thesis topics for general surgery 2023

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Surgery Thesis Topics for MS /DNB. 

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• A study of morbidity associated with temporary loop ileostomy in perforation peritonitis cases
• Investigation of hyperbilirubinemia in amoebic liver abscess patients
• Comparison between ‘Fistulectomy’ and ‘Fistulotomy with marsupialisation’ for treating simple anal fistula: A randomized clinical trial
• Quality of life and rehabilitation requirements of breast cancer survivors
• Assessing lingual mucosal grafts in urethral stricture management
• Correlation between coagulation markers and axillary lymph node metastasis in breast carcinoma
• A clinico-bacteriological examination of post-surgical wound infections
• A controlled examination of risk factors in benign prostatic hyperplasia and prostate carcinoma patients
• Hyperbilirubinemia as a novel diagnostic predictor of gangrenous/perforated appendicitis
• Comparative analysis of elective laparoscopic cholecystectomy with vs. without antibiotic prophylaxis
• Effects of adding levamisole to standard anthracycline-based preoperative chemotherapy on local immune response in invasive breast carcinoma
• Impact of laparoscopic cholecystectomy on gastroesophageal reflux via 24-hour ambulatory esophageal pH monitoring
• The utility of video-assisted thoracoscopic surgery (VATS) in chest trauma patients not improving as expected on tube thoracostomy: A forward-looking clinical trial
• Utility of radioiodine (131 I) uptake and technetium (99m Tc) scans in evaluating thyroid function post-subtotal thyroidectomy for multinodular goitre
• Predicting laparoscopic cholecystectomy challenges using clinical and ultrasonographic criteria
• A prospective, randomized clinical comparison of phytotherapy and potassium citrate in managing mild renal stone disease
• Diagnostic laparoscopy role evaluation in nonspecific abdominal pain patients and its correlation with clinical and imaging findings
• Clinical outcome assessment of laparoscopic anterior partial fundoplication for gastroesophageal reflux disease (GERD)
• Efficacy comparison of ultrasonically activated scalpel (harmonic scalpel)® vs electrocautery in gallbladder removal from the gallbladder bed Role of diagnostic modalities in assessment of Solitary thyroid nodule and management.
• Impact of open tension-free bilateral mesh inguinal hernioplasty on vas deferens functionality
• A comparative study of preservation vs division of ilioinguinal iliohypogastric, and genital nerves during lichenstein hernioplasty.
• A prospective clinical study of acute intestinal obstruction.
• A prospective clinical study of duodenal perforation.
• A prospective clinical study & management of umbilical & para umbilical hernia in adults.
• A prospective clinical study on mass in the right iliac fossa.
• A prospective clinical study of acute appendicitis and evaluation of Alvardo score in the diagnosis”.
• A prospective study on management protocols of lump breast depending on FNAC-excision biopsy and its histopathological correlation.
• A prospective clinical study on gastro intestinal perforation.
• A prospective clinical study on benign thyroid swellings”.
• A prospective clinical study and management of incisional hernia.
• A prospective clinical study of acute peritonitis”.
• A prospective clinical study of benign breast disorders”.
• A prospective clinical study of efficacy of band ligation in the treatment of second-degree haemorrhoids”.
• A prospective clinical study and management of blunt trauma abdomen”.
• A prospective clinical evaluation and management of cholelithiasis”.
• A prospective clinical study and management of varicose veins in the lower limb”.
• Acute intestinal obstruction in adults”
• Comparative study of anatomical repair and lichenstein repair for inguinal hernia.
• Different strategies ( i.v. Lidocaine & gum feeding ) to shorten post surgical ileus — A prospective study.”
• Hyperbilirubinemia and crp as predictors of appendiceal gangrene / perforation — A prospective study
• A clinical study on duodenal perforation”
• A clinical study and different modalities of treatment in ventral hernias.
• Clinico-etio-pathological study of liver abscess.
• Clinical study of acute appendicitis with ference to clinical presentation, treatment and follow up.
• A randomized case control clinical trial to compare antibiotic versus normal saline instillation into the peritoneum in the management of secondary peritonitis.”
• Efficacy of fine needle aspiration cytology in the pathological diagnosis of solitary thyroid nodule.
• Comparative study of laparoscopic and open cholecystectomy for symptomatic stone diseases.
• A prospective study of incidence of malignancy in multi nodular goiters.”
• Evaluation and management of diabetic foot according to wagner’s classification”
• Study on clinical presentation and various modalities of treatment of gall stone disease”
• A clinical study of conventional dressing in diabetic wounds”
• A clinical study of peritonitis
• A clinical study of benign breast disorders”
• A case study of 100 cases of acute abdomen excluding trauma cases with reference to epidemiology and management”
• A clinical study of acute appendicitis and evaluating alvarado score in diagnosis and treatment”.
• Utility of surgical apgar score in predicting post operative morbidity and mortality in general surgical procedures.
• A clinical study of resection and anastomosis of bowel in our surgical practice.
• Role of diagnostic laparoscopy for staging in abdominal malignancies .”
• Clinico pathological study of chronic cervical lymphadenopathy.
• Incidence of SSI in elective abdominal surgery.
• A prospective  comparative study of open vs laparoscopic appendicectomy.
• Study of clinical features & management of benign ulcers of the leg & foot.”
• A clinical study of abdominal wound dehiscence.”
• A clinical study of post operative complications of thyroidectomy.”
• A clinical study of hollow viscus perforation. “
• Port site infiltration and intra peritoneal injection of bupivacine vs conventional analgesics in controlling post operative pain following laparoscopic surgeries.”
• Effect of platelet rich plasma on wound healing of leg ulcers. ”
• The study of antibiotic prophylaxis in clean and clean contaminated surgical wounds .”
• Evaluation of upper abdominal pain by upper gastrointestinal endoscopy.”
• Accuracy of ultrasonography in acute and chronic abdominal conditions .”
• Comparative study of topical application of 2% diltiazem and lateral sphincterotomy of chronic fissure in ano. ”
• Clinico pathological study of salivary gland swellings.”
• Role of endoscopic iii ventriculostomy in the comprehensive management of hydrocephalus.”
• A comparative study of clinical findings, ultrasonography and histopathology in benign breast diseases.
• Comparative study between conservative dressings and dressings with papain – urea & silver colloid in case of skin ulcers.
• A case study on post — operative wound infections. “
• A comparative study of open vs laparoscopic hernia repair for umbilical and para umbilical hernia”.
• Evaluation of portsmouth — possum scoring system in assesing the surgical outcome in general surgery patients”.
• A study of uncomplicated inguinal hernia repair as a day care surgery”.
• A clinical study to correlate between cytological and histopathological findings in diagnosis of multinodular goitre”.
• Management   of lower limb varicose veins conservatively and surgically based on ceap classification”.
• Comparative study of stainless steel staples closure of skin wound versus 3.0 ethilon closure”.
• Prospective analysis of outcomes in elderly patients undergoing laparotomies for gastro intestinal causes”.
• Clinico pathological study and management of blunt trauma abdomen
• A comparative study of colostrum dressing versus convential dressing in wounds.
• Evaluation of Mannheim’s peritonitis index in patients with peritonitis due to hollow viscus perforation”.
• Comparative study  between intermittent & continous suturing in emergency laparotomy”.
• A clinical study comparing pdgf dressing and vac dressing in diabetic ulcer”.
• Clinical study and management of solitary thyroid nodules
• A comparative study   of stapler haemorhoidopexy  versus  open haemorrhoidectomy”.
• Clinical study and management of incisional hernia with mesh repair.
• A clinical study to determine pre-operative predictive factors for difficult laparoscopic cholecystectomy.
• A study of clinical profile and management of non-thyroidal neck swellings.
• A comparative study of serum cholesterol, biiirubin,phospate and calcium in patients with gail stone and normal persons”.
• A clinical study of pancreatitis due to gail stone disease.
• A evaluation of alvarado scoring in diagnosis of acute appendicitis and its correlation with histopathological and operative findings”.
• A clinical study of post operative complications of thyroidectomy.
• A comparative study of percutaneous cathater drainage vs percutaneous needle aspiration in the treatment of liver abscess in teretiary care center.
• A prospective study on factors affecting the outcome in bowel anastamosis in tertiary care center, asram,eluru”.
• An analytical study of clinicopathological and predictive factors in diagnosis, management and outcome in necrotising fascitis”.
• A comparative study of topical phenytoin vs normal saline dressing in the healing of chronic diabetic foot ulcers — a randomized control study”.
• A prospective study comparing the effectiveness of apache ii and mannheim peritonitis index in predecting the outcome in patients with perforative peritonitis”.
• A clinical study of various prognosis factors for better management of diabetic foot.
• Study of breast lumps in females upto 40 years of age.
• A study of patients of HIV presenting with surgical emergencies.
• Clinical study of splenk injury in abdominal trauma and its management.
• A study of abdominal lumps,diagnostic evaluation and operative correlation.
• Study of trauma outcome using the triss method at a tertiary care center.
• Comparison between RTS and GAP scoring systems to predict survival in patients of trauma. (Revised trauma score and Glasgow coma scale- age-pressure)
• A study of the correlation of pre-operative risk factors and complications occuring during and after laparoscopic procedures.
• Study of management of upper gastrointestinal malignancies.
• Clinicopathological study of small bowel and related mesenteric tumours.
• Clinicopathological study and management of breast cancer.
• Role of hyperbaric oxygen therapy in chronic non healing diabetic foot ulcers.
• Neo-adjuvant chemotherapy in locally advanced carcinoma of breast.
• Study of non-Traumatic lower limb amputations.
• A comparative study of three port versus four port techniques in laparoscopic cholecystectomy.
• A prospective study of the common bile duct status during laparoscopic cholecystectomy by using intraoperative cholangiogram.

Disclaimer!

There are many methods of sample size determination. It is one of the first hurdle when someone starts writing a thesis. I have tried to give simplest way of determination of sample size. You need to show the method to your PG teacher before you include this method in your thesis. First confirm from your PG teacher and then only proceed.

Home > FACULTIES > Surgery > SURGERY-ETD

Surgery Theses and Dissertations

This collection contains theses and dissertations from the Department of Surgery, collected from the Scholarship@Western Electronic Thesis and Dissertation Repository

Theses/Dissertations from 2023 2023

Malperfusion Syndrome in the Setting of Type A Aortic Dissection , Karama Yaslam Karama Bayamin

Use of Resting State Functional MRI and functional NIRS for Language Localization in Presurgical Evaluation of Children with Drug Resistant Epilepsy , Juan S. Bottan

A biomechanical comparison of a subacromial balloon spacer, superior capsular reconstruction, and a rigid subacromial spacer in a massive irreparable rotator cuff cadaveric model , Devin Ferguson

A Comparison of the Thulium Fiber Laser versus Holmium:YAG Laser Lithotripsy of Upper Urinary Tract Calculi: Preliminary Results of a Randomized Prospective Clinical Trial , Eduardo Gonzalez Cuenca

The Shared Contributions of the Capsule, Labrum, and Bone on the Suction Seal of the Hip , Alexander J. Hoffer

Remote assessment of finger joint range of motion: Validation of virtual techniques , Sasha G. Letourneau

Treatment of Blunt Cerebrovascular Injury - A Systematic Review and Meta-Analysis, Multicenter Retrospective Review, and Protocol for a Feasibility Randomized Controlled Trial , Jovana Momic

The changing landscape of orthopaedic surgery in Ontario: Where we are, where we have been, and where we are going. , Silvio Ndoja

Theses/Dissertations from 2022 2022

Breast Augmentation: The Current Landscape , Khalifa Sh. Al-Ghanim

The Biomechanical Effects of Glenoid and Humeral Lateralization on the Rotator Cuff Muscles in Reverse Total Shoulder Arthroplasty , Yousif Atwan

Hand Swelling after Hand and Wrist Surgery: An Evaluation of its Effects and Assessment of Feasibility of a Double Blinded, Randomized Controlled, Pilot Study: Tranexamic Acid in Hand And Wrist Surgery (THAW) Study , Kendrick Au

Biomechanical Characterization of Semi-Rigid Constructs and the Potential Effect on Proximal Junctional Kyphosis in the Thoracic Spine , Chloe Cadieux

Total Hip Arthroplasty in Young Patients , Aaron G. Chen

Development of a Novel Rodent Model of Radiation-Induced Implant Capsular Contracture , Tanya DeLyzer

Shockwave Lithotripsy of Upper Urinary Tract Calculi - Outcomes of a Multicentre International Prospective Observational Study , Fernanda C. Gabrigna Berto

The molecular landscape of early-stage breast cancer with lymph node metastasis , Farhad Ghasemi

Determination of the Protective Capacity of Hand Wraps in Combat Athletes Using Force Analysis , Eva M. Gusnowski

Severe lower extremity trauma in Ontario: A linked population-based analysis , Stephanie M. Kim

Topical Gentamicin and Vancomycin for Surgical Site Infection Prophylaxis in Patients 5. Undergoing High-Risk Vascular Surgery , Dominic LeBlanc

Comparison of Hip Navigation System Accuracy in Direct Anterior Approach , Jeremy Loh

Development of an On-Call Assessment Tool for Competency-Based Surgical Training , Eric C. Mitchell

The Impact of Frailty and Sarcopenia in Patients Undergoing Esophagectomy for Esophageal Cancer , Linda Chang Qu

Feasibility and Clinical Value of 3-Dimensional Myocardial Deformation Analysis by Computed Tomography in Transcatheter Aortic Valve Replacement Patients , Mohamad Rabbani

Decompression vs. Decompression and Fusion in Cauda Equina Syndrome Secondary to Massive Lumbar Disc Herniation , Ruheksh Raj

Radiographic Predictors of Functional Outcome in Degenerative Lumbar Spondylolisthesis Surgery , Patrick Thornley

The Role of Urinary Modulators in the Development of Infectious Kidney Stones , Brendan Wallace

Indocyanine Green Angiography in Pediatric Colorectal Surgery , Robin B. Wigen

Theses/Dissertations from 2021 2021

Exploring Methods for Improving Baseplate Fixation in Reverse Total Shoulder Arthroplasty , Sejla Abdic

The Antimicrobial Properties of Exogenous Copper in Human Synovial Fluid Against Staphylococcus aureus: An In-Vitro Study , Fernando Diaz Dilernia

Is there an increased risk of delirium among patients with overactive bladder treated with newer anticholinergic medication compared to a beta-3 agonist? , Khaled Ashraf Etaby

4DCT analysis of in-vivo carpal kinematics during FEM , Manisha R. Mistry

The impact of Quality-Based Procedures on radical prostatectomy outcomes in Ontario , Nickan Motamedi

The Effect of Obesity on Revision Total Knee Arthroplasty: Functional Outcome, Ninety-Day Costs, Reoperations, Readmissions and Cost-Effectiveness , Mohamad Nasser Eddine

PLeurodesis Using hypertonic Glucose administration to treat post-operative air leaks following lung resection surgery (PLUG): Phase I trial , Mehdi Qiabi

Biomechanical strategies to reduce subsidence in Posterior Lumbar Interbody Fusion procedures , Renan Jose Rodrigues Fernandes

Kinematics in Total Knee Arthroplasty , Allan Roy Sekeitto

Surgical Residency workload, perceptions and educational value: implications for competency- based medical education , Eric Walser

Theses/Dissertations from 2020 2020

Navigation and Patient Specific Instrumentation in Shoulder Arthroplasty , Joseph Cavanagh

Comparing Motion Outcomes in Salvage Procedures for Wrist Arthritis , Stacy Fan

Growth and Development Analysis of Unilateral Cleft Palate Patients at One, Five, and Ten Years , Katie Garland

The of Application of 3D-Printing to Lumbar Spine Surgery , Andrew J. Kanawati

Feasibility of Post-Operative Mobile Health Monitoring Among Colorectal Surgery Patients , Tanya Kuper

Ultrasound-Guided Resuscitation in Open Aortic Surgery - The AORTUS Trial , John H. Landau

Quadriceps Muscle Layer Thickness in Kidney Transplant Recipients: A Potential Measure of Frailty and Sarcopenia , Max A. Levine

Biomechanical analysis of Total Knee Arthroplasty performed on a 6 degree of freedom joint motion simulator linked to a virtual ligament model in mechanical and kinematic alignments , Jance McGale

Microorganisms in Presumed Aseptic Revision Hip and Knee Arthroplasty , Michael E. Neufeld

The effect of mTOR inhibitor rapamycin on a dietary Drosophila melanogaster model of calcium oxalate nephrolithiasis , Michael T. Pignanelli

Synergistic effects of Non Contact Induction Heating & Antibiotics on Staphylococcus aureus Biofilm , Rajeshwar Singh Sidhu

Lateral Subvastus Lateralis Versus Medial Parapatellar Approach for Total Knee Arthroplasty , Sahil Prabhnoor S. Sidhu

The Impact of Ethnicity and Immigration on Prostate Cancer Mortality in Canada , Noah Stern

Potential Use of Carbon Monoxide as a Non-Surgical Intervention in a Rat Model of Acute Compartment Syndrome , Patrick Qi Wang

The Examination of Expectations in Day-Surgery Patients and the Development of a Patient Satisfaction Questionnaire for Day-Surgery Patients , Tishara M. Wijayanayaka

Theses/Dissertations from 2019 2019

Post-Operative Analgesia Following Total Knee Arthroplasty: A Randomized Controlled Trial Comparing Regional Techniques , James H. Allen

Radial Head Stability in Anterior Monteggia Injuries: An In Vitro Biomechanical Study , Armin Badre

Examining the Relationship between Urinary Pathogens, Antibiotic Exposure and Urolithiasis , Jennifer Bjazevic

The Impact of Scaphoid Malunion on Wrist Kinematics & Kinetics: A Biomechanical Investigation , Spencer B. Chambers

Biomechanics Analysis of Anterior Cortical Perforation in Antegrade Femoral Nailing , Michael Ching

Academic Center Tiered Operating Room Strategy (ACTION): Comparing a High Efficiency OR to the Conventional OR , Moaz Bin Yunus Chohan

The Standardization Of Outpatient Procedure (STOP) Narcotics: A Prospective Non-Inferiority Study To Reduce Opioid Use In Outpatient General Surgical Procedures , Luke B. Hartford

VOice analysis with Iphones: a low Cost Experimental Solution , Benjamin van der Woerd

Theses/Dissertations from 2018 2018

Design, development, manufacturing and biomechanical testing of Stand-alone cage for posterior lumbar interbody fusion , Fahad Alhelal

Cost effectiveness of bilateral prophylactic mastectomy with and without different breast reconstruction techniques versus screening in women with high risk of breast cancer in the Canadian province of Ontario , badria Aljohani

The Impact of Free Radical Stabilization Techniques on In Vivo Property Changes in Highly Cross-Linked Polyethylene Acetabular Liners , Michael M. Decker .

Revision Total Knee Arthroplasty using a Novel 3D Printed Titanium Augment: A Cadaveric Biomechanical Study , Charles-Antoine Dion

Evaluation of Perioperative Peripheral Nerve Injury in Cardiac Surgery Using a Novel Automated SSEP Monitoring Device , Satoru Fujii

Collared Vs. Collarless Total Hip Arthroplasty In Both Direct Anterior And Direct Lateral Approach Surgery: A Prospective Cohort Comparison Study , Seb Heaven

A Randomized Controlled Trial of a Modified Cystoscopy Technique , Khalil Hetou

Investigating the pathogenesis of Staphylococcus aureus in periprosthetic joint infections , Santiago L. Iglesias

Acromial Insufficiency Fractures in Reverse Total Shoulder Arthroplasty: A Biomechanical Study , Alicia Kerrigan

Oncoplastic Surgery: Is It Time to Change? From Innovation to Adoption Using Mentorship Program , Eman Khayat

The Effects of Tracheal Occlusion on Wnt Signaling in a Rabbit Model of Congenital Diaphragmatic Hernia , Martina M. Mudri

Choice of implant filler in breast reconstruction: A study of the cost-effectiveness of saline and silicone implants , Kathleen Nelligan

Tibiotalar arthrodesis: development of a novel jig and alignment guide , Adam Mathew Ropchan

The Effect of Function-blocking RHAMM Peptides in a Mouse Model of Bleomycin-induced Systemic Sclerosis , Kitty Y. Wu

Aggregate morbidity and mortality of defunctioning loop ileostomy fro formation to closure: a large population retrospective cohort analysis , Mei Yang

Theses/Dissertations from 2017 2017

The Drosophila melanogaster model of human uric acid nephrolithiasis as a novel in vivo drug screening platform , Aymon N. Ali

Triple Positive Microparticles as a “Liquid Biopsy” for Risk Stratification of Prostate Cancer , Harmenjit Singh Brar

Prostate Cancer Microparticles in Men Undergoing Radical Prostatectomy , Malcolm James Dewar

The Effect of Radial and Ulnar Length Change on Distal Forearm Loading , Ahaoiza D. Isa

Bio-modulation of Primary Human Tenon’s Capsule Fibroblasts Using a Novel Application of Coated Magnesium , Xiangji LI

UNDERSTANDING TRANSITION INTO PRACTICE AFTER POST GRADUATE MEDICAL EDUCATION IN SURGICAL SPECIALTIES , Mohammed M. Malak

Resiliency in the Operating Room: Exploring Trainee Stress During Surgery and the Role of Individual Resilience , Richard Ng

Comparing Mid Lumbar Interbody Fusion (MIDLF) with Traditional Posterior Lumbar Interbody Fusion (PLIF) , Joel T. Phillips

Cost Effectiveness of Primary Total Hip Arthroplasty for Varying Levels of BMI , Karthikeyan E. Ponnusamy

Mechanical Properties of Retrieved Highly Cross-linked Polyethylene Acetabular Liners in Total Hip Arthroplasty , Gurpreet Singh

A Biomechanical Study Examining The Subacromial Balloon Spacer and Superior Capsular Reconstruction in the Treatment of Massive, Irreparable Rotator Cuff Tears , Supriya Singh

Combat Vascular Trauma: From Characterization to Innovation , Shane A. Smith

Effect of Carbon Monoxide-Releasing Molecule-3 on the Severity of Endothelial Dysfunction Due to Elevation of Hydrostatic Pressure in an In Vitro Model of Compartment Syndrome , Michel A. Taylor

The Promotion of Adipogenesis in a Rat Model of Radiation-Induced Mammary Fat Pad Fibrosis , Jessica Truong

Theses/Dissertations from 2016 2016

Physiological and psychological responses of surgeons and trainees , Sarantis Abatzoglou

The Effect of the GekoTM Device on Post Kidney and Pancreatic Transplantation Leg Edema , Bijad Alharbi

The Development Of Novel Imaging Modalities & High-throughput Drug Screening Platforms In The Drosophila Melanogaster Model of Human Calcium Oxalate Nephrolithiasis , Sohrab Naushad Ali

Physical Activity Levels in Total Hip Arthroplasty Comparing the Direct Anterior Approach to the Direct Lateral Approach: A Prospective Cohort Study , Abdulaziz N. Aljurayyan

Paediatric Surgical Outcomes Across Ontario , Damian Dylkowski

Early experimental results of using a novel delivery carrier, Hyaluronan-phosphatidylethanolamine (HA-PE) which may allow simple bladder instillation of Botulinum Toxin A as effectively as direct detrusor muscle injection. , Mohamed G. El Shatoury

The Role of Scapular Morphology in Reverse Shoulder Arthroplasty , Ashish Gupta

Evaluating the Effects of Patellofemoral Offset Changes and Trochlear Design in Total Knee Arthroplasty: A Radiographic, Visual, and Topographical Analysis , Jacob Matz

Intra-abdominal Hypertension and Abdominal Compartment Syndrome , Patrick B. Murphy

Acute Kidney Injury Biomarkers: A Prospective Cohort Study In Urological Patients , Daniel Olvera-Posada

The impact of surgical technique on coronal plane motion in total knee arthroplasty , Kevin I. Perry

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• January 2, 2024 Issue
• Access Expert-Led Panel Se...

Hot Topics in General Surgery, Opioids for Surgical Pain, and More Sessions Are Available to Watch with Clinical Congress On Demand

January 2, 2024

Clinical Congress 2023 offered nearly 100 expert-led Panel Sessions to share the latest in surgical education, and these sessions remain available online through the Clinical Congress 2023 on-demand platform that is open to all in-person and virtual attendees, as well as new registrants. Check out some of these popular sessions from Clinical Congress 2023 and claim CME by May 1.

Ten Hot Topics in General Surgery

This popular annual session provides brief presentations by experts in general surgery who discuss a specific topic in a rapid-fire format. ACS Immediate Past-President E. Christopher Ellison, MD, FACS, and Regent Kenneth W. Sharp, MD, FACS, moderated the wide-ranging session, which included presentations on:

• Repair of Paraesophageal Hiatal Hernias—Add a Fundoplication or Not? Kelly Haisley, MD, FACS
• Peritoneal Dialysis Catheters—Tips and Tricks Nelson, MD, FACS
• Transanal Mesorectal Excision for Rectal Cancer Patricia Sylla, MD, FACS
• Glucagon-like Peptide-1 (GLP-1) Agonists—The End of Bariatric Surgery? Matthew D. Spann, MD, FACS
• Perforated Duodenal Ulcers: Close or Patch—And How? Jon C. Gould, MD, FACS
• Biliary Dyskinesia—Why Are We Still Debating This? Bryan K. Richmond, MD, MBA, FACS
• Appendiceal Carcinoma: Decision-Making for the General Surgeon Matthew F. Kalady, MD, FACS
• Transoral Thyroidectomy William B. Inabnet III, MD, MHA, FACS
• Surgical Rib Fixation in Trauma—Who and When? Brian J. Daley, MD, FACS
• Choosing Wisely—Management of the Axilla in Women over 70 with Breast Cancer Kelly C. Hewitt, MD, FACS

After reviewing the session, ACS First Vice-President Tyler Hughes, MD, FACS, said: “Minute for minute, probably the best use of time for the broad-based surgeon. Super talks on paraesophageal hernia, great tips on peritoneal dialysis catheters, GLP1 Agonists and bariatric surgery and much more. Some of these address little things like how to determine if a PD catheter is going to work well while one puts it in and big things like how to deal with an unexpected appendiceal carcinoma.”

The Great Debates - Biliary and Hernia

This inaugural Pro/Con debate covers two common topics faced by general surgeons: percutaneous cholecystostomy versus cholecystectomy for acute cholecystitis and open versus minimally invasive surgery repair for inguinal hernia. Experts in their respective techniques held a spirited discussion that provided informed perspective based on personal experience and a review on current literature.

Surgical Pain Management in the Setting of the Opioid Epidemic

Prescribing practices in surgery and societal expectations for post-operative pain management have been implicated in the opioid epidemic that has resulted in significant adverse effects related to opioid exposure and use throughout the US. However, inadequate pain management is a concern, particularly when treating patients with preexisting opioid use disorder, including those on medication assisted treatment. The ability to safely and effectively prescribe opioids and identify and mitigate high risk prescribing events is a core competency.

This panel brings together experts from diverse perspectives to provide best practice recommendations for pain and opioid management in a variety of surgical contexts, including acute, perioperative, and end-of-life scenarios. Panelists offer perspectives on multiple levels including augmenting surgical providers’ attitudes and skills in accordance with Centers for Disease Control and Prevention guidance, improving management of patient knowledge and expectations, and engineering of surgical systems and programs for safe and effective opioid use.

Dr. Hughes also raved about this session: “I tuned in because, you know, I had to for my Kansas state license requirements; but it was riveting and much more useful than a lot of pain talks I've attended. The talk on marijuana and pain was really good. I was surprised that chronic marijuana users actually experience more pain and anxiety after surgery... All the talks in the session were very good, but perhaps the most important for me was the last talk by Dr. Elizabeth Lilley on nociplastic and total pain. Since I didn't know much about these newer areas of studies, I assume many surgeons may an unfamiliar with them. Here she explains the entire picture of pain in about 20 minutes very well and those concepts are immediately useful to you tomorrow when you see your next patient. Just superb.”

There is much more to learn through the on-demand platform. Start watching today!

In This Issue

Take Advantage of Early Bird Discount for ACS Cancer Conference by Friday

Join Cancer Program leaders and your peers in Austin, Texas, for 3 days of learning, interaction, and networking at the 2024 ACS Cancer Conference.

US Resident Members: Apply for Leadership & Advocacy Summit Resident Travel Award

The ACS will again be offering a limited number of scholarships to US-based Resident Members of the College who are interested in attending the upcoming Leadership & Advocacy Summit.

Nominations Are Open for ACS Officers-Elect, Regent Positions

Nominations will be accepted through February 16, 2024, for seven leadership positions in the College.

Current Literature

Commentaries summarizing important new scientific literature pertinent to surgeons and care teams.

Xenotransplantation Expert Discusses History, Present, and Future of the Field

The John H. Gibbon Jr. Lecture at Clinical Congress 2023 featured Dr. Bartley Griffith discussing his experiences in xenotransplantation.

View the Most Popular Articles from JACS in 2023

Lessons from the war in Ukraine, modern yield of staging laparoscopy for pancreatic cancer, and whole blood resuscitation were topics of the three most popular articles published in the Journal of the American College of Surgeons (JACS) in 2023.

Register for Residents as Teachers and Leaders Course

Registration is open for the annual ACS Residents as Teachers and Leaders Course, which will be held on February 23–25, 2024, at ACS Headquarters in Chicago.

Nominate Your Altruistic Peers for 2024 ACS/Pfizer Surgical Volunteerism and Humanitarian Awards

Elevate passion, diversity, and dedication to service by nominating your peers in the ACS community.

Researcher Discusses Conflicts of Interest in Robotic GI Surgery Studies

Five author videos are available from the January 2024 issue of the Journal of the American College of Surgeons.

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Energy expenditure related biomarkers following bariatric surgery: a prospective six-month cohort study

Mitochondria dysfunction is one of the major causes of insulin resistance, and other countless complications of obesity. PGC-1α, and UCP-2 play key roles in energy expenditure regulation in the mitochondrial t...

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Unveiling the hidden: identification and management of overlooked blood vessels in laparoscopic left hemicolectomy for splenic flexure cancer

During laparoscopic left hemicolectomy procedures, a previously overlooked consistently thick blood vessel within the gastrocolic ligament near the splenic hilum may contribute to post-operative bleeding compl...

Comparison of endoscopic thyroidectomy via the oral vestibule approach and the areola approach for papillary thyroid carcinoma

The endoscopic thyroidectomy areola approach (ETAA) has been widely applied for papillary thyroid carcinoma (PTC), but leaves scars and is not truly minimally invasive. The oral vestibular approach (ETOVA) lea...

Feasibility and efficacy of minimally invasive limited resection for primary duodenal gastrointestinal stromal tumors: a retrospective cohort study

The primary duodenal gastrointestinal stromal tumor (GIST) is a rare type of gastrointestinal tract tumor. Limited resection (LR) has been increasingly performed for duodenal GIST. However, only a few studies ...

Does the coronoid fracture in terrible triad injury always need to be fixed?

The ideal treatment of terrble triad injuries and whether fixation of coronoid process fractures is needed or not are still debated. Therefore, we aimed to investigate if terrible triad injuries necessitate co...

Incidentally found parotid gland lesion in 18 F-FDG PET/CT for staging evaluation of patients with hepatocellular carcinoma: remote possibility of metastatic tumor or second primary salivary gland malignancy

We primarily aimed to evaluate whether parotid incidental lesion (PIL) in 18 F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18 F-FDG PET/CT) for staging evaluation of patients with hepatocel...

Modified Q-type purse-string suture duodenal stump embedding method for laparoscopic gastrectomy for gastric cancer

This study introduced the modified Q-type purse-string suture duodenal stump embedding method, a convenient way to strengthen the duodenum, and compared it to the conventional one to assess its efficacy and sa...

Efficacy and safety of fibrin sealant application in patients undergoing thyroidectomy: a systematic review and meta-analysis

Various studies have focused on the application of fibrin sealants (FS) in thyroid surgery. Utilizing a meta-analysis, this systematic review analyzed the findings of recent randomized controlled trials on the...

Retrospective analysis of the incidence of appendiceal neoplasm and malignancy in patients treated for suspected acute appendicitis

Nonoperative management of uncomplicated appendicitis is currently being promoted as treatment option, albeit 0.7–2.5% of appendectomies performed due to suspected acute appendicitis show histologically malign...

Fully endoscopic approach for resection of brainstem cavernous malformations: a systematic review of the literature

Brainstem cavernous malformations (BCMs) are benign lesions that typically have an acute onset and are associated with a high rate of morbidity. The selection of the optimal surgical approach is crucial for ob...

Application and effect of tension-reducing suture in surgical treatment of hypertrophic scar

To investigate the application and effectiveness of tension-reducing suture in the repair of hypertrophic scars.

Application of pocket-first technique for implantation of totally implantable venous access ports

While vascular puncture is always performed before making port pocket in the implantation of totally implantable venous access ports (TIVAP), some surgeons preferred to make port pocket first. This study seeks...

Clinical application of indocyanine green fluorescence navigation technique in laparoscopic common bile duct exploration for complex hepatolithiasis

This study investigated the clinical application of the indocyanine green (ICG) fluorescence navigation technique in bile duct identification during laparoscopic common bile duct exploration (LCBDE) for comple...

Prognostic value of combined psoas muscle mass and controlling nutritional status in patients with pancreatic ductal adenocarcinoma: a retrospective cohort study

Pancreatic ductal carcinoma (PDAC) is an extremely poor prognostic disease. Even though multidisciplinary treatment for PDAC has developed, supportive therapies, such as nutritional therapy or perioperative re...

Comparison of three frailty scales for prediction of prolonged postoperative ileus following major abdominal surgery in elderly patients: a prospective cohort study

To determine whether frailty can predict prolonged postoperative ileus (PPOI) in older abdominal surgical patients; and to compare predictive ability of the FRAIL scale, the five-point modified frailty index (...

Perioperative mortality rate and its predictors after emergency laparatomy at Debre Markos comprehensive specialized hospital, Northwest Ethiopia: 2023: retrospective follow-up study

Emergency laparatomy is abdominal surgery associated with a high rate of mortality. There are few reports on rates and predictors of postoperative mortality, whereas disease related or time specific studies ar...

Transforaminal endoscopic lumbar discectomy with two-segment foraminoplasty for the treatment of very highly migrated lumbar disc herniation: a retrospective analysis

The surgical resection of very highly migrated lumbar disc herniation (VHM-LDH) is technically challenging owing to the absence of technical guidelines. Hence, in the present study, we introduced the transfora...

A new dressing system for accelerating wound recovery after primary total knee arthroplasty: a feasibility study

Currently, postoperative wound infection and poor healing of total knee arthroplasty have been perplexing both doctors and patients. We hereby innovatively invented a new dressing system to reduce the incidenc...

Body composition assessment by artificial intelligence can be a predictive tool for short-term postoperative complications in Hartmann’s reversals

Hartmann's reversal, a complex elective surgery, reverses and closes the colostomy in individuals who previously underwent a Hartmann's procedure due to colonic pathology like cancer or diverticulitis. It dema...

Observed rates of surgical instrument errors point to visualization tasks as being a critically vulnerable point in sterile processing and a significant cause of lost chargeable OR minutes

The reporting of surgical instrument errors historically relies on cumbersome, non-automated, human-dependent, data entry into a computer database that is not integrated into the electronic medical record. The...

Single-port robotic-assisted laparoscopic synchronous surgery in pediatric patent processus vaginalis

Patent processus vaginalis (PPV) is usually observed in pediatric abdominal surgery; however, robotic single-port surgery in repairing processus vaginalis has not been reported in children. Herein, we present ...

Real-time imaging of ipsilateral parathyroid glands by retrograde injection of methylene blue into the superior thyroid artery: a new intraoperative parathyroid protection method

Postoperative hypoparathyroidism caused by parathyroid injury is a problem faced by thyroid surgeons. The current technologies for parathyroid imaging all have some defects.

The preliminary analysis of lymphatic flow around the connective tissues surrounding SMA and SpA elucidates patients’ oncological condition in borderline-resectable pancreatic cancer

In pancreatic ductal adenocarcinoma (PDAC), invasion of connective tissues surrounding major arteries is a crucial prognostic factor after radical resection. However, why the connective tissues invasion is ass...

A new technique for closure of pericardial defects: pericardial rug weave

Pericardial defect that occurs after intrapericardial pneumonectomy can cause many fatal complications, and closing the defect with mesh is a widely used surgical method to prevent these complications.

Does a novel 3D printed individualized guiding template based on cutaneous fiducial markers contribute to accurate percutaneous insertion of pelvic screws? A preliminary phantom and cadaver study

Most 3D-printed guiding templates require dissection of soft tissues to match the corresponding surfaces of the guiding templates. This study sought to explore the accuracy and acceptability of the novel 3D pr...

Widening of narrow urethral plates with lateral skin in TIP hypospadias repair: single center series

To compare the outcomes of hypospadias repair using tubularized incised plate (TIP) urethroplasty and modified TIP with lateral skin to widen the urethral plate (WTIP).

Application of double plate fixation combined with Masquelet technique for large segmental bone defects of distal tibia: a retrospective study and literature review

There is no effective consensus on the choice of internal fixation method for the Masquelet technique in the treatment of large segmental bone defects of the distal tibia. Thus, the study aimed to investigate ...

Modified technique of Hepatojejunostomy for biliary tract reconstruction after resection of tumors affecting the perihilar region: a case series

Radical resection is the most effective treatment for perihilar tumors. Biliary tract reconstruction after resection is one of the key steps in this surgery. Mucosa-to-mucosa cholangiojejunostomy is traditiona...

Which factors predict tumor recurrence and survival after curative hepatectomy in hepatocellular carcinoma? Results from a European institution

High tumor recurrence and dismal survival rates after curative intended resection for hepatocellular carcinoma (HCC) are still concerning. The primary goal was to assess predictive factors associated with dise...

The impact of preoperative nutritional status on postoperative outcomes: an insight from Geriatric Nutritional Risk Index in elderly pancreaticoduodenectomy patients

Malnutrition is not uncommon among the elderly undergoing pancreatoduodenectomy (PD) and is related to increased complications. Previous studies have shown that the Geriatric Nutritional Risk Index (GNRI) pred...

Ultrasound-guided percutaneous transhepatic one-step biliary fistulation combined with rigid choledochoscopy for recurrent hepatolithiasis

Percutaneous transhepatic one-step biliary fistulation (PTOBF) is used to treat choledocholithiasis and biliary stricture. This study aimed to evaluate the safety and efficacy of ultrasound-guided PTOBF combin...

Advancing laparoscopy in resource-limited settings

Although laparoscopic surgery has made remarkable progress and become the standard approach for various surgical procedures worldwide over the past 30 years, its establishment in low-resource settings, particu...

Diagnostic and therapeutic approach to abdominal masses in a country with limited resources

To report the diagnostic and therapeutic approach for the management of abdominal masses in the General Surgery department of the Niamey General Reference Hospital (HGR).

Anastomosis selection in liver transplantation for recipients with unusable recipient hepatic arteries: a bayesian network meta-analysis

The anastomosis of donor and recipient hepatic arteries is standard in liver transplantations. For transplant recipients with unusable hepatic arteries, appropriate artery selection should be conducted using e...

Essential surgery delivery in the Northern Kivu Province of the Democratic Republic of the Congo

Surgical services are an essential part of a functional healthcare system, but the Lancet Commission of Global Surgery (LCoGS) indicators of surgical capacity such as perioperative workforce and surgical volum...

Serum lactate normalization time associated with prolonged postoperative ileus after surgical management of the small bowel and/or mesenteric injuries

Back ground: Determining the optimal timing of postoperative oral feeding in trauma patients who have undergone abdominal surgery with small bowel and/or mesenteric injuries is challenging. The aim of this stu...

Cold EMR vs. Hot EMR for the removal of sessile serrated polyps larger than 10 mm: a systematic review and meta-analysis

Endoscopic mucosal resection (EMR) appears to be a promising technique for the removal of sessile serrated polyps (SSPs) ≥ 10 mm. To assess the effectiveness and safety of EMR for removing SSPs ≥ 10 mm, we con...

Interleukin-6 on postoperative day three as an early predictor of infections following laparoscopic gastric cancer resection

To investigate the role of C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) as early predictors of infectious complications after laparoscopic gastric cancer surgery.

U-shaped kirschner wire transfixation: effective treatment for Skier’s thumb

Skier’s thumb is a type of injury to the ulnar collateral ligament of the metacarpophalangeal joint of the thumb, which can result in bone fragmentation and joint instability.

Thickness of melanocytes in giant congenital melanocytic nevus for complete surgical excision: clinicopathological evaluation of 117 lesions according to the area and size

Giant congenital melanocytic nevi (GCMN) are usually defined as nevi that exceed 20 cm in maximal diameter or 15% of the total body surface area. There have been reports of life-long malignant change risks ari...

Predictive effect of the systemic inflammation response index (SIRI) on the efficacy and prognosis of neoadjuvant chemoradiotherapy in patients with locally advanced rectal cancer

Inflammation is a part of tumours, and inflammatory cells can affect the proliferation, invasion, and development of tumour cells. An increasing number of peripheral blood inflammatory markers have been found ...

Total intracorporeal laparoscopic ileal ureter replacement in a single position for ureteral stricture based on membrane anatomy

The aim of this study was to present our initial experience and prove the feasibility of total intracorporeal laparoscopic ileal ureter replacement (TILIUR) in a single position for ureteral stricture based on...

Outcomes after laparoscopic cholecystectomy in patients older than 80 years: two-years follow-up

The laparoscopic cholecystectomy is the treatment of choice for patients with benign biliary disease. It is necessary to evaluate survival after laparoscopic cholecystectomy in patients over 80 years old to de...

Comparison of the efficacy of neuronavigation-assisted intracerebral hematoma puncture and drainage with neuroendoscopic hematoma removal in treatment of hypertensive cerebral hemorrhage

To compare neuronavigation-assisted intracerebral hematoma puncture and drainage with neuroendoscopic hematoma removal for treatment of hypertensive cerebral hemorrhage.

Palliative primary tumor resection may not offer survival benefits for patients with unresectable metastatic colorectal neuroendocrine neoplasms, one multicenter retrospective cohort study

The efficacy of palliative primary tumor resection (PTR) in improving prognosis for patients with unresectable metastatic colorectal neuroendocrine neoplasms (NENs) has not been fully explored.

Outcomes of primary versus conversional Roux-En-Y gastric bypass after laparoscopic sleeve gastrectomy: a retrospective propensity score–matched cohort study

Conversional surgery is common after laparoscopic sleeve gastrectomy (LSG) because of suboptimal weight loss (SWL) or poor responders and gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB)...

Comparison of laparoscopic hepatectomy and percutaneous radiofrequency ablation for the treatment of small hepatocellular carcinoma: a meta-analysis

The purpose of this study was to compare the long-term outcomes of laparoscopic hepatectomy (LH) and percutaneous radiofrequency ablation (PRFA) for the treatment of small hepatocellular carcinoma.

Factors influencing the bariatric surgery treatment of bariatric surgery candidates in underdeveloped areas of China

From year to year, the proportion of people living with overweight and obesity in China rises, along with the prevalence of diseases linked to obesity. Although bariatric surgery is gaining popularity, there a...

TPP (totally preperitoneal) making single incision laparoscopic inguinal hernia repair more feasible: a comparison with single incision laparoscopic totally extraperitoneal hernioplasty (SIL-TEP)

Totally preperitoneal hernioplasty (TPP) is a concept which was introduced for distinguishing with totally extraperitoneal (TEP). There is few evidence reflecting the single incision laparoscopic totally prepe...

A prediction nomogram for perineural invasion in colorectal cancer patients: a retrospective study

Perineural invasion (PNI), as the fifth recognized pathway for the spread and metastasis of colorectal cancer (CRC), has increasingly garnered widespread attention. The preoperative identification of whether c...

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Key Topics in Surgical Research and Methodology

• © 2010
• Thanos Athanasiou 0 ,
• Haile Debas 1 ,
• Ara Darzi 2

Dept. Biosurgery & Surgical Technology, Imperial College London St. Mary's Hospital London, London, United Kingdom

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UCSF Global Health Sciences, San Francisco L, USA

Comprehensive textbook on key issues in surgical research and methodology

Valuable resource for surgeons at all levels embarking on an academic career

Includes supplementary material: sn.pub/extras

209k Accesses

43 Citations

4 Altmetric

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Table of contents (74 chapters)

Front matter, the role of surgical research.

• Omer Aziz, John G. Hunter

Evidence-Based Surgery

• Hutan Ashrafian, Nick Sevdalis, Thanos Athanasiou

The Role of the Academic Surgeon in the Evaluation of Healthcare Assessment

• Roger M. Greenhalgh

Study Design, Statistical Inference and Literature Search in Surgical Research

• Petros Skapinakis, Thanos Athanasiou

Randomised Controlled Trials: What the Surgeon Needs to Know

• Marcus Flather, Belinda Lees, John Pepper

Monitoring Trial Effects

• Hutan Ashrafian, Erik Mayer, Thanos Athanasiou

How to Recruit Patients in Surgical Studies

• Hutan Ashrafian, Simon Rowland, Thanos Athanasiou

Diagnostic Tests and Diagnostic Accuracy in Surgery

• Catherine M. Jones, Lord Ara Darzi, Thanos Athanasiou

Research in Surgical Education: A Primer

• Adam Dubrowski, Heather Carnahan, Richard Reznick

Measurement of Surgical Performance for Delivery of a Competency-Based Training Curriculum

• Raj Aggarwal, Lord Ara Darzi

Health-Related Quality of Life and its Measurement in Surgery – Concepts and Methods

• Jane M. Blazeby

Surgical Performance Under Stress: Conceptual and Methodological Issues

• Sonal Arora, Nick Sevdalis

How can we Assess Quality of Care in Surgery?

• Erik Mayer, Andre Chow, Lord Ara Darzi, Thanos Athanasiou

Patient Satisfaction in Surgery

• Andre Chow, Erik Mayer, Lord Ara Darzi, Thanos Athanasiou

How to Measure Inequality in Health Care Delivery

• Erik Mayer, Julian Flowers

The Role of Volume–Outcome Relationship in Surgery

• Erik Mayer, Lord Ara Darzi, Thanos Athanasiou

An Introduction to Animal Research

• James Kinross, Lord Ara Darzi

The Ethics of Animal Research

• Hutan Ashrafian, Kamran Ahmed, Thanos Athanasiou

Ethical Issues in Surgical Research

• Amy G. Lehman, Peter Angelos
• Evidnece systhesis
• Translational Research
• colorectal cancer
• general surgery
• methodology
• neurosurgery
• quality of life
• vascular surgery

About this book

Editors and affiliations, dept. biosurgery & surgical technology, imperial college london st. mary's hospital london, london, united kingdom.

Thanos Athanasiou, Ara Darzi

Haile Debas

Bibliographic Information

Book Title : Key Topics in Surgical Research and Methodology

Editors : Thanos Athanasiou, Haile Debas, Ara Darzi

DOI : https://doi.org/10.1007/978-3-540-71915-1

Publisher : Springer Berlin, Heidelberg

eBook Packages : Medicine , Medicine (R0)

Copyright Information : Springer-Verlag Berlin Heidelberg 2010

Hardcover ISBN : 978-3-540-71914-4 Due: 17 December 2009

Softcover ISBN : 978-3-662-51836-6 Published: 23 August 2016

eBook ISBN : 978-3-540-71915-1 Published: 28 February 2010

Edition Number : 1

Number of Pages : XXXI, 1019

Topics : Surgery , Gastroenterology , Endocrinology , Cardiac Surgery , Thoracic Surgery , Health Promotion and Disease Prevention

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Page 1 of 59

My anesthesia Choice-HF: development and preliminary testing of a tool to facilitate conversations about anesthesia for hip fracture surgery

Patients often desire involvement in anesthesia decisions, yet clinicians rarely explain anesthesia options or elicit preferences. We developed My Anesthesia Choice-Hip Fracture, a conversation aid about anest...

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Role of preoperative zinc, magnesium and budesonide gargles in Postoperative Sore Throat (POST) - a randomised control trial

Post-operative sore throat (POST) has an incidence ranging from 21 to 80%. To prevent the development of POST, several pharmacological measures have been tried. Aim of this study was to compare the efficacy of...

Effect of intravenous anesthetic drugs on fertilization rate in oocyte retrieval

The purpose of this study was to investigate the effects of intravenous anesthetic drugs on fertilization rate in subjects receiving oocyte retrieval by assisted reproduction technology (ART).

Lidocaine effects on neutrophil extracellular trapping and angiogenesis biomarkers in postoperative breast cancer patients with different anesthesia methods: a prospective, randomized trial

Anesthesia techniques and drug selection may influence tumor recurrence and metastasis. Neutrophil extracellular trapping (NETosis), an immunological process, has been linked to an increased susceptibility to ...

Predictive value of S100B and brain derived neurotrophic factor for radiofrequency treatment of lumbar disc prolapse

This work aimed to analyze serum S100B levels and brain-derived neurotrophic factor (BDNF) in patients with lumbar disc prolapse to test their predictive values concerning the therapeutic efficacy of pulsed ra...

Correction: Evaluation the quality of bag-mask ventilation by E/C, T/E and hook technique (a new proposed technique)

The original article was published in BMC Anesthesiology 2023 23 :384

Continuous serratus posterior superior intercostal plane block for postoperative analgesia management in the patient who underwent right atrial mass excision: a case report

Serratus posterior intercostal plane block (SPSIPB) is a novel periparavertebral block. It provides anterolateral posterior chest wall analgesia. It is an interfascial plane block, performed under ultrasound g...

Impact of sarcopenia in elderly patients undergoing elective total hip arthroplasty on postoperative outcomes: a propensity score-matched study

Frailty poses a crucial risk for postoperative complications in the elderly, with sarcopenia being a key component. The impact of sarcopenia on postoperative outcomes after total hip arthroplasty (THA) is stil...

Determinants of difficult laryngoscopy based on upper airway indicators: a prospective observational study

The main cause of anesthesia-related deaths is the failure to manage difficult airways. Difficult laryngoscopic exposure is a major cause of unsuccessful management of difficult airways. Inadequate preoperativ...

Erector spinae plane block did not improve postoperative pain-related outcomes and recovery after video-assisted thoracoscopic surgery : a randomised controlled double-blinded multi-center trial

There is a sizable niche for a minimally invasive analgesic technique that could facilitate ambulatory video-assisted thoracoscopic surgery (VATS). Our study aimed to determine the analgesic potential of a sin...

Optimizing nicardipine dosage for effective control of pituitrin-induced hypertension in laparoscopic myomectomy undergoing total intravenous anesthesia

This study aimed to determine the median effective dose (ED50) and 95% effective dose (ED95) of nicardipine for treating pituitrin-induced hypertension during laparoscopic myomectomy, providing guidance for th...

Perioperative serum syndecan-1 concentrations in patients who underwent cardiovascular surgery with cardiopulmonary bypass and its association with the occurrence of postoperative acute kidney injury: a retrospective observational study

Various factors can cause vascular endothelial damage during cardiovascular surgery (CVS) with cardiopulmonary bypass (CPB), which has been suggested to be associated with postoperative complications. However,...

Regional analgesia using ultrasound-guided intermediate cervical plexus block versus cervical erector spinae block for anterior cervical spine surgery: a randomized trial

Regional analgesia techniques are crucial for pain management after cervical spine surgeries. Anesthesiologists strive to select the most effective and least hazardous regional analgesia technique for the cerv...

Comparison of bicarbonate Ringer’s solution with lactated Ringer’s solution among postoperative outcomes in patients with laparoscopic right hemihepatectomy: a single-centre randomised controlled trial

The study was aimed to investigate the positive impact of bicarbonate Ringer’s solution on postoperative outcomes in patients who underwent laparoscopic right hemihepatectomy. Patients in the two groups were i...

Effect of converting from propofol to remimazolam with flumazenil reversal on recovery from anesthesia in outpatients with mental disabilities: a randomized controlled trial

General anesthesia is often necessary for dental treatment of outpatients with mental disabilities. Rapid recovery and effective management of postoperative nausea and vomiting (PONV) are critical for outpatie...

Double lumen endobronchial tube intubation: lessons learned from anatomy

Double lumen endobronchial tubes (DLTs) are frequently used to employ single lung ventilation strategies during thoracic surgical procedures. Placement of these tubes can be challenging even for experienced cl...

50% efficacy dose of intravenous lidocaine in supressing sufentanil-induced cough in children: a randomised controlled trial

Opioids such as sufentanil are used as anaesthetics due to their rapid action and superior analgesic effect. However, sufentanil induces a huge cough in paediatric patients. In contrast, intravenous (IV) lidoc...

Profound hypoxemia and hypotension during posterior spinal fusion in a spinal muscular atrophy child with severe scoliosis: a case report

Anesthesia for spinal muscular atrophy (SMA) patients undergoing spinal deformity surgery is challenging. We report an unusual case of an SMA girl who developed severe intraoperative hypoxemia and hypotension ...

Application of propofol-remifentanil intravenous general anesthesia combined with regional block in pediatric ophthalmic surgery

The aim of this study is to observe the anesthetic effect and safety of intravenous anesthesia without muscle relaxant with propofol-remifentanil combined with regional block under laryngeal mask airway in ped...

Continuation of chronic antiplatelet therapy is not associated with increased need for transfusions: a cohort study in critically ill septic patients

The decision to maintain or halt antiplatelet medication in septic patients admitted to intensive care units presents a clinical dilemma. This is due to the necessity to balance the benefits of preventing thro...

The potentiating effect of intravenous dexamethasone upon preemptive pudendal block analgesia for hypospadias surgery in children managed with Snodgrass technique: a randomized controlled study

Evidence regarding the potentiating effects of intravenous dexamethasone on peripheral regional anesthesia in children is sparse. The objective of the current study was to investigate the potentiating effect o...

The efficacy and safety of perioperative glucocorticoid for total knee arthroplasty: a systematic review and meta-analysis

An increasing number of individuals undergo total knee arthroplasty (TKA), which can result in pain, limited motor function and adverse complications such as infection, nausea and vomiting. Glucocorticoids hav...

Anesthesia management for a child with the Koolen-de Vries syndrome: a case report

The Koolen-de Vries syndrome (KdVS) is a relatively new rare disease caused by micro-deletion of 17q21.31 which was first reported by Koolen in 2006. Typical phenotypes for KdVS include hypotonia, developmenta...

A novel combined approach to placement of a double lumen endobronchial tube using a video laryngoscope and fiberoptic bronchoscope: a retrospective chart review

The objective of this study was to evaluate a modern combined video laryngoscopy and flexible fiberoptic bronchoscope approach to placement of a double lumen endobronchial tube and further characterize potenti...

Retraction Note: Dose selection of central or peripheral administration of sufentanil affect opioid induced cough?: a prospective, randomized, controlled trial

This article has been retracted. Please see the Retraction Notice for more detail: https://doi.org/10.1186/s12871-024-02522-9.

One-year survival of aneurysmal subarachnoid hemorrhage after airplane transatlantic transfer – a monocenter retrospective study

Aneurysmal subarachnoid hemorrhage (aSAH) is preferentially treated by prompt endovascular coiling, which is not available in Guadeloupe. Subsequently, patients are transferred to Paris, France mainland, by co...

Association between serum calcium and prognosis in patients with acute ischemic stroke in ICU: analysis of the MIMIC-IV database

While serum Ca has proven to be a reliable predictor of mortality across various diseases, its connection with the clinical outcomes of ischemic stroke (IS) remains inconclusive. Our research aimed to explore ...

Effect of subclavian vein diameter combined with perioperative fluid therapy on preventing post-induction hypotension in patients with ASA status I or II

Perioperative hypotension is frequently observed following the initiation of general anesthesia administration, often associated with adverse outcomes. This study assessed the effect of subclavian vein (SCV) d...

Ultrasound-guided stellate ganglion block benefits the postoperative recovery of patients undergoing laparoscopic colorectal surgery: a single-center, double-blinded, randomized controlled clinical trial

With the increasing prevalence of colorectal cancer (CRC), optimizing perioperative management is of paramount importance. This study investigates the potential of stellate ganglion block (SGB), known for its ...

Machine learning approach for predicting post-intubation hemodynamic instability (PIHI) index values: towards enhanced perioperative anesthesia quality and safety

Adequate preoperative evaluation of the post-intubation hemodynamic instability (PIHI) is crucial for accurate risk assessment and efficient anesthesia management. However, the incorporation of this evaluation...

Timing of early water intake post-general anaesthesia: a systematic review and meta-analysis

Early water intake has gained widespread attention considering enhanced recovery after surgery (ERAS). In the present systematic evaluation and meta-analysis, we assessed the effects of early water intake on t...

Effect of epidural dexmedetomidine in single-dose combined with ropivacaine for cesarean section

Dexmedetomidine has arousal sedation and analgesic effects. We hypothesize that epidural dexmedetomidine in single-dose combined with ropivacaine improves the experience of parturient undergoing cesarean secti...

Laparoscopic assisted versus ultrasound guided transversus abdominis plane block in laparoscopic bariatric surgery: a randomized controlled trial

Transversus abdominis plane block (TAPB) guided by laparoscopy and ultrasound showed promise in enhancing the multimodal analgesic approach following several abdominal procedures. This study aimed to compare t...

Super-refractory status epilepticus, rhabdomyolysis, central hyperthermia and cardiomyopathy attributable to spinal anesthesia: a case report and review of literature

There are only six past reports of super-refractory status epilepticus induced by spinal anesthesia. None of those patients have died. Only < 15 mg of bupivacaine was administered to all six of them and to our...

Analysis of influencing factors and construction of prediction model for postoperative nausea and vomiting in patients undergoing laparoscopic sleeve gastrectomy: a single-center retrospective cohort study

With the increasing number of bariatric surgeries, the high incidence of postoperative nausea and vomiting (PONV) associated with this surgery has also gradually attracted attention. Among the common bariatric...

Skin mottling score assesses peripheral tissue hypoperfusion in critically ill patients following cardiac surgery

Skin mottling is a common manifestation of peripheral tissue hypoperfusion, and its severity can be described using the skin mottling score (SMS). This study aims to evaluate the value of the SMS in detecting ...

Incidence and factors associated with failed spinal anaesthesia among patients undergoing surgery: a multi- center prospective observational study

Failed spinal anaesthesia causes prolonging of operation time, insufficient analgesia for surgery and needs repeating spinal anaesthesia which in turn causes local anaesthesia toxicity, high spinal and total s...

Echocardiographic features of right ventricle in septic patients with elevated central venous pressure

Elevated central venous pressure (CVP) is deemed as a sign of right ventricular (RV) dysfunction. We aimed to characterize the echocardiographic features of RV in septic patients with elevated CVP, and quantif...

Sex differences in pain catastrophizing and its relation to the transition from acute pain to chronic pain

Differences exist between sexes in pain and pain-related outcomes, such as development of chronic pain. Previous studies suggested a higher risk for pain chronification in female patients. Furthermore, pain ca...

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AIRWAY MANAGEMENT

Obesity and increased risk of perioperative cardiac arrest (March 2024)

Obesity is a risk factor for difficulty with airway management and for rapid apneic oxygen desaturation during airway management. Both can result in hypoxic brain damage or death. In an analysis of causes of perioperative cardiac arrest reported to the Seventh National Audit Project (NAP7) in the United Kingdom, 35 percent of airway- and respiratory-related cardiac arrests occurred in patients with body mass index 35 to 50 kg/m 2 , while this cohort comprised only 12 percent of the survey population [ 1 ]. These findings reinforce the need to consider obesity when choosing general versus regional anesthesia and planning the airway management strategy. (See "Airway management for induction of general anesthesia", section on 'Obesity as a risk factor' .)

CARDIOVASCULAR AND THORACIC ANESTHESIA

Moderate hypothermia during aortic arch surgery with antegrade cerebral perfusion (March 2024)

Observational data have supported a shift from deep to moderate hypothermia during circulatory arrest for aortic arch surgery, particularly with adjunctive antegrade cerebral perfusion (ACP). A recent trial has now compared outcomes for 251 patients undergoing aortic arch surgery with ACP and randomly assigned to deep (≤20.0°C), low-moderate (20.1 to 24.0°C), or high-moderate (24.1 to 28.0°C) circulatory arrest temperature [ 2 ]. At one-month follow-up, the three groups had similar neurocognitive and neuroimaging outcomes and similar mortality, major morbidity, and quality of life. The volume of transfused blood products was higher in the deep group, but transfusion-related complications were not different. Based on this trial, moderate (20.1 to 28.0°C) rather than deep hypothermia is reasonable during aortic arch surgery when ACP is also used. Whether a low-moderate or high-moderate temperature is selected depends on the complexity of the arch intervention and the anticipated duration of hypothermia. (See "Overview of open surgical repair of the thoracic aorta", section on 'Hypothermic circulatory arrest' .)

OBSTETRIC ANESTHESIA

Labor epidural analgesia and risk of emergency delivery (December 2023)

It is well established that contemporary neuraxial labor analgesia does not increase the overall risk of cesarean or instrument-assisted vaginal delivery. However, a new retrospective database study of over 600,000 deliveries in the Netherlands reported that epidural labor analgesia was associated with an increased risk of emergency delivery (cesarean or instrument-assisted vaginal) compared with alternative analgesia (13 versus 7 percent) [ 3 ]. Because of potential confounders and lack of detail on epidural and obstetric management, we consider these data insufficient to avoid neuraxial analgesia or change the practice of early labor epidural placement to reduce the potential need for general anesthesia in patients at high risk for cesarean delivery. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the progress and outcome of labor' .)

PATIENT SAFETY

Use of a formal handoff tool during intraoperative transfer of anesthetic care (March 2024)

Intraoperative handoffs of care from one anesthesia provider to another have been associated with adverse outcomes, possibly due to inadequate communication of clinical information. A retrospective study noted that an intraoperative handoff (defined as transfer of care lasting more than 35 minutes) occurred in 40 percent of approximately 120,000 noncardiac surgical cases performed from 2016 to 2021 [ 4 ]. Adverse outcomes (defined as a composite of postoperative mortality or major morbidity) occurred more often when a handoff occurred (7.2 versus 6.2 percent with no handoff). After implementation of a structured electronic handoff tool in 2019, a correlation over time was noted between increased handoff tool usage and decreased likelihood of the composite adverse outcome. We use a formal handoff protocol during all phases of perioperative care. (See "Handoffs of surgical patients", section on 'Use of a formal handoff procedure' .)

PEDIATRIC ANESTHESIA

New guidelines for airway management in infants (January 2024)

Very young children are at higher risk of complications of airway management than children in older age groups; however, guidelines for infants have been lacking. In 2024, the European Society of Anesthesiology and Intensive Care and the British Journal of Anesthesia published joint guidelines for airway management in neonates and infants [ 5 ]. A summary of their recommendations appears in the following table ( table 1 ). (See "Airway management for pediatric anesthesia", section on 'Pediatric airway management guidelines' .)

Videolaryngoscopy for endotracheal intubation in critically ill children (January 2024)

Use of videolaryngoscopy (VL) in children provides a shared view during emergency endotracheal intubation (ETI) that permits an experienced physician observer to give assistance to the proceduralist. In a multicenter quality study of VL during ETI in pediatric intensive care units with standardized coaching by an attending, over 3500 ETIs were performed with VL, and use of VL increased from 30 percent to 89 percent of ETIs over four years [ 6 ]. Compared with direct laryngoscopy, VL was associated with lower adverse events (9 versus 15 percent). The majority of proceduralists were residents or fellows. These findings and prior studies confirm the safety of VL during emergency ETI in children and demonstrate the value of standardized coaching during the procedure for less experienced clinicians. (See "Technique of emergency endotracheal intubation in children", section on 'Video versus direct laryngoscopy' .)

PREOPERATIVE AND POSTOPERATIVE MANAGEMENT

Association of preoperative anemia with adverse outcomes after cardiac surgery (March 2024)

Studies continue to show a high rate of preoperative anemia in patients undergoing cardiac surgery and an association with adverse surgical outcomes. In a retrospective study of >4000 patients undergoing coronary artery bypass grafting surgery, 30 percent had preoperative anemia, which was associated with dose-dependent increases in postoperative acute kidney injury (AKI) and longer hospital stay [ 7 ]. In a 2024 meta-analysis with nearly 160,000 patients who underwent cardiac surgery, 28 percent had preoperative anemia, which was associated with increased mortality, AKI, other morbidities, and longer hospital stay [ 8 ]. When feasible, we postpone major surgery in patients with anemia to diagnose the cause and provide treatment. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia' .)

Postoperative noninvasive ventilation or high-flow nasal oxygen for patients with obesity (November 2023)

The optimal postoperative ventilatory strategy for patients with severe obesity has been unclear. In a 2023 network meta-analysis of randomized trials that compared various postoperative noninvasive ventilatory strategies in these patients, high-flow nasal oxygen (HFNO) or bilevel positive airway pressure (BiPAP) reduced atelectasis; HFNO, BiPAP, or continuous positive airway pressure (CPAP) reduced postoperative pneumonia; and HFNO reduced length of stay compared with conventional oxygen therapy [ 9 ]. For patients with obesity who are hypoxic in the post-anesthesia care unit despite oxygen supplementation and incentive spirometry, we suggest a trial of HFNO, BiPAP, or CPAP prior to considering intubation. (See "Anesthesia for the patient with obesity", section on 'Post-anesthesia care unit management' .)

SURGICAL CRITICAL CARE

Tranexamic acid for burn wound excision (November 2023)

Randomized trials have established that tranexamic acid (TXA) reduces blood loss and transfusion requirements in various surgical settings, but data in burn surgery are limited. In a meta-analysis of observational studies evaluating intravenous and topical TXA in burn surgery, use of TXA was associated with reductions in blood loss, use of intraoperative transfusion, and number of units transfused but no change in venous thromboembolism or mortality rates [ 10 ]. Based on this review and data from other surgical settings, we routinely administer intravenous TXA for burn wound excisions over 20 percent of total body surface area. (See "Overview of the management of the severely burned patient", section on 'Coagulopathy' .)

OTHER ANESTHESIA

Updated guideline on postoperative delirium in adults (February 2024)

The European Society of Anaesthesiology and Intensive Care Medicine has published an updated guideline on postoperative delirium (POD) [ 11 ]. Recommendations include preoperatively screening older adults for risk factors for POD and multicomponent nonpharmacological interventions for all patients with risk factors. In addition, review of recent evidence showed that perioperative use of dexmedetomidine was associated with a lower incidence of POD, particularly when administered postoperatively in the intensive care unit. We agree with the recommendations and often use dexmedetomidine in the perioperative period to reduce the incidence of POD in high-risk patients. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Intravenous agents associated with lower risk' .)

Supplemental neuraxial or regional analgesia and postoperative neurocognitive disorders (January 2024)

Supplementing general anesthesia with neuraxial or regional analgesic techniques reduced postoperative neurocognitive disorders (PND) and/or delirium in some studies, but results have been inconsistent. Differences in techniques and timing of analgesic administration, and confounding patient variables may explain the inconsistencies. In a meta-analysis of randomized trials of patients undergoing major noncardiac surgery under general or neuraxial anesthesia, supplemental postoperative neuraxial or regional analgesia (eg, epidural or peripheral or fascial plane block) reduced PND (both delirium and delayed neurocognitive recovery) in the first postoperative month compared with no supplemental analgesia [ 12 ]. Although supplemental analgesia may reduce PND, selection of anesthetic techniques is based primarily on other considerations. (See "Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies", section on 'Choice of anesthetic technique' .)

Thyroid hormone administration in deceased organ donors (December 2023)

Thyroid hormone administration has been a longstanding component of some organ procurement protocols due to concern that acute hypothyroidism might contribute to hemodynamic instability and left ventricular dysfunction, reducing heart and other organ procurement; however, evidence for the practice has been inconsistent. In a recent trial of 838 hemodynamically unstable, brain-dead donors assigned to receive a levothyroxine infusion or saline placebo, there was little to no difference in number of hearts transplanted or 30-day cardiac graft survival [ 13 ]. Recovery of other organs was similarly unaffected. More cases of severe hypertension or tachycardia occurred in the levothyroxine group than in the saline group. Based on these data, we suggest avoiding thyroid hormone administration in deceased organ donors. (See "Management of the deceased organ donor", section on 'Thyroid hormone' .)

Aerosol generation during noninvasive respiratory support modalities (October 2023)

Studies have reported conflicting data as to whether high levels of aerosols are generated when noninvasive ventilation (NIV) or high-flow nasal oxygen (HFNO) is used. In a 2023 systematic review including 12 studies in patients with respiratory infections and 15 studies in healthy volunteers, use of NIV or HFNO was not associated with increased generation of pathogen-laden aerosols compared with controls with unsupported normal or labored breathing, low-flow nasal oxygen, or oxygen or nonrebreather mask [ 14 ]. Inconsistency among studies may reflect differences in sampling and detection methodologies and operating room ventilation. Notably, the National Health Service in the United Kingdom has removed mask ventilation, intubation, and extubation from its list of aerosol-generating procedures. (See "Overview of infection control during anesthetic care", section on 'Considerations during aerosol-generating procedures' .)

Effectiveness of intraoperative blood salvage for reducing need for allogenic transfusion (October 2023)

Intraoperative blood salvage is a blood conservation technique in which autologous blood is aspirated, concentrated, washed, and reinfused. A 2023 meta-analysis of randomized trials involving >14,000 patients found that it reduced the need for allogeneic red blood cell transfusions in cardiovascular surgery with or without cardiopulmonary bypass and in major orthopedic hip, knee, or spine surgery [ 15 ]. Benefits were uncertain in vascular, cancer, and obstetric surgery. We recommend intraoperative blood salvage in surgical procedures with blood loss >750 mL, particularly if transfusion of allogeneic blood is likely. (See "Surgical blood conservation: Intraoperative blood salvage", section on 'Benefits' .)

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• Damhuis SE, Groen H, Thilaganathan B, et al. Effect of intrapartum epidural analgesia on rate of emergency delivery for presumed fetal compromise: nationwide registry-based cohort study. Ultrasound Obstet Gynecol 2023; 62:668.
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• Giuliano J Jr, Krishna A, Napolitano N, et al. Implementation of Video Laryngoscope-Assisted Coaching Reduces Adverse Tracheal Intubation-Associated Events in the PICU. Crit Care Med 2023; 51:936.
• Warner MA, Hanson AC, Schulte PJ, et al. Preoperative Anemia and Postoperative Outcomes in Cardiac Surgery: A Mediation Analysis Evaluating Intraoperative Transfusion Exposures. Anesth Analg 2024; 138:728.
• Lau MPXL, Low CJW, Ling RR, et al. Preoperative anemia and anemia treatment in cardiac surgery: a systematic review and meta-analysis. Can J Anaesth 2024; 71:127.
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• Lloyd TD, Geneen LJ, Bernhardt K, et al. Cell salvage for minimising perioperative allogeneic blood transfusion in adults undergoing elective surgery. Cochrane Database Syst Rev 2023; 9:CD001888.

• Open access
• Published: 06 October 2023

Enhanced perioperative care in emergency general surgery: the WSES position paper

• Marco Ceresoli 1 , 2 ,
• Marco Braga 1 , 2 ,
• Nicola Zanini 3 ,
• Fikri M. Abu-Zidan 4 ,
• Dario Parini 5 ,
• Thomas Langer 1 , 6 ,
• Massimo Sartelli 7 ,
• Dimitrios Damaskos 8 ,
• Walter L. Biffl 9 ,
• Francesco Amico 10 ,
• Luca Ansaloni 11 ,
• Zsolt J. Balogh 12 ,
• Luigi Bonavina 13 ,
• Ian Civil 14 ,
• Enrico Cicuttin 11 ,
• Mircea Chirica 15 ,
• Yunfeng Cui 16 ,
• Belinda De Simone 17 ,
• Isidoro Di Carlo 18 ,
• Andreas Fette 19 ,
• Giuseppe Foti 1 , 20 ,
• Michele Fogliata 1 , 2 ,
• Gustavo P. Fraga 21 ,
• Paola Fugazzola 11 ,
• Joseph M. Galante 22 ,
• Solomon Gurmu Beka 23 ,
• Andreas Hecker 24 ,
• Johannes Jeekel 25 ,
• Andrew W. Kirkpatrick 26 ,
• Kaoru Koike 27 ,
• Ari Leppäniemi 28 , 29 ,
• Ingo Marzi 30 ,
• Ernest E. Moore 31 ,
• Edoardo Picetti 32 ,
• Emmanouil Pikoulis 33 ,
• Michele Pisano 34 ,
• Mauro Podda 35 ,
• Boris E. Sakakushev 36 ,
• Vishal G. Shelat 37 , 38 ,
• Edward Tan 39 ,
• Giovanni D. Tebala 40 ,
• George Velmahos 41 ,
• Dieter G. Weber 42 ,
• Vanni Agnoletti 43 ,
• Yoram Kluger 44 ,
• Gianluca Baiocchi 45 ,
• Fausto Catena 3 &
• Federico Coccolini 46  

World Journal of Emergency Surgery volume  18 , Article number:  47 ( 2023 ) Cite this article

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Enhanced perioperative care protocols become the standard of care in elective surgery with a significant improvement in patients’ outcome. The key element of the enhanced perioperative care protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach to reduce surgical stress and improve perioperative recovery. Enhanced perioperative care in emergency general surgery is still a debated topic with little evidence available. The present position paper illustrates the existing evidence about perioperative care in emergency surgery patients with a focus on each perioperative intervention in the preoperative, intraoperative and postoperative phase. For each item was proposed and approved a statement by the WSES collaborative group.

Introduction

Enhanced recovery after surgery (ERAS®) protocol refers to a standardized multimodal approach based on the application of structured protocols in perioperative patients' management. The main goal of these interventions is patient management optimization during the perioperative period under all aspects of perioperative care, not only about the surgical technique, by reducing surgical stress, minimizing the physiological response to surgery, and improving postoperative recovery. The key element of the ERAS protocol is the multimodal and interdisciplinary approach targeted to the patient, focused on a holistic approach [ 1 ].

Perioperative care protocols are structured as a bundle of interventions to be applied during the preoperative, intraoperative and postoperative periods. Each intervention is linked to the others and shares the common goal of reducing the burden of perioperative patient stress (Fig.  1 ). For this reason, it is very difficult to evaluate the efficacy of a single item without considering the effect of all the others, applied as a bundle. Designing studies to evaluate and demonstrate the effect of every single intervention is therefore a major challenge, markedly limiting the available scientific evidence.

Enhanced perioperative care items and interventions

The effectiveness and safety of ERAS protocols in elective surgery are now widely established. Several meta-analyses comparing standard care and fast-track approach show that ERAS protocols in elective surgery lead to a reduction in length of stay and in the rate of postoperative non-surgical complications [ 2 , 3 , 4 , 5 ]. Most of the available studies focused on the postoperative phase, considering the main “surgical” items as study outcomes, with relatively small attention being devoted to preoperative and intraoperative interventions. However, main postoperative items such as oral feeding, urinary drain removal and mobilization should also be considered as compliance indicators rather than only interventions to be implemented [ 6 ]. From a methodological standpoint, there is a clear difference between adherence and compliance to an enhanced recovery protocol. Adherence should identify the percentage of items applied throughout the perioperative care process, while postoperative compliance also reflects how the patient follows the enhanced recovery process. For example, patients’ compliance to a postoperative pathway including early oral feeding and mobilization can be obtained easier if there is good adherence to a preoperative and an intraoperative enhanced pathway (and not only for a medical decision).

Based on the beneficial effect of enhanced perioperative care protocols in elective surgery, the implementation of structured protocols for emergency general surgery patients has also been advocated after the promising results of some studies [ 7 , 8 ]. However, enhanced perioperative care in emergency general surgery remains a “grey area” with little evidence available and great debate.

Patients undergoing elective surgery should be normothermic, euvolemic, clean, and “healthy”, and surgery per se represents their main stressful factor. Emergency surgery represents a more complex scenario where surgery is at the same time a stressful factor but also the key-intervention to solve the pre-existing physiologic imbalance secondary to the acute underlying disease (Fig.  2 ).

Perioperative diagram of patient’s homeostasis in elective and emergency general surgery

The diagram (Fig.  2 ) shows the impact of the pre-existing acute disorder causing a marked decline of the physiological reserve. The importance of the preoperative phase (re-equilibration) seems intuitive. Despite emergency surgery by definition does not allow schedulable interventions, some preoperative optimization is still possible in the emergency setting, though with much reduced time. The time available between patient presentation and surgery should be optimized to improve the patient’s physiological status to promote post-surgical recovery. In this complex scenario, also the timing of surgery should be carefully evaluated. One of the most intriguing and difficult challenges is to identify the right balance between hastening surgery to directly "face" the acute disease and delaying surgery in trying to improve the patient's condition.

Evidence supporting enhanced perioperative care in emergency general surgery.

Currently, available studies about enhanced perioperative care in emergency general surgery are few, sparse and very heterogeneous. In addition, the perioperative care protocol derived from the elective ERAS protocol but with several and substantial differences [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ]. Tables 1 and 2 show in detail the protocols adopted in the evaluated studies. A single perioperative care protocol cannot be identified through the existing literature, and each study applied different interventions.

Huddart et al. demonstrated that the introduction of a bundle evidence care protocol decreased mortality among patients undergoing emergency laparotomy, with a reduction in delayed diagnosis, increased implementation of goal-directed fluid therapy, and improved restoration of biochemical homeostasis [ 29 ]. The bundle protocol consisted in an accurate preoperative assessment with early warning score, early broad-spectrum antibiotics, prompt resuscitation using goal-directed techniques and postoperative ICU admission for all high-risk patients.

Tandberg and colleagues introduced a standardized perioperative care protocol in patients undergoing high-risk emergency abdominal surgery [ 9 ]. The study protocol included consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided volume status optimization, standardized analgesic treatment, early mobilization and early oral feeding. Compared with a historical cohort from the same department, the introduction of the protocol lead to a significant reduction in mortality from 21.8 to 15.5%.

An Italian observational multicentric study demonstrated that adherence to the intraoperative protocol items was low. Major determinants of postoperative compliance were minimally invasive surgery and low intraoperative fluid infusions [ 22 ].

Several other studies investigated the introduction of enhanced perioperative care protocols in emergency general surgery [ 10 , 12 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 22 , 23 , 27 ]. Each study applied a different protocol in different subsets of patients with contrasting results. Some studies adopted a modified ERAS protocol in patients with obstructive colorectal cancer [ 13 , 14 , 16 , 19 ], others on patients with perforated peptic ulcer [ 10 , 15 , 17 ], others on major emergency laparotomy and trauma [ 12 , 18 , 20 , 22 ]. Most of the published enhanced recovery programs in emergency surgery focus on the intra- and postoperative phases of the program, reporting no substantial differences in the preoperative care of patients enrolled in ERAS protocols versus standard “not-ERAS” patients. The majority of the existing studies did not report results on adherence to the protocol items; moreover, also data on compliance to the postoperative pathway were lacking.

The results of some of these studies were included in a meta-analysis published by Hajibandeh et al. published in 2020 [ 30 ]. Despite the great heterogeneity and the poor quality of the evidence, the results showed a reduction in length of stay, pulmonary complications, postoperative ileus and wound infections. No differences were observed in 30-day rehospitalization and 30-day mortality rates.

Despite the promising results, the implementation of an enhanced perioperative care protocol in emergency general surgery may encounter several obstacles. Patients receiving urgent care typically present to medical teams with a complex situation: their conditions at the time of admission are not optimal and they have extremely heterogeneous characteristics [ 31 , 32 ]. The acute illness often leads to several physiological derangements secondary to fasting, vomiting, dehydration, augmented capillary permeability, and metabolic imbalance.

Columbus et al. [ 33 ] have identified two main critical issues concerning the urgent care field: the diversification of patients and the wide range of possible settings and operative contexts (including the hospital organization and the medical team management). Therefore, efforts should focus on improving the structural and organizational aspects. Dedicated medical personnel training and a widespread standardization of the diagnostic and therapeutic process may improve medical performance and, ultimately, the clinical outcome. A recent study demonstrated that the familiarity between surgeon and anesthetist used to work together improve patients’ outcome [ 34 ]. Unfortunately, emergency general surgery is rarely managed by a dedicated staff. Emergency care requires a higher number of specialists and personnel turnover and, therefore, it would lead to wider cross-collaborations and variability in staff composition. In addition, patients undergoing emergency surgery are rarely managed by enhanced recovery-trained anesthetists, surgeons and nurses (working in abdominal surgery), making the development of new treatment protocols very difficult.

The availability of resources is another central tenant to the safe and optimal delivery of surgical care in the emergency setting. For example, laparoscopic facilities or advanced hemodynamic monitoring systems are not universally available, and reported unavailable by some authors, due to logistical issues, timing of surgical interventions (e.g., in office hours vs. after hours), and higher costs [ 18 , 35 ].

The WSES panel promoted the development of this position paper. The work process consisted of two different phases. The first phase was a review of the existing literature about enhanced recovery protocol in emergency general surgery. The second phase was the identification of enhanced recovery protocol items and the development of position statements for each perioperative intervention. This position paper was written according to the WSES methodology [ 36 ]. All the statements contained the level of evidence (LoE) available about the topic, graded according to the GRADE methodology. The consensus on the position paper statements was assessed through a web survey (by Google Form) open to all the members of the steering committee and the experts’ panel, as well as the board of governor members of the WSES. The consensus was reached if a statement was associated with ≥ 70% of the agreement. Otherwise, the statement was re-discussed by email or videoconference, modified, and resubmitted to the experts’ vote until consensus was reached. Table 3 summarizes approved statements.

Preoperative interventions

Education and counseling, patient counseling and education should be encouraged and implemented to explain perioperative risks and post-operative pathway (loe d).

Relieving patient anxiety through preoperative counseling is of utmost importance, especially in an emergent situation. Full preoperative counseling, which is known to reduce post-operative stress, pain and anxiety, may not be possible in the emergency setting. Nevertheless, information such as details of the procedure, possible perioperative complications, the need for the creation of a stoma and length of hospitalization should be communicated with patients and their families before the procedure [ 30 , 37 ]. A recent meta-analysis focusing on the implementation of enhanced recovery protocols in emergency abdominal surgery reported that adapted preoperative counseling was carried out in all of the six included studies. No data about adherence to this counseling were reported [ 30 ]. Depending on the urgency of surgery, preoperative education/counseling may not be possible. However, a recently published multidisciplinary experience reported very high compliance (more than 90% 1 year after implementation) with items such as standardized preoperative patient information and bilateral ostomy marking in patients undergoing emergency general surgery [ 11 , 38 ]. In the case of stoma creation, the implementation of patient education reduced stoma complications and improved postoperative quality of life, reducing the average hospital stay [ 39 ]. However, although it seems feasible and of some utility to appropriately counsel patients before emergency procedures, evidence in support of this hypothesis has not been produced yet and the degree of benefit in terms of postoperative recovery has not been measured.

Fluid balance and volemic status

Volemic status should be evaluated and corrected with goal-directed fluid therapy as soon as possible in the pre-operative phase (loe b).

The majority of emergency general surgery patients present with fluid derangements, mostly related to acute illness, underlying sepsis, prolonged fasting and vomiting. In this setting, preoperative evaluation of the patient should focus on the volemic assessment to rapidly correct alterations in patients' homeostasis, including stress response, gut dysfunction, insulin resistance, electrolyte imbalances, fluid shifts, SIRS and sepsis with varying degrees of organ dysfunction. Although complete optimization of medical conditions cannot be fully achieved in the emergency setting, adequate intravenous fluid resuscitation in emergency general surgery is crucial and feasible, and it should be attempted in all patients. A prospective randomized trial demonstrated better postoperative outcomes when patients were preoperatively managed with a fixed protocol to reach homeostasis [ 40 ]. The adopted protocol defined three targets for the goal-directed crystalloid resuscitation: central venous pressure of 8–12 cmH 2 O, mean arterial pressure > 65 mmHg and urinary output > 0.5 mL/Kg/h. The initial resuscitation should be titrated to the clinical response, such as fluid responsiveness, and not solely guided by a predetermined protocol, with particular attention to the underlying disease. Despite restoring homeostasis should be considered a goal, surgical treatment should not be delayed. According to the indications from the 2016 Surviving Sepsis Guidelines, resuscitation from sepsis-induced hypoperfusion should require at least 30 ml/kg of intravenous crystalloid fluids within the first 3 h [ 41 ]. However, in the updated 2021 version of the Guidelines, the strength of this recommendation was downgraded from “strong” to “weak” (quality of evidence: low) and the recommendation was modified in a suggestion [ 42 ]. Massive fluid therapy has been challenged in the enhanced recovery approach [ 9 ]. Fluid overload should be avoided since it is associated with higher rates of respiratory complications ( i.e., pneumonia, pleural effusion, and respiratory failure) and secondary anastomotic leaks. Early, i.e., preoperative, goal-directed fluid therapy in sepsis was the treatment of the experimental arm in a randomized clinical trial enrolling septic patients published in 2001 [ 43 ]. Excluding patients who needed immediate surgery from the trial, in-hospital mortality was 30.5% in the group assigned to early goal-directed therapy, as compared with 46.5% in the group assigned to standard therapy ( P  = 0.009). Tendberg et al. developed a perioperative protocol for emergency high-risk abdominal surgery in which stroke volume-guided hemodynamic optimization before surgery was a key element. The study has shown a significant reduction in mortality as well as postoperative length of ICU stay after the introduction of the standardized protocol [ 9 ]. Therefore, patients should be carefully evaluated and goal-directed fluid resuscitation should be implemented as soon as possible.

Metabolic balance

Glycemic control should be implemented in all emergency surgery patients to prevent both hypo- and hyperglycemia (loe c).

Perioperative hyperglycemia has been demonstrated to be associated with adverse clinical outcomes [ 44 ]. The correction of hyperglycemia with insulin administration and the management of glycemia with the implementation of glycaemic control protocols have been shown to reduce hospital complications and decreases mortality in elective general surgery patients [ 45 ]. Pre-existing diabetes mellitus, acute illness and physiologic changes accompanying a surgical procedure contribute to the worsening of glycemic control. The resulting hyperglycemia due to an abnormal glucose balance is a risk factor for postoperative complications that include poor wound healing and postoperative infections as well as an increase in morbidity, mortality, intensive care unit admission, and hospital length of stay [ 46 ]. Preoperative hyperglycemia has been demonstrated to have a role in postoperative compliance to an enhanced recovery pathway also in emergency surgery patients [ 22 ]. However, in emergency general surgery and in critically ill patients the role of hyperglycemia is more debated and less certain. Hyperglycemia could be considered a marker of organ failure and disease severity. A recent network meta-analysis comparing four different target blood glucose concentrations (< 110, 110–144, 144–180, and > 180 mg/dL) in terms of the benefit and risk of insulin therapy found no significant difference in the risk of mortality and infection among four target blood glucose ranges in critically ill patients, but indicated that target blood glucose levels of below 144 mg/dL were associated with a higher risk of hypoglycemia [ 47 ]. Although a proactive approach to avoid both hyper- and hypoglycemia should be suggested in emergency patients, close glycemic control is advisable and Institutions should develop their own protocols to treat both hyper and hypoglycemia in critically ill patients.

Intraoperative interventions

Postoperative nausea and vomiting (ponv) prevention, ponv prevention with a multimodal approach in an emergency setting should be implemented (loe d).

Prevention of PONV in elective general surgery has become a key element of enhanced recovery protocols [ 48 ]. PONV is very common after general anesthesia and it may negatively impact recovery and short-term outcomes [ 49 ]. Several factors are linked to the occurrence of PONV; however, its exact pathophysiology is still unclear [ 50 ]. Some risk factors are patient-related such as advanced age, female gender, non-smoking status, pain, and anxiety. Other risk factors are related to the type of operative gastro-intestinal manipulation and vagal stimulation, anesthetics, and opioids [ 50 , 51 , 52 ]. Few data are available on emergency patients who frequently complain of nausea and vomiting before surgery in association with anxiety and pain. Several studies investigated the role of different drugs to prevent PONV. The commonest antiemetic drugs are dopamine and serotonin antagonists (e.g., ondansetron) and corticosteroids (e.g., dexamethasone) [ 53 , 54 , 55 , 56 ]. Pre-emptive anesthesia was associated with better pain control and reduction in PONV [ 57 , 58 ].

Other suggested interventions are opioid-sparing anesthesia and avoidance of volatile anesthetics. Unfortunately, the vast majority of evidence is based on elective surgery and very few data are available on emergency general surgery. The emergency setting is associated with more fear, anxiety, pain and, probably, nausea even before surgery. Nevertheless, prevention of PONV should be implemented also in emergency general surgery. Among the interventions suggested, there are opioid-sparing anesthesia, avoidance of volatile anesthetics and a multimodal approach to pharmacological prevention.

Anesthesia and analgesia

General anesthesia warrants proper analgesia, amnesia and muscle relaxation. The ideal general anesthesia protocol should target all these goals, but it should also reduce the need for intraoperative fluids, reduce post-operative residual effects, such as PONV and delirium and it should permit rapid awakening. Several interventions have been implemented to optimize the intraoperative management of the patient. Whether anesthesia should be maintained by a totally intravenous approach or with inhalation drugs still remains uncertain and no recommendations can be made [ 59 ]

Benzodiazepines

Benzodiazepines should be avoided in the emergency anesthetic protocol, in particular in older patients, to reduce delirium risk in the postoperative period (loe c).

The incidence of delirium in the postoperative period has an important impact on clinical outcomes including higher mortality, functional decline, prolonged hospitalizations and risk for institutionalization [ 60 ]. Upon the several risk factors for development, that include acute illness and pain management, medications adopted also for general anesthesia play an important role [ 61 ]. For these reasons, anesthetic protocols should focus on reducing the use of these medications. Benzodiazepines have been linked with the development of delirium in the postoperative period, with a marked effect in elderly and frail patients [ 62 , 63 ]. Despite the potential beneficial effects in treating preoperative anxiety, these drugs should be avoided.

Opioid use should be limited to short-acting drugs in the perioperative period (LoE D)

Opioids are related to several adverse effects such as nausea, vomiting, respiratory depression, sedation and postoperative ileus. Despite their important role in pain management, the undesired effects may impact negatively on patients' recovery. Some experiences exist about opioid-free anesthesia, with the claim of more patient safety [ 64 ]. For this reason, opioids use should be limited to short-acting drugs avoiding morphine to minimize residual effects and to warrant rapid recovery [ 65 ].

Anesthesia depth monitoring

Anesthesia depth monitoring should be implemented in the emergency setting, to minimize anesthesia side effects such intra-operative hypotension, increased need for fluids and postoperative delirium (loe c).

To reduce all the detrimental effects of general anesthetics, such as cognitive effects and vasoactive depressing activity, titrating the minimal needed drug dose guided by the depth of anesthesia monitoring has been recommended. Monitoring of anesthesia depth could be guided by the bispectral index (BIS) or other techniques based on electrical brain activity (EEG). Anesthesia depth monitoring has been demonstrated to be associated with a lower incidence of postoperative delirium and with decreased morbidity [ 66 , 67 , 68 ]. Moreover, depth monitoring has been demonstrated to be associated also with a higher intraoperative mean arterial pressure, possibly reducing the need for fluid administration to maintain adequate systemic perfusion [ 69 ].

Neuromuscular blockade monitoring

Neuromuscular blockade monitoring should be implemented to reduce post-operative morbidity (loe c).

Neuromuscular blockade is needed during abdominal surgery to improve surgical exposure. A post-operative residual neuromuscular block is a risk factor for morbidity and mortality, conditioning weakness of airway muscles, airway obstruction and aspiration with consequent increased postoperative pulmonary complications [ 70 ]. Residual neuromuscular block has been reported in up to 40% of patients treated with neuromuscular blocking agents [ 71 ]. Adopting strategies such as the qualitative monitoring of the peripheral muscular blockade as the train of four (TOF) has been demonstrated to significantly reduce the residual blockade at the end of anesthesia [ 72 ]. Monitoring of the neuromuscular blockade is therefore recommended to avoid potential side effects.

Multimodal pain control

Multimodal analgesia, with a combination of systemic and loco-regional approaches, should be encouraged in the emergency setting to improve pain control and reduce the need for analgesics and opioids (loe c).

Pain is one of the limitations to patient recovery after surgery. Standard general anesthesia warrants analgesia during surgery, but has no effect on pain control after surgery, requiring drug administration with possible detrimental effects such as opioids. Multimodal analgesia has been proposed to manage pain with several different treatments reducing the need for systemic opioids and avoiding their potential side effects [ 73 ]. The association of general and locoregional analgesia has been demonstrated also to reduce the incidence of postoperative delirium [ 74 ].

Thoracic epidural analgesia (TEA) has been demonstrated to be superior to systemic opioids in pain management in open elective abdominal surgery [ 75 ]. A recent Scandinavian population study reported that epidural analgesia was adopted in emergency general surgery in less than one third of patients; epidural analgesia was associated with lower 90-day mortality probably due to a reduction in paralytic ileus and pain that most likely allowed an early mobilization and coughing [ 76 ]. TEA was included in an emergency general surgery enhanced recovery protocol that demonstrated a significant reduction in mortality, despite the adherence to this specific item was not reported [ 9 ]. Spinal analgesia has been proposed as an alternative to epidural analgesia in patients treated with minimally invasive colorectal surgery: the administration of long-acting local anesthetics and opioids warrant pain control in the first postoperative hours allowing early mobilization. Moreover, it has been associated with a lower risk of hypotension and fluid overload [ 77 ]. However, spinal and epidural anesthesia should be considered with caution in septic patients.

Surgical incision is one of the main responsible of postoperative pain. To manage this pain, abdominal wall blockade such as the Transversus abdominis plane (TAP) block has been proposed. The adjunct of abdominal wall blocks to general anesthesia has been demonstrated to have beneficial effects on pain control during the first 24 h and to allow faster recovery and better hemodynamic control in elective abdominal surgery [ 78 , 79 , 80 , 81 ]. Of note, the TAP block can be performed both ultrasound-guided and laparoscopy-guided [ 82 ]. Currently, no studies focus on the performance of the TAP block in emergency general surgery. However, abdominal wall blocks should be considered in a multimodal analgesic approach.

Active warming

Active warming and body temperature monitoring should be encouraged in the emergency setting to reduce postoperative morbidity (loe c).

Body temperature plays an important role in several pathophysiologic mechanisms Hypothermia typically occurs during general and locoregional anesthesia due to vasodilatation and a rapid redistribution of heat from the core to peripheral districts. Moreover, several anesthetic drugs impair thermoregulatory control, further contributing to the maintenance of hypothermia. Finally, the development of hypothermia is facilitated by direct heat loss deriving from the surgical exposure of the abdominal cavity and by the low operating theater temperature. Importantly, perioperative hypothermia implicates an increased risk of surgical site infection, morbidity and mortality. Moreover, hypothermia may alter drug metabolism and it is also associated with an increased risk for coagulopathy and a consequent increased blood loss [ 83 ]. Body temperature monitoring is therefore mandatory and allows temperature correction with active warming. Active warming, ideally starting before the entrance to the operating room, has been recognized as one of the core items of the enhanced recovery pathway and its implementation significantly reduced postoperative morbidity [ 84 , 85 ].

Fluid management

Fluids should be managed within a goal-directed fluid therapy strategy to target the amount of given fluids on patient needs (loe c).

General anesthetics lead to dose-depend myocardial depression and systemic vasodilatation. The associated increased venous capacitance leads to a relative hypovolemia that, along with myocardial depression, might lead to hypotension, and organ hypoperfusion with the related consequences. Therefore, during surgery, fluids are frequently administered to maintain an adequate intravascular volume status and systemic perfusion. However, both hypovolemia and hypervolemia are associated with postoperative morbidity and several studies demonstrated the J-shaped relation between intraoperative fluids administered and postoperative morbidity [ 86 , 87 , 88 ]. Intraoperative fluid management should therefore be balanced, giving the needed amounts of fluids to warrant euvolemia and systemic perfusion, but avoiding fluid overload [ 89 , 90 ]. Fluid overload is associated with several detrimental effects related to tissue edema. Increased interstitial fluids might impair gas exchange with consequent respiratory failure and foster the development of pneumonia. Moreover, fluid overload is associated with bowel edema and postoperative ileus, conditioning a delayed recovery of GI function [ 91 ]. For these reasons in elective surgery, a restrictive fluid strategy has been proposed, with the target of a near-zero fluid balance during surgery and a limited amount of fluids given (generally around 3 mL/Kg/h) [ 92 ]. This approach is valid under the condition that patients arrive at the surgery in perfect homeostasis without fluid derangements.

Several factors may worsen and make fluid management in emergency surgery patients more difficult. Increased vascular permeability related to acute illness, preoperative fasting, preoperative dehydration and blood loss may dramatically increase the need for intraoperative fluids compared to elective surgical patients. In this complex scenario, goal-directed fluid therapy has been proposed to titrate and balance the amount of fluids. Fluid therapy should be guided by hemodynamic monitoring systems, ideally capable of monitoring dynamic parameters, such as cardiac output, stroke volume variation, pulse pressure variation and stroke volume variation [ 93 , 94 ]. The implementation of an intraoperative goal-directed fluid strategy, associated with restrictive fluid regimens and the early adoption of vasopressors to maintain adequate circulating volumes has been demonstrated to significantly reduce perioperative morbidity [ 94 ]. While only few studies exist on fluid management during general emergency surgery, available evidence derived from elective surgery and current pathophysiological understanding strongly underlines the importance of reasoned fluid management during emergency surgery. In the emergency setting, a recent study highlighted the importance of fluid therapy, with a negative correlation between increasing intraoperative fluids given and patients' recovery [ 22 ].

Minimally invasive surgery

Minimally invasive surgery approach in emergency surgery should be encouraged whenever possible and needed skills are available (loe c).

Reducing surgical stress is the cornerstone of an enhanced perioperative care protocol. The use of minimally invasive surgery in elective major surgery has been demonstrated to reduce inflammation, improve pulmonary function, and facilitate GI function with a consequent reduction in morbidity and length of stay [ 95 , 96 , 97 ]. Minimally invasive surgery, even within an enhanced recovery pathway, has been associated with a faster recovery when compared with open surgery [ 98 ]. In emergency major abdominal surgery, such as repair for perforated peptic ulcer and colorectal surgery invasive minimally techniques have been associated with better clinical outcomes with a lower mortality and length of stay [ 99 , 100 , 101 ]. A population study on the commonest abdominal surgical emergencies in the USA demonstrated an increasing trend of a laparoscopic approach. Minimally invasive surgery was associated with lower mortality, surgical site infection rate and length of stay. However, minimally invasive surgery in major interventions such as peptic ulcer repair and small bowel obstruction was adopted in less than 40% and 10%, respectively [ 102 ]. Data from the national emergency laparotomy audit (NELA) from the U.K. demonstrated that laparoscopy is adopted in less than 20% of major surgeries [ 99 ]. Existing data demonstrated the beneficial effect of minimally invasive surgery but also its poor diffusion among surgeons with several difficulties [ 103 ]. A recent prospective study identified minimally invasive surgery as the major determinant of postoperative compliance to an enhanced recovery protocol [ 22 ]. Efforts should be made to implement laparoscopy in emergency general surgery daily practice.

Abdominal drains should be placed for limited indications, including in the presence of gross bacterial contamination and inadequate source control (LoE D)

The routine positioning of a peritoneal drain after elective major colorectal surgery has been demonstrated to be ineffective in preventing surgical complications and is not recommended [ 104 ]. Moreover, the presence of a drain has been identified as one of the main failure predictors of an enhanced recovery pathway, both in elective and emergency surgery [ 22 , 105 ]. Drain in emergency general surgery is justified by a clear rationale, in case of contaminated surgical field and intra-abdominal infections. Few experiences exist about avoiding drains in emergency general surgery: some studies focused on the introduction of enhanced perioperative care protocol on colorectal emergencies (obstructions) demonstrated better results avoiding the drain (along with other interventions) [ 13 , 14 , 16 ]; other studies demonstrated the safety of an early removal in perforated peptic ulcer and trauma [ 15 , 20 ]. Evidence quality is very low to recommend avoiding abdominal drains, but we believe drains should be placed only in case of gross abdominal contamination and high risk for collection and abdominal abscess.

Postoperative care

Multimodal analgesia, using different classes of analgesics and avoiding long-acting opioids, should be recommended in the postoperative phase (loe c).

Proper analgesia and pain control are key elements of a patient’s recovery after surgery. The control of pain in the postoperative period is the result of many several factors related to patients' characteristics, invasiveness of surgical intervention, the underlying diagnosis and adopted intra- and post-operative analgesia techniques. Perioperative management should be focused on maximizing the effect of pain control and avoiding the side effects of drugs. The use of long-acting opioids, such as morphine, should be ideally avoided also in the postoperative period. Indeed, avoiding opioids has been demonstrated to facilitate mobilization and to fasten GI function recovery [ 65 ]. The treatment of pain should be multimodal and tailored to patients’ conditions, according to available skills [ 106 ].

Early nasogastric tube removal

The nasogastric tube should be removed as soon as possible, even at the end of surgery (loe d).

According to a reactive policy, the nasogastric tube (NGT) was traditionally removed after GI function recovery to prevent PONV and inhalation. Enhanced recovery protocols recommend the removal of NGT at the end of elective surgery. This practice reduced pulmonary complications and promoted GI function recovery [ 107 ]. Preliminary studies carried out in patients with obstructive colorectal cancer or perforated peptic ulcer reported a high patient compliance to NGT removal at the end of surgery [ 17 , 19 , 108 ]. Other studies suggested removing the NGT when the output was less than 300 ml [ 15 , 18 ]. When patients are managed according to enhanced recovery protocols, the early removal of NGT is safe and should be implemented in clinical practice.

Early mobilization

Early mobilization should be encouraged and stimulated as soon as possible to reduce post-operative morbidity (loe c).

Prolonged immobilization is associated with insulin resistance, thromboembolic events and respiratory complications [ 109 ]. Several studies reported that early mobilization after surgery reduced overall morbidity and shortened the length of hospital stay [ 110 , 111 , 112 , 113 ]. Several factors can negatively impact on patient’s mobilization such as abdominal drain, urinary catheter, suboptimal pain control, prolonged i.v fluids, and patient's motivation. In emergency surgery, different protocols have been proposed targeting mobilization the same day of surgery [ 15 , 18 ] or on postoperative day 1 [ 14 , 16 , 19 ]. According to existing evidence, patient mobilization should be encouraged as early as possible, along with all the interventions that could facilitate it, such as proper pain control, and the early removal of urinary catheter and drains.

Nutrition and early oral feeding

Early oral feeding should be encouraged and promoted as soon as tolerated by patients (loe c).

The close relationship between preoperative nutritional status and surgical outcomes has been extensively reported in elective surgery, where tailored nutritional and prehabilitation programs can be planned before the operation [ 114 ]. Postoperative fasting has been demonstrated to be harmful in elective surgery with delayed recovery and increased complications[ 2 , 115 , 116 ]. Oral feeding can be resumed early after surgery regardless of bowel canalization, whether removal of the nasogastric tube, PONV prophylaxis, near zero fluid balance, early mobilization, and pain control have been carried out according to enhanced recovery protocol. Patients undergoing emergency surgery often have an altered metabolic status, with dehydration and several derangements such as prolonged fasting, vomiting, impairment of GI function, and fluid loss related to the acute illness. The great condition's heterogeneity in emergency surgery patients makes quite impossible to standardize the timing of oral feeding recovery. However, studies carried out in patients with perforated peptic ulcer or obstructive colorectal cancer demonstrated both feasibility and safety of early oral feeding [ 19 , 20 , 117 ]. Perioperative nutritional intervention should be therefore tailored to the patient's conditions adopting as the target the earliest possible recovery.

Urinary catheter removal

Urinary catheter should be removed as soon as possible when urinary output no longer needs to be monitored (loe c).

Urinary output monitoring is a key element to assess patients' volemic status and to guide goal-directed fluid therapy. In emergency surgery patients, the urine output target should be 0.5 ml/Kg/h. Different policies about the timing of catheter removal have been proposed: immediately after surgery in a randomized study on perforated peptic ulcer patients [ 17 ], on postoperative day 1 [ 19 , 20 ] or according to urinary output (> 1 ml/Kg/h) [ 15 , 18 ]. Regardless, the urinary catheter should be removed as early as possible after reaching the minimum urinary output target to facilitate mobilization and reduce infections.

Postoperative fluids

Postoperative intravenous fluids should be minimized and maintained until oral fluid intake is adequate (loe c).

Fluid therapy should be targeted to restore the euvolemic status and to maintain adequate hydration and tissue perfusion until the oral intake can be restarted. As reported for operative management, fluid therapy can be harmful if too many or too few fluids are given [ 86 , 87 , 88 ]. Following elective colorectal surgery i.v. fluids should be stopped on postoperative day one. Studies performed on emergency surgery patients did not report on timing to stop i.v fluids; however, infusions should be tailored to patient conditions, giving the minimum fluid amount to restore and maintain euvolemia and to obtain adequate perfusion.

Antibiotic therapy

Antibiotic therapy should not be continued in case of non-complicated intra-abdominal infections, while a short course antibiotic therapy is indicated in case of complicated infection (LoE A).

A large part of emergency patients undergo surgery for intra-abdominal infections; therefore, antibiotic therapy is a cornerstone of treatment along with surgical source control . The need for antibiotics during the postoperative period may contribute to delaying patient recovery, as an obstacle to active mobilization and i.v. infusions suspension; moreover, prolonged antibiotic therapies may have a role in delaying home return. Postoperative antibiotic therapy should be reserved for patients with complicated intra-abdominal infections. In these patients, a short therapy (3–5 days) after adequate surgical source control is not inferior when compared to longer therapy [ 118 , 119 , 120 ]. In non-complicated infections, antibiotic therapy should be stopped at the end of surgery if the source control is adequate.

The majority of patients presenting with a severe infection who initially require IV therapy can be switched to oral therapy after 24–48 h provided that they are improving clinically and can tolerate an oral formulation. The switch from IV to oral route should be encouraged.

Research agenda

The present position paper highlights the great heterogeneity of protocols adopted and the lack of good-quality evidence supporting the implementation of enhanced recovery pathway in emergency general surgery. Further studies on this topic should address:

The definition of the safety, feasibility and effectiveness of each perioperative intervention.

The definition of a standardized enhanced recovery protocol for emergency general surgery procedures

The selection of patients who may benefit from an enhanced recovery pathway and the clinical scenarios in which enhanced recovery pathway could be applied.

Conclusions

Enhanced perioperative care, similar to elective surgery, should be implemented in emergency general surgery. One of the key elements for the success of the enhanced pathways is the multimodal approach involving surgeons, anesthetists, ICU physicians, nurses, patients and patient families. Available evidence suggests future required research on the implementation of enhanced recovery pathways in clinical practice.

Availability of data and materials

Data are available under request to the corresponding author.

Change history

15 october 2023.

The CRUE CSIC TA funding note has been removed

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Ceresoli, M., Braga, M., Zanini, N. et al. Enhanced perioperative care in emergency general surgery: the WSES position paper. World J Emerg Surg 18 , 47 (2023). https://doi.org/10.1186/s13017-023-00519-2

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