Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022.

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature. A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system. A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy. These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed

Harmonic long shears further reduce operation time in transanal endoscopic microsurgery

Background: Previous research indicates that application of 5-mm harmonic shears rather than diathermia significantly reduces operation time in transanal endoscopic microsurgery (TEM). Frequently, however, additional instruments were required to complete resection. We investigated whether the new 5-mm harmonic long shears (H-LS) are better equipped for TEM compared with regular harmonic shears (HS). Methods: Between 2001 and 2006, 162 tumors (117 adenomas, 42 carcinomas, and 3 other tumors; mean distance 6.6 cm, mean area 40 cm2) were excised in 161 patients (82 men, 79 women; mean age 66 years). Results: Eighty-eight resections were performed with HS and 74 with H-LS. Tumor and patient characteristics were similar except for specimen area. Tumors resected by H-LS were on average smaller than those resected by HS (34.4 versus 44.1 cm2; Mann-Whitney U-test: p = 0.027). Mean operation time was 48 min and proportional to area in both groups (univariate analysis of variance p<0.001). Mean operation time was 54 min using HS and 41 min using H-LS (t-test: p<0.001). After correction for area, operation time for H-LS was reduced by 14% compared with HS (t-test: p<0.001). H-LS is singly capable of completing resection in 88% compared with 26% for HS (Mann- Whitney U-test: p<0.001). Mean blood loss was 16 cc for HS and 3 cc for H-LS (p<0.001). Morbidity (11%) and mortality (0.6%) were not different between the two groups (Fisher's exact test). Conclusion: Performing transanal endoscopic microsurgery with 5-mm harmonic long shears reduces operation time compared with regular shears, and completing resection seldom requires other instruments

Predictive risk factors for intra- and postoperative complications in 526 laparoscopic sigmoid resections due to recurrent diverticulitis : a multivariate analysis

Laparoscopic sigmoid resection is a feasible and frequent operation for patients who suffer from recurrent diverticulitis. There is still an ongoing debate about the optimal timing for surgery in patients who suffer from recurrent diverticulitis episodes. In elective situations the complication rate for this procedure is moderate, but there are patients at high risk for perioperative complications. The few identified risk factors so far refer to open surgery. Data for the elective laparoscopic approach is rare. The objective of this study was to identify potential predictive risk factors for intra- and postoperative complications in patients who underwent laparoscopic sigmoid resection due to diverticular disease

Laparoscopically assisted colectomy: a study of risk factors and predictors of open conversion

The original publication can be found at www.springerlink.comBackground Conversion to an open procedure during laparoscopically assisted colorectal resection may be necessary because of technical, patient, or pathologic factors. Recent literature has indicated that converted patients may have poorer outcomes than those undergoing open or completed laparoscopically assisted procedure. This study aimed to audit the authors’ experience with laparoscopically assisted colectomy and to assess the clinical outcomes of patients undergoing conversion. Methods All laparoscopic right hemicolectomies or anterior resections performed at seven South Australian hospitals from 1997 to 2006 were reviewed. Data pertaining to patient sex, age, American Society of Anesthesiology (ASA) score, pathology, operative outcomes including operating time, conversion, reason for conversion, length of hospital stay, and intra- and postoperative complications were analyzed. Results Laparoscopic anterior resection had a higher rate of open conversion than laparoscopic right hemicolectomy (18.7% vs 10.4%; p = 0.028). In the right hemicolectomy group, none of the investigated risk factors for conversion were statistically significant, and the morbidity rates for the two groups were similar. The median hospital stay was significantly longer in the anterior resection group (p < 0.001), and the wound morbidity rate was higher in the converted group (12.8% vs 3.0%; p = 0.022). Age older than 75 years and a high ASA status were independent risk factors for conversion in anterior resection. Conclusions Conversion of laparoscopic anterior resection to open procedure is associated with higher wound morbidity and a longer hospital stay. The authors recommend that surgeons carefully consider the selection of patients 75 years of age or older and high ASA status for laparoscopic anterior resection