demographics and outcomes were retrospectively collected from medical records. Association between prognostic markers and 30-day mortality was assessed using Poisson and backward stepwise regression models. Prognostic value was assessed using receiver operating characteristic (ROC) curves.

Results: 209 patients were included with a mean age of 76 ± 7.3 years. American Society of Anesthesiologists (ASA) classification, age, indication and type of surgery, hypotension, transfusion requirement and current malignancy proved to be statistically significant predictors of 30-day mortality. P-POSSUM mortality was statistically significant in the backward stepwise regression (incidence rate ratio=1.58, 95% CI: 1.16-2.15, =0.004) while osteopenia was not. P-POSSUM had poor prognostic value for 30-day mortality with an area under the ROC curve (AUC) of 0.59. The prognostic value of P-POSSUM improved significantly when adjusting for patient covariates (AUC=0.83).

Conclusion: P-POSSUM and osteopenia alone hardly predict 30-day mortality in geriatric patients following emergency laparotomy. P-POSSUM adjusted for other patient covariates improves the prediction.
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http://dx.doi.org/10.29252/beat-070303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681876PMC
July 2019
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