Utilidad de un cuestionario postal en el seguimiento de la reparación de la hernia incisional: estudio prospectivo de una cohorte

ResumenObjetivoEvaluamos la utilidad de un cuestionario postal en el seguimiento de la cirugía de la eventración.Pacientes y métodoSe analiza prospectivamente una cohorte de 285 pacientes intervenidos por una eventración entre 1998 y 2003 mediante una técnica con malla prefascial y que recibieron un cuestionario de 6 preguntas e ideogramas, con estrategia de reenvíos y llamada telefónica para aumentar la respuesta. Se citaron a examen clínico a los pacientes sin inconveniente a ser visitados. Se revisaron todas las hojas operatorias. Se estudia la respuesta al cuestionario y hallazgos de la visita (test exacto de Fisher y Chi cuadrado), la concordancia con los datos operatorios (índices Kappa de Cohen y de Fleiss) y el valor predictivo del cuestionario.ResultadosUn total de 215 pacientes devolvieron el cuestionario después de tres envíos, con lo que se recogió información de un 75.4% de la cohorte, que aumentó al 94% después de la llamada telefónica. Un total de 168 pacientes (el 78.2%) aceptaron ser visitados, aunque finalmente solo acudieron 62 (el 36.9%). La concordancia entre las respuestas al cuestionario e ideogramas y los datos de las hojas operatorias fue baja (índice Kappa de Cohen de 0.065 e índice Kappa de Fleiss de 0.170).ConclusionesUn cuestionario postal con medidas para aumentar la respuesta puede ser efectivo para recoger información básica sobre la cirugía de la hernia incisional. La utilidad de dicha información resulta cuestionable por falta de cumplimiento de los pacientes en los controles y por dificultades en la comprensión del cuestionario, aunque este sea corto y/o en forma de ideograma.AbstractAimTo assess the usefulness of a short postal questionnaire as a method of follow-up in incisional hernia repair.Patients and methodAll consecutive patients (n=285) undergoing open mesh repair of incisional hernia using an onlay technique between 1998 and 2003 received a six-item self-administered questionnaire complemented with ideograms. Non-responders received two successive new questionnaires and a telephone call. All patients’ operation forms were reviewed. Patients with no objections to physical examination were contacted by phone for an appointment. The Fisher's exact test or the chi-square (χ2) tests were used to compare categorical variables between clinical visits and response to questionnaire. Agreement between response to the questionnaire and data on the operation forms was measured with the Cohen's kappa index and the Fleiss kappa index. The predictive values of the questionnaire were calculated.Results215 patients returned questionnaires after three reminders, allowing us to reach 75.4% of the study cohort, which in turn increased to 94% after the telephone call. A total of 168 (78.2%) patients were willing to come for a physical examination. Finally 62 (36.9%) patients were examined. The overall agreement between response to the questionnaire and data on the operation forms was poor (Cohen's kappa coefficient = 0.065 and Fleiss kappa coefficient = 0.170).ConclusionsA postal questionnaire can be effective to gather information. However, the usefulness of this information in the follow-up was low due to the small percentage of patients examined and difficulties in comprehension despite making the questionnaire short and illustrated by ideograms

Estandares de calidad para la cirugía del cáncer de recto. Factores pronósticos

El tratamiento de las neoplasias de recto ha cambiado favorablemente en los últimos años gracias a los avances en la técnica quirúrgica, fundamentalmente con la introducción del concepto de la exéresis total del mesorrecto, y en los tratamientos adyuvantes con radioterapia y quimioterapia. Todo esto conlleva un abordaje multidisciplinar en el que intervienen varios especialistas. El desarrollo de Unidades específicas de Cirugía Colo-rectal ha aumentado las posibilidades del paciente de recibir un tratamiento curativo adecuado, con menor morbilidad, y con mayores posibilidades de preservación de los esfínteres. En el Hospital General Vall d´Hebron durante el periodo desde 1970 hasta 1997, existe una plantilla con unos 40 cirujanos distribuidos en cinco Servicios de Cirugía. En el año 2000 se consolida la creación de un Servicio de Cirugía único con el establecimiento definitivo de las unidades especializadas incluyendo la Unidad de Cirugía Colo-rectal. Por otro lado, en el Hospital General Vall d´Hebron en el año 1998 se constituye el Comité de Cáncer Colo-rectal iniciándose el funcionamiento de la Unidad de Cirugía Colo-rectal. Para poder valorar y comparar los resultados en el tratamiento del cáncer de recto se han establecido unos indicadores o parámetros por distintas asociaciones e instituciones, aceptados globalmente por la comunidad quirúrgica y reflejadas en numerosos estudios publicados, que se conocen como los estándares de calidad para la cirugía del cáncer de recto.Este trabajo se plantea con la finalidad de estudiar los resultados en el tratamiento del cáncer de recto en el Hospital Vall d´Hebron en los primeros años de funcionamiento de la Unidad Colo-rectal, donde no todos los pacientes eran tratados por la Unidad de Cirugía Colo-rectal, obteniendo y analizando los estándares de calidad e identificando los factores pronósticos que se han relacionado con dichos estándares de calidad en los pacientes con cirugía curativa y sin enfermedad metastásica.Se incluyen todos los pacientes tratados en el Hospital Vall d´Hebron entre el 1 de enero de 1998 y el 31 de diciembre de 2003, con diagnóstico de cáncer de recto confirmadas con anatomía patológica, o confirmadas por el cirujano en la intervención quirúrgica, o con diagnóstico de cáncer de recto por la TAC o la RMN. Se excluyen los pacientes que cumpliendo los criterios de inclusión, no se logra recuperar la Historia Clínica o faltan los datos del periodo asistencial. Se asignan los pacientes en 6 grupos. Se realiza un estudio descriptivo y de supervivencias para cada grupo del estudio. Se realiza un análisis univariante y multivariante, para cada uno de los estándares de calidad, para los grupos con cirugía curativa sin enfermedad metastásica y un subgrupo del anterior con el cáncer localizado en el recto bajo. Para el análisis estadístico se utilizan los programas Statistical Package for the Social Sciences® versión 13.0 (SPSS, Chicago, Illinois, USA) y Stata versión 8.13, se ha establecido un nivel de significación α=0.05 en todas la pruebas realizadas y se ha considerado una relación como estadísticamente significativa cuando pLos valores de los estándares de calidad obtenidos en nuestro estudio, cuando se trata de una cirugía curativa sin enfermedad metastásica, se encuentran dentro de los rangos descritos por los grupos de referencia en esta patología. Se han obtenido unos factores pronósticos relacionados con dichos estándares de calidad para la cirugía del cáncer de recto. El tratamiento de un cáncer de recto en una Unidad de Cirugía Colo-rectal disminuye la morbilidad perioperatoria, aumenta la realización de cirugías con preservación esfinteriana y se traduce en una menor mortalidad por cáncer.The treatment of rectal cancer has changed positively in recent years thanks to advances in surgical technique, particularly with the introduction of the concept of total excision of mesorrecto and adjuvant treatment with radiation and chemotherapy. All this involves a multidisciplinary approach in which several specialists partaken. The development of specific units of colorectal surgery has increased the chances of the patient to receive appropriate curative treatment, with lower morbidity and greater potential for preservation of the sphincters. At the Hospital General Vall d'Hebron during the period from 1970 to 1997, there is a template with 40 surgeons on five Surgery Services. In 2000, consolidates the creation of a single Service of Surgery with the definitive establishment of specialized units including the Unit for Colorectal Surgery. On the other hand, in the Hospital General Vall d'Hebron, in 1998 constituted a Committee of Colorectal cancer, starting the operation of the Unit for Colorectal Surgery. To evaluate and compare the results in the treatment of rectal cancer have been established indicators or benchmarks for various associations and institutions, broadly accepted by the surgical community and reflected in numerous published studies, which are known as quality standards for rectal cancer surgery. This work is in order to study the results in the treatment of rectal cancer at the Hospital Vall d'Hebron in the early years of the beginning of the operation of the Colorectal Unit, where not all patients were treated by the Colorectal Surgery Unit, obtaining and analyzing the quality standards and identifying prognostic factors have been related to such standards of quality in patients with curative surgery and without metastatic disease.Includes all patients treated in the Vall d'Hebron Hospital between January 1 of 1998 to December 31 of 2003, diagnosed with cancer of the rectum confirmed with pathologic findings or confirmed by the surgeon in the surgery or diagnosed with rectal cancer by CT or MRI. This excludes patients who met the inclusion criteria, were not able to retrieve the medical history or missing data from the period of care. Patients were allocated into 6 groups. A descriptive study and survival for each study group is performed. We carried out a univariate and multivariate analysis for each of the quality standards for curative surgery group without metastatic disease and for a subgroup of the previous with the cancer located in the low rectum. For the statistical analysis we used the Statistical Package for the Social Sciences ® version 13.0 (SPSS, Chicago, Illinois, USA) and Stata version 8.13, a α=0.05 significance level was considered in all tests and was considered statistically significant when p The values of quality standards achieved in our study, when a curative surgery without metastatic disease is performed, are within the ranges described by the reference groups in this condition. Have been obtained the prognostic factors associated with such quality standards for rectal cancer surgery. The treatment of rectal cancer in a Colorectal Unit decreases perioperative morbidity, enhances the performance of sphincter preserving surgery and resulting in a lower cancer mortality

Estándares de calidad para la cirugía del cáncer de recto : factores pronósticos

Descripció del recurs: 10 juny 2010El tratamiento de las neoplasias de recto ha cambiado favorablemente en los últimos años gracias a los avances en la técnica quirúrgica, fundamentalmente con la introducción del concepto de la exéresis total del mesorrecto, y en los tratamientos adyuvantes con radioterapia y quimioterapia. Todo esto conlleva un abordaje multidisciplinar en el que intervienen varios especialistas. El desarrollo de Unidades específicas de Cirugía Colo-rectal ha aumentado las posibilidades del paciente de recibir un tratamiento curativo adecuado, con menor morbilidad, y con mayores posibilidades de preservación de los esfínteres. En el Hospital General Vall d'Hebron durante el periodo desde 1970 hasta 1997, existe una plantilla con unos 40 cirujanos distribuidos en cinco Servicios de Cirugía. En el año 2000 se consolida la creación de un Servicio de Cirugía único con el establecimiento definitivo de las unidades especializadas incluyendo la Unidad de Cirugía Colo-rectal. Por otro lado, en el Hospital General Vall d'Hebron en el año 1998 se constituye el Comité de Cáncer Colo-rectal iniciándose el funcionamiento de la Unidad de Cirugía Colo-rectal. Para poder valorar y comparar los resultados en el tratamiento del cáncer de recto se han establecido unos indicadores o parámetros por distintas asociaciones e instituciones, aceptados globalmente por la comunidad quirúrgica y reflejadas en numerosos estudios publicados, que se conocen como los estándares de calidad para la cirugía del cáncer de recto. Este trabajo se plantea con la finalidad de estudiar los resultados en el tratamiento del cáncer de recto en el Hospital Vall d'Hebron en los primeros años de funcionamiento de la Unidad Colo-rectal, donde no todos los pacientes eran tratados por la Unidad de Cirugía Colo-rectal, obteniendo y analizando los estándares de calidad e identificando los factores pronósticos que se han relacionado con dichos estándares de calidad en los pacientes con cirugía curativa y sin enfermedad metastásica. Se incluyen todos los pacientes tratados en el Hospital Vall d'Hebron entre el 1 de enero de 1998 y el 31 de diciembre de 2003, con diagnóstico de cáncer de recto confirmadas con anatomía patológica, o confirmadas por el cirujano en la intervención quirúrgica, o con diagnóstico de cáncer de recto por la TAC o la RMN. Se excluyen los pacientes que cumpliendo los criterios de inclusión, no se logra recuperar la Historia Clínica o faltan los datos del periodo asistencial. Se asignan los pacientes en 6 grupos. Se realiza un estudio descriptivo y de supervivencias para cada grupo del estudio. Se realiza un análisis univariante y multivariante, para cada uno de los estándares de calidad, para los grupos con cirugía curativa sin enfermedad metastásica y un subgrupo del anterior con el cáncer localizado en el recto bajo. Para el análisis estadístico se utilizan los programas Statistical Package for the Social Sciences® versión 13.0 (SPSS, Chicago, Illinois, USA) y Stata versión 8.13, se ha establecido un nivel de significación &=0.05 en todas la pruebas realizadas y se ha considerado una relación como estadísticamente significativa cuando p 0,05. Los valores de los estándares de calidad obtenidos en nuestro estudio, cuando se trata de una cirugía curativa sin enfermedad metastásica, se encuentran dentro de los rangos descritos por los grupos de referencia en esta patología. Se han obtenido unos factores pronósticos relacionados con dichos estándares de calidad para la cirugía del cáncer de recto. El tratamiento de un cáncer de recto en una Unidad de Cirugía Colo-rectal disminuye la morbilidad perioperatoria, aumenta la realización de cirugías con preservación esfinteriana y se traduce en una menor mortalidad por cáncer.The treatment of rectal cancer has changed positively in recent years thanks to advances in surgical technique, particularly with the introduction of the concept of total excision of mesorrecto and adjuvant treatment with radiation and chemotherapy. All this involves a multidisciplinary approach in which several specialists partaken. The development of specific units of colorectal surgery has increased the chances of the patient to receive appropriate curative treatment, with lower morbidity and greater potential for preservation of the sphincters. At the Hospital General Vall d'Hebron during the period from 1970 to 1997, there is a template with 40 surgeons on five Surgery Services. In 2000, consolidates the creation of a single Service of Surgery with the definitive establishment of specialized units including the Unit for Colorectal Surgery. On the other hand, in the Hospital General Vall d'Hebron, in 1998 constituted a Committee of Colorectal cancer, starting the operation of the Unit for Colorectal Surgery. To evaluate and compare the results in the treatment of rectal cancer have been established indicators or benchmarks for various associations and institutions, broadly accepted by the surgical community and reflected in numerous published studies, which are known as quality standards for rectal cancer surgery. This work is in order to study the results in the treatment of rectal cancer at the Hospital Vall d'Hebron in the early years of the beginning of the operation of the Colorectal Unit, where not all patients were treated by the Colorectal Surgery Unit, obtaining and analyzing the quality standards and identifying prognostic factors have been related to such standards of quality in patients with curative surgery and without metastatic disease. Includes all patients treated in the Vall d'Hebron Hospital between January 1 of 1998 to December 31 of 2003, diagnosed with cancer of the rectum confirmed with pathologic findings or confirmed by the surgeon in the surgery or diagnosed with rectal cancer by CT or MRI. This excludes patients who met the inclusion criteria, were not able to retrieve the medical history or missing data from the period of care. Patients were allocated into 6 groups. A descriptive study and survival for each study group is performed. We carried out a univariate and multivariate analysis for each of the quality standards for curative surgery group without metastatic disease and for a subgroup of the previous with the cancer located in the low rectum. For the statistical analysis we used the Statistical Package for the Social Sciences ® version 13.0 (SPSS, Chicago, Illinois, USA) and Stata version 8.13, a &=0.05 significance level was considered in all tests and was considered statistically significant when p 0.05

Postoperative Diet with an Oligomeric Hyperproteic Normocaloric Supplement versus a Supplement with Immunonutrients in Colorectal Cancer Surgery: Results of a Multicenter, Double-Blind, Randomized Clinical Trial

(1) Background: For normo-nourished colorectal cancer patients, the need for immunonutrients after elective surgery is not known. (2) Methods: Multicenter, randomized, double-blind, phase III clinical trial comparing the postoperative diet with 200 mL oligomeric hyperproteic normocaloric (OHN; experimental arm) supplement vs. 200 mL immunonutritional (IN) (active comparator) supplement twice a day for five days in 151 normo-nourished adult colorectal-resection patients following the multimodal rehabilitation ERAS protocol. The proportions of patients with complications (primary outcome) and those who were readmitted, hospitalized for <7 days, had surgical site infections, or died due to surgical complications (secondary outcome) were compared between the two groups until postoperative day 30. Tolerance to both types of supplement and blood parameters was also assessed until day 5. (3) Results: Mean age was 69.2 and 84 (58.7%) were men. Complications were reported in 41 (28.7%) patients and the incidence did not differ between groups (18 (25%) vs. 23 (32.4%) patients with OHN and IN supplement, respectively; p = 0.328). No significant differences were found for the rest of the variables. (4) Conclusions: IN supplement may not be necessary for the postoperative recovery of colorectal cancer patients under the ERAS regimen and with normal nutritional status at the time of surgery

Patients with Crohn's disease have longer post-operative in-hospital stay than patients with colon cancer but no difference in complications' rate

BACKGROUNDRight hemicolectomy or ileocecal resection are used to treat benign conditions like Crohn's disease (CD) and malignant ones like colon cancer (CC).AIMTo investigate differences in pre- and peri-operative factors and their impact on post-operative outcome in patients with CC and CD.METHODSThis is a sub-group analysis of the European Society of Coloproctology's prospective, multi-centre snapshot audit. Adult patients with CC and CD undergoing right hemicolectomy or ileocecal resection were included. Primary outcome measure was 30-d post-operative complications. Secondary outcome measures were post-operative length of stay (LOS) at and readmission.RESULTSThree hundred and seventy-five patients with CD and 2,515 patients with CC were included. Patients with CD were younger (median = 37 years for CD and 71 years for CC (P < 0.01), had lower American Society of Anesthesiology score (ASA) grade (P < 0.01) and less comorbidity (P < 0.01), but were more likely to be current smokers (P < 0.01). Patients with CD were more frequently operated on by colorectal surgeons (P < 0.01) and frequently underwent ileocecal resection (P < 0.01) with higher rate of de-functioning/primary stoma construction (P < 0.01). Thirty-day post-operative mortality occurred exclusively in the CC group (66/2515, 2.3%). In multivariate analyses, the risk of post-operative complications was similar in the two groups (OR 0.80, 95%CI: 0.54-1.17; P = 0.25). Patients with CD had a significantly longer LOS (Geometric mean 0.87, 95%CI: 0.79-0.95; P < 0.01). There was no difference in re-admission rates. The audit did not collect data on post-operative enhanced recovery protocols that are implemented in the different participating centers.CONCLUSIONPatients with CD were younger, with lower ASA grade, less comorbidity, operated on by experienced surgeons and underwent less radical resection but had a longer LOS than patients with CC although complication's rate was not different between the two groups

The impact of stapling technique and surgeon specialism on anastomotic failure after right?sided colorectal resection: an international multicentre, prospective audit

Aim There is little evidence to support choice of technique and configuration for stapled anastomoses after right hemicolectomy and ileocaecal resection. This study aimed to determine the relationship between stapling technique and anastomotic failure. Method Any unit performing gastrointestinal surgery was invited to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side?to?side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak. Results One thousand three hundred and forty?seven patients were included from 200 centres in 32 countries. The overall anastomotic leak rate was 8.3%. Upon multivariate analysis there was no difference in leak rate with use of a cutting stapler for apical closure compared with a noncutting stapler (8.4% vs 8.0%, OR 0.91, 95% CI 0.54–1.53, P = 0.72). Oversewing of the apical staple line, whether in the cutting group (7.9% vs 9.7%, OR 0.87, 95% CI 0.52–1.46, P = 0.60) or noncutting group (8.9% vs 5.7%, OR 1.40, 95% CI 0.46–4.23, P = 0.55) also conferred no benefit in terms of reducing leak rates. Surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% vs 7.3%, OR 1.65, 95% CI 1.04–2.64, P = 0.04). Conclusion This study did not identify any difference in anastomotic leak rates according to the type of stapling device used to close the apical aspect. In addition, oversewing of the anastomotic staple lines appears to confer no benefit in terms of reducing leak rates. Although general surgeons operated on patients with more high?risk characteristics than colorectal surgeons, a higher leak rate for general surgeons which remained after risk adjustment needs further exploration

Relationship between method of anastomosis and anastomotic failure after right hemicolectomy and ileo-caecal resection: an international snapshot audit

Aim: The anastomosis technique used following right-sided colonic resection is widely variable and may affect patient outcome. This study aimed to assess the association between leak and anastomosis technique (stapled vs handsewn). Method: This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a 2-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30\ua0days of surgery, determined using a prespecified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random-effect variable. Results: This study included 3208 patients, of whom 78.4% (n\ua0=\ua02515) underwent surgery for malignancy and 11.7% (n\ua0=\ua0375) underwent surgery for Crohn's disease. An anastomosis was performed in 94.8% (n\ua0=\ua03041) of patients, which was handsewn in 38.9% (n\ua0=\ua01183) and stapled in 61.1% (n\ua0=\ua01858). Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn vs 12.9% stapled) and to undergo open surgery (54.7% handsewn vs 36.6% stapled). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques (P\ua0=\ua00.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted OR\ua0=\ua01.43; 95% CI: 1.04\u20131.95; P\ua0=\ua00.03). Conclusion: Despite being used in lower-risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe

An international assessment of the adoption of enhanced recovery after surgery (ERAS®) principles across colorectal units in 2019–2020

AimThe Enhanced Recovery After Surgery (ERAS®) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units.MethodAn online survey was circulated amongst European Society of Coloproctology members in 2019–2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 (‘rarely’) to 4 (‘always’). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted.ResultsOf hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they ‘most often’ or ‘always’ adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from ‘rarely’ to ‘always’ in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017.ConclusionsUptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.AimThe Enhanced Recovery After Surgery (ERAS®) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units.MethodAn online survey was circulated amongst European Society of Coloproctology members in 2019–2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 (‘rarely’) to 4 (‘always’). Respondents were also asked to recall whether practice had changed since 2017. Subgroup analyses based on hospital characteristics were conducted.ResultsOf hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they ‘most often’ or ‘always’ adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from ‘rarely’ to ‘always’ in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017.ConclusionsUptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.A