title: Preoperative biliary drainage for cancer of the head of the pancreas. Octreotide Does Not Prevent Pancreatic Fistula Following Pancreatoduodenectomy in Patients with Soft Pancreas and Non-dilated Duct: A Prospective Randomized Controlled Trial Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. Effects of chewing gum against postoperative ileus after pancreaticoduodenectomy – a randomized controlled trial A Clinical Outcome-Based Prospective Study on Venous Thromboembolism After Cancer Surgery: The @RISTOS Project Does Prophylactic Octreotide Decrease the Rates of Pancreatic Fistula and Other Complications After Pancreaticoduodenectomy?: Results of a Prospective Randomized Placebo-Controlled Trial Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours Effects of a Circulating-water Garment and Forced-air Warming on Body Heat Content and Core Temperature Comparison of ramosetron and ondansetron for the treatment of established postoperative nausea and vomiting after laparoscopic surgery: a prospective, randomized, double-blinded multicenter trial Perioperative Antibiotics Covering Bile Contamination Prevent Abdominal Infectious Complications After Pancreatoduodenectomy in Patients With Preoperative Biliary Drainage Risk factors, complications and survival after upper abdominal surgery: a prospective cohort study A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. ALEXIS O‐Ring wound retractor vs conventional wound protection for the prevention of surgical site infections in colorectal resections 1 Early oral feeding after pancreatoduodenectomy enhances recovery without increasing morbidity. Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Restrictive intraoperative fluid optimisation algorithm improves outcomes in patients undergoing pancreaticoduodenectomy: A prospective multicentre randomized controlled trial Randomized controlled trial of perioperative antimicrobial therapy based on the results of preoperative bile cultures in patients undergoing biliary reconstruction Intraoperative Fluid Restriction in Pancreatic Surgery: A Double Blinded Randomised Controlled Trial Effects of a Perioperative Smoking Cessation Intervention on Postoperative Complications: A Randomized Trial Reconsideration of Postoperative Oral Intake Tolerance After Pancreaticoduodenectomy: Prospective Consecutive Analysis of Delayed Gastric Emptying According to the ISGPS Definition and the Amount of Dietary Intake The HYSLAR Trial: A Prospective Randomized Controlled Trial of the Use of a Restrictive Fluid Regimen With 3% Hypertonic Saline Versus Lactated Ringers in Patients Undergoing Pancreaticoduodenectomy Determinants of Surgical Site Infections Following Pancreatoduodenectomy Ensuring Early Mobilization Within an Enhanced Recovery Program for Colorectal Surgery: A Randomized Controlled Trial Preoperative oral carbohydrate treatment attenuates immediate postoperative insulin resistance. CONSORT 2010 Statement: Updated Guidelines for Reporting Parallel Group Randomized Trials Specific Antibiotic Prophylaxis Based on Bile Cultures Is Required to Prevent Postoperative Infectious Complications in Pancreatoduodenectomy Patients Who Have Undergone Preoperative Biliary Drainage Core temperatures during major abdominal surgery in patients warmed with new circulating-water garment, forced-air warming, or carbon-fiber resistive-heating system Continuous Epidural Blockade Arrests the Postoperative Decrease in Muscle Protein Fractional Synthetic Rate in Surgical Patients Postoperative Complications Reduce Adjuvant Chemotherapy Use in Resectable Pancreatic Cancer Prospective Randomized Controlled Trial of Liberal Vs Restricted Perioperative Fluid Management in Patients Undergoing Pancreatectomy Prospective Randomized Clinical Trial of the Value of Intraperitoneal Drainage After Pancreatic Resection Laparoscopic surgery for pancreatic neoplasms: the European association for endoscopic surgery clinical consensus conference Intensive Versus Intermediate Glucose Control in Surgical Intensive Care Unit Patients Pasireotide for postoperative pancreatic fistula. Circulating-water garment or the combination of a circulating-water mattress and forced-air cover to maintain core temperature during major upper-abdominal surgery. Information gain in patients using a multimedia website with tailored information on anaesthesia. Delayed gastric emptying following pancreaticoduodenectomy: Incidence, risk factors, and healthcare utilization Effect of polylactic film (Surgi-Wrap) on preventing postoperative ileus after major hepato-pancreato-biliary surgery Preventing opioid-induced nausea and vomiting: Rest your head and close your eyes? Randomized, multicenter trial of antibiotic prophylaxis in elective colorectal surgery: single dose vs 3 doses of a second-generation cephalosporin without metronidazole and oral antibiotics. Intravenous versus epidural analgesia to reduce the incidence of gastrointestinal complications after elective pancreatoduodenectomy (the PAKMAN trial, DRKS 00007784): study protocol for a randomized controlled trial Continuous wound infiltration versus epidural analgesia after hepato-pancreato-biliary surgery (POP-UP): a randomised controlled, open-label, non-inferiority trial. Strategies to attenuate the catabolic response to surgery and improve perioperative outcomes Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial Clinical and Immunological Impact of Early Postoperative Enteral Immunonutrition After Total Gastrectomy in Gastric Cancer Patients: A Prospective Randomized Study Forced-air warming and fluid warming minimize core hypothermia during abdominal surgery. Optimal duration and timing of adjuvant chemotherapy after definitive surgery for ductal adenocarcinoma of the pancreas: ongoing lessons from the ESPAC-3 study. Impact of fluid resuscitation on major adverse events following pancreaticoduodenectomy. Multicenter, Prospective Trial of Selective Drain Management for Pancreatoduodenectomy Using Risk Stratification Efficacy of external warming in attenuation of hypothermia in surgical patients. Influence of Food Intake on the Healing Process of Postoperative Pancreatic Fistula After Pancreatoduodenectomy: A Multi-institutional Randomized Controlled Trial Preoperative Oral Supplementation with Long-Chain Ω-3 Fatty Acids Beneficially Alters Phospholipid Fatty Acid Patterns in Liver, Gut Mucosa, and Tumor Tissue. Pylorus Resection Does Not Reduce Delayed Gastric Emptying After Partial Pancreatoduodenectomy: A Blinded Randomized Controlled Trial (PROPP Study, DRKS00004191) Impact of the Reconstruction Method on Delayed Gastric Emptying After Pylorus-Preserving Pancreaticoduodenectomy: A Prospective Randomized Study Perioperative Enteral Immunonutrition Modulates Systemic and Mucosal Immunity and the Inflammatory Response in Patients With Periampullary Cancer Scheduled for Pancreaticoduodenectomy: A Randomized Clinical Trial Minimally invasive versus open pancreatoduodenectomy (LEOPARD-2): study protocol for a randomized controlled trial Comparative analysis of the efficacy and complications of nasojejunal and jejunostomy on patients undergoing pancreaticoduodenectomy. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: A randomized controlled trial. The effect of early mobilization protocols on postoperative outcomes following abdominal and thoracic surgery: A systematic review. Continuous postoperative blood glucose monitoring and control by artificial pancreas in patients having pancreatic resection: a prospective randomized clinical trial. Intraoperative Fluid Resuscitation Strategies in Pancreatectomy: Results from 38 Hospitals in Michigan Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. Relationship Between Intraoperative Fluid Administration and Perioperative Outcome After Pancreaticoduodenectomy: Results of a Prospective Randomized Trial of Acute Normovolemic Hemodilution Compared With Standard Intraoperative Management Early Versus Late Drain Removal After Standard Pancreatic Resections: Results of a Prospective Randomized Trial Barrier Wound Protection Decreases Surgical Site Infection in Open Elective Colorectal Surgery: A Randomized Clinical Trial Preoperative immunonutrition decreases postoperative complications by modulating prostaglandin E2 production and T-cell differentiation in patients undergoing pancreatoduodenectomy. Enteral nutrition is superior to total parenteral nutrition for pancreatic cancer patients who underwent pancreaticoduodenectomy. Intensive versus conventional glucose control in critically ill patients. A prospective study of prophylactic long-acting octreotide in high-risk patients undergoing pancreaticoduodenectomy. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Treatment of bacteriobilia decreases wound infection rates after pancreaticoduodenectomy. Prospective randomized trial of the effect of octreotide on pancreatic juice output after pancreaticoduodenectomy in relation to histological diagnosis, duct size and leakage. Early Enteral Versus Total Parenteral Nutrition in Patients Undergoing Pancreaticoduodenectomy: A Randomized Multicenter Controlled Trial (Nutri-DPC) Epidural Analgesia for Pancreatoduodenectomy: A Critical Appraisal Effect of Mosapride on Recovery of Intestinal Motility After Hand-Assisted Laparoscopic Colectomy for Carcinoma Postoperative Nausea and Vomiting Are Strongly Influenced by Postoperative Opioid Use in a Dose-Related Manner A systematic review of information format and timing before scheduled adult surgery for peri‐operative anxiety A Prognostic Score to Predict Major Complications After Pancreaticoduodenectomy Prospectively Randomized Trial Using Perioperative Low Dose Octreotide to Prevent Organ Related and General Complications Following Pancreatic Surgery and Pancreatico-jejunostomy No Need for Routine Drainage After Pancreatic Head Resection: The Dual-Center, Randomized, Controlled PANDRA Trial (ISRCTN04937707) Factors associated with delayed gastric emptying after pancreaticoduodenectomy. Role of Somatostatin in the Prevention of Pancreatic Stump-related Morbidity following Elective Pancreaticoduodenectomy in High-risk Patients and Elimination of Surgeon-related Factors: Prospective, Randomized, Controlled Trial Effects of Somatostatin Prophylaxis after Pylorus-preserving Pancreaticoduodenectomy: Increased Delayed Gastric Emptying and Reduced Plasma Motilin The Value of Drains as a Fistula Mitigation Strategy for Pancreatoduodenectomy: Something for Everyone? Results of a Randomized Prospective Multi-institutional Study Allowing Normal Food at Will After Major Upper Gastrointestinal Surgery Does Not Increase Morbidity: A Randomized Multicenter Trial The effect of interactive multimedia on preoperative knowledge and postoperative recovery of patients undergoing laparoscopic cholecystectomy. Perioperative antibiotics for surgical site infection in pancreaticoduodenectomy: does the SCIP-approved regimen provide adequate coverage? Effect of dexmedetomidine on the minimum alveolar concentration (MAC) of sevoflurane in adults age 55 to 70 years. GRADE: assessing the quality of evidence for diagnostic recommendations Hypoglycemia and risk of death in critically ill patients. Evidence-based analysis of risk factors for postoperative nausea and vomiting. The Impact of Immunostimulating Nutrition on Infectious Complications After Upper Gastrointestinal Surgery: A Prospective, Randomized, Clinical Trial Efficacy of octreotide in the prevention of complications after pancreaticoduodenectomy in patients with soft pancreas and non-dilated pancreatic duct: A prospective randomized trial. Effect of preoperative warming on intraoperative hypothermia: a randomized-controlled trial The Impact of Preoperative Enteral Nutrition Enriched with Eicosapentaenoic Acid on Postoperative Hypercytokinemia after Pancreatoduodenectomy: The Results of a Double-Blinded Randomized Controlled Trial Minimum Effective dose of Dexamethasone in Combination with Midazolam as Prophylaxis against Postoperative Nausea and Vomiting after Laparoscopic Cholecystectomy Factors Affecting Postoperative Nausea and Vomiting in Surgical Patients Comparison of Perioperative Outcomes Between Laparoscopic and Open Approach for Pancreatoduodenectomy: The PADULAP Randomized Controlled Trial Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial. Warming with an underbody warming system reduces intraoperative hypothermia in patients undergoing laparoscopic gastrointestinal surgery: a randomized controlled study. Routine nasogastric suction may be unnecessary after a pancreatic resection. Prospective Evaluation of Pasireotide in Patients Undergoing Pancreaticoduodenectomy: The Washington University Experience. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Prophylactic octreotide and delayed gastric emptying after pancreaticoduodenectomy: results of a prospective randomized double-blinded placebo-controlled trial.
abstract: BACKGROUND The benefits of preoperative biliary drainage , which was introduced to improve the postoperative outcome in patients with obstructive jaundice caused by a tumor of the pancreatic head , are unclear . METHODS In this multicenter , r and omized trial , we compared preoperative biliary drainage with surgery alone for patients with cancer of the pancreatic head . Patients with obstructive jaundice and a bilirubin level of 40 to 250 micromol per liter ( 2.3 to 14.6 mg per deciliter ) were r and omly assigned to undergo either preoperative biliary drainage for 4 to 6 weeks , followed by surgery , or surgery alone within 1 week after diagnosis . Preoperative biliary drainage was attempted primarily with the placement of an endoprosthesis by means of endoscopic retro grade cholangiopancreatography . The primary outcome was the rate of serious complications within 120 days after r and omization . RESULTS We enrolled 202 patients ; 96 were assigned to undergo early surgery and 106 to undergo preoperative biliary drainage ; 6 patients were excluded from the analysis . The rates of serious complications were 39 % ( 37 patients ) in the early-surgery group and 74 % ( 75 patients ) in the biliary-drainage group ( relative risk in the early-surgery group , 0.54 ; 95 % confidence interval [ CI ] , 0.41 to 0.71 ; P<0.001 ) . Preoperative biliary drainage was successful in 96 patients ( 94 % ) after one or more attempts , with complications in 47 patients ( 46 % ) . Surgery-related complications occurred in 35 patients ( 37 % ) in the early-surgery group and in 48 patients ( 47 % ) in the biliary-drainage group ( relative risk , 0.79 ; 95 % CI , 0.57 to 1.11 ; P=0.14 ) . Mortality and the length of hospital stay did not differ significantly between the two groups . CONCLUSIONS Routine preoperative biliary drainage in patients undergoing surgery for cancer of the pancreatic head increases the rate of complications . ( Current Controlled Trials number , IS RCT N31939699 . Background Whether octreotide prevents pancreatic fistula following pancreatoduodenectomy is controversial and it is believed to be beneficial in soft gl and s and normal-sized ducts . The aim of this study is to assess the potential value of octreotide in reducing the incidence of pancreatic fistula , postoperative complications , morbidity and hospital stay in patients with soft pancreas and non-dilated ducts . Methods A total of 109 patients undergoing elective pancreatoduodenectomy with soft pancreas and non-dilated duct were r and omized to  octreotide group versus no octreotide —  the control group . Surgical steps were st and ardized and incidences of pancreatic fistula , complications , death and hospital stay were assessed . Results There were 55 patients in  octreotide group and 54 in the control group . Demographic features and pancreatic duct diameter of the groups were comparable . The rates of clinical ly significant pancreatic fistulae ( grade s B and C ) were 10.9 and 18.5 % ( p = ns ) , and morbidity was 18 and 29.6 % ( p = ns ) , respectively . Patients who received octreotide resumed oral diet early and had a shorter hospital stay . Conclusion This study demonstrated no statistical difference in pancreatic fistulae with the use of octreotide , though there was a trend towards fewer incidences of pancreatic fistulae , morbidity and shorter hospital stay . Clinical Trials.gov Identifier : BACKGROUND Mild perioperative hypothermia , which is common during major surgery , may promote surgical-wound infection by triggering thermoregulatory vasoconstriction , which decreases subcutaneous oxygen tension . Reduced levels of oxygen in tissue impair oxidative killing by neutrophils and decrease the strength of the healing wound by reducing the deposition of collagen . Hypothermia also directly impairs immune function . We tested the hypothesis that hypothermia both increases susceptibility to surgical-wound infection and lengthens hospitalization . METHODS Two hundred patients undergoing colorectal surgery were r and omly assigned to routine intraoperative thermal care ( the hypothermia group ) or additional warming ( the normothermia group ) . The patient 's anesthetic care was st and ardized , and they were all given cefam and ole and metronidazole . In a double-blind protocol , their wounds were evaluated daily until discharge from the hospital and in the clinic after two weeks ; wounds containing culture-positive pus were considered infected . The patients ' surgeons remained unaware of the patients ' group assignments . RESULTS The mean ( + /- SD ) final intraoperative core temperature was 34.7 + /- 0.6 degrees C in the hypothermia group and 36.6 + /- 0.5 degrees C in the normothermia group ( P < 0.001 ) Surgical-wound infections were found in 18 of 96 patients assigned to hypothermia ( 19 percent ) but in only 6 of 104 patients assigned to normothermia ( 6 percent , P = 0.009 ) . The sutures were removed one day later in the patients assigned to hypothermia than in those assigned to normothermia ( P = 0.002 ) , and the duration of hospitalization was prolonged by 2.6 days ( approximately 20 percent ) in hypothermia group ( P = 0.01 ) . CONCLUSIONS Hypothermia itself may delay healing and predispose patients to wound infections . Maintaining normothermia intraoperatively is likely to decrease the incidence of infectious complications in patients undergoing colorectal resection and to shorten their hospitalizations Background Postoperative ileus is common after surgery . One non-pharmacological intervention that has shown promising results in reducing the duration of postoperative ileus is chewing gum after surgery . However , this has not been investigated in upper gastrointestinal surgery such as pancreatic surgery . Hence the aim of this study was to investigate the effects of chewing gum treatment on patients undergoing pancreaticoduodenectomy ad modum whipple due to pancreatic or periampullary cancer . Methods This study was conducted as a phase III trial that was terminated early . Patients diagnosed with pancreatic tumours scheduled for pancreaticoduodenectomy ad modum whipple were included . The treatment group received chewing gum postoperatively and st and ard care . Controls received glucose solution and st and ard care . Chewing gum and glucose were used four times a day during the whole hospital stay . Time to first flatus and stool was defined as the primary outcome . The secondary outcome was start with clear liquids , start with liquid diet and length of hospital stay . Results No statistically significant differences could be observed between the chewing gum intervention group and the control group . However , a numerical difference in mean time was observed in first flatus , first stool , start of clear fluids , and start of liquid diet and length of hospital stay in favour of the intervention group . Conclusions Although this study did not find statistically significant differences favouring the use of chewing gum for postoperative ileus , a positive trend was observed of a reduction of the impact of postoperative ileus among patients after pancreatic surgery . It also contributes valuable method ological experience that is important for future studies of chewing gum interventions during recovery after pancreatic surgery . Trial registration Clinical Trials.gov identifier : NCT02319512 , publication date 2014 - 12 - 17 Summary Background Data : The epidemiology of venous thromboembolism ( VTE ) after cancer surgery is based on clinical trials on VTE prophylaxis that used venography to screen deep vein thrombosis ( DVT ) . However , the clinical relevance of asymptomatic venography-detected DVT is unclear , and the population of these clinical trials is not necessarily representative of the overall cancer surgery population . Objective : The aim of this study was to evaluate the incidence of clinical ly overt VTE in a wide spectrum of consecutive patients undergoing surgery for cancer and to identify risk factors for VTE . Methods : @RISTOS was a prospect i ve observational study in patients undergoing general , urologic , or gynecologic surgery . Patients were assessed for clinical ly overt VTE occurring up to 30 ± 5 days after surgery or more if the hospital stay was longer than 35 days . All outcome events were evaluated by an independent Adjudication Committee . Results : A total of 2373 patients were included in the study : 1238 ( 52 % ) undergoing general , 685 ( 29 % ) urologic , and 450 ( 19 % ) gynecologic surgery . In-hospital prophylaxis was given in 81.6 % and postdischarge prophylaxis in 30.7 % of the patients . Fifty patients ( 2.1 % ) were adjudicated as affected by clinical ly overt VTE ( DVT , 0.42 % ; nonfatal pulmonary embolism , 0.88 % ; death 0.80 % ) . The incidence of VTE was 2.83 % in general surgery , 2.0 % in gynecologic surgery , and 0.87 % in urologic surgery . Forty percent of the events occurred later than 21 days from surgery . The overall death rate was 1.72 % ; in 46.3 % of the cases , death was caused by VTE . In a multivariable analysis , 5 risk factors were identified : age above 60 years ( 2.63 , 95 % confidence interval , 1.21–5.71 ) , previous VTE ( 5.98 , 2.13–16.80 ) , advanced cancer ( 2.68 , 1.37–5.24 ) , anesthesia lasting more than 2 hours ( 4.50 , 1.06–19.04 ) , and bed rest longer than 3 days ( 4.37 , 2.45–7.78 ) . Conclusions : VTE remains a common complication of cancer surgery , with a remarkable proportion of events occurring late after surgery . In patients undergoing cancer surgery , VTE is the most common cause of death at 30 days after surgery Objective To evaluate the endpoints of complications ( specifically pancreatic fistula and total complications ) and death in patients undergoing pancreaticoduodenectomy . Summary Background Data Four r and omized , placebo-controlled , multicenter trials from Europe have evaluated prophylactic octreotide ( the long-acting synthetic analog of native somatostatin ) in patients undergoing pancreatic resection . Each trial reported significant decreases in overall complication rates , and two of the four reported significantly lowered rates of pancreatic fistula in patients receiving prophylactic octreotide . However , none of these four trials studied only pancreaticoduodenal resections , and all trials had high pancreatic fistula rates ( > 19 % ) in the placebo group . A fifth r and omized trial from the United States evaluated the use of prophylactic octreotide in patients undergoing pancreaticoduodenectomy and found no benefit to the use of octreotide . Prophylactic use of octreotide adds more than $ 75 to the daily hospital charge in the United States . In calendar year 1996 , 288 patients received octreotide on the surgical service at the authors ’ institution , for total billed charges of $ 74,652 . Methods Between February 1998 and February 2000 , 383 patients were recruited into this study on the basis of preoperative anticipation of pancreaticoduodenal resection . Patients who gave consent were r and omized to saline control versus octreotide 250 & mgr;g subcutaneously every 8 hours for 7 days , to start 1 to 2 hours before surgery . The primary postoperative endpoints were pancreatic fistula , total complications , death , and length of hospital stay . Results Two hundred eleven patients underwent pancreaticoduodenectomy with pancreatic-enteric anastomosis , received appropriate saline/octreotide doses , and were available for endpoint analysis . The two groups were comparable with respect to demographics ( 54 % male , median age 66 years ) , type of pancreaticoduodenal resection ( 60 % pylorus-preserving ) , type of pancreatic-enteric anastomosis ( 87 % end-to-side pancreaticojejunostomy ) , and pathologic diagnosis . The pancreatic fistula rates were 9 % in the control group and 11 % in the octreotide group . The overall complication rates were 34 % in the control group and 40 % in the octreotide group ; the in-hospital death rates were 0 % versus 1 % , respectively . The median postoperative length of hospital stay was 9 days in both groups . Conclusions These data demonstrate that the prophylactic use of perioperative octreotide does not reduce the incidence of pancreatic fistula or total complications after pancreaticoduodenectomy . Prophylactic  octreotide use in this setting should be eliminated , at a considerable cost savings Laparoscopic resection as an alternative to open pancreatoduodenectomy may yield short‐term benefits , but has not been investigated in a r and omized trial . The aim of this study was to compare laparoscopic and open pancreatoduodenectomy for short‐term outcomes in a r and omized trial Background : Forced-air warming is sometimes unable to maintain perioperative normothermia . Therefore , the authors compared heat transfer , regional heat distribution , and core rewarming of forced-air warming with a novel circulating-water garment . Methods : Nine volunteers were each evaluated on two r and omly ordered study days . They were anesthetized and cooled to a core temperature near 34 ° C . The volunteers were subsequently warmed for 2.5 h with either a circulating-water garment or a forced-air cover . Overall , heat balance was determined from the difference between cutaneous heat loss ( thermal flux transducers ) and metabolic heat production ( oxygen consumption ) . Average arm and leg ( peripheral ) tissue temperatures were determined from 18 intramuscular needle thermocouples , 15 skin thermal flux transducers , and “ deep ” h and and foot thermometers . Results : Heat production ( approximately 60 kcal/h ) and loss ( approximately 45 kcal/h ) were similar with each treatment before warming . The increases in heat transfer across anterior portions of the skin surface were similar with each warming system ( approximately 65 kcal/h ) . Forced-air warming had no effect on posterior heat transfer , whereas circulating-water transferred 21 ± 9 kcal/h through the posterior skin surface after a half hour of warming . Over 2.5 h , circulating water thus increased body heat content 56 % more than forced air . Core temperatures thus increased faster than with circulating water than forced air , especially during the first hour , with the result that core temperature was 1.1 ° ± 0.7 ° C greater after 2.5 h ( P < 0.001 ) . Peripheral tissue heat content increased twice as much as core heat content with each device , but the core-to-peripheral tissue temperature gradient remained positive throughout the study . Conclusions : The circulating-water system transferred more heat than forced air , with the difference result ing largely from posterior heating . Circulating water rewarmed patients 0.4 ° C/h faster than forced air . A substantial peripheral-to-core tissue temperature gradient with each device indicated that peripheral tissues insulated the core , thus slowing heat transfer Background Postoperative nausea and vomiting ( PONV ) is a common complication after surgery , which increases physical and psychological discomfort and delays recovery . The aim of this study was to test the hypothesis that ramosetron is comparable to ondansetron for the treatment of established PONV after laparoscopic surgery using a prospect i ve , r and omized , double-blinded , noninferiority study . Methods Patients who had at least two risk factors of PONV and underwent laparoscopic surgery under general anesthesia were assessed for eligibility . Patients who developed PONV within the first 2 h after anesthesia received ondansetron ( 4 mg ) or ramosetron ( 0.3 mg ) intravenously in a r and omized double-blind manner . Patients were then observed for 24 h after drug administration . The incidence of nausea and vomiting , severity of nausea , rescue antiemetic necessity , and adverse effects at 0–2 or 2–24 h after drug administration was evaluated . The primary endpoint was the rate of patients exhibiting a complete response , defined as no emesis and no further rescue antiemetic medication for 24 h after drug administration . Results Among the 583 patients , 210 ( 36.0 % ) developed PONV and were r and omized to either the ondansetron ( n=105 ) or ramosetron ( n=105 ) group . Patient ’s characteristics were similar between the groups . The complete response rate was 44.1 % in the ondansetron group and 52.9 % in the ramosetron group after 24 h of initial antiemetic administration . The incidence of adverse events was not different between the groups . Conclusion We found evidence to support the noninferiority of ramosetron ( 0.3 mg ) compared to ondansetron ( 4 mg ) for the treatment of established PONV in moderate to high-risk patients undergoing laparoscopic surgery Background Although bile contamination caused by preoperative biliary drainage ( PBD ) is a risk factor for infectious complications after pancreatoduodenectomy , the appropriate perioperative antibiotic regimen remains unclear . We evaluated a perioperative antibiotic strategy targeting bile contamination associated with PBD procedures for preventing abdominal infectious complications after pancreatoduodenectomy . Methods Consecutive patients ( n = 254 ) underwent pancreatoduodenectomy at a single center .  Perioperative antibiotics were mainly cefazolin in non-PBD cases ( n = 116 ) and cefozopran in internal-PBD cases ( n = 87 ) . They were based on preoperative bile cultures in 51 of the external-PBD cases . Intraoperative bile cultures were examined prospect ively . Morbidity and abdominal infectious complication rates were evaluated . Results The incidence of positive intraoperative bile cultures was significantly higher in the internal-PBD ( 85 % ) and external-PBD ( 90 % ) cases than in the non-PBD cases ( 26 % ) ( p < 0.001 ) . The 91 % susceptibility to cefazolin for non-PBD was significantly higher than the 61 % for internal-PBD or 45 % for external-PBD ( p < 0.001 ) . Overall morbidity rates ( 23 , 23 , and 25 % ) and abdominal infectious complications ( 13 , 17 , and 14 % ) did not differ among the non-PBD , internal-PBD , and external-PBD cases , respectively . Only susceptibility to perioperative antibiotics  of biliary microorganisms classified as resistant was a significant independent risk factor for abdominal infectious complications ( p = 0.003 ) . Conclusions A perioperative antibiotic strategy particular to PBD procedures is valid for covering biliary microorganisms during pancreatoduodenectomy . Perioperative antibiotics covering bile contamination may prevent abdominal infectious complications after pancreatoduodenectomy in patients with and without PBD Background Preoperative weight loss and abnormal serum-albumin have traditionally been associated with reduced survival . More recently , a correlation between postoperative complications and reduced long-term survival has been reported and the significance of the relative proportion of skeletal muscle , visceral and subcutaneous adipose tissue has been examined with conflicting results . We investigated how preoperative body composition and major non-fatal complications related to overall survival and compared this to established predictors in a large cohort undergoing upper abdominal surgery .  Methods From 2001 to 2006 , 447 patients were included in a Norwegian multicenter r and omized controlled trial in major upper abdominal surgery .  Patients were now , six years later , analyzed as a single prospect i ve cohort and overall survival was retrieved from the National Population Registry . Body composition indices were calculated from CT images taken within three months preoperatively . Results Preoperative serum-albumin < 35 g/l ( HR = 1.52 , p = 0 .014 ) and weight loss > 5 % ( HR = 1.38 , p = 0.023 ) were independently associated with reduced survival . There was no association between any of the preoperative body composition indices and reduced survival . Major postoperative complications were independently associated with reduced survival but only as long as patients who died within 90 days were included in the analysis . Conclusions Our study has confirmed the robust significance of the traditional indicators , preoperative serum-albumin and weight loss . The body composition indices did not prove beneficial as global indicators of poor prognosis in upper abdominal surgery . We found no association between non-fatal postoperative complications and long-term survival BACKGROUND Clinical ly relevant postoperative pancreatic fistulas ( CR-POPF ) are serious inherent risks of pancreatic resection . Preoperative CR-POPF risk assessment is currently inadequate and rarely disqualifies patients who need resection . The best evaluation of risk occurs intraoperatively , and should guide fistula prevention and response measures thereafter . We sought to develop a risk prediction tool for CR-POPF that features intraoperative assessment and reveals associated clinical and economic significance . STUDY DESIGN Based on International Study Group of Pancreatic Fistula classification , recognized risk factors for CR-POPF ( small duct , soft pancreas , high-risk pathology , excessive blood loss ) were evaluated during  pancreaticoduodenectomy .  An optimal risk score range model , selected from 3 different constructs , was first derived ( n = 233 ) and then vali date d prospect ively ( n = 212 ) . Clinical and economic outcomes were evaluated across 4 ranges of scores ( negligible risk , 0 points ; low risk , 1 to 2 ; intermediate risk , 3 to 6 ; high risk , 7 to 10 ) . RESULTS Clinical ly relevant postoperative pancreatic fistulas occurred in 13 % of patients . The incidence was greatest with excessive blood loss . Duct size < 5 mm was associated with increased fistula rates that rose with even smaller ducts . These factors , together with soft pancreatic parenchyma and certain disease pathologies , afforded a highly predictive 10-point Fistula Risk Score . Risk scores strongly correlated with fistula development ( p < 0.001 ) . Notably , patients with scores of 0 points never developed a CR-POPF , while fistulas occurred in all patients with scores of 9 or 10 . Other clinical and economic outcomes segregated by risk profile across the 4 risk strata . CONCLUSIONS A simple 10-point Fistula Risk Score derived during pancreaticoduodenectomy accurately predicts subsequent CR-POPF . It can be readily learned and broadly deployed . This prediction tool can help surgeons anticipate , identify , and manage this ominous complication from the outset Aim Surgical site infection ( SSI ) remains a common postoperative morbidity , particularly in colorectal resections , and poses a significant financial burden to the healthcare system . The omission of mechanical bowel preparation , as is performed in enhanced recovery after surgery programmes , appears to further increase the incidence . Various wound protection methods have been devised to reduce the incidence of SSIs . However , there are few r and omized controlled trials assessing their efficacy . The aim of this study is to investigate whether ALEXIS wound retractors with reinforced O‐rings are superior to conventional wound protection methods in preventing SSIs in colorectal resections OBJECTIVE The aim of this study was to evaluate whether a change in the routine feeding strategy applied after pancreatoduodenectomy ( PD ) from nasojejunal tube ( NJT ) feeding to early oral feeding improved clinical outcomes . METHODS An observational cohort study was performed in 102 consecutive patients undergoing PD . In period 1 ( n = 51 , historical controls ) , the routine postoperative feeding strategy was NJT feeding . This was changed to a protocol of early oral feeding with on-dem and NJT feeding in period 2 ( n = 51 , consecutive prospect i ve cohort ) . The primary outcome was time to resumption of adequate oral intake . RESULTS The baseline characteristics of study subjects in both periods were comparable . In period 1 , 98 % ( n = 50 ) of patients received NJT feeding , whereas in period 2 , 53 % ( n = 27 ) of patients did so [ for delayed gastric empting ( DGE ) ( n = 20 ) or preoperative malnutrition ( n = 7 ) ] . The time to resumption of adequate oral intake significantly decreased from 12 days in period 1 to 9 days in period 2 ( P = 0.015 ) , and the length of hospital stay shortened from 18 days in period 1 to 13 days in period 2 ( P = 0.015 ) . Overall , there were no differences in the incidences of complications of Clavien-Dindo Grade III or higher , DGE , pancreatic fistula , postoperative haemorrhage and mortality between the two periods . CONCLUSIONS The introduction of an early oral feeding strategy after PD reduced the time to resumption of adequate oral intake and length of hospital stay without negatively impacting postoperative morbidity BACKGROUND Falls are a common adverse event during hospitalization of older adults , and few interventions have been shown to prevent them . METHODS This study was a 3-group r and omized trial to evaluate the efficacy of 2 forms of multimedia patient education compared with usual care for the prevention of in-hospital falls .  Older hospital patients ( n = 1206 ) admitted to a mixture of acute ( orthopedic , respiratory , and medical ) and subacute ( geriatric and neurorehabilitation ) hospital wards at 2 Australian hospitals were recruited between January 2008 and April 2009 . The interventions were a multimedia patient education program based on the health-belief model combined with trained health professional follow-up ( complete program ) , multi-media patient education material s alone ( material s only ) , and usual care ( control ) .  Falls data were collected by blinded research assistants by review ing hospital incident reports , h and search ing medical records , and conducting weekly patient interviews . RESULTS Rates of falls per 1000 patient-days did not differ significantly between groups ( control , 9.27 ; material s only , 8.61 ; and complete program , 7.63 ) . However , there was a significant interaction between the intervention and presence of cognitive impairment . Falls were less frequent among cognitively intact patients in the complete program group ( 4.01 per 1000 patient-days ) than among cognitively intact patients in the material s-only group ( 8.18 per 1000 patient-days ) ( adjusted hazard ratio , 0.51 ; 95 % confidence interval , 0.28 - 0.93 ] ) and control group ( 8.72 per 1000 patient-days ) ( adjusted hazard ratio , 0.43 ; 95 % confidence interval , 0.24 - 0.78 ) . CONCLUSION Multimedia patient education with trained health professional follow-up reduced falls among patients with intact cognitive function admitted to a range of hospital wards . Trial Registration anzctr.org.au Identifier : ACTRN12608000015347 We aim ed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy with or without a cardiac output goal directed therapy ( GDT ) algorithm .  We conducted a multicentre r and omised controlled trial in four high volume hepatobiliary-pancreatic surgery centres . We evaluated whether the additional impact of a intraoperative fluid optimisation algorithm would influence the amount of fluid delivered , reduce fluid related complications , and improve length of hospital stay .  Fifty-two consecutive adult patients were recruited . The median ( IQR ) duration of surgery was 8.6 hours ( 7.1:9.6 ) in the GDT group vs. 7.8 hours ( 6.8:9.0 ) in the usual care group ( p = 0.2 ) . Intraoperative fluid balance was 1005mL ( 475:1873 ) in the GDT group vs. 3300mL ( 2474:3874 ) in the usual care group ( p<0.0001 ) . Total volume of fluid administered intraoperatively was also lower in the GDT group : 2050mL ( 1313:2700 ) vs. 4088mL ( 3400:4525 ) , p<0.0001 and vasoactive medications were used more frequently . There were no significant differences in proportions of patients experiencing overall complications ( p = 0.179 ) ; however , fewer complications occurred in the GDT group : 44 vs. 92 ( Incidence Rate Ratio : 0.41 ; 95%CI 0.24 to 0.69 , p = 0.001 ) . Median ( IQR ) length of hospital stay was 9.5 days ( IQR : 7.0 , 14.3 ) in the GDT vs. 12.5 days in the usual care group ( IQR : 9.0 , 22.3 ) for an Incidence Rate Ratio 0.64 ( 95 % CI 0.48 to 0.85 , p = 0.002 ) . In conclusion , using a surgery-specific , patient-specific goal directed restrictive fluid therapy algorithm in this cohort of patients , can justify using enough fluid without causing oedema , yet as little fluid as possible without causing hypovolaemia i.e. “ precision ” fluid therapy . Our findings support the use of a perioperative haemodynamic optimization plan that prioritizes preservation of cardiac output and organ perfusion pressure by judicious use of fluid therapy , rational use of vasoactive drugs and timely application of inotropic drugs . They also suggest the need for further larger studies to confirm its findings BACKGROUND The high frequency of surgical site infections ( SSIs )  after hepato-pancreato-biliary ( HPB ) surgery is a problem that needs to be addressed . This prospect i ve , r and omized , controlled study examined whether perioperative prophylactic use of antibiotics based on preoperative bile culture results in HPB surgery could decrease SSI . METHODS Participants comprised 126 patients who underwent HPB ( bile duct , gallbladder , ampullary , or pancreatic ) cancer surgery with biliary reconstruction at Hokkaido University Hospital between August 2008 and March 2013 ( UMIN Clinical Trial Registry # 00001278 ) . Before surgery , subjects were r and omly allocated to a targeted group administered antibiotics based on bile culture results or a st and ard group administered cefmetazole . The primary endpoint was SSI rates within 30 days after surgery . Secondary endpoint was SSI rates for each operative procedure . RESULTS Of the 126 patients , 124 were r and omly allocated ( targeted group , n = 62 ; st and ard group , n = 62 ) . Frequency of SSI after surgery was significantly lower in the targeted group ( 27 patients , 43.5 % ) than in the st and ard group ( 44 patients , 71.0 % ; P = 0.002 ) . Among patients who underwent pancreaticoduodenectomy and hepatectomy , SSI occurred significantly less frequently in the targeted group ( P = 0.001 and P = 0.025 , respectively ) . CONCLUSIONS This study demonstrated that preoperative bile culture-targeted administration of prophylactic antibiotics decreased SSIs following HBP surgery with biliary reconstruction Background Perioperative fluid restriction in a variety of operations has shown improvement of : complications , recovery of gastrointestinal function and length of stay ( LOS ) . We investigated effects of crystalloid fluid restriction in pancreatic surgery . Our hypothesis : enhanced recovery of gastrointestinal function . Methods In this double-blinded r and omized trial , patients scheduled to undergo pancreatoduodenectomy ( PD ) were r and omized : st and ard ( S:10ml/kg/hr ) or restricted ( R:5ml/kg/hr ) fluid protocol s. Primary endpoint : gastric emptying scintigraphically assessed on postoperative day 7 . Results In 66 r and omized patients , complications and 6-year survival were analyzed . 54 patients were analyzed in intention to treat : 24 S-group and 30 R-group . 32 patients actually underwent a PD and 16 patients had a palliative gastrojejunostomy bypass operation  in the full protocol analysis . The median gastric emptying time ( T½ ) was 104 minutes ( S-group , 95 % confidence interval : 74–369 ) versus 159 minutes ( R-group , 95 % confidence interval : 61–204 ) ( P = 0.893 , NS ) . Delayed gastric emptying occurred in 10 patients in the S-group and in 13 patients in the R-group ( 45 % and 50 % , P = 0.779 , NS ) . The primary outcome parameter , gastric emptying time , did not show a statistically significant difference between groups . Conclusion A fluid regimen of 10ml/kg/hr or 5ml/kg/hr during pancreatic surgery did not lead to statistically significant differences in gastric emptying . A larger study would be needed to draw definite conclusions about fluid restriction in pancreatic surgery . Trial registration IS RCT Objective : To determine whether an intervention with smoking cessation starting 4 weeks before general and orthopedic surgery would reduce the frequency of postoperative complications . Summary Background Data : Complications are a major concern after elective surgery and smokers have an increased risk . There is insufficient evidence concerning how the duration of preoperative smoking intervention affects postoperative complications . Methods : A r and omized controlled trial , conducted between February 2004 and December 2006 at 4 university-affiliated hospitals in the Stockholm region , Sweden . The outcome assessment was blinded . The follow-up period for the primary outcome was 30 days . Eligibility criteria were active daily smokers , aged 18 to 79 years . Of the 238 patients assessed , 76 refused participating , and 117 men and women undergoing surgery for primary hernia repair , laparoscopic cholecystectomy , or a hip or knee prosthesis were enrolled . Intervention : Smoking cessation therapy with individual counseling and nicotine substitution started 4 weeks before surgery and continued 4 weeks postoperatively . The control group received st and ard care . The main outcome measure was frequency of any postoperative complication . Results : An intention-to-treat analysis showed that the overall complication rate in the control group was 41 % , and in the intervention group , it was 21 % ( P = 0.03 ) . Relative risk reduction for the primary outcome of any postoperative complication was 49 % and number needed to treat was 5 ( 95 % CI , 3–40 ) . An analysis per protocol showed that abstainers had fewer complications ( 15 % ) than those who continued to smoke or only reduced smoking ( 35 % ) , although this difference was not statistically significant . Conclusion : Perioperative smoking cessation seems to be an effective tool to reduce postoperative complications even if it is introduced as late as 4 weeks before surgery Objective : A prospect i ve consecutive study was planned to evaluate the postpancreaticoduodenectomy ( PD ) oral intake tolerance .  The occurrence of delayed gastric emptying ( DGE ) , as defined by the International Study Group of Pancreatic Surgery ( ISGPS ) , and the amount of dietary intake were analyzed . The risk factors for low oral intake tolerance were additionally determined . Summary Background Data : The causation of DGE after PD is still unclear . Several possible factors have been discussed , such as reconstruction methods and other complications . However , none of them has followed the definition of ISGPS . Methods : Between 2003 and 2007 , 101 consecutive patients underwent PD-related surgery , and st and ard operative procedure was performed on 85 patients . Perioperative data were prospect ively collected in all patients , and the patient 's postoperative dietary intake was recorded for all meals until discharge . As an indicator of early postoperative oral intake tolerance , we added up the dietary intake from postoperative day 1 to 21 and called this value the total amount of dietary intake ( TDI ) . The postoperative outcomes were compared between non-DGE and DGE . The high-low of TDI values was also analyzed . Multivariate analysis for factors associated with the occurrence of DGE and TDI was performed . Results : The occurrence of DGE as defined by ISGPS was 42 % . The postoperative outcomes of DGE patients were significantly poor compared with those of non-DGE patients . TDI values were significantly low in DGE patients , and non-DGE patients with low TDI values showed a significantly extended duration of parenteral nutrition and postoperative hospitalization . Operative bleeding ( > 1,000 mL ) and pancreatic fistulas were likely to be associated with DGE occurrence . Gender ( women ) , BMI ( > 25 kg/m2 ) , postoperative intraabdominal infection , and DGE were significantly associated with low TDI values . Conclusions : The ISGPS definition of DGE seemed feasible for patient management . TDI values provided additional information for analyzing postoperative oral intake tolerance , especially when describing the differences among non-DGE patients . Substantial risk factors for low oral intake tolerance were high BMI , postoperative intraabdominal infection , and DGE Objective : This study was design ed to determine whether the volume and type of fluid administered for pancreaticoduodenectomy impacts postoperative outcomes . Background : Three percent hypertonic saline ( HYS ) has been suggested as a means of reducing the volume of fluid required to sustain tissue perfusion in the perioperative period . Methods : Between May 2011 and November 2013 , patients undergoing pancreaticoduodenectomy were enrolled in an institutional review board – approved , single-center , prospect i ve , parallel , r and omized controlled trial ( NCT 01428050 ) , comparing lactated Ringers ( LAR ) ( 15 mL/kg/hr LAR intraoperation , 2 mL/kg/hr LAR postoperation ) with HYS ( 9 mL/kg/hr LAR and 1 mL/kg/hr HYS intraoperation , 1 mL/kg/hr HYS postoperation ) . Results : A total of 264 patients were r and omized . Demographic variables between groups were similar . The HYS patients had a significantly reduced net fluid balance ( 65 vs 91 mL/kg , P = 0.02 ) . The overall complication rate was reduced in the HYS group ( 43 % vs 54 % ) , with a relative risk of 0.79 [ 95 % confidence interval ( CI ) , 0.62–1.02 ; P = 0.073 ] , factoring stratification for pancreas texture . After adjustment for age and weight , the relative risk was 0.75 [ 95 % CI ( 0.58–0.96 ) ; P = 0.023 ] . The total number of complications was significantly reduced in the HYS group ( 93 vs 123 ) , with an incidence rate ratio of 0.74 [ 95 % CI ( 0.56–0.97 ) ; P = 0.027 ] . After adjustment for age and weight , the incidence rate ratio was 0.69 [ 95 % CI ( 0.52–0.90 ) ; P = 0.0068 ] . Reoperations , length of stay , readmissions , and 90-day mortality were similar between groups . Conclusions : A moderately restrictive fluid regimen with HYS result ed in a statistically significant 25 % reduction in complications when adjusted for age , weight , and pancreatic texture Background Surgical site infections ( SSI ) following pancreatoduodenectomy ( PD ) contribute to adverse perioperative and long-term outcomes . Hence , the need to determine the modifiable factors related to their causation . Aim To identify demographic , nutritional , surgical and histopathological factors significantly associated with incisional SSIs . Methods A retrospective analysis of a prospect ively maintained data base of consecutive patients who underwent PD for pancreatic and periampullary lesions at a tertiary care referral centre , between April 2010 and June 2014 was carried out . Patients were divided into two groups based on the SSIs ( Group 1—With SSI ; Group 2—No SSI ) . All patients were administered three , once daily doses of Ertapenem ( 1 g ) as follows : within 1 h prior to induction , and on day 1 and day 2 following surgery . No further antibiotics were given prior to discharge unless clinical ly indicated . Results 35 out of 277 patients ( 12.6 % ) developed SSIs . No demographic ( age , sex , BMI ) , nutritional ( serum albumin ) , surgical ( pancreatic duct size and texture , surgical duration and intraoperative blood transfusions ) and histopathological factors ( malignancy vs. benign ) were noted between the two groups . However , SSIs were significantly higher in patients with endocrine co-morbidities ( other than diabetes mellitus ) , in those patients who had undergone prior ERCP and stenting , as well as an end-to-side pancreaticojejunostomy . Patients with diabetes mellitus had a significantly lower incidence of wound infections ( P = .014 ) . Conclusion Preoperative ERCP and stenting , end-to-side PJ and the presence of non-diabetic endocrine co-morbidity may result in a significantly higher risk of SSIs . Further studies targeting these patient sub population s are warranted to enable a better underst and ing of how these factors contribute to the incidence of SSIs following PD Objective : To estimate the extent to which the addition of staff-directed facilitation of early mobilization to an Enhanced Recovery Program ( ERP ) impacts recovery after colorectal surgery , compared with usual care . Summary Background Data : Early mobilization is considered an important component of ERPs but , despite guidelines recommendations , adherence remains quite low . The value of dedicating specific re sources ( eg , staff time ) to increase early mobilization is unknown . Methods : This r and omized trial involved 99 colorectal surgery patients in an established ERP ( median age 63 , 57 % male , 80 % laparoscopic ) r and omized 1:1 to usual care  ( including preoperative education about early mobilization with postoperative daily targets ) or facilitated mobilization [ staff dedicated to assist transfers and walking from postoperative days ( PODs ) 0–3 ] . Primary outcome was the proportion of patients returning to preoperative functional walking capacity ( 6-min walk test ) at 4 weeks after surgery . We also explored the association of the intervention with in-hospital mobilization , time to achieve discharge criteria , time to recover gastrointestinal function , 30-day comprehensive complication index , and patient-reported outcome measures . Results : In the facilitated mobilization group , adherence to mobilization targets was greater on POD0 [ OR 4.7 ( 95 % CI 1.8–11.9 ) ] , POD1 [ OR 6.5 ( 95 % CI 2.3–18.3 ) ] , and POD2 [ OR 3.7 ( 95 % CI 1.2–11.3 ) ] . Step count was at least 2-fold greater on POD1 [ mean difference 843.3 steps ( 95 % CI 219.5–1467.1 ) ] and POD2 [ mean difference 1099.4 steps ( 95 % CI 282.7–1916.1 ) ] There was no between-group difference in recovery of walking capacity at 4 weeks after surgery [ OR 0.77 ( 95 % CI 0.30–1.97 ) ] . Other outcome measures were also not different between groups . Conclusions : In an ERP for colorectal surgery , staff-directed facilitation of early mobilization increased out-of-bed activities during hospital stay but did not improve outcomes . This study does not support the value of allocating additional re sources to ensure early mobilization in ERPs . Trial Registration : Clinical Trials.gov Identifier : Postoperative insulin resistance is a well-characterized metabolic state that has been shown to correlate with the length of postoperative stay in hospital . Preoperative intravenous or oral carbohydrate treatment has been shown to attenuate the development of postoperative insulin resistance measured 1 day after surgery . To study the effects of preoperative oral carbohydrate treatment on postoperative changes in insulin resistance and substrate utilization , in the absence of postoperative confounding factors , 15 patients were double-blindly treated with either a carbohydrate-rich beverage ( 12.5 % ) ( n = 8) or placebo ( n = 7 ) before undergoing total hip replacement surgery .  Insulin sensitivity , endogenous glucose release , and substrate oxidation rates were measured before and immediately after surgery . Whole body insulin sensitivity decreased by 18 % in the treatment group vs. 43 % in the placebo group ( P < 0.05 , Student 's t-test for unpaired data ) . In both groups , the major mechanism of insulin resistance was an inhibition of insulin-induced nonoxidative glucose disposal after surgery . The better preservation of insulin sensitivity in the treatment group was attributable to a less reduced glucose disposal in peripheral tissues and increased glucose oxidation rates The CONSORT ( Consoli date d St and ards of Reporting Trials ) statement is used worldwide to improve the reporting of r and omized , controlled trials . Schulz and colleagues describe the latest version , CONSORT 2010 , which up date s the reporting guideline based on new method ological evidence and accumulating experience . Background Preoperative biliary drainage ( PBD )  is associated with bacterial contamination of bile , but the effects of PBD on morbidity after pancreatoduodenectomy remain controversial . The aim of this study was to characterize bile contamination to develop successful specific antibiotic prophylactic strategies for pancreatoduodenectomy . Methods Ninety-one consecutive patients who underwent pancreatoduodenectomy for periampullary tumor were prospect ively evaluated .  Prophylactic antibiotics were selected based on preoperative bile cultures . Bile cultures and postoperative complications were compared in 46 patients who underwent PBD ( drainage group ) versus 45 patients who did not ( nondrainage group ) . Results The incidence of positive bile cultures was higher in the drainage group ( 78 % ) than in the nondrainage group ( 36 % ) ( P < 0.001 ) . In the drainage group , positive bile cultures were frequently polymicrobial ( 61 % ) and demonstrated resistance to several antibiotics , including cefazolin ( 83 % ) , cefmetazole ( 72 % ) , and cefpirome ( 64 % ) . Overall morbidity ( 30 % and 22 % ) and infectious morbidity ( 13 % and 11 % ) did not differ significantly between the drainage and nondrainage groups , respectively . Conclusions PBD had a notable influence on bile microbial contamination , including a higher rate of antibiotic resistance . Therefore , specific antibiotic prophylaxis based on bile culture is required for preventing infectious complications in pancreatoduodenectomy patients who undergo PBD Purpose It has been reported that recently developed circulating-water garments transfer more heat than a forced-air warming system . The authors evaluated the hypothesis that circulating-water leg wraps combined with a water mattress better maintain intraoperative core temperature ≥36 ° C than either forced-air warming or carbon-fiber resistive heating during major abdominal surgery . Methods Thirty-six patients undergoing open abdominal surgery were r and omly assigned to warming with : ( 1 ) circulating-water leg wraps combined with a full-length circulating-water mattress set at 42 ° C , ( 2 ) a lower-body forced-air cover set on high ( ≈43 ° C ) , and ( 3 ) a carbon-fiber resistive-heating cover set at 42 ° C . Patients were anesthetized with general anesthesia combined with continuous epidural analgesia . The primary outcome was intraoperative tympanic-membrane temperature ≥36 ° C . Results In the 2 h after anesthesia induction , core temperature decreased 1.0 ± 0.5 ° C in the forced-air group , 0.9 ± 0.2 ° C in the carbon-fiber group , and 0.4 ± 0.4 ° C in the circulating-water leg wraps and mattress group ( P < 0.05 vs. forced-air and carbon-fiber heating ) . At the end of surgery , core temperature was 0.2 ± 0.7 ° C above preoperative values in the circulating-water group but remained 0.6 ± 0.9 ° C less in the forced-air and 0.6 ± 0.4 ° C less in the carbon-fiber groups ( P < 0.05 vs. carbon fiber ) . Conclusions The combination of circulating-water leg wraps and a mattress better maintain intraoperative core temperature than did forced-air and carbon-fiber warming systems Background : Epidural anesthesia with local anesthetics is associated with postoperative attenuation of nitrogen loss . The protein‐sparing effect could be the result of either a decreased protein breakdown or increased protein synthesis . Although the role of epidural local anesthetics in effectively limiting the increase in postoperative protein breakdown is established at the whole‐body level , it is necessary to determine whether the muscle protein fractional synthetic rate is directly modulated when nociceptive stimuli are blocked . Methods : Twelve otherwise healthy patients scheduled for elective colorectal surgery , who were receiving a constant intake of nitrogen ( 0.1 g [ center dot ] kg sup ‐1 [ center dot ] day sup ‐1 ) and calories ( 20 kcal [ center dot ] kg sup ‐1 [ center dot ] day sup ‐1 ) before and after surgery , were r and omly assigned to receive either general anesthesia ( with thiopentone , vecuronium , fentanyl , or enflurane ; control group , n = 6 ) or epidural anesthesia ( T3‐S5 sensory block with 0.75 % bupivacaine ) and general anesthesia ( epidural group , n = 6 ) . In the control group , postoperative analgesia was achieved with papaveretum given subcutaneously , whereas a continuous epidural bupivacaine infusion ( T8‐L5 sensory block ) was maintained for 48 h in the epidural group . The postabsorptive muscle protein fractional synthetic rate was determined using a 6‐h continuous infusion of13 C‐labeled leucine ( 1 mg [ center dot ] kg sup ‐1 [ center dot ] h sup ‐1 ) , and the13 C enrichment in muscle biopsy specimens before surgery and 48 h after surgery was measured . Results : Plateau13 C enrichment of plasma alpha‐ketoisocaproate ( taken to represent the intracellular leucine precursor pool enrichment for protein synthesis ) was achieved during the 6‐h infusion ( mean coefficient of variation was 2.8 % ) . Muscle protein synthesis at 48 h after operation compared with preoperative levels decreased significantly in the control group ( P = 0.03 ) . In contrast , it increased by 25 % in the epidural group . Although this was not significantly ( P = 0.15 ) different from preoperative levels , it was significantly greater than in the control patients . Conclusions : Epidural infusion of local anesthetics begun before surgery and continued during the first 48 h after operation significantly attenuates the decrease in the postabsorptive muscle protein synthesis rate associated with surgical injury . Effective block of nociceptive stimuli thus preserves tissue protein synthesis Objective : To assess the impact of postoperative complications on the receipt of adjuvant chemotherapy . Background : R and omized trials have demonstrated that adjuvant chemotherapy is associated with improved long-term survival . However , pancreatic surgery is associated with significant morbidity and the degree to which complications limit subsequent treatment options is unknown . Methods : Patients from the American College of Surgeons National Surgical Quality Improvement Program and the National Cancer Data Base who underwent pancreatic resection for cancer were linked ( 2006–2009 ) . The associations between complications and adjuvant chemotherapy use or treatment delay ( ≥70 days from surgery ) were assessed using multivariable regression methods . Results : From 149 hospitals , 2047 patients underwent resection for stage I-III pancreatic adenocarcinoma of which 23.2 % had at least 1 serious complication .  Overall adjuvant chemotherapy  receipt was 57.7 % : 61.8 % among patients not experiencing any complication and 43.6 % among those who had a serious complication . Serious complications increased the likelihood of not receiving adjuvant therapy over twofold [ odds ratio ( OR ) = 2.20 , 95 % confidence interval ( CI ) : 1.73–2.80 ] . Specific complications associated with adjuvant chemotherapy omission were reintubation ( OR = 7.79 , 95 % CI : 3.59–16.87 ) , prolonged ventilation ( OR = 5.92 , 95 % CI : 3.23–10.86 ) , pneumonia ( OR = 2.83 , 95 % CI : 1.63–4.90 ) , sepsis/shock ( OR = 2.76 , 95 % CI : 2.02–3.76 ) , organ space/deep surgical site infection ( OR = 2.19 , 95 % CI : 1.53–3.13 ) , venous thromboembolism ( OR = 1.92 , 95 % CI : 1.08–3.43 ) , and urinary tract infection ( OR = 1.61 , 95 % CI : 1.02–2.54 ) . Serious complications also doubled the likelihood of delaying adjuvant treatment administration ( OR = 2.08 , 95 % CI : 1.42–3.05 ) . Sensitivity analysis in a younger , healthier patient cohort demonstrated similar associations . Conclusions : Postoperative complications are common following pancreatic surgery and are associated with adjuvant chemotherapy omission and treatment delays Objective : The aim of this study is to examine , by a prospect i ve r and omized controlled trial , the influence of liberal ( LIB ) vs restricted ( RES ) perioperative fluid administration on morbidity  following pancreatectomy . Summary of Background Data : R and omized controlled trials in patients undergoing major intra-abdominal surgery have challenged the historical use of LIB fluid administration , suggesting that a more restricted regimen may be associated with fewer postoperative complications . Methods : Patients scheduled to undergo pancreatic resection were consented for r and omization to a LIB ( n = 164 ) or RES ( n = 166 ) perioperative fluid regimen . Sample size was design ed with 80 % power to decrease Grade 3 complications from 35 % to 21 % . Results : Between July 2009 and July 2015 , we r and omized 330 patients undergoing pancreaticoduodenectomy ( PD , n = 218 ) , central ( n = 16 ) , or distal pancreatectomy ( DP , n = 96 ) . Patients were equally distributed for all demographic and intraoperative characteristics . Intraoperatively , LIB patients received crystalloid 12 mL/kg/h and RES patients 6 mL/kg/h . Cumulative crystalloid given ( median , range , mL ) days 0 to 3 was LIB : 12,252 ( 6600 to 21,365 ) , RES 7808 ( 2700 to 16,274 ) P < 0.0001 . Sixty-day mortality was 2 of 330 ( 0.6 % ) . Median operative time for PD was 227 minutes ( 105 to 462 ) and DP 150 ( 44 to 323 ) . Grade 3 complications occurred in 20 % of LIB and 27 % of RES patients ( P = 0.6 ) . Median length of stay was 7 and 5 days for PD and DP , respectively , in both arms . Conclusions : In a high volume institution , major perioperative complications from pancreatic resection were not significantly influenced by fluid regimens that differed approximately 1.6-fold Objective To test the hypothesis that routine intraperitoneal drainage is not required after pancreatic resection . Summary Background Data The use of surgically placed intraperitoneal drains has been considered routine after pancreatic resection . Recent studies have suggested that for other major upper abdominal resections , routine postoperative drainage is not required and may be associated with an increased complication rate . Methods After informed consent , eligible patients with peripancreatic tumors were r and omized during surgery either to have no drains placed or to have closed suction drainage placed in a st and ardized fashion after pancreatic resection . Clinical , pathologic , and surgical details were recorded . Results One hundred seventy-nine patients were enrolled in the study , 90 women and 89 men . Mean age was 65.4 years ( range 23–87 ) . The pancreas was the tumor site in 142 ( 79 % ) patients , with the ampulla ( n = 24 ) , duodenum ( n = 10 ) , and distal common bile duct ( n = 3 ) accounting for the remainder . A pancreaticoduodenectomy was performed in 139 patients and a distal pancreatectomy in 40 cases . Eighty-eight patients were r and omized to have drains placed . Demographic , surgical , and pathologic details were similar between both groups . The overall 30-day death rate was 2 % ( n = 4 ) . A postoperative complication occurred during the initial admission in 107 patients ( 59 % ) . There was no significant difference in the number or type of complications between groups . In the drained group , 11 patients ( 12.5 % ) developed a pancreatic fistula . Patients with a drain were more likely to develop a significant intraabdominal abscess , collection , or fistula . Conclusion This r and omized prospect i ve clinical trial failed to show a reduction in the number of deaths or complications with the addition of surgical intraperitoneal closed suction drainage after pancreatic resection . The data suggest that the presence of drains failed to reduce either the need for interventional radiologic drainage or surgical exploration for intraabdominal sepsis . Based on these results , closed suction drainage should not be considered m and atory or st and ard after pancreatic resection Background Introduced more than 20 years ago , laparoscopic pancreatic surgery ( LAPS ) has not reached a uniform acceptance among HPB surgeons . As a result , there is no consensus regarding its use in patients with pancreatic neoplasms . This study , organized by the European Association for Endoscopic Surgery ( EAES ) , aim ed to develop consensus statements and clinical recommendations on the application of LAPS in these patients . Methods An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery . Each panelist performed a critical appraisal of the literature and prepared evidence -based statements assessed by other panelists during Delphi process . The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi . Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey . Results LAPS included laparoscopic distal pancreatectomy ( LDP ) , pancreatoduodenectomy ( LPD ) , enucleation , central pancreatectomy , and ultrasound . In general , LAPS was found to be safe , especially in experienced h and s , and also advantageous over an open approach in terms of intraoperative blood loss , postoperative recovery , and quality of life . Eighty-five percent or higher proportion of responders agreed with the majority ( 69.5 % ) of statements . However , the evidence is predominantly based on retrospective case – control studies and systematic review s of these studies , clearly affected by selection bias . Furthermore , no r and omized controlled trials ( RCTs ) have been published to date , although four RCTs are currently underway in Europe . Conclusions LAPS is currently in its development and exploration stages , as defined by the international IDEAL framework for surgical innovation . LDP is feasible and safe , performed in many centers , while LPD is limited to few centers . RCTs and registry studies are essential to proceed with the assessment of LAPS OBJECTIVE The optimal perioperative blood glucose range to improve surgical site infection ( SSI ) in surgical intensive care unit ( ICU ) patients remains unclear . We sought to determine whether the incidence of SSI is reduced by perioperative intensive insulin therapy ( IT ) . RESEARCH DESIGN AND METHODS Patients were r and omly assigned to receive perioperative intensive IT , with a target blood glucose range of 4.4–6.1 mmol/L , or intermediate IT , with a target blood glucose range of 7.7–10.0 mmol/L in the surgical ICU . We defined the primary end point as the incidence of SSI . RESULTS Study participants were r and omly assigned to glucose control with one of two target ranges : for 225 patients in the intermediate IT group or for 222 patients in the intensive IT group , respectively . No patients in either group became hypoglycemic ( < 4.4 mmol/L ) during their stay in the surgical ICU . In our series , the rate of SSI after hepato-biliary-pancreatic surgery was 6.7 % . Patients in the intensive IT group , compared with the intermediate IT group , had fewer postoperative SSIs ( 9.8 % vs. 4.1 % , P = 0.028 ) and a lower incidence of postoperative pancreatic fistula after pancreatic resection ( P = 0.040 ) . The length of hospitalization required for patients in the intensive IT group was significantly shorter than that in the intermediate IT group ( P = 0.017 ) . CONCLUSIONS We found that intensive IT decreased the incidence of SSI among patients who underwent hepato-biliary-pancreatic surgery : a blood glucose target of 4.4 to 6.1 mmol/L result ed in lower rate of SSI than did a target of 7.7–10.0 BACKGROUND  Postoperative pancreatic fistula is a major contributor to complications and death associated with pancreatic resection . Pasireotide , a somatostatin analogue that has a longer half-life than octreotide and a broader binding profile , decreases pancreatic exocrine secretions and may prevent postoperative pancreatic fistula . METHODS We conducted a single-center , r and omized , double-blind trial of perioperative subcutaneous pasireotide in patients undergoing either pancreaticoduodenectomy or distal pancreatectomy . We r and omly assigned 300 patients to receive 900 μg of subcutaneous pasireotide ( 152 patients ) or placebo ( 148 patients ) twice daily beginning preoperatively on the morning of the operation and continuing for 7 days ( 14 doses ) . R and omization was stratified according to the type of resection and whether the pancreatic duct was dilated at the site of transection . The primary end point was the development of pancreatic fistula , leak , or abscess of grade 3 or higher ( i.e. , requiring drainage ) . RESULTS The primary end point occurred in 45 of the 300 patients ( 15 % ) . The rate of grade 3 or higher postoperative pancreatic fistula , leak , or abscess was significantly lower among patients who received pasireotide than among patients who received placebo ( 9 % vs. 21 % ; relative risk , 0.44 ; 95 % confidence interval [ CI ] , 0.24 to 0.78 ; P=0.006 ) . This finding was consistent among 220 patients who underwent pancreaticoduodenectomy ( 10 % vs. 21 % ; relative risk , 0.49 ; 95 % CI , 0.25 to 0.95 ) and 80 patients who underwent distal pancreatectomy ( 7 % vs. 23 % ; relative risk , 0.32 ; 95 % CI , 0.10 to 0.99 ) , as well as among 136 patients with a dilated pancreatic duct ( 2 % vs. 15 % ; relative risk , 0.11 ; 95 % CI , 0.02 to 0.60 ) and 164 patients with a nondilated pancreatic duct ( 15 % vs. 27 % ; relative risk , 0.55 ; 95 % CI , 0.29 to 1.01 ) . CONCLUSIONS Perioperative treatment with pasireotide decreased the rate of clinical ly significant postoperative pancreatic fistula , leak , or abscess . ( Funded by Novartis Pharmaceuticals ; Clinical Trials.gov number , NCT00994110 . ) BACKGROUND A recent heat-balance study in volunteers suggested that greater efficacy of circulating-water garments ( CWGs ) results largely from increased heat transfer across the posterior skin surface since heat transfer across the anterior skin surface was similar with circulating-water and forced-air . We thus tested the hypothesis that the combination of a circulating-water mattress ( CWM ) and forced-air warming prevents core temperature reduction during major abdominal surgery no worse than a CWG does . METHODS Fifty adult patients aged between 18 and 85 yr old , undergoing major abdominal surgery , were r and omly assigned to intraoperative warming with a combination of forced-air and a CWM or with a CWG ( Allon ThermoWrap ) . Core temperature was measured in the distal oesophagus . Non-inferiority of the CWM to the CWG on change from baseline to median intraoperative temperature was assessed using a one-tailed Student 's t-test with an equivalency buffer of -0.5 ° C . RESULTS Data analysis was restricted to 16 CWG and 20 CWM patients who completed the protocol . Core temperature increased in both groups during the initial hours of surgery . We had sufficient evidence ( P=0.001 ) , to conclude that the combination of a CWM and forced-air warming was non-inferior to a CWG in preventing temperature reduction , with mean ( 95 % CI ) difference in the temperature change between the CWM and the CWG groups ( CWM-CWG ) of 0.46 ° C ( -0.09 ° C , 1.00 ° C ) . CONCLUSIONS The combination of a CWM and forced-air warming is significantly non-inferior in maintaining intraoperative core temperature than a CWG . TRIAL REGISTRY This trial has been registered at clinical trials.gov , identifier : NCT 00651898 BACKGROUND The preoperative visit is an appropriate time to educate the patient on anaesthesia . The aim of this study was to determine if a website , as an information source for anaesthesia before the visit to the preoperative assessment clinic ( PAC ) , increases patients '  knowledge on anaesthesia . METHODS A multimedia website was developed containing specific information about anaesthesia relevant to the patient . A question naire was developed to measure knowledge gain .  Patients were divided into three groups : ( i ) those who read the existing brochure ; ( ii ) those who looked at the new website ; and ( iii ) a cluster of non-brochure and non-website users : those who did not read the brochure or website but had completed the question naire . An anaesthesiologist also informed all three groups during the preoperative visit at the PAC . RESULTS Patients visiting the website had a higher educational level than others . A significant increase in knowledge was observed after using the website information compared with the other two groups ( P<0.001 ) . The group with higher education levels had higher knowledge gains , and the website independently contributed to the knowledge gain . CONCLUSIONS A patient-tailored multimedia website is an effective way to support the information provided by the anaesthesiologist in order to inform patients about their upcoming anaesthetic procedure . The use of such a website gives a significant increase in knowledge compared with only spoken information , or spoken information combined with a brochure AIM To characterize incidence and risk factors for delayed gastric emptying ( DGE ) following pancreaticoduodenectomy  and examine its implication s on healthcare utilization . METHODS A prospect ively-maintained data base was review ed . DGE was classified using International Study Group of Pancreatic Surgery criteria . Patients who developed DGE and those who did not were compared . RESULTS Two hundred and seventy-six patients underwent pancreaticoduodenectomy ( PD ) ( > 80 % pylorus-preserving , antecolic-reconstruction ) .  DGE developed in 49 patients ( 17.8 % ) : 5.1 % grade B , 3.6 % grade C. Demographic , clinical , and operative variables were similar between patients with DGE and those without . DGE patients were more likely to present multiple complications ( 32.6 % vs 4.4 % , ≥ 3 complications , P < 0.001 ) , including postoperative pancreatic fistula ( POPF ) ( 42.9 % vs 18.9 % , P = 0.001 ) and intra-abdominal abscess ( IAA ) ( 16.3 % vs 4.0 % , P = 0.012 ) . Patients with DGE had longer hospital stay ( median , 12 d vs 7 d , P < 0.001 ) and were more likely to require transitional care upon discharge ( 24.5 % vs 6.6 % , P < 0.001 ) . On multivariate analysis , predictors for DGE included POPF [ OR = 3.39 ( 1.35 - 8.52 ) , P = 0.009 ] and IAA [ OR = 1.51 ( 1.03 - 2.22 ) , P = 0.035 ] . CONCLUSION Although DGE occurred in < 20 % of patients after PD , it was associated with increased healthcare utilization . Patients with POPF and IAA were at risk for DGE . Anticipating DGE can help individualize care and allocate re sources to high-risk patients Background s/ Aims Major hepato-pancreato-biliary ( HPB ) surgery is usually performed via an open method rather than a laparoscopic method . Postoperative ileus ( POI ) is a classic complication after open surgery . The purpose of this study was to determine whether polylactic film is useful in the prevention of POI . Methods A total of 179 patients who underwent major HPB surgery between 2005 and 2014 , were retrospectively review ed . A diagnosis of POI was made by a physical examination , laboratory , and radiological findings . Surgi-Wrap ® polylactic film was preferentially used intraperitoneally by surgeons , just before wound closure . Results Major HPB surgery included pancreatoduodenectomy ( n=48 ) , distal or subtotal pancreatectomy ( n=24 ) , hepatectomy ( n=67 ) , other bile duct or gallbladder operations ( n=35 ) , and others ( n=5 ) . Although patients with polylactic film showed a significantly lower incidence of POI ( n=3 , 4.1 % vs. n=14 , 13.3 % , p=0.041 ) , they showed a significantly higher complication rate ( n=20 , 27.0 % vs. n=19 , 18.1 % , p=0.004 ) , particularly intra-abdominal fluid collection ( n=7 , 9.4 % vs. n=2 , 1.9 % ) , and wound infections ( n=6 , 8.1 % vs. n=3 , 2.9 % ) , than those who did not receive the film , respectively . Conclusions Although the polylactic film  prevented POI , more complications other than POI were observed . Well- design ed r and omized controlled trials , using this anti-adhesive product , are needed to evaluate its effect on POI after major HPB surgery Although opioid-induced nausea and vomiting ( OINV ) is common and debilitating , its mechanism is still unclear . Recently , we suggested that opioids affect semicircular canal function and that this leads to a mismatch between canal input and other sensory information during head motion , which triggers OINV . Here , we assess if visual input is relevant for this mismatch . In a r and omized-controlled crossover study 14 healthy men ( 26.9±3.4 years , mean±SD ) were tested twice , once blindfolded and once with eyes open , with at least one-day washout . The opioid remifentanil was administered intravenously ( 0.15 μg/kg/min ) for 60 minutes . After a thirty-minutes resting period , subjects ’ head and trunk were passively moved . Nausea was rated before remifentanil start ( T0 ) , before the movement intervention ( T30 ) and after 60 minutes ( T60 ) of administration . At rest ( T0 , T30 ) , median nausea ratings were zero whether subjects were blindfolded or not . Movement triggered nausea independently of visual input ( nausea rating 1.5/3.0 ( median/interquartile range ) in the blindfolded , 2.5/6 in the eyes-open condition , χ2(1 ) = 1.3 , p = 0.25 ) . As movement exacerbates OINV independently of visual input , a clash between visual and semicircular canal information is not the relevant trigger for OINV . To prevent OINV , emphasis should be put on head-rest , eye-closure is less important HYPOTHESIS Use of prophylactic antibiotics in elective colorectal surgery is essential . Although single-dose prophylactic antibiotics are recommended , the efficacy of single-dose cephalosporin without metronidazole and oral antibiotics is not fully proven . We conducted a multicenter , r and omized trial of a single dose vs 3 doses of the second-generation cephalosporin cefmetazole . DESIGN A prospect i ve , r and omized , multicenter trial in patients undergoing elective colorectal surgery . SETTING Seven major hospitals in Japan that offer cancer treatment . PATIENTS Patients with colorectal cancer treated from May 6 , 2004 , to April 25 , 2005 . INTERVENTIONS Patients were r and omized to 1 of 2 groups : a single-dose group given a single dose of cefmetazole just before skin incision and a 3-dose group given 2 additional doses of cefmetazole every 8 hours after the first dose just before skin incision . MAIN OUTCOME MEASURES Incidences of incisional surgical site infection ( SSI ) , organ or space SSI , and all other infectious complications within 30 days after surgery . RESULTS A total of 384 patients were enrolled . Seven patients were excluded because of additional surgery or the inability to tolerate mechanical preparation . The incidence of incisional SSI was higher in the single-dose group ( 27/190 or 14.2 % ) than in the 3-dose group ( 8/187 or 4.3 % ) ( P = .009 ) . Incidences of organ or space SSI and other postoperative infectious diseases did not differ significantly between the 2 groups . In multivariate analysis , antibiotic dose was the only significant factor related to the incidence of incisional SSI . CONCLUSION Three-dose cefmetazole administration is significantly more effective for prevention of incisional SSI than single-dose antibiotic administration . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00292708 Background Despite substantial improvements in surgical and anesthesiological practice s leading to decreased mortality of less than 5 % at high-volume centers , pancreatic surgery is still associated with high morbidity rates of up to 50 % . Attention is increasingly directed toward the optimization of perioperative management to reduce complications and enhance postoperative recovery . Currently , two different strategies for postoperative pain management after pancreatoduodenectomy are being routinely used : patient-controlled intravenous analgesia and thoracic epidural analgesia . Evidence is lacking to assess which strategy entails fewer postoperative complications . Methods / design The PAKMAN trial is design ed as an adaptive , pragmatic , r and omized , controlled , multicenter , open-label , superiority trial with two parallel study groups . A total of 370 patients scheduled for elective pancreatoduodenectomy will be r and omized after giving written informed consent , and 278 patients are needed for analysis . Patients with chronic pancreatitis , severe chronic obstructive pulmonary disease ( COPD ) , American Society of Anesthesiologists ( ASA ) physical status classification ≥ IV , or chronic pain syndrome will be excluded . The group A intervention includes intraoperative general anesthesia and postoperative patient-controlled intravenous analgesia ; the group B intervention comprises combined intraoperative general anesthesia and epidural analgesia with postoperative epidural analgesia . The primary endpoint of this trial is a composite of the gastrointestinal complications ( delayed gastric emptying , pancreatic fistula , biliary leak , gastrointestinal bleeding , and postoperative ileus ) up to postoperative day 30 . The aim is to investigate whether the frequency of gastrointestinal complications following pancreatoduodenectomy can be reduced by 15 % using postoperative , patient-controlled intravenous analgesia compared with epidural analgesia . Discussion Several previous studies investigating the two different strategies for postoperative pain management have mainly focused on their effectiveness in pain control . However , the PAKMAN trial is the first to compare them with regard to their impact on the surgical endpoint “ postoperative gastrointestinal complications ” after pancreatoduodenectomy . Trial registration German Clinical Trials Register , BACKGROUND Epidural analgesia is the international st and ard for pain treatment in abdominal surgery . Although some studies have advocated continuous wound infiltration with local anaesthetics , robust evidence is lacking , especially on patient-reported outcome measures . We aim ed to determine the effectiveness of continuous wound infiltration in hepato-pancreato-biliary surgery . METHODS In this r and omised controlled , open label , non-inferiority trial ( POP-UP ) , we enrolled adult patients undergoing hepato-pancreato-biliary surgery by subcostal or midline laparotomy in two Dutch hospitals . Patients were central ly r and omised ( 1:1 ) to receive either pain treatment with continuous wound infiltration using bupivacaine plus patient-controlled analgesia with morphine or to receive ( patient-controlled ) epidural analgesia with bupivacaine and sufentanil . All patients were treated within an enhanced recovery setting . R and omisation was stratified by centre and type of incision . The primary outcome was the mean Overall Benefit of Analgesic Score ( OBAS ) from day 1 - 5 , a vali date d composite endpoint of pain scores , opioid side-effects , and patient satisfaction ( range 0 [ best ] to 28 [ worst ] ) . Analysis was per- protocol . The non-inferiority limit of the mean difference was + 3·0 . This trial is registered with the Netherl and s Trial Registry , number NTR4948 . FINDINGS Between Jan 20 , 2015 , and Sept 16 , 2015 , we r and omly assigned 105 eligible patients : 53 to receive continuous wound infiltration and 52 to receive epidural analgesia . One patient in the continuous wound infiltration group discontinued treatment , as did five in the epidural analgesia group ; of these five patients , preoperative placement failed in three ( these patients were treated with continuous wound infiltration instead ) , one patient refused an epidural , and data for the primary endpoint was lost for one . Thus , 55 patients were included in the continuous wound infiltration group and 47 in the epidural analgesia group for the per- protocol analyses . Mean OBAS was 3·8 ( SD 2·4 ) in the continuous wound infiltration group versus 4·4 ( 2·2 ) in the epidural group ( mean difference -0·62 , 95 % CI -1·54 to 0·30 ) . Because the upper bound of the one-sided 95 % CI did not exceed + 3·0 , non-inferiority was shown . Four ( 7 % ) patients in the continuous wound infiltration group and five ( 11 % ) of those in the epidural group had an adverse event . One patient in the continuous wound infiltration group had a serious adverse event ( temporary hypotension and arrhythmia after bolus injection ) ; no serious adverse events were noted in the epidural group . INTERPRETATION These data suggest that continuous wound infiltration is non-inferior to epidural analgesia in hepato-pancreato-biliary surgery within an enhanced recovery setting . Further large-scale trials are required to make a definitive assessment of non-inferiority . FUNDING Academic Medical Centre , Amsterdam , Netherl and ATIENTS undergoing major surgery encounter stereotypical alterations in carbohydrate and protein metabolism often referred to as the catabolic response . Characteristic features of impaired carbohydrate homeostasis are increased production of glucose combined with decreased glucose utilization result ing in hyperglycemia . The magnitude of hyperglycemia depends on the severity of surgical tissue trauma . In fasting non-diabetic patients undergoing elective intra-abdominal operations  , blood glucose levels increase to 7–10 mmol·L –1 . During cardiac surgery , blood glucose values frequently exceed 15 mmol·L –1 in non-diabetic patients and 20 mmol·L –1 in diabetic subjects . Protein catabolism is characterized by a net loss of body protein . In metabolically healthy patients cumulative nitrogen losses , after elective abdominal operations , range between 40 and 80 g , equivalent to 1.2 to 2.4 kg lean tissue . Postoperative protein loss in patients with type 2 diabetes is 50 % greater than in their non-diabetic counterparts . 1 Much of the catabolic profile can be explained by specific neuroendocrine changes , including increased circulating concentrations of cortisol , glucagon , and catecholamines . These hormones exert catabolic effects , either directly or indirectly , by inhibiting insulin secretion and /or counteracting its peripheral action leading to the impairment of tissue insulin sensitivity . The extent of insulin resistance depends on the intensity of trauma , suggesting that insulin resistance is a marker of surgical stress . Clinical significance of the catabolic response to surgery Evidence is mounting that even moderate increases in blood glucose are associated with adverse outcomes . Patients with fasting glucose levels > 7 mmol·L –1 or r and om blood glucose levels > 11.1 mmol·L –1 on general surgical wards showed an 18-fold increase in in-hospital mortality , a longer length of stay , and a greater risk of infection . 2 In critically ill patients  , mortality was directly correlated with increasing glucose levels above 5 mmol·L –1 . 3 In patients undergoing cardiovascular procedures  , hyperglycemia was associated with increased mortality and organ dysfunction . 4 Furthermore , detrimental effects of acute hyperglycemia were documented in patients with cerebrovascular disease , myocardial ischemia , and trauma . Erosion of lean tissue protein delays wound healing , compromises immune function , and diminishes muscle strength after surgery . The result ing muscle weakness prolongs mechanical ventilation , inhibits effective coughing , and impedes mobilization . The length of time for return of normal physiologic function after discharge from the hospital is related to the extent of loss of lean body mass during hospitalization . BACKGROUND Smokers are at higher risk of cardiopulmonary and wound-related postoperative complications than non-smokers . Our aim was to investigate the effect of preoperative smoking intervention on the frequency of postoperative complications in patients undergoing hip and knee replacement . METHODS We did a r and omised trial in three hospitals in Denmark . 120 patients were r and omly assigned 6 - 8 weeks before scheduled surgery to either the  control ( n=60 ) or smoking intervention ( 60 ) group .  Smoking intervention was counselling and nicotine replacement therapy , and either smoking cessation or at least 50 % smoking reduction . An assessor , who was masked to the intervention , registered the occurrence of cardiopulmonary , renal , neurological , or surgical complications and duration of hospital admittance . The main analysis was by intention to treat . FINDINGS Eight controls and four patients from the intervention group were excluded from the final analysis because their operations were either postponed or cancelled . Thus , 52 and 56 patients , respectively , were analysed for outcome . The overall complication rate was 18 % in the smoking intervention group and 52 % in controls ( p=0.0003 ) . The most significant effects of intervention were seen for wound-related complications ( 5 % vs 31 % , p=0.001 ) , cardiovascular complications ( 0 % vs 10 % , p=0.08 ) , and secondary surgery ( 4 % vs 15 % , p=0.07 ) . The median length of stay was 11 days ( range 7 - 55 ) in the intervention group and 13 days ( 8 - 65 ) in the control group . INTERPRETATION An effective smoking intervention programme 6 - 8 weeks before surgery reduces postoperative morbidity , and we recommend , on the basis of our results , this programme be adopted Background Enteral immunodiet has been gaining increasing attention , but experimental data of its clinical effects in patients with gastric cancer are inconsistent , contradictory , and poorly investigated . The aim of this study was to assess the impact of early postoperative enteral immunonutrition on clinical and immunological outcomes in a homogeneous group of gastric cancer patients su bmi tted to total gastrectomy . Methods A total of 109 patients with gastric cancer were r and omized to receive early postoperative enteral immunonutrition ( formula supplemented with arginine , omega-3 fatty acids and ribonucleic acid [ RNA ] ) , or an isocaloric – isonitrogenous control . The postoperative outcome was evaluated based on clinical variables , including postoperative infectious complications , anastomotic leak rate , and length of hospitalization . In addition , state of cellular immunity was evaluated and compared between the 2 groups . Results The incidence of postoperative infectious complications in the immunodiet group ( 7.4 % ) was significantly ( p < .05 ) lower than that of the control group ( 20 % ) , as well as the anastomotic leak rate ( 3.7 % in immunodiet group vs 7.3 % in st and ard nutrition group , p < .05 ) . Mortality rate did not show any significant differences ; patients of the immunodiet group were found to have a significantly reduced length of hospitalization ( 12.7 ± 2.3 days ) when compared with st and ard diet group ( 15.9 ± 3.4 days , p = .029 ) . The data on cellular immunity showed that the postoperative CD4 + T-cell counts decreased in both groups , but the reduction in the IED group was significantly higher ( p = .032 ) compared with the SND group . Conclusions Early postoperative enteral immunonutrition significantly improves clinical and immunological outcomes in patients undergoing gastrectomy for gastric cancer OBJECTIVE To evaluate the effect of intraoperative combined forced-air warming and fluid warming system on  patient 's core temperature , blood loss , transfusion dem and , extubation time , and incidence of postoperative shivering . METHODS Forty patients with American Society of Anesthesiologists physical status I and II , aged 18 - 70 years , scheduled for elective abdominal surgery were r and omly assigned to receive intraoperative warming from a forced-air blanket and fluid warming system or conventional cotton blanket , 20 in each group . The core temperature was recorded every 20 minutes during the operation , as well as the blood loss , blood transfusion , extubation time , and incidence of postoperative shivering . RESULTS The core temperature at the end of the surgery in the warming group was significantly different from that in the control group ( 36.4 + /- 0.4 degrees C vs. 35.3 + /- 0.5 degrees C , P < 0.001 ) . Application of intraoperative warming significantly shortened the time between the end of the surgery and extubation ( P < 0.01 ) . Postoperative shivering occurred in 30 % of the patients in the control group compared to no patient in the warming group ( P < 0.01 ) . CONCLUSION Active warming with air-forced blanket and fluid warming system provides sufficient heat to prevent hypothermia during abdominal surgery PURPOSE Adjuvant chemotherapy improves patient survival rates after resection for pancreatic adenocarcinoma , but the optimal duration and time to initiate chemotherapy is unknown . PATIENTS AND METHODS Patients with pancreatic ductal adenocarcinoma treated within the international , phase III , European Study Group for Pancreatic Cancer-3 ( version 2 ) study were included if they had been r and omly assigned to chemotherapy .  Overall survival analysis was performed on an intention-to-treat basis , retaining patients in their r and omized groups , and adjusting the overall treatment effect by known prognostic variables as well as the start time of chemotherapy . RESULTS There were 985 patients , of whom 486 ( 49 % ) received gemcitabine and 499 ( 51 % ) received fluorouracil ;  675 patients ( 68 % ) completed all six cycles of chemotherapy ( full course ) and 293 patients ( 30 % ) completed one to five cycles . Lymph node involvement , resection margins status , tumor differentiation , and completion of therapy were all shown by multivariable Cox regression to be independent survival factors . Overall survival favored patients who completed the full six courses of treatment versus those who did not ( hazard ratio [ HR ] , 0.516 ; 95 % CI , 0.443 to 0.601 ; P < .001 ) . Time to starting chemotherapy  did not influence overall survival rates for the full study population ( HR , 0.985 ; 95 % CI , 0.956 to 1.015 ) .  Chemotherapy start time was an important survival factor only for the subgroup of patients who did not complete therapy , in favor of later treatment ( P < .001 ) . CONCLUSION Completion of all six cycles of planned adjuvant chemotherapy rather than early initiation was an independent prognostic factor after resection for pancreatic adenocarcinoma . There seems to be no difference in outcome if chemotherapy is delayed up to 12 weeks , thus allowing adequate time for postoperative recovery BACKGROUND Pancreaticoduodenectomy remains a major undertaking with substantial perioperative morbidity and mortality . Previous studies in the colorectal population have noted a correlation between excessive postoperative fluid resuscitation and anastomotic complications . This study sought to assess the relationship between perioperative fluid management and clinical outcomes in patients undergoing pancreaticoduodenectomy . METHODS Data from a single institution , prospect i ve data base over a 10-year period ( 2002 to 2012 ) were review ed . Patients were compared for perioperative fluid balance and postoperative outcomes . Multivariable analysis was performed to assess the relationship between perioperative fluid administration and incidence of major adverse events . RESULTS Higher positive fluid balance on postoperative day 0 , postoperative day 1 , and postoperative day 2 was associated with increased incidence of major adverse events , increased postoperative intensive care unit admission , and longer hospital stay . Higher positive fluid balance on postoperative day 0 was most strongly associated with postoperative morbidity ( odds ratio 1.39 , confidence interval 1.16 to 1.66 , P = .0003 ) . Fluid balance on postoperative day 3 was not associated with adverse events . CONCLUSIONS Increased early perioperative fluid resuscitation  is associated with major adverse events in patients undergoing pancreaticoduodenectomy . More restrictive fluid administration may improve postoperative outcomes ; further prospect i ve clinical trials focused on fluid resuscitation and goal -directed therapy are needed Objective : This multicenter study sought to prospect ively evaluate a drain management protocol for pancreatoduodenectomy ( PD ) . Background : Recent evidence suggests value for both selective drain placement and early drain removal for PD . Both strategies have been associated with reduced rates of clinical ly relevant pancreatic fistula (CR-POPF)—the most common and morbid complication after PD . Methods : The protocol was applied to 260 consecutive PDs performed at two institutions over 17 months . Risk for ISGPF CR-POPF was determined intraoperatively using the Fistula Risk Score ( FRS ) ; drains were omitted in negligible/low risk patients and drain fluid amylase ( DFA ) was measured on postoperative day 1 ( POD 1 ) for moderate/high risk patients . Drains were removed early ( POD 3 ) in patients with POD 1 DFA ⩽5,000 U/L , whereas patients with POD 1 DFA > 5,000 U/L were managed by clinical discretion . Outcomes were compared with a historical cohort ( N = 557 ; 2011–2014 ) . Results : Fistula risk did not differ between cohorts ( median FRS : 4 vs 4 ; P = 0.933 ) . No CR-POPFs developed in the 70 ( 26.9 % ) negligible/low risk patients . Overall CR-POPF rates were significantly lower after protocol implementation ( 11.2 vs 20.6 % , P = 0.001 ) . The protocol cohort also demonstrated lower rates of severe complication , any complication , reoperation , and percutaneous drainage ( all P < 0.05 ) . These patients also experienced reduced hospital stay ( median : 8 days vs 9 days , P = 0.001 ) . There were no differences between cohorts in the frequency of bile or chyle leaks . Conclusions : Drains can be safely omitted for one-quarter of PDs . Drain amylase analysis identifies which moderate/high risk patients benefit from early drain removal . This data -driven , risk-stratified approach significantly decreases the occurrence of clinical ly relevant pancreatic fistula BACKGROUND / AIM Hypothermia in surgical patients can be the consequence of long duration of surgical intervention , general anaesthesia and low temperature in operating room . Postoperative hypothermia contributes to a number of postoperative complications such as arrhythmia , myocardial ischemia , hypertension , bleeding , wound infection , coagulopathy , and prolonged effect of muscle relaxants . External heating procedures are used to prevent this condition . The aim of this study was to evaluate the efficiency of external warming system in alleviation of cold stress and hypothermia in patients who underwent major surgical procedures . METHODS The study was conducted in the Military Medical Academy in Bel grade . A total of 30 patients of both genders underwent abdominal surgical procedures , r and omly divided into two equal groups : the one was externally warmed using warm air mattress ( W ) , while in the control group ( C ) surgical procedure was performed in regular conditions , without additional warming . Oesophageal temperature ( Te ) was used as indicator of changes in core temperature , during surgery and awakening postoperative period , and temperature of control sites on the right h and ( Th ) and the right foot ( Tf ) reflected the changes in skin temperatures during surgery . Te and skin temperatures were monitored during the intraoperative period , with continuous measurement of Te during the following 90 minutes of the postoperative period . Heart rates and blood pressures were monitored continuously during the intraoperative and awakening period . RESULTS In the W group , the average Te , Tf and Th did not change significantly during the intraoperative as well as the postoperative period . In the controls , the average Te significantly decreased during the intraoperative period ( from 35.61 ± 0.35 ° C at 0 minute to 33.86 ± 0.51 ° C at 120th minute ) . Compared to the W group , Te in the C group was significantly lower in all the observed periods . Average values of Tf and Th significantly decreased in the C group ( from 30.83 ± 1.85 at 20th minute to 29.0 ± 1.39 ° C at 120th minute , and from 32.75 ± 0.96 to 31.05 ± 1.09 ° C , respectively ) . CONCLUSION The obtained results confirm that the external warming using warm air mattress was able to attenuate hypothermia , i.e. substantial decrease in core temperature , compared with the similar exposure to cold stress in the control group Background The usefulness of enteral nutrition via a nasointestinal tube for patients who develop postoperative pancreatic fistula ( POPF ) after miscellaneous pancreatectomy procedures has been reported . However , no clear evidence regarding whether oral intake is possible during management of POPF after pancreatoduodenectomy ( PD ) is currently available . We investigated the effects of oral food intake on the healing process of POPF after PD by a multi-institutional r and omized controlled trial . Methods Patients who developed POPF were r and omly assigned to the dietary intake ( DI ) group ( n = 30 ) or the fasted group [ no dietary intake ( NDI ) group ] ( n = 29 ) . The primary endpoint was the length of drain placement . Results No significant differences were found in the length of drain placement between the DI and NDI groups [ 27 ( 7–80 ) vs. 26 ( 7–70 ) days , respectively ; p = .8858 ] . POPF progressed to a clinical ly relevant status ( grade B/C ) in 20 patients in the DI group and 19 patients in the NDI group ( p = .9257 ) . POPF-related intra-abdominal hemorrhage was found in 2 patients in the NDI group , but in no patients in the DI group ( p = .1434 ) . There were no significant differences in POPF-related intra-abdominal hemorrhage , the incidence of other complications , or the length of the postoperative hospital stay between the 2 groups . Conclusion Food intake did not aggravate POPF and did not prolong the length of drain placement or hospital stay after PD . There may be no need to avoid oral dietary intake in patients with POPF BACKGROUND The uptake of ω-3 polyunsaturated fatty acids ( PUFAs ) into the liver , gut mucosa , and tumor tissue and plasma levels after preoperative administration of supplemented enteral nutrition was investigated in patients with malignancies of the upper gastrointestinal tract . The objective of the study was to evaluate the incorporation of preoperatively administrated PUFAs , eicosapentaenoic acid ( EPA ) , and docosahexaenoic acid ( DHA ) into cell phospholipids . METHODS Patients undergoing major gastrointestinal surgery ( n = 40 ) were prospect ively r and omized to receive a PUFA-supplemented liquid oral diet 5 days preoperatively or an isocaloric control diet . The planned diet intake was 1000 mL/d providing 3.7 g of PUFA . The diet was given in addition to the usual hospital diet . The phospholipid fractions in plasma were analyzed on the day of surgery . Tissue sample s of liver , gut mucosa ( small intestine ) , and tumor were taken during surgery and homogenized . EPA and DHA content was analyzed using liquid gas chromatography . RESULTS Both patient groups ( PUFA group : n = 20 ; control group : n = 20 ) were similar in age , weight , and surgical procedures . As compared with the control group , the PUFA group had significantly increased levels of EPA in liver tissue ( 0.4 vs 1.3 weight % ) , gut mucosa ( 0.3 vs 1.0 weight % ) , and tumor tissue ( 0.3 vs 0.8 weight % ) . Also , the DHA levels in the PUFA group were significantly higher than the control group : liver tissue ( 4.1 vs 7.5 weight % ) , gut mucosa ( 2.1 vs 3.7 weight % ) and tumor tissue ( 1.9 vs 4.2 weight % ) . CONCLUSIONS This study suggests that administration of PUFA-enriched diets leads to increased incorporation of EPA and DHA not only in liver and gut mucosa tissue , but also in tumor tissue in patients with solid gastrointestinal tumors . Thus , preoperative administration of oral PUFA-enriched diets could have an impact on the postoperative inflammatory response after major abdominal surgery Objectives : The aim of this study was to investigate the effect of pylorus resection on postoperative delayed gastric emptying ( DGE ) after  partial pancreatoduodenectomy ( PD ) . Background : PD is the st and ard treatment for tumors of the pancreatic head . Preservation of the pylorus has been widely accepted as st and ard procedure . DGE is a common complication causing impaired oral intake , prolonged hospital stay , and postponed further treatment . Recently , pylorus resection has been shown to reduce DGE . Methods : Patients undergoing PD for any indication at the University of Heidelberg were r and omized to either PD with pylorus preservation ( PP ) or PD with pylorus resection and complete stomach preservation ( PR ) . The primary endpoint was DGE within 30 days according to the International Study Group of Pancreatic Surgery definition . Results : Ninety-five patients were r and omized to PP and 93 patients to PR . There were no baseline imbalances between the groups . Overall , 53 of 188 patients ( 28.2 % ) developed a DGE ( grade : A 15.5 % ; B 8.8 % ; C 3.3 % ) . In the PP group 24 of 95 patients ( 25.3 % ) and in the PR group 29 of 93 patients ( 31.2 % ) developed DGE ( odds ratio 1.534 , 95 % confidence interval 0.788 to 2.987 ; P = 0.208 ) . Higher BMI , indigestion , and intraabdominal major complications were significant risk factors for DGE . Conclusions : In this r and omized controlled trial , pylorus resection during PD did not reduce the incidence or severity of DGE . The development of DGE seems to be multifactorial rather than attributable to pyloric dysfunction alone . Pylorus preservation should therefore remain the st and ard of care in PD . Trial Registration : German Clinical Trials Register Background Delayed gastric emptying ( DGE ) is of considerable concern in patients undergoing pylorus-preserving pancreaticoduodenectomy ( PPPD ) . Prolonged hospital stay , increased cost , and decreased quality of life add on to interventions needed to treat DGE . This study was conducted to determine if performing duodenojejunostomy via the antecolic rather than the retrocolic route improved incidence of DGE . Methods Patients undergoing PPPD between April 2007 and November 2009 were r and omized for either antecolic or retrocolic reconstruction of the duodenojejunostomy .  DGE was then assessed by clinical criteria on postoperative day ( POD ) 10 . A paracetamol absorption test was also administered with a liquid meal , and serial plasma levels of intestinal peptides were measured . Results Overall , 64 patients were amenable for analysis : 36 in the antecolic group and 28 in the retrocolic group . The incidences of DGE on POD 10 were 17.6 and 23.1 % ( antecolic vs. retrocolic , respectively ) ( p = 0.628 ) . The two groups did not differ in regard to their median ( interquartile range ) postoperative hospital length of stay [ 13.0 ( 10.0–17.5 ) vs. 12.5 ( 11.0–17.0 ) days ; p = 0.446 ] , time to regular diet [ 5 ( 5–7 ) vs. 5 ( 4–6 ) days ; p = 0.353 ] , or morbidity ( 52.9 vs. 50.0 % ; p = 0.777 ) . The median length of nasogastric tube decompression was similar in the two groups [ 4 ( 3–7 ) vs. 3 ( 3–5 ) days ; p = 0.600 ] . Levels of paracetamol and glucagon-like peptide-1 were markedly decreased in patients with DGE . Conclusions Antecolic reconstruction after PPPD does not improve the occurrence/the incidence of DGE and is similar to retrocolic reconstruction with regard to secondary outcome parameters Objectives Nutritional deficiencies and immune dysfunction in cancer patients may contribute to postoperative septic morbidity . This trial compared the effects of perioperative enteral immunonutrition ( EIN ) versus st and ard enteral nutrition ( SEN ) on systemic and mucosal immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer . Methods Thirty-seven patients were r and omized ( EIN , n = 17 ; SEN , n = 20 ) to receive feed for 14 days preoperatively and 7 days postoperatively . Mediators of systemic immunity ( interleukin 1&agr ; , tumor necrosis factor & agr ; , lymphocytes subsets , and complement components ) and of mucosal immunity in duodenal biopsies , nutritional markers and parameters were evaluated . Results The groups were comparable for demographics , the concentrations of mediators of systemic and mucosal immunity at time of recruitment , and for the duration and amount of feed received . Preoperative EIN rather than SEN was associated with significant reductions in plasma tumor necrosis factor & agr ; and total hemolytic complement . Enteral immunonutrition – fed patients had significantly higher total lymphocyte count on the third postoperative day and significantly greater rise in CD4/CD8 ratio from day 3 to day 7 postoperatively compared with SEN-fed patients . Conclusions The perioperative administration of EIN rather than SEN is associated with a favorable modulation of the inflammatory response and enhancement of systemic immunity in patients undergoing pancreaticoduodenectomy for periampullary cancer Background Data from observational studies suggest that minimally invasive pancreatoduodenectomy ( MIPD ) is superior to open pancreatoduodenectomy regarding intraoperative blood loss , postoperative morbidity , and length of hospital stay , without increasing total costs . However , several case-matched studies failed to demonstrate superiority of MIPD , and large registry studies from the USA even suggested increased mortality for MIPDs performed in low-volume ( < 10 MIPDs annually ) centers . R and omized controlled multicenter trials are lacking but clearly required . We hypothesize that time to functional recovery is shorter after MIPD compared with open pancreatoduodenectomy , even in an enhanced recovery setting . Methods / design LEOPARD-2 is a r and omized controlled , parallel-group , patient-blinded , multicenter , phase 2/3 , superiority trial in centers that completed the Dutch Pancreatic Cancer Group LAELAPS-2 training program for laparoscopic pancreatoduodenectomy or LAELAPS-3 training program for robot-assisted pancreatoduodenectomy and have performed ≥ 20 MIPDs . A total of 136 patients with symptomatic benign , premalignant , or malignant disease will be r and omly assigned to undergo minimally invasive or open pancreatoduodenectomy in an enhanced recovery setting . After the first 40 patients ( phase 2 ) , the data safety monitoring board will assess safety outcomes ( not blinded for treatment allocation ) and decide on continuation to phase 3 . Patients from phase 2 will then be included in phase 3 . The primary outcome measure is time ( days ) to functional recovery . All patients will be blinded for the surgical approach , at least until postoperative day 5 , but preferably until functional recovery has been attained . Secondary outcome measures are operative and postoperative outcomes , including clinical ly relevant complications , mortality , quality of life , and costs . Discussion The LEOPARD-2 trial is design ed to assess whether MIPD  reduces time to functional recovery , as compared with open pancreatoduodenectomy in an enhanced recovery setting .Trial registration Netherl and s Trial Register , NTR5689 . Registered on 2 March 2016 BACKGROUND The efficacy and feeding-related complications of a nasojejunal feeding tube and jejunostomy after pancreaticoduodenectomy ( PD ) was investigated with a r and omized , controlled clinical trial at the Affiliated Drum Tower Hospital . METHODS Sixty-eight patients who underwent PD in the Department of Hepatobiliary Surgery were r and omly divided into 2 groups : 34 patients received enteral feeding via a nasojejunal tube ( NJT group ) and 34 patients received enteral feeding via a jejunostomy tube ( JT group ) . The assessment of clinical outcome was based on postoperative investigation of complications . The second part of the assessment included tube related complications and an index on catheter efficiency . RESULTS There were 15 cases with infectious complications in the JT group and 13 cases in the NJT group , and there was no significant difference in the rate of infectious complications between the 2 groups . The rate of intestinal obstruction and delayed gastric emptying was significantly decreased in the NJT group ( P < .05 ) . Catheter-related complications were more common in the JT group as compared with the NJT group ( 35.3 % vs 20.6 % , P < .05 ) . The time for removal of the feeding tube and nasogastric tube was significantly decreased in the NJT group . The postoperative hospital stay in the NJT group was significantly decreased ( P < .05 ) , and there was no hospital mortality in this study . CONCLUSION Nasojejunal feeding is safer than jejunostomy , and it is associated with only minor complications . Nasojejunal feeding can significantly decrease the incidence of delayed gastric emptying and shorten the postoperative hospital stay Objective : The aim of this study was to assess the impact of personalized prehabilitation on postoperative complications in high-risk patients undergoing elective major abdominal surgery . Summary Background Data : Prehabilitation , including endurance exercise training and promotion of physical activity , in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications . However , the existing studies provide controversial results and show a clear bias toward low-risk patients . Methods : This was a r and omized blinded controlled trial . Eligible c and i date s accepting to participate were blindly r and omized ( 1:1 ratio ) to  control ( st and ard care ) or intervention ( st and ard care + prehabilitation )  groups . Inclusion criteria were : i ) age > 70 years ; and /or , ii ) American Society of Anesthesiologists score III/IV .  Prehabilitation covered 3 actions : i ) motivational interview ; ii ) high-intensity endurance training ; and promotion of physical activity . The main study outcome was the proportion of patients suffering postoperative complications . Secondary outcomes included the endurance time ( ET ) during cycle-ergometer exercise . Results : We r and omized 71 patients to the control arm and 73 to intervention . After excluding 19 patients because of changes in the surgical plan , 63 controls and 62 intervention patients were included in the intention-to-treat analysis . The intervention group enhanced aerobic capacity [ & Dgr;ET 135 ( 218 ) % ; P < 0.001 ) , reduced the number of patients with postoperative complications by 51 % ( relative risk 0.5 ; 95 % confidence interval , 0.3–0.8 ; P = 0.001 ) and the rate of complications [ 1.4 ( 1.6 ) and 0.5 ( 1.0 ) ( P = 0.001 ) ] as compared with controls . Conclusion : Prehabilitation enhanced postoperative clinical outcomes in high-risk c and i date s for elective major abdominal surgery , which can be explained by the increased aerobic capacity BACKGROUND & AIMS Evidence of the advantages of enhanced recovery after surgery ( ERAS ) protocol s following pancreaticoduodenectomy ( PD ) is limited . The aim of this study was to examine the efficiency of ERAS protocol s in patients following PD . METHODS Between June 2014 and October 2016 , patients undergoing PD were r and omly assigned to receive ERAS protocol s or st and ard care . The primary endpoint was the postoperative length of stay . Secondary endpoints included postoperative complications , postoperative quality -of-life ( QoR-40J ) , readmission , and medical cost . RESULTS Of 80 eligible patients , 74 were analyzed in intention-to-treat principles : 37 in the control group and 37 in the ERAS group . The mean length of stay in the ERAS group was significantly shorter than that in the control group ( 20.1 ± 5.4 vs 26.9 ± 13.5 days , P < 0.001 ) . The ERAS group had a significantly lower percentage of postoperative complications ( 32.4 % vs 56.8 % , P = 0.034 ) and readmissions ( 0 % vs 8.1 % , P = 0.038 ) . Quality -of-life was also significantly better in the ERAS group ( 184 ± 12.4 vs 177 ± 14.5 , P = 0.022 ) . The total medical cost was lower in the ERAS group , but not significantly ( $ 25,445 ± 5065 vs $ 28,384 ± 9999 , P = 0.085 ) . CONCLUSIONS The optimization of ERAS protocol s in patients undergoing PD  is safe and accelerates perioperative recovery and quality -of-life , thereby reducing the length of stay . Morbidity was significantly decreased in the ERAS group without compromising surgical outcome . REGISTRATION NUMBER UMIN000014068 BACKGROUND Early mobilization is considered an important element of postoperative care ; however , how best to implement this intervention in clinical practice is unknown . This systematic review summarizes the evidence regarding the impact of specific early mobilization protocol s on postoperative outcomes after abdominal and thoracic surgery . METHOD The review was performed according to PRISMA guidelines . We search ed 8 electronic data bases to identify studies comparing patients receiving a specific protocol of early mobilization to a control group .  Method ologic quality was assessed using the Downs and Black tool . RESULTS Four studies in abdominal surgery ( 3 r and omized controlled trials [ RCTs ] and 1 observational prospect i ve study ) and 4 studies in thoracic surgery ( 3 RCTs and 1 observational retrospective study ) were identified . None of the 5 studies evaluating postoperative complications reported differences between groups . One of 4 studies evaluating duration of stay reported a significant decrease in the intervention group . One of 3 studies evaluating gastrointestinal function reported differences in favor of the intervention group . One of 4 studies evaluating performance-based outcomes reported differences in favor of the intervention group . One of 5 studies evaluating patient-reported outcomes reported differences in favor of the intervention group . Overall method ologic quality was poor . CONCLUSION Few comparative studies have evaluated the impact of early mobilization protocol s on outcomes after abdominal and thoracic surgery . The quality of these studies was poor and results were conflicting . Although bed rest is harmful , there is little available evidence to guide clinicians in effective early mobilization protocol s that increase mobilization and improve outcomes OBJECTIVE To evaluate a closed-loop system providing continuous monitoring and strict control of perioperative blood glucose following pancreatic resection . DESIGN Prospect i ve , r and omized clinical trial . PATIENTS Thirty patients who had pancreatic resection for pancreatic neoplasm . INTERVENTIONS Patients were prospect ively r and omized . Perioperative blood glucose levels  were continuously monitored using an artificial endocrine pancreas ( STG-22 ) . Glucose levels were controlled using either the sliding scale method ( sliding scale group , n = 13 ) or the artificial pancreas ( artificial pancreas group , n = 17 ) . MAIN OUTCOME MEASURES Incidence of severe hypoglycemia ( < 40 mg/dL ) during the intensive care period following pancreatic resection in patients monitored with the artificial pancreas . The secondary outcome measure was the total amount of insulin required for glycemic control in the first 18 hours after pancreatic resection in each patient group . RESULTS In the sliding scale group , postoperative blood glucose levels rose initially before reaching a plateau of approximately 200 mg/dL between 4 and 6 hours after pancreatectomy . The levels remained high for 18 hours postoperatively . In the artificial pancreas group , blood glucose levels reduced steadily , reaching the target zone ( 80 - 110 mg/dL ) by 6 hours after surgery . The total insulin dose administered per patient during the first postoperative 18 hours was significantly higher in the artificial pancreas group ( mean [ SD ] , 107 [ 109 ] IU ) than the sliding scale group ( 8 [ 6 ] IU ; P < .01 ) . Neither group showed hypoglycemia . CONCLUSIONS Perioperative use of an artificial endocrine pancreas to control pancreatogenic diabetes after pancreatic resection is an easy and effective way to maintain near-normal blood glucose levels . The artificial pancreas shows promise for use as insulin treatment for patients with pancreatogenic diabetes after pancreatic resection Abstract Background Fluid administration practice s may affect complication rates in some abdominal surgeries , but effects in patients undergoing pancreatectomy are not understood well . We sought to determine whether amount of intraoperative fluid administered to patients undergoing pancreatectomy is associated with postoperative complication rates and to determine whether hospitals vary in their fluid administration practice s. Methods Data for 504 patients undergoing pancreatectomy at 38 hospitals between 2012 and 2015 were evaluated . The main exposure was intraoperative fluid administration ( ≤10 , 10–15 , > 15 mL/kg/h ) . Mortality , complications , and length of stay were the main outcomes of interest . Patient-level associations between exposure and outcome were tested , with adjustment for potentially confounding patient and surgical factors , using r and om intercept , mixed-effects linear or logistic regression models . Hospitals were then categorized as having a restrictive , intermediate , or liberal resuscitation practice , and adjusted outcomes were compared . Results A total of 167 ( 33.1 % ) , 185 ( 36.7 % ) and 152 ( 30.2 % ) patients received restrictive , intermediate , or liberal fluid administration , respectively . Hospitals with more restrictive practice s had significantly lower adjusted 30-day mortality than those with more liberal practice s ( 2.7 vs. 6.6 % ; P < 0.001 ) . Hospitals with more restrictive practice s had the lowest rates of severe ( Grade 2 and 3 ) complications ( 15.4 % restrictive vs. 25.3 % intermediate vs. 44.3 % liberal ; P < 0.001 ) . More restrictive hospitals had decreased adjusted mean length of stay ( 9.5 days vs. 12.7 days intermediate vs. 11.6 days liberal ; P < 0.001 ) . Conclusions More restrictive intraoperative resuscitation practice s in pancreatectomy are associated with decreased hospital-level mortality , severe complications , and length of stay OBJECTIVE To assess the relationship between body temperature and cardiac morbidity during the perioperative period . DESIGN R and omized controlled trial comparing routine thermal care ( hypothermic group ) to additional supplemental warming care ( normothermic group ) . SETTING Operating rooms and surgical intensive care unit at an academic medical center . SUBJECTS Three hundred patients undergoing abdominal , thoracic , or vascular surgical procedures who either had documented coronary artery disease or were at high risk for coronary disease . OUTCOME MEASURE The relative risk of a morbid cardiac event ( unstable angina/ischemia , cardiac arrest , or myocardial infa rct ion ) according to thermal treatment . Cardiac outcomes were assessed in a double-blind fashion . RESULTS Mean core temperature after surgery was lower in the hypothermic group ( 35.4+/-0.1 degrees C ) than in the normothermic group ( 36.7+/-0.1 degrees C ) ( P<.001 ) and remained lower during the early postoperative period . Perioperative morbid cardiac events occurred less frequently in the normothermic group than in the hypothermic group ( 1.4 % vs 6.3 % ; P=.02 ) . Hypothermia was an independent predictor of morbid cardiac events by multivariate analysis ( relative risk , 2.2 ; 95 % confidence interval , 1.1 - 4.7 ; P=.04 ) , indicating a 55 % reduction in risk when normothermia was maintained . Postoperative ventricular tachycardia also occurred less frequently in the normothermic group than in the hypothermic group ( 2.4 % vs 7.9 % ; P=.04 ) . CONCLUSION In patients with cardiac risk factors who are undergoing noncardiac surgery , the perioperative maintenance of normothermia is associated with a reduced incidence of morbid cardiac events and ventricular tachycardia Background :  Pancreaticoduodenectomy ( PD ) can be associated with significant blood loss and transfusion requirements , with potential adverse short- and long-term consequences . The aim of this study was to determine whether acute normovolemic hemodilution ( ANH ) , an established blood conservation technique , reduces perioperative allogeneic transfusions in patients undergoing PD . Methods : One hundred thirty patients undergoing PD were r and omized to ANH or st and ard management ( STDM ) . In the ANH group , intraoperative blood collection was performed to a target hemoglobin of 8.0 g/dL ; crystalloid and colloid were used for volume replacement . Strict transfusion triggers were applied during and after operation . Perioperative complications were prospect ively assessed and grade d for severity . Results : From July 2005 to May 2009 , 209 patients were registered , 79 excluded , 65 were r and omized to ANH , and 65 to STD . The groups were well matched for demographic , operative , and histopathologic variables . Patients undergoing ANH received over 2 L more fluid intraoperatively ( 6250 mL , range 2000–11850 ) compared with patients undergoing STD ( 3900 mL , range 2000–9000 ) ( P < 0.001 ) . Transfusion rates were similar ( ANH = 16.9 % , 30 units vs STD = 18.5 % , 33 units ; P = 0.82 ) , as was overall perioperative morbidity ( ANH = 49.2 % vs STD = 47 % , P = 0.86 ) . There was , however , a trend toward more grade -3 complications in patients undergoing ANH ( 32 % vs 23.1 % STD , P = 0.17 ) , and complications related to the pancreatic anastomosis ( leak/fistula/abscess ) were significantly higher in the ANH group ( 21.5 % vs 7.7 % , P = 0.045 ) . The intraoperative fluid volume was higher for all patients with pancreatic anastomotic complications ( n = 19 ) , regardless of r and omization arm ( ANH 6000 mL , range 2800–11350 mL vs STD 5000 mL , range 2000–11850 mL , P < 0.042 ) . Conclusion : In this r and omized trial of patients undergoing PD , ANH did not reduce allogeneic transfusions and result ed in more pancreatic anastomotic complications , likely related to greater intraoperative fluid administration . The benefits of ANH do not necessarily extend to all procedures , and restrictive intravenous fluid management during PD may help improve postoperative outcome Summary of Background Data : The role of surgically placed intra-abdominal drainages after pancreatic resections has not been clearly established . In particular , their effect on morbidity rates and the optimal timing for their removal remains controversial . Methods : A total of 114 eligible patients who underwent st and ard pancreatic resections and at low risk of postoperative pancreatic fistula according to our institutional protocol ( amylase value in drains ≤5000 U/L on postoperative day [ POD ] 1 ) were r and omized on POD 3 to receive either early ( POD 3 ) or st and ard drain removal ( POD 5 or beyond ) . The primary end point of the study was the incidence of pancreatic fistula . Secondary endpoints included abdominal complications , pulmonary complications , in-hospital stay , and perioperative mortality . Cost- analysis between the 2 groups was also made . Results : Early drain removal was associated with a decreased rate of pancreatic fistula ( P = 0.0001 ) , abdominal complications ( P = 0.002 ) , and pulmonary complications ( P = 0.007 ) . Median in-hospital stay was shorter ( P = 0.018 ) , and hospital costs decreased ( P = 0.02 ) . Mortality was nil . A significant association with pancreatic fistula was found for timing of drain removal ( P < 0.001 ) , unintentional weight decrease before surgery ( P = 0.022 ) , type of pancreas texture ( P = 0.015 ) , serum amylase levels on POD 1 ( P = 0.001 ) , and albumin levels on POD 1 ( P = 0.039 ) . Multivariate analysis showed that timing of drain removal ( P = 0.0003 ) and unintentional weight decrease before surgery ( P = 0.02 ) were independent risk factors of pancreatic fistula . Conclusions : In patients at low risk of pancreatic fistula  , intra-abdominal drains can be safely removed on POD 3 after st and ard pancreatic resections . A prolonged period of drain insertion is associated with a higher rate of postoperative complications with increased hospital stay and costs . The manuscript is a r and omized trial , registered in the NLM data base as NCT00931554 PURPOSE : Surgical site infection following colorectal surgery is a frequent and costly problem . Barrier protection at the time of this form of surgery has been used with varying results . The aim of this r and omized study was to examine the efficacy of barrier retractional wound protection in the prevention of surgical site infections in open , elective colorectal surgery . METHODS : One hundred thirty consecutive patients undergoing open elective colorectal resectional surgery were r and omly assigned to have either barrier retractional wound protection or st and ard wound retraction . Patients were then followed up for a minimum of 30 days postoperatively . The primary end point was surgical site infection as defined by the Centers for Disease Control and Prevention . The secondary end point was performance of the wound protector as assessed by operating surgeons . RESULTS : There was a significant reduction in the incidence of incisional surgical site infections when the wound protector was used : 3 of 64 ( 4.7 % ) vs 15 of 66 ( 22.7 % ) ; P = .004 . Most surgical site infections were diagnosed after discharge from the hospital ( 78 % ) , and there was no difference in the rates of reoperation , readmission , or formal wound drainage between the 2 groups . Surgeons found the wound protector to be helpful with retraction during surgery , with 88 % ( 7/8 ) adopting it as part of their st and ard setup . CONCLUSIONS : In this study the use of barrier wound protection in elective open colorectal resectional surgery result ed in a clinical ly significant reduction in incisional surgical site infections .  Barrier wound protection of this nature should be considered routine in this type of surgery BACKGROUND An immune-enhancing diet has been used to alter eicosanoid synthesis , cytokine production , and immune function in an attempt to limit the undesired immune reactions after injury from surgery . This prospect i ve r and omized study was design ed to investigate the effect of preoperative immunonutrition on operative complications , and the participation of prostagl and in E2 ( PGE2 ) on T-cell differentiation in patients undergoing a severely stressful surgery . METHODS The enrolled patients who were scheduled to undergo pancreatoduodenectomy were r and omized into two groups . Patients in the immunonutrition group ( n = 25 ) received oral supplementation containing arginine , ω-3 fatty acids , and RNA for 5 days before the procedure in addition to a 50 % reduction in the amount of regular food . Patients in the control group ( n = 25 ) received no artificial nutrition and were allowed to consume regular food before surgery . All patients received early postoperative enteral infusion of a st and ard formula intended to provide 25 kcal/kg/day . The primary endpoint was the rate of infectious complications ; the secondary endpoint was immune responses . This study is registered with Clinical Trials.gov ( NCT01256034 ) . RESULTS Infectious complication rate and severity of complications ( Clavien-Dindo classification ) were lesser in the immunonutrition group than in the control group . mRNA expression levels of T-bet were greater in the immunonutrition group than in the control group ( P < .05 ) . Serum eicosapentaenoic acid and eicosapentaenoic acid/arachidonic acid ratios were greater in the immunonutrition group than in the control group ( P < .05 ) . The levels of plasma PGE2 were lesser in the immunonutrition group than in the control group ( P < .05 ) . CONCLUSION Preoperative immunonutrition modulates PGE2 production and T-cell differentiation and may protect against the aggravation of operative complications in patients undergoing pancreatoduodenectomy OBJECTIVE To determine the effects of total parenteral nutrition ( TPN ) and enteral nutrition ( EN ) on biochemical and clinical outcomes in pancreatic cancer patients who underwent pancreaticoduodenectomy . METHODS From the year 2006 to 2008 , 60 patients who underwent pancreaticoduodenectomy in Tianjin Third Central Hospital were enrolled in this study . They were r and omly divided into the EN group and the TPN group . The biochemical and clinical parameters were recorded and analyzed between the two groups . RESULTS There was no significant difference in the nutritional status , liver and kidney function , and blood glucose levels between the TPN and EN groups on the preoperative day , the 1st and 3 rd postoperative days . However , on the 7th postoperative day , there was significant difference between the two groups in 24 h urinary nitrogen , serum levels of , total protein ( TP ) , transferrin ( TF ) , alanine aminotransferase ( ALT ) , aspartate aminotransferase ( AST ) , alkaline phosphatase ( ALP ) , and γ-glutamyl transpeptadase ( GGT ) , blood urea nitrogen ( BUN ) and creatinine ( Cr ) . On the 14th postoperative day , there was a significant difference between the two groups in terms of urinary levels of 24 h nitrogen , TP , TF , retinol binding protein , ALT , AST , ALP , GGT , total bilirubin , direct bilirubin , BUN , Cr , and glucose . The incidence of delayed gastric emptying in the EN and TPN groups was 0 % and 20 % , respectively . Moreover , the incidence of pancreatic fistulas and hemorrhages in the EN group were 3.6 % and 3.6 % , versus 26.7 % and 30 % in the TPN group , respectively . CONCLUSIONS EN is better than TPN for pancreatic cancer patients who received pancreaticoduodenectomy BACKGROUND The optimal target range for blood glucose in critically ill patients remains unclear . METHODS Within 24 hours after admission to an intensive care unit ( ICU ) , adults who were expected to require treatment in the ICU on 3 or more consecutive days were r and omly assigned to undergo either intensive glucose control , with a target blood glucose range of 81 to 108 mg per deciliter ( 4.5 to 6.0 mmol per liter ) , or conventional glucose control , with a target of 180 mg or less per deciliter ( 10.0 mmol or less per liter ) . We defined the primary end point as death from any cause within 90 days after r and omization . RESULTS Of the 6104 patients who underwent r and omization , 3054 were assigned to undergo intensive control and 3050 to undergo conventional control ; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients , respectively . The two groups had similar characteristics at baseline . A total of 829 patients ( 27.5 % ) in the intensive-control group and 751 ( 24.9 % ) in the conventional-control group died ( odds ratio for intensive control , 1.14 ; 95 % confidence interval , 1.02 to 1.28 ; P=0.02 ) . The treatment effect did not differ significantly between operative ( surgical ) patients and nonoperative ( medical ) patients ( odds ratio for death in the intensive-control group , 1.31 and 1.07 , respectively ; P=0.10 ) . Severe hypoglycemia ( blood glucose level , < or = 40 mg per deciliter [ 2.2 mmol per liter ] ) was reported in 206 of 3016 patients ( 6.8 % ) in the intensive-control group and 15 of 3014 ( 0.5 % ) in the conventional-control group ( P<0.001 ) . There was no significant difference between the two treatment groups in the median number of days in the ICU ( P=0.84 ) or hospital ( P=0.86 ) or the median number of days of mechanical ventilation ( P=0.56 ) or renal-replacement therapy ( P=0.39 ) . CONCLUSIONS In this large , international , r and omized trial , we found that intensive glucose control increased mortality among adults in the ICU : a blood glucose target of 180 mg or less per deciliter result ed in lower mortality than did a target of 81 to 108 mg per deciliter . ( Clinical Trials.gov number , NCT00220987 . BACKGROUND Postoperative pancreatic fistula ( postoperative pancreatic fistula [ POPF ] ) is the most common complication after  pancreaticoduodenectomy . Despite some studies showing little effect of octreotide in unselected patients , we hypothesized that in high-risk patients depot octreotide may reduce the risk of POPF . METHODS Sixty-eight patients were prospect ively evaluated for inclusion in the current study . Two groups were identified : pancreatic ducts ≤3 mm ( high risk ) and those with ducts > 3 mm ( low risk ) . Thirty-two patients were low risk , whereas 36 patients were high risk . High-risk patients were treated preoperatively with depot octreotide and begun on an intravenous drip for 24 hours . Low-risk patients underwent pancreaticoduodenectomy without pharmacologic intervention . In contrast , the control cohort represents 106 retrospectively analyzed patients who underwent a pancreaticoduodenectomy without depot octreotide injection without regard to low- or high-risk status . RESULTS Overall , POPF was 11 of 68 ( 16 % ) . Nine of 36 high risk patients treated with depot octreotide developed POPF ( 25 % ) , and 2 of 32 low risk patients developed POPF ( 6 % ) . In the control cohort of high-risk patients , 9 of 44 ( 20 % ) and 3 of 62 ( 5 % ) low-risk patients developed POPF ( P = .628 when comparing the development of POPF in high-risk patients with or without pharmacologic intervention ) . CONCLUSIONS Prophylactic use of depot octreotide in high-risk patients does not result in reduced incidence of POPF . Duct size has a significant impact on the occurrence of POPF BACKGROUND & AIMS Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . METHODS An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated " high " , " moderate " , " low " or " very low " . Recommendations were grade d as " strong " or " weak " . RESULTS Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . CONCLUSIONS The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials BACKGROUND Although mortality following pancreaticoduodenectomy is decreasing , postoperative morbidity remains high . It was hypothesized that culture-directed treatment of bacteriobilia would decrease the incidence of infectious complications following pancreaticoduodenectomy . METHODS In a retrospective study of 197 pancreaticoduodenectomy patients , those in the control group ( n = 128 , 2005 - 2009 ) were given perioperative prophylactic antibiotics , whereas those in the  treatment group ( n = 69 , 2009 - 2011 ) were continued on antibiotics until intraoperative bile culture results became available . Patients with bacteriobilia received 10 days of antibiotic treatment , which was otherwise discontinued in patients without bacteriobilia . Various complication rates were compared using Fisher 's exact test for categorical variables , Wilcoxon rank sum test for ordinal variables , and a two- sample t-test for continuous variables . RESULTS Demographics , comorbidities , baseline clinical characteristics , and intraoperative and postoperative variables were similar between the two groups . There were higher incidences of elevated creatinine ( 19 % versus 4 % ; P = 0.004 ) and preoperative hyperglycaemia ( 18 % versus 7 % ; P = 0.053 ) in the control group . Fewer patients in the control group underwent preoperative biliary stenting ( 48 % versus 67 % ; P = 0.017 ) and intraperitoneal drains were placed at the time of resection more frequently in the control group ( 85 % versus 38 % ; P < 0.001 ) . Bacteriobilia was found in 59 % of patients . Treatment of bacteriobilia was associated with a decrease in the rate of postoperative wound infections ( 12 % in the control group versus 3 % in the treatment group ; P = 0.036 ) and overall complication severity score ( 1 in the control group versus 0 in the treatment group ; P = 0.027 ) . CONCLUSIONS Prolonged antibiotic therapy for bacteriobilia may decrease postoperative wound infection rates after pancreaticoduodenectomy . A r and omized prospect i ve trial is warranted to provide evidence to further support this practice BACKGROUND Octreotide is generally administered based on the surgeon 's interpretation of perceived risk for pancreatic fistula at the time of pancreaticoduodenectomy ( PD ) . METHODS A single-institution , prospect i ve r and omized trial was conducted between April 2009 and December 2011 involving 62 PD patients who were r and omized to receive octreotide ( 100 μg subcutaneously every 8 h ; n = 32 ) or placebo ( n = 30 ) . Pancreatic juice output was measured after the operation using a catheter inserted into the pancreatic duct . Postoperative complications were recorded . RESULTS No significant differences in median output were found between the octreotide ( 82.5 ml ) and placebo ( 77.5 ml ) groups ( P = 0.538 ) . Median total output was significantly lower in patients with adenocarcinoma compared with those with periampullary tumours ( P = 0.004 ) and in patients with a duct diameter of > 5 mm compared with those with a duct diameter of < 5 mm ( P = 0.001 ) . There were no significant differences in overall morbidity between the octreotide and placebo groups ( P = 0.819 ) . Grade B pancreatic fistula ( International Study Group for Pancreatic Fistula ) was observed in two and three patients in the octreotide and placebo groups , respectively . CONCLUSIONS Morbidity did not differ significantly between the groups . This study did not demonstrate an inhibitory effect of octreotide on exocrine pancreatic secretion . Based on these results , the routine use of octreotide after PD can not be recommended Objectives : The aim of this study was to compare nasojejunal early enteral nutrition ( NJEEN ) with total parenteral nutrition ( TPN ) , after pancreaticoduodenectomy ( PD ) , in terms of postoperative complications . Background : Current nutritional guidelines recommend the use of enteral over parenteral nutrition in patients undergoing gastrointestinal surgery . However , the NJEEN remains controversial in patients undergoing PD . Methods : Multicenter , r and omized , controlled trial was conducted between 2011 and 2014 . Nine centers in France analyzed 204 patients undergoing PD to NJEEN ( n = 103 ) or TPN ( n = 101 ) . Primary outcome was the rate of postoperative complications according to Clavien-Dindo classification . Successful NJEEN was defined as insertion of a nasojejunal feeding tube , delivering at least 50 % of nutritional needs on PoD 5 , and no TPN for more than consecutive 48 hours . Results : Postoperative complications occurred in 77.5 % [ 95 % confidence interval ( 95 % CI ) 68.1–85.1 ] patients in the NJEEN group versus 64.4 % ( 95 % CI 54.2–73.6 ) in TPN group ( P = 0.040 ) . NJEEN was associated with higher frequency of postoperative pancreatic fistula ( POPF ) ( 48.1 % vs 27.7 % , P = 0.012 ) and higher severity ( grade B/C 29.4 % vs 13.9 % ; P = 0.007 ) . There was no significant difference in the incidence of post-pancreatectomy hemorrhage , delayed gastric emptying , infectious complications , the grade of postoperative complications , and the length of postoperative stay . A successful NJEEN was achieved in 63 % patients . In TPN group , average energy intake was significantly higher ( P < 0.001 ) and patients had an earlier recovery of oral feeding ( P = 0.0009 ) . Conclusions : In patients undergoing PD , NJEEN was associated with an increased overall postoperative complications rate . The frequency and the severity of POPF were also significantly increased after NJEEN . In terms of safety and feasibility , NJEEN should not be recommended Introduction Epidural analgesia has emerged as a commonly applied method to improve pain management and reduce perioperative complications in major abdominal surgery . However , there is no detailed analysis of its efficacy for pancreatic operations . This study compares clinical and economic outcomes after epidural and intravenous analgesia for pancreatoduodenectomy . Material and methods Data for 233 consecutive patients , who underwent pancreatoduodenectomy , were prospect ively acquired and retrospectively review ed at a single institution , pancreato-biliary specialty practice . From October 2001 to February 2007 , all patients were offered thoracic epidural analgesia , and those who declined received intravenous analgesia . Perioperative pain management was dictated as an element of a st and ardized clinical pathway for pancreatic resections . Clinical and economic outcomes were analyzed and compared for epidural analgesia and intravenous analgesia groups . Results One hundred eighty-five patients received epidural analgesia , and 48 received intravenous analgesia , with equivalent baseline patient demographics between the groups . Patients administered epidural analgesia had lower pain scores but significantly higher rates of major complications . Pancreatic fistulae and postoperative ileus occurred more frequently , and patients with epidural analgesia more often required discharge to rehabilitation facilities . A trend towards longer hospitalizations was observed among epidural analgesia patients , but total costs were statistically equivalent between the groups . Further analysis demonstrates that 31 % of epidural infusions were aborted before anticipated ( fourth postoperative day ) because of hemodynamic compromise and /or inadequate analgesia . These select patients required more transfusions , aggressive fluid resuscitation , and subsequently suffered even higher rates of gastrointestinal and respiratory complications , all attributing to higher costs . Multivariate analysis demonstrates that preoperative hematocrit concentration less than 36 % , elderly age ( > 75 years ) , and chronic pancreatitis predict failure of epidural infusions . Conclusion Thoracic epidural analgesia after pancreatic resections is associated with hemodynamic instability , which may compromise enteric anastomoses , gastrointestinal recovery , and respiratory function . These outcomes are exacerbated in poorly functioning epidurals and suggest that epidural analgesia may not be the optimal method for perioperative pain control when pancreatoduodenectomy is performed Purpose Mosapride citrate ( mosapride ) is a serotonin 5-hydroxytryptamine 4 receptor agonist known to promote gastric emptying and large-intestine motility . We assessed the effect of mosapride on postoperative ileus following colon surgery . Methods Forty patients with colon cancer undergoing h and -assisted laparoscopic colectomy were r and omly assigned to a mosapride group or a control group . The mosapride group received 15 mg of mosapride by mouth with 50 ml of water three times a day , starting on postoperative day 1 . The control group received 50 ml of water on the same schedule . Patients were allowed to resume oral feeding on the evening of postoperative day 2 . Postoperative time to first bowel movement was evaluated by one investigator blinded to treatment . Postoperative gastric emptying was evaluated with the [13C]-acetate breath test at 24 and 48 hours after the operation . Results Postoperative time to first bowel movement was significantly shorter in the mosapride group than in the control group ( 48.5 vs. 69.3 hours , P = 0.0149 ) . The time to maximal gastric emptying rate as determined by the breath test was significantly shorter in the mosapride group than in the control group at the 48-hour time point ( 27.9 vs. 35.3 minutes , P = 0.0294 ) . Postoperative hospital stay was shorter in patients receiving mosapride  than in controls ( 6.7 vs. 8.4 days , P = 0.0398 ) . No adverse effects were observed with mosapride . Conclusions Gastric emptying was improved by mosapride . The results suggested that the period of postoperative ileus following h and -assisted laparoscopic colectomy can be shortened by treatment with mosapride We prospect ively examined the incidence of postoperative nausea and vomiting ( PONV ) in a group of 193 elderly surgical in patients receiving no postoperative antiemetic prophylaxis .  Risk factors for PONV and detailed data on postoperative opioid use were recorded . The overall postoperative vomiting ( POV ) rate was 23.8 % , whereas postoperative nausea ( PON ) was 51.3 % . Opioid use ( P = 0.025 ) , and female gender ( P = 0.038 ) were identified as significantly influencing POV in this relatively small population . There was a strong logarithmic dose-response relationship between postoperative opioid dose and POV ( r2 = 0.98 , P < 0.01 ) , as well as PON ( r2 = 0.98 , P = 0.01 ) . Use of patient-controlled analgesia or epidural analgesia was a marker for large-dose opioid use ( P < 0.001 ) and was associated with POV in the 24-h postoperative period of 41 % and 31 % respectively , compared with 11 % for other patients ( P < 0.001 ) . Future studies defining risk factors for POV should treat postoperative opioid use as a continuous variable , rather than treat it as a dichotomous variable We included 34 trials with 3742 participants , identified through 6 data base and supplementary search es ( to May 2017 ) : 29 were r and omised ; 4 were quasi‐r and omised and 1 was cluster‐r and omised . Disparate measurements and outcomes precluded meta‐analyses . Blinding was attempted in only 6 out of 34 ( 18 % ) trials . A multimedia format , alone or in combination with text or verbal formats , was studied in 20/34 ( 59 % ) trials : pre‐operative anxiety was unaffected in 10 out of 14 trials and reduced by the multimedia format in three ; postoperative anxiety was unaffected in four out of five trials in which formats were compared . Multimedia formats increased knowledge more than text , which in turn increased knowledge more than verbal formats . Other outcomes were unaffected by information format . The timing of information did not affect pre‐operative anxiety , postoperative pain or length of stay . In conclusion , the effects of pre‐operative information on peri‐operative anxiety and other outcomes were affected little by format or timing Objective : To develop and vali date a simple prognostic score to predict major postoperative complications after  pancreaticoduodenectomy ( PD ) .  Background : PD still carries a high rate of severe postoperative complications . No specific score is currently available to stratify the patient 's risk of major morbidity . Methods : Between 2002 and 2010 , preoperative , intraoperative , and outcome data from 700 consecutive patients undergoing PD in our institution were prospect ively collected in an electronic data base . Major complications were defined as levels III to V of Clavien-Dindo classification . On the basis of a multivariate regression model , the score was developed using a r and om two-thirds of the population ( n = 469 ) and was vali date d on the remaining 231 patients . Results : Major complication rate was 16.7 % ( 117/700 ) . Significant predictors included in the scoring system were : pancreas texture , pancreatic duct diameter , operative blood loss , and ASA score . The mean risk of developing major postoperative complications was 7 % in patients with score 0 to 3 , 13 % in patients with score 4 to 7 , 23 % in patients with score 8 to 11 , and 36 % in patients with score 12 to 15 . In the validation population , the predicted risk of major complications was 15.2 % versus a 16.9 % observed risk ( C-statistic index = 0.743 ) . Conclusion : This new score may accurately predict a patient 's postoperative outcome . Early identification of high-risk patients could help the surgeon to adopt intraoperative and postoperative strategies tailored on individual basis Abstract Background : The aim of the study was to evaluate the influence of low dose perioperative Octreotide on the prevention of complications ( pancreatic fistula and general complications ) in patients undergoing pancreatic surgery followed by pancreatico-jejunostomy . Material and Methods : 105 patients were r and omized to receive either Octreotide 0.1 mg subcutaneously 3 times/day for a total of 7 days or no Octreotide . The primary endpoints were the occurrence of a pancreatic fistula and /or general complications including the length of hospital stay . There were 25 surgical draining procedures performed and 80 duodeno-pancreatectomies with or without preservation of the pylorus . Twenty-six ( 24.8 % ) of the patiënts were treated for chronic pancreatitis , 8 ( 7.6 % ) for benign tumoral disease and 71 ( 67.6 % ) for carcinoma . All patients underwent pancreatico-jejunostomy . Results : 56 patients received Octreotide and 49 did not . The incidence of fistula formation in the Octreotide group was 8.9 % ( n = 5 ) and in the control group 8.2 % ( n = 4 ) for a total incidence of 8.5 % . The difference between the two groups was not statistically significant . There was one death in the Octreotide group and none in the control group for an overall mortality of 0.9 % . The morbidity , except fistulas , was 10.7 % in the Octreotide group and 12.2 % in the control group . The length of hospital stay was 23.1 ± 15.1 days in the group receiving Octreotide vs 20.4 ± 8.1 days in the control group ( p = 0.808 ) . Stratifying the data for duodenopancreatectomy and for draining procedures there was no difference between the groups either . Conclusion : In patients undergoing pancreatic surgery and pancreatico-jejunostomy , the perioperative use of 3 χ 0.1 mg Octreotide for 7 days does not reduce general complications nor fistula formation Objective : This dual-center , r and omized , controlled , noninferiority trial aim ed to prove that omission of drains does not increase reintervention rates after pancreatic surgery . Background : There is considerable uncertainty regarding intra-abdominal drainage after pancreatoduodenectomy . Methods : Patients undergoing pancreatic head resection with pancreaticojejunal anastomosis were r and omized to intra-abdominal drainage versus no drainage . Primary endpoint was overall reintervention rate ( relaparotomy or radiologic intervention ) . Secondary endpoints were clinical ly relevant pancreatic fistula ( grade B/C ) , mortality , morbidity , and hospital stay . The planned sample size was 188 patients per group . Results : A total of 438 patients were r and omized . Forty-three patients ( 9.8 % ) were excluded because no pancreatic anastomosis was performed , and 395 patients ( 202 drain , 193 no-drain ) were analyzed . Reintervention rates were not inferior in the no-drain group ( drain 21.3 % , no-drain 16.6 % ; P = 0.0004 ) . Overall in-hospital mortality ( 3.0 % ) was the same in both groups ( drain 3.0 % , no-drain 3.1 % ; P = 0.936 ) . Overall surgical morbidity ( 41.8 % ) was comparable ( P = 0.741 ) . Clinical ly relevant pancreatic fistula ( grade B/C : drain 11.9 % , no-drain 5.7 % ; P = 0.030 ) and fistula-associated complications ( drain 26.4 % ; no drain 13.0 % ; P = 0.0008 ) were significantly reduced in the no-drain group . Operation time ( P = 0.093 ) , postoperative hemorrhage ( P = 0.174 ) , intra-abdominal abscess formation ( P = 0.199 ) , biliary leakage ( P = 0.382 ) , delayed gastric emptying ( P = 0.062 ) , burst abdomen ( P = 0.480 ) , wound infection ( P = 0.758 ) , and hospital stay ( P = 0.487 ) did not show significant differences . Conclusions : Omission of drains was not inferior to intra-abdominal drainage in terms of postoperative reintervention and superior in terms of clinical ly relevant pancreatic fistula rate and fistula-associated complications . There is no need for routine prophylactic drainage after pancreatic resection with pancreaticojejunal anastomosis BACKGROUND The factors associated with  delayed gastric emptying ( DGE ) after a pancreaticoduodenectomy ( PD ) are not definitively known . METHODS From November 2011 through to May 2012 , data were prospect ively collected on 711 patients undergoing a pancreaticoduodenectomy or total pancreatectomy as part of the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project . Bivariate and multivariate models were employed to determine the factors that predicted DGE . RESULTS In the 711 patients , the overall rate of DGE was 20.1 % . In a bivariate analysis , intra-operative factors such as pylorus-preservation ( 47.1 % versus 43.7 % , P = 0.40 ) , intra-operative drain placement ( 85.5 % , versus 85.1 % , P = 0.91 ) and an antecolic compared with a retrocolic gastrojejunostomy ( 60.1 % versus 65.1 % , P = 0.26 ) were not different between the DGE and no DGE groups . Pancreatic fistula formation ( 31.2 % versus 10.1 % ) , post-operative sepsis ( 21.7 % versus 7.0 % ) , organ space surgical site infection ( SSI ) ( 23.9 % versus 7.9 % ) , need for percutaneous drainage ( 23.0 % versus 10.6 % ) and reoperation ( 10.6 % versus 3.1 % ) were higher in patients with DGE ( P < 0.0001 ) . In a multivariable model , only pancreatic fistula , post-operative sepsis and reoperation were independently associated with DGE . DISCUSSION In this multicentre study , only post-operative complications were associated with DGE . Neither pylorus preservation nor route of enteric reconstruction ( antecolic versus retrocolic ) was associated with delayed gastric emptying A prospect i ve , r and omized , controlled trial was performed to determine the efficacy of somatostatin in the prevention of pancreatic stump-related complications with elimination of surgeon-related factors in high-risk patients undergoing panceaticoduodenectomy . From August 1997 to December 2000 , 54 patients , 28 men and 26 women , with age ranged from 32 to 89 years , were r and omly assigned to somatostatin group ( n = 27 ) or placebo group ( n = 27 ) . Ninety-four percent of the patients had pancreatic and periampullary lesions ; 6 % had secondary lesion involving the duodenum such as local recurrent colon carcinoma and renal cell carcinoma . These patients received either st and ard pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy . An experienced surgeon performed all operations in same fashion to minimize the surgical factor . A transanastomotic tube was inserted into the pancreatic duct for diversion of pancreatic juice in the pancreaticojejunostomy for a 3-weeks period postoperatively . Intravenous infusion of somatostatin was given at a dose of 250μg/hr in the somastotatin group and normal saline was given to the control group for 7 days postoperatively . There was one perioperative death in each group , result ing in a 3.7 % mortality rate . In the somastotatin group , as compared to the placebo group , the incidence of overall morbidity and pancreatic stump related complications were significantly lower with a mean decrease of 50 % pancreatic juice output and a slightly shorter duration of hospital stays . In conclusion , after excluding surgeon related factor , prophylactic use of somatostatin  reduces the incidence and severity of pancreatic stump related complications in high-risk patients having pancreaticoduodenectomy via decreased secretion of pancreatic exocrine Somatostatin inhibits gastroenteropancreatic exocrine secretion and is often used after pancreaticoduodenectomy to reduce pancreatic secretion to minimize tissue damage and pancreatic stump complications . Because our earlier clinical work saw a major increase in delayed gastric emptying ( DGE ) with somatostatin prophylaxis after  pylorus-preserving pancreaticoduodenectomy ( PPPD ) , this small-group study was design ed to confirm or disprove that observation . From August 1997 to December 2000 , a total of 23 post-PPPD patients were r and omized to receive somatostatin prophylaxis [ somatostain ( + ) ] ( n = 11 ) or not [ somatostatin ] ( − ) ( n = 12 ) . The incidence of DGE , scintographic solid-phase emptying results on day 14 postoperatively , and sequential fasting plasma motilin levels were compared , as motilin levels are related to both gastric motility and somatostatin levels . The somatostatin(+ ) group exhibited greatly increased patient complaints of DGE : 9 of 11 ( 82 % ) versus 3 of 12 ( 25 % ) in the somatostatin(− ) group . Radiologic scintography showed somatostatin prophylaxis prolonged the half-time ( T1/2 ) of solid-phase emptying : 144.5 ± 51.4 minutes for somatostatin(+ ) versus 89.0 ± 59.9 minutes for somatostatin(− ) ( p < 0.001 ) . Comparing pre-PPPD and post-PPPD plasma motilin levels prior to somatostatin infusion , motilin decreased 80 % in reaction to the surgery . For somatostatin(− ) patients , motilin levels oscillated , or “ rang , ” postoperatively , reaching a higher level on day 3 , declined to a new record minimum on day 7 , and by day 21 were 50 % of the original and the slope of the recovery curve was increasing well . In somatostatin(+ ) patients the same ringing pattern was observed but decreased with motilin levels 30 % to 70 % lower than in the somatostatin(− ) patients . By day 21 somatostatin(+ ) motilin levels were recovering but still only 20 % original levels , and the slope of the recovery curve was not optimistic . On postoperative day 14 the plasma motilin levels ( below approximately 6 bg/ml ) correlated strongly with DGE for both groups . Despite the small sample size , the results indicated that ( 1 ) somatostatin prophylaxis significantly decreases fasting plasma motilin ; ( 2 ) somatostatin prophylaxis produces lingering suppression of plasma motilin ; ( 3 ) PPPD surgery itself significantly reduces fasting motilin levels with recovery to 50 % normal at day 21 ; ( 4 ) the mechanism of somatostatin-induced DGE seems related to reduced fasting plasma motilin levels Background A recent r and omized , controlled trial investigating intraperitoneal drain use during pancreatoduodenectomy ( PD ) had a primary goal of assessing overall morbidity . It was terminated early with findings that routine elimination of drains in PD increases mortality and the severity and frequency of overall complications . Here , we provide a follow-up analysis of drain value in reference to clinical ly relevant postoperative pancreatic fistula ( CR-POPF ) . Methods Nine institutions performed 137 PDs , with patients r and omized to intraperitoneal drainage ( N = 68 ) or no drainage ( N = 69 ) . The Fistula Risk Score ( FRS ) , a 10-point scale derived from four vali date d risk factors for CR-POPF , facilitated risk adjustment between treatment groups . Results There was no difference in fistula risk between the two cohorts . Overall , CR-POPF rates were higher in the no drain group compared to the drain group ( 20.3 vs. 13.2 % ; p = 0.269 ) . Patients with negligible/low FRS risk had higher rates of CR-POPF when drains were used ( 14.8 vs. 4.0 % ; p = 0.352 ) . Conversely , there were significantly fewer CR-POPFs ( 12.2 vs. 29.5 % ; p = 0.050 ) when drains were used with moderate/high risk patients . Lastly , moderate/high risk patients who suffered a CR-POPF had reduced 90-day mortality ( 22.2 vs. 42.9 % ) when a drain was used . Conclusion The results of this analysis suggest that drains diminish the rate and severity of CR-POPF in patients with moderate/high risk , but they could possibly be avoided in the roughly one third of patients with negligible/low risk Objective : The aim of this trial was to investigate whether a routine of allowing normal food at will increases morbidity after major upper gastrointestinal ( GI ) surgery . Summary Background Data : Nil-by-mouth with enteral tube feeding is widely practice d for several days after major upper GI surgery . After other abdominal operations , normal food at will has been shown to be safe and to improve gut function . Methods : Patients were r and omly assigned to a routine of nil-by-mouth and enteral tube feeding by needle-catheter jejunostomy ( ETF group ) or normal food at will from the first day after major upper GI surgery . Primary end point was rate of major complications and death . Secondary outcomes were minor complications and adverse events , bowel function , and length of stay . All patients were invited to a follow-up at 8 weeks after discharge from the hospital . Results : Four hundred fifty-three patients who underwent major open upper GI surgery in 5 centers were enrolled between 2001 and 2006 . Four hundred forty-seven patients were correctly r and omized . Of 227 patients 76 ( 33.5 % ) had major complications in the ETF group compared with 62 ( 28.2 % ) of 220 patients allowed normal food at will ( P = 0.26 , 95 % CI for the difference in rate from −3.3 to 13.9 ) . In the ETF group , 36 ( 15.9 % ) patients were reoperated compared with 29 ( 13.2 % ) in the group allowed normal food at will ( P = 0.50 ) and 30-day mortality was 10 ( 4.4 % ) of 227 and 11 ( 5.0 % ) of 220 patients , respectively ( P = 0.83 ) . Time to resumed bowel function was significantly in favor of allowing normal food at will ( P = 0.01 ) , as were the total number of major complications , length of stay , and rate of postdischarge complications . Conclusions : Allowing patients to eat normal food at will from the first day after major upper GI surgery does not increase morbidity compared with traditional care with nil-by-mouth and enteral feeding OBJECTIVES Aim of this study is the evaluation of the impact of a multimedia CD ( MCD ) on preoperative anxiety and postoperative recovery of patients undergoing elective laparoscopic cholecystectomy ( LC ) . METHODS Sixty consecutive c and i date s for elective LC were r and omly assigned to four groups . Group A included 15 patients preoperatively informed regarding LC through the MCD presented by Registered Nurse ( RN ) . Patients in group B ( n = 15 ) were informed through a leaflet . Patients in group C ( n = 15 ) were informed verbally from a RN . Finally , the control Group D included 15 patients  informed conventionally by the attending surgeon and anesthesiologist , as every other patient included in groups A , B , and C. Preoperative assessment of knowledge about LC was performed after each informative session through a question naire . Evaluation of preoperative anxiety was conducted using APAIS scale . Postoperative pain and nausea scores were measured using an NRS scale , 16 hours after the patient had returned to the ward . RESULTS Statistical processing of the results ( single linear regression ) showed that patients in groups A , B , and C achieved a higher knowledge score , less preoperative anxiety score and less postoperative pain and nausea , compared to Group D. In multiple regression analysis , group A had a higher knowledge score compared to the four groups ( p < 0.001 r(2 ) = 0.41 ) . CONCLUSION Informative sessions using MCD is an effective means of improving patient 's preoperative knowledge , especially in day-surgery cases , like LC INTRODUCTION The Joint Commission Surgical Care Improvement Project ( SCIP ) includes performance measures aim ed at reducing surgical site infections ( SSI ) . One measure defines approved perioperative antibiotics for general operative procedures . However , there may be a subset of procedures not adequately covered with the use of approved antibiotics . We hypothesized that piperacillin-tazobactam is a more appropriate perioperative antibiotic for pancreaticoduodenectomy ( PD ) . METHODS In collaboration with hospital epidemiology and the Division of Infectious Diseases , we retrospectively review ed records of 34 patients undergoing PD between March and May 2008 who received SCIP-approved perioperative antibiotics and calculated the SSI rate .  After changing our perioperative antibiotic to piperacillin-tazobactam , we prospect ively review ed PDs performed between June 2008 and March 2009 and compared the SSI rates before and after the change . RESULTS For 34 patients from March through May 2008 , the SSI rate for PD was 32.4 per 100 cases . Common organisms from wound cultures were Enterobacter and Enterococcus ( 50.0 % and 41.7 % , respectively ) , and these were cefoxitin resistant . From June 2008 through March 2009 , 106 PDs were performed . During this period , the SSI rate was 6.6 per 100 surgeries , 80 % lower than during March through May 2008 ( relative risk , 0.204 ; 95 % confidence interval [ CI ] , 0.086 - 0.485 ; P = .0004 ) . CONCLUSION Use of piperacillin-tazobactam as a perioperative antibiotic in PD may reduce SSI compared with the use of SCIP-approved antibiotics . Continued evaluation of SCIP performance measures in relationship to patient outcomes is integral to sustained quality improvement STUDY OBJECTIVE To determine the effect of two target dexmedetomidine infusions ( 0.3 ng/ml and 0.6 ng/ml ) on the minimal alveolar concentration ( MAC ) of sevoflurane in adults age 55 to 70 years . DESIGN Prospect i ve , r and omized , placebo-controlled study . SETTING University-affiliated hospital . PATIENTS 45 ASA physical status I and II adults , age 55 to 70 years , undergoing elective surgery with at least a 3 inch skin incision . INTERVENTIONS Patients were given a dexmedetomidine or placebo infusion for at least 15 minutes before anesthetic induction with sevoflurane in oxygen by face mask . After tracheal intubation , a target sevoflurane concentration was maintained for 15 minutes while the dexmedetomidine or placebo infusion continued to run . MEASUREMENTS AND MAIN RESULTS At the time of skin incision , two observers independently determined movement or nonmovement to the incision . Blood sample s for dexmedetomidine were taken before the infusion and at the time of skin incision . The  dexmedetomidine plasma concentrations were 0 before infusion with all treatment groups . At the time of incision , they were 0 in the placebo group , 0.39 + /- 0.13 ng/ml in the 0.3 ng/ml target group , and 0.7 + /- 0.13 ng/ml in the 0.6 ng/ml target group . The MAC of sevoflurane was 1.83 % in the placebo group , 1.78 % in the 0.3 ng/ml target dexmedetomidine group , and 1.51 % in the 0.6 ng/ml target dexmedetomidine group . CONCLUSIONS Dexmedetomidine 0.7 ng/ml decreased the MAC of sevoflurane by 17 % , whereas there was no difference between the placebo and the dexmedetomidine 0.39 ng/ml group Making a diagnosis is the bread and butter of clinical practice , but in light of the number of tests now available to clinician , diagnosing illness has become a complicated process . Guidelines for making an evidence -based diagnosis abound , but those making recommendations about diagnostic tests or test strategies must realize that clinicians require support to make diagnostic decisions that they can easily implement in daily practice . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) Working Group has developed a rigorous , transparent , and increasingly adopted approach for grading the quality of research evidence and strength of recommendations to guide clinical practice . This editorial summarizes GRADE 's process for developing recommendations for tests ( 1 ) . Clinicians are trained to use tests for screening and diagnosis ; identifying physiologic derangements ; establishing a prognosis ; and monitoring illness and treatment response by assessing signs and symptoms , imaging , biochemistry , pathology , and psychological testing techniques ( 2 ) . Sensitivity , specificity , positive predictive value , likelihood ratios , and diagnostic odds ratios are among the challenging terms that diagnostic studies typically deliver to clinicians , and all have to do with diagnostic accuracy . Not only do clinicians have difficulties remembering the definitions and calculations for these terms , application of the concepts to individual patients is often complicated . Many clinicians order a test despite uncertainty about how to interpret the result , and they also contribute to testing errors by incorrectly ordering tests ( 3 , 4 ) . GRADE 's framework for developing recommendations for diagnostic management studies is based on what is needed for practical clinical applicationthat is , how to weigh the benefits and harms of ordering and using a diagnostic test in caring for patients ( 1 ) . The approach begins with specifying the PICO : the relevant population ( P ) , diagnostic intervention or test ( I ) ( including its purpose , such as triage , replacement , or an add-on test ) , comparison test ( C ) , and patient-important outcomes ( O ) related to the use of a test for a focused clinical question . If a test fails to improve patient-important outcomes , there is no reason to use it , whatever its accuracy . For example , the results of genetic testing for Huntington chorea , an untreatable condition , may provide either welcome reassurance that a patient will not have the condition or the ability to plan for his future knowing that he will sadly fall victim ( 1 ) . Here , the ability to plan is analogous to an effective treatment , and the benefits of planning need to be balanced against the downsides of receiving an early diagnosis ( 5 - 7 ) . The best evidence of test performance comes from large r and omized trials of diagnostic strategies that directly measure patient-important outcomes ( 1 ) . However , these trials are few and far between : An informal review of the Cochrane data base of r and omized trials revealed < 100 such studies . Therefore , most recommendations about diagnostic testing are based on an implicit 2-step process of how the accuracy of a test indirectly changes patient-important outcomes . In the first step , a diagnostic-test accuracy study ( Figure ) , patients may receive both a new test and a reference test ( i.e. , the best available method for detecting the target condition ) . Investigators can then calculate the accuracy of the test compared with the reference test ( first step ) . In the second step , judgments about the patient importance of test accuracy are based on the consequences of being correctly or incorrectly classified as having or not having the disease . These include the benefits and harms of receiving treatment or follow-up tests for those correctly classified as having the disease , reassurance or receipt of other follow-up tests for those correctly classified as not having the disease , receipt of unnecessary treatment or additional tests for those incorrectly classified as having the disease , delayed or no treatment for those incorrectly classified as not having the disease , and any adverse effects of the diagnostic test ( e.g. , from invasive tests ) . Those making recommendations about diagnostic tests must then compare patient-important outcomes ( and costs ) in all patients receiving the new test with all patients receiving the old , or comparator , test . For the first step ( i.e. , assessing test accuracy ) , there are well-described method ological criteria for assessing risk for bias in an estimate of test accuracy , ideally based on a systematic review of relevant studies . For instance , studies of diagnostic test accuracy with a low risk for bias enroll consecutive patients for whom there is legitimate diagnostic uncertaintythat is , the type of patients to whom clinicians would apply the test in the course of regular clinical practice . If studies fail this criterion ( e.g. , only enroll patients with severe disease and healthy controls ) , the apparent accuracy of a test is likely to be misleadingly high ( 8 , 9 ) . The second step shown in the Figure is , in most situations , based on judgments of test accuracy as a surrogate for patient-important outcomes . The key issue about these judgments is that they should be made transparent to those using the recommendations . For example , in the diagnosis of suspected acute urolithiasis , well- design ed studies demonstrate fewer false-negative results with noncontrast helical computed tomography ( CT ) than with intravenous pyelography ( IVP ) ( 10 ) . However , those ureteric stones that CT detects but IVP misses are smaller and therefore are more likely to spontaneously pass . Before r and omized trials evaluating outcomes in patients treated for smaller stones , evidence from observational studies was of lower quality . Thus , it remained uncertain how patients were affected by missed cases and follow-up of incidental findings unrelated to renal calculi with CT .  Recommendations about using one test ( IVP ) over the other ( helical CT ) were based on judgments of how the cases that were detected or missed would fare with or without treatment ( 11 ) . These judgments were likely to be based on indirect evidence and would be less certain than judgments based on direct evidence from a r and omized trial comparing the 2 tests . The GRADE approach requires making these judgments about the relation between accuracy and patient-important outcomes transparent . The example of IVP versus helical CT for patients with suspected acute shows exemplifies how the quality of evidence for an accurate test would be down grade d because of the lack of direct evidence on patient-important outcomes . Uncertainty about patient-important consequences and associated uncertainty about benefits and harms would probably have result ed in weak GRADE recommendations about the use of IVP compared with helical CT . Those making recommendations using the GRADE approach should also explicitly consider judgments and evidence about the values and preferences that patients attach to important consequences , as described more fully elsewhere ( 1 ) . Acknowledgments : This work was partially funded by a The human factor , mobility and Marie Curie Actions Scientist Reintegration European Commission Grant ( IGR 42192 ) GRADE to Dr. Schnemann BACKGROUND Whether hypoglycemia leads to death in critically ill patients is unclear . METHODS We examined the associations between moderate and severe hypoglycemia ( blood glucose , 41 to 70 mg per deciliter [ 2.3 to 3.9 mmol per liter ] and ≤40 mg per deciliter [ 2.2 mmol per liter ] , respectively ) and death among 6026 critically ill patients in intensive care units ( ICUs ) . Patients were r and omly assigned to intensive or conventional glucose control . We used Cox regression analysis with adjustment for treatment assignment and for baseline and postr and omization covariates . RESULTS Follow-up data were available for 6026 patients : 2714 ( 45.0 % ) had moderate hypoglycemia , 2237 of whom ( 82.4 % ) were in the intensive-control group ( i.e. , 74.2 % of the 3013 patients in the group ) , and 223 patients ( 3.7 % ) had severe hypoglycemia , 208 of whom ( 93.3 % ) were in the intensive-control group ( i.e. , 6.9 % of the patients in this group ) . Of the 3089 patients who did not have hypoglycemia , 726 ( 23.5 % ) died , as compared with 774 of the 2714 with moderate hypoglycemia ( 28.5 % ) and 79 of the 223 with severe hypoglycemia ( 35.4 % ) . The adjusted hazard ratios for death among patients with moderate or severe hypoglycemia , as compared with those without hypoglycemia , were 1.41 ( 95 % confidence interval [ CI ] , 1.21 to 1.62 ; P<0.001 ) and 2.10 ( 95 % CI , 1.59 to 2.77 ; P<0.001 ) , respectively . The association with death was increased among patients who had moderate hypoglycemia on more than 1 day ( > 1 day vs. 1 day , P=0.01 ) , those who died from distributive ( vasodilated ) shock ( P<0.001 ) , and those who had severe hypoglycemia in the absence of insulin treatment ( hazard ratio , 3.84 ; 95 % CI , 2.37 to 6.23 ; P<0.001 ) . CONCLUSIONS In critically ill patients  , intensive glucose control leads to moderate and severe hypoglycemia , both of which are associated with an increased risk of death . The association exhibits a dose-response relationship and is strongest for death from distributive shock . However , these data can not prove a causal relationship . ( Funded by the Australian National Health and Medical Research Council and others ; NICE-SUGAR Clinical Trials.gov number , NCT00220987 . ) BACKGROUND /st > In assessing a patient 's risk for postoperative nausea and vomiting ( PONV ) , it is important to know which risk factors are independent predictors , and which factors are not relevant for predicting PONV . METHODS /st > We conducted a systematic review of prospect i ve studies ( n>500 patients ) that applied multivariate logistic regression analyses to identify independent predictors of PONV . Odds ratios ( ORs ) of individual studies were pooled to calculate a more accurate overall point estimate for each predictor . RESULTS /st > We identified 22 studies ( n=95 154 ) . Female gender was the strongest patient-specific predictor ( OR 2.57 , 95 % confidence interval 2.32 - 2.84 ) , followed by the history of PONV/motion sickness ( 2.09 , 1.90 - 2.29 ) , non-smoking status ( 1.82 , 1.68 - 1.98 ) , history of motion sickness ( 1.77 , 1.55 - 2.04 ) , and age ( 0.88 per decade , 0.84 - 0.92 ) . The use of volatile anaesthetics was the strongest anaesthesia-related predictor ( 1.82 , 1.56 - 2.13 ) , followed by the duration of anaesthesia ( 1.46 h(-1 ) , 1.30 - 1.63 ) , postoperative opioid use ( 1.39 , 1.20 - 1.60 ) , and nitrous oxide ( 1.45 , 1.06 - 1.98 ) . Evidence for the effect of type of surgery is conflicting as reference groups differed widely and funnel plots suggested significant publication bias . Evidence for other potential risk factors was insufficient ( e.g. preoperative fasting ) or negative ( e.g. menstrual cycle ) . CONCLUSIONS /st > The most reliable independent predictors of PONV were female gender , history of PONV or motion sickness , non-smoker , younger age , duration of anaesthesia with volatile anaesthetics , and postoperative opioids . There is no or insufficient evidence for a number of commonly held factors , such as preoperative fasting , menstrual cycle , and surgery type , and using these factors may be counterproductive in assessing a patient 's risk for PONV Background and Aim : Immunomodulating nutrition is supposed to reduce the number of complications and lengthen of hospital stay during the postoperative period in patients after major gastrointestinal surgery . The aim of the study was to assess the clinical effect of immunostimulatory enteral and parenteral nutrition in patients undergoing resection for gastrointestinal cancer in the group of well-nourished patients . Material and Methods : Between June 1 , 2001 , and December 31 , 2005 , a group of 214 well-nourished patients was initially assessed ( 150 men , 64 women , mean age 61.2 years ) to participate in the study . Nine patients were subsequently excluded and the remaining 205 subjects were r and omly assigned in a 2 × 2 factorial design into 4 study groups , ie , st and ard enteral nutrition ( n = 53 ) , immunomodulating enteral nutrition ( n = 52 ) , st and ard parenteral nutrition ( n = 49 ) , and immunomodulating enteral nutrition ( n = 51 ) . The study was design ed to test the hypothesis that immunonutrition and enteral nutrition would reduce the incidence of infectious complications after upper gastrointestinal surgery ; the secondary objective of the study was to evaluate the effect of nutritional intervention on overall morbidity and mortality rates , and hospital stay . The study was registered in the Clinical Trials Data base – number NCT 00558155 . Results : The overall morbidity rate was 33 % and the incidence of individual complications was comparable between all groups . Infectious complications occurred in 26 of 102 patients given st and ard diets and in 22 of 103 patients receiving immunomodulatory formulas ( odds ratio 0.81 ; 95 % CI , 0.43–1.50 ) . There were no significant differences between infectious complications in patients using parenteral nutrition ( 22 of 100 patients ) and parenteral formulas ( 26 of 105 , odds ratio 1.14 ; 95 % CI , 0.61–2.14 ) . Neither immunostimulating formulas nor enteral feeding significantly affected secondary outcome measures , including overall morbidity and mortality rates , and hospital stay . Conclusions : Our study failed to demonstrate any clear advantage of routine postoperative immunonutrition in patients undergoing elective upper gastrointestinal surgery . Both enteral and parenteral treatment options showed similar efficacy , tolerance , and effects on protein synthesis .  Parenteral nutrition composed according to contemporary rules showed similar efficiency to enteral nutrition . However , because of its cost-efficiency , enteral therapy should be considered as the treatment of choice in all patients requiring nutritional therapy BACKGROUND The efficacy of octreotide to prevent postoperative pancreatic fistula ( POPF ) of pancreaticoduodenectomy ( PD ) is still controversial . This study aim ed to evaluate the effect of postoperative use of octreotide on the outcomes after PD . METHODS This is a prospect i ve r and omized controlled trial for postoperative use of octreotide in patients undergoing PD . Patients with soft pancreas and pancreatic duct < 3 mm were r and omized to 2 groups . Group I did not receive postoperative octreotide . Group II received postoperative octreotide . The primary end of the study is to compare the rate of POPF . RESULTS A total of 104 patients were included in the study and were divided into two r and omized groups . There were no significant difference in overall complications and its severity . POPF occurred in 11 patients ( 21.2 % ) in group I and 10 ( 19.2 % ) in group II , without statistical significance ( P = 0.807 ) . Also , there was no significant differences between both groups regarding the incidence of biliary leakage ( P = 0.083 ) , delayed gastric emptying ( P = 0.472 ) , and early postoperative mortality ( P = 0.727 ) . CONCLUSIONS Octreotide did not reduce postoperative morbidities , reoperation and mortality rate . Also , it did not affect the incidence of POPF and its clinical ly relevant variants Purpose The purpose of this study was to evaluate the effects of preoperative forced-air warming on intraoperative hypothermia . Methods In this r and omized-controlled trial , adult patients scheduled for elective , non-cardiac surgery under general anesthesia were stratified by scheduled surgical duration ( < 2.5 hr or ≥ 2.5 hr ) and then r and omized to a pre-warming group using a BairPaws ™ forced-air warming system for at least 30 min preoperatively or to a control group with warmed blankets on request . All patients were warmed intraoperatively via convective forced-air warming blankets .  Perioperative temperature was measured using the SpotOn ™ temperature system consisting of a single-use disposable sensor applied to the participant ’s forehead . The primary outcome was the magnitude of intraoperative hypothermia calculated as the area under the time-temperature curve for core temperatures < 36 ° C between induction of general anesthesia and leaving the operating room . Secondary outcomes included surgical site infections , packed red blood cell requirements , and 24 hr postoperative opioid consumption . Results Two hundred participants were analyzed ( 101 control ; 99 pre-warmed ) . Pre-warmed participants had a lower median [ interquartile range ] magnitude of hypothermia than controls ( 0.00 [ 0.00 - 0.12 ] ° C·hr−1vs 0.05 [ 0.00 - 0.36 ] ° C·hr−1 , respectively ; median difference , −0.01 ° C·hr−1 ; 95 % confidence interval , −0.04 to 0.00 ° C·hr−1 ; P = 0.005 ) . There were no between-group differences in the secondary outcomes . Conclusion A minimum of 30 min of preoperative forced-air convective warming decreased the overall intraoperative hypothermic exposure . While redistribution hypothermia still occurs despite pre- and intraoperative forced-air warming , their combined application results in greater preservation of intraoperative normothermia compared with intraoperative forced-air warming alone . Trial registration www . clinical trials.gov ( NCT02177903 ) . Registered 25 June 2014.RésuméObjectifL’objectif de cette étude était d’évaluer les conséquences du réchauffement préopératoire par air forcé sur l’hypothermie peropératoire . MéthodesDans cette étude r and omisée contrôlée , des patients adultes devant subir une chirurgie élective non cardiaque sous anesthésie générale ont été stratifiés en fonction de la durée prévue de l’intervention ( < 2,5 h ou ≥ 2,5 h ) puis r and omisés dans un groupe de réchauffement préalable utilisant un système à air forcé BairPaws ™ pendant au moins 30 min en préopératoire ou dans un groupe témoin avec couvertures chauffantes sur dem and e. Tous les patients ont été réchauffés pendant l’intervention au moyen de couvertures chauffantes à air forcé par convection . La température périopératoire a été mesurée au moyen du système de surveillance de la température SpotOnMD consistant en un capteur jetable à usage unique placé sur le front des patients . Le critère principal d’évaluation était l’ampleur de l’hypothermie peropératoire calculée comme l’aire sous la courbe température-temps pour des températures central es < 36 ° C entre l’induction de l’anesthésie générale et la sortie de la salle d’opération . Les critères d’évaluation secondaires ont inclus les infections du site chirurgical , le nombre de culots de globules rouges nécessaires et la consommation d’opioïdes au cours des 24 heures postopératoires . RésultatsLes résultats de 200 participants ont été analysés ( 101 contrôles ; 99 patients préréchauffés ) . L’amplitude médiane de l’hypothermie [ écart interquartile ] des participants préréchauffés a été plus faible que celle des contrôles ( respectivement , 0,00 [ 0,00 - 0,12 ] ° C·hr−1 contre 0,05 [ 0,00 - 0,36 ] ° C·hr−1 ; différence entre médianes , −0,01 ° C·hr−1 ; intervalle de confiance à 95 % , −0,04 à 0,00 ° C·hr−1 ; P < 0,005 ) . Il n’y a pas eu de différence entre les groupes sur les critères d’évaluation secondaires . Conclusion Un minimum de 30 min de réchauffement préopératoire au moyen d’un système à air forcé à convection a diminué l’exposition globale à l’hypothermie peropératoire . Bien qu’une hypothermie de redistribution survienne toujours en dépit du réchauffement peropératoire à l’air forcé , leur application combinée entraîne une meilleure conservation de la normothermie peropératoire , comparativement au réchauffement peropératoire à l’air forcé seul . Enregistrement de l’essai cliniquewww.essaiscliniques.gov ( NCT02177903 ) . Enregistré le 25 juin 2014 Aims : To investigate whether preoperative enteral diets enriched in eicosapentaenoic acid ( EPA ) supplements could reduce the incidence of hypercytokinemia after pancreatoduodenectomy ( PD ) in a double-blinded r and omized controlled trial . Methods : Patients with resectable periampullary cancer were r and omized into either the control group or the treatment group . Patients in the treatment group received oral supplementation ( 600 kcal/day ) containing EPA for 7 days before surgery . Patients in the control group received isocaloric isonitrogenous st and ard nutrition ( 600 kcal/day ) without EPA for 7 days before surgery . The primary endpoint was postoperative serum concentrations of interleukin-6 ( IL-6 ) . The secondary endpoints were the postoperative nutritional status and the incidence of postoperative infectious complications . Results : Twenty-four patients were enrolled in the present study . After exclusion , 20 patients ( control group , n = 9 ; treatment group , n = 11 ) were analyzed . There were no significant differences in the curves for the serum concentration of IL-6 ( p = 0.68 ) or the incidence of infectious complications between the 2 groups ( control group : 78 % , treatment group : 55 % , p = 0.37 ) . Conclusions : The results of a double-blinded r and omized controlled trial indicated that preoperative immunonutrition had no marked impact on the rates of postoperative hypercytokinemia or infectious complications after PD Background : Postoperative nausea and vomiting ( PONV ) affects 20 % and 30 % of patients . As many as 60%–80 % patients at high risk may be affected . Dexamethasone ( D ) and midazolam ( M ) are well studied as antiemetic . Use of D can be associated with certain undesirable side effects so minimum dose is preferred . M is a routinely used premedicant . Hence , this study was design ed with both D and M in high risk patients for PONV to find minimum effective dose of D. Aims : To determine the minimum dose of D that combined with M would provide effective prophylaxis of PONV after laparoscopic cholecystectomy ( LC ) in patients at high risk for PONV . Setting and Design : This is a prospect i ve , r and omized double-blind trial . Material s and Methods : One hundred and fifty-five patients scheduled for elective LC were r and omized to 5 groups of 31 each . Group C was given normal saline , and the rest were administered D 1 mg ( group MD1 ) , 2 mg ( group MD2 ) , 4 mg ( group MD4 ) , or 8 mg ( group MD8 ) in combination with 0.04 mg/kg M at induction . The incidence of nausea , vomiting , severity of nausea , and the use of rescue antiemetic and postoperative pain was analyzed . Statistical Analysis : Chi-square test was used to compare incidence of study variables . Independent Student 's t-test was used for continuous variables . Demographic data were compared using ANOVA . P < 0.05 was considered statistically significant . Results : The incidence of nausea was significantly lower in group MD4 ( 29 % ) and MD8 ( 6 % ) compared to placebo group ( 71 % ) ( P < 0.001 ) and of vomiting was significantly lower in groups of MD2 ( 58 % ) , MD4 ( 48 % ) , and MD8 ( 6 % ) compared with placebo ( 90 % ) ( P < 0.001 ) at 24 h. There was significant reduction in nausea , pain severity , and incidence of use of rescue antiemetic in MD4 and MD8 groups with no discernable side effects of the drugs . Conclusion : We conclude that 4 mg D with M and 2 mg D with M is effective for prevention of nausea and vomiting , respectively , in patients at high risk for PONV undergoing LC Purpose : This study was to identify factors affecting postoperative nausea and vomiting ( PONV ) and to investigate the incidence of PONV for the first 24 hours after operation . Design : The prospect i ve research was performed in an 1,100‐bed university hospital , from April to December , 2011 . The sample consisted of 609 patients with elective surgery . Methods : Factors affecting PONV were identified by multiple logistic regression . Findings : Incidence of PONV was 27.1 % for the first postoperative 24 hours . Insertion of nasogastric tube ( OR , 4.54 , P = .002 ) , history of PONV ( OR , 3.24 , P < .001 ) , general anesthesia ( OR , 2.76 , P = .002 ) , history of motion sickness ( OR , 2.33 , P < .001 ) , and female sex ( OR , 2.05 , P = .004 ) were high risk factors of PONV . The nonadministration of antiemetics during operation ( OR , 1.70 , P = .014 ) and nonuse  of intravenous patient‐controlled analgesia  ( OR , 1.54 , P = .038 ) increased PONV during the first postoperative 24 hours . Conclusions : Patients of female gender , history of motion sickness and PONV , general anesthesia , and nasogastric insertion are more likely to experience PONV Objective : To compare perioperative outcomes of  pancreatoduodenectomy ( PD ) performed through the laparoscopic route or by open surgery . Summary Background Data : Laparoscopic PD is being progressively performed in selected patients . Methods : An open-label single-center RCT was conducted between February 2013 and September 2017 . The primary endpoint was the length of hospital stay ( LOS ) . Secondary endpoints were operative time , transfusion requirements , specific pancreatic complications ( pancreatic or biliary fistula , pancreatic hemorrhage , and delayed gastric emptying ) , Clavien – Dindo grade ≥ 3 complications , comprehensive complication index ( CCI ) score , poor quality outcome ( PQO ) , and the quality of pathologic resection . Analyses were performed on an intention to treat basis . Results : Of 86 patients assessed for PD , 66 were r and omized ( 34 laparoscopic approach , 32 open surgery ) . Conversion to an open procedure was needed in 8 ( 23.5 % ) patients . Laparoscopic versus open PD was associated with a significantly shorter LOS ( median 13.5 vs. 17 d ; P = 0.024 ) and longer median operative time ( 486 vs. 365 min ; P = 0.0001 ) . The laparoscopic approach was associated with significantly better outcomes regarding Clavien – Dindo grade ≥ 3 complications ( 5 vs. 11 patients ; P = 0.04 ) , CCI score ( 20.6 vs. 29.6 ; P = 0.038 ) , and PQO ( 10 vs. 14 patients ; P = 0.041 ) . No significant differences in transfusion requirements , pancreas-specific complications , the number of lymph nodes retrieved , and resection margins between the two approaches were found . Conclusions : Laparoscopic PD versus open surgery is associated with a shorter LOS and a more favorable postoperative course while maintaining oncological st and ards of a curative-intent surgical resection . Trial registry : IS RCT N93168938 BACKGROUND Laparoscopic pancreatoduodenectomy may improve postoperative recovery compared with open pancreatoduodenectomy . However , there are concerns that the extensive learning curve of this complex procedure could increase the risk of complications . We aim ed to assess whether laparoscopic pancreatoduodenectomy could reduce time to functional recovery compared with open pancreatoduodenectomy . METHODS This multicentre , patient-blinded , parallel-group , r and omised controlled phase 2/3 trial was performed in four centres in the Netherl and s that each do 20 or more pancreatoduodenectomies annually ; surgeons had to have completed a dedicated training programme for laparoscopic pancreatoduodenectomy and have done 20 or more laparoscopic pancreatoduodenectomies before trial participation . Patients with a benign , premalignant , or malignant indication for pancreatoduodenectomy , without signs of vascular involvement , were r and omly assigned ( 1:1 ) to undergo either laparoscopic or open pancreatoduodenectomy using a central web-based system . R and omisation was stratified for annual case volume and preoperative estimated risk of pancreatic fistula . Patients were blinded to treatment allocation . Analysis was done according to the intention-to-treat principle . The main objective of the phase 2 part of the trial was to assess the safety of laparoscopic pancreatoduodenectomy ( complications and mortality ) , and the primary outcome of phase 3 was time to functional recovery in days , defined as all of the following : adequate pain control with only oral analgesia ; independent mobility ; ability to maintain more than 50 % of the daily required caloric intake ; no need for intravenous fluid administration ; and no signs of infection ( temperature < 38·5 ° C ) . This trial is registered with Trialregister.nl , number NTR5689 . FINDINGS Between May 13 and Dec 20 , 2016 , 42 patients were r and omised in the phase 2 part of the trial . Two patients did not receive surgery and were excluded from analyses in accordance with the study protocol . Three ( 15 % ) of 20 patients died within 90 days after laparoscopic pancreatoduodenectomy , compared with none of 20 patients after open pancreatoduodenectomy . Based on safety data from the phase 2 part of the trial , the data and safety monitoring board and protocol committee agreed to proceed with phase 3 . Between Jan 31 and Nov 14 , 2017 , 63 additional patients were r and omised in phase 3 of the trial . Four patients did not receive surgery and were excluded from analyses in accordance with the study protocol . After r and omisation of 105 patients ( combining patients from both phase 2 and phase 3 ) , of whom 99 underwent surgery , the trial was prematurely terminated by the data and safety monitoring board because of a difference in 90-day complication-related mortality ( five [ 10 % ] of 50 patients in the laparoscopic pancreatoduodenectomy group vs one [ 2 % ] of 49 in the open pancreatoduodenectomy group ; risk ratio [ RR ] 4·90 [ 95 % CI 0·59 - 40·44 ] ; p=0·20 ) . Median time to functional recovery was 10 days ( 95 % CI 5 - 15 ) after laparoscopic pancreatoduodenectomy versus 8 days ( 95 % CI 7 - 9 ) after open pancreatoduodenectomy ( log-rank p=0·80 ) . Clavien-Dindo grade III or higher complications ( 25 [ 50 % ] of 50 patients after laparoscopic pancreatoduodenectomy vs 19 [ 39 % ] of 49 after open pancreatoduodenectomy ; RR 1·29 [ 95 % CI 0·82 - 2·02 ] ; p=0·26 ) and grade B/C postoperative pancreatic fistulas ( 14 [ 28 % ] vs 12 [ 24 % ] ; RR 1·14 [ 95 % CI 0·59 - 2·22 ] ; p=0·69 ) were comparable between groups . INTERPRETATION Although not statistically significant , laparoscopic pancreatoduodenectomy was associated with more complication-related deaths than was open pancreatoduodenectomy , and there was no difference between groups in time to functional recovery . These safety concerns were unexpected and worrisome , especially in the setting of trained surgeons working in centres performing 20 or more pancreatoduodenectomies annually . Experience , learning curve , and annual volume might have influenced the outcomes ; future research should focus on these issues . FUNDING Grant for investigator-initiated studies by Johnson & Johnson Medical Limited BACKGROUND Intraoperative hypothermia is a common event during laparoscopic abdominal surgery . On one h and , intraoperative hypothermia can delay the metabolism and prevent tissue damage . One the other h and , long-term and severe intraoperative hypothermia may also lead to perioperative complications , such as increasing of peripheral resistance , coagulation dysfunction , intraoperative hemorrhage and postoperative shivering . Maintenance of normothermia during surgical procedures may improve the quality of patient care . OBJECTIVES This study investigated the feasibility and efficacy of intraoperative cutaneous warming with an underbody warming system during laparoscopic gastrointestinal surgery . METHODS 110 patients undergoing laparoscopic surgery for gastrointestinal cancer between January and December 2011 were r and omized into the laparoscopic control ( Control ) group and laparoscopic intervention ( Intervention ) group . Nasopharyngeal temperature , prothrombin time , activated partial thromboplastin time , and thrombin time were measured before and during surgery , intraoperative and postoperative complications , as well as shivering after anesthesia and visual analog scale score for pain evaluation after surgery were also recorded . Clinical risk factors that may cause intraoperative hypothermia during laparoscopic surgery were also analyzed by correlation analysis . RESULTS The two groups were comparable at the baseline . Intraoperative hypothermia was observed in 29 patients ( 52.7 % ) in Control group and 3 ( 5.5 % ) in Intervention group . Nasopharyngeal temperature in Control group was significantly decreased since 30min after the start of operation until the end of surgery comparing to that at the start of anesthesia , but there was no difference in the Intervention group . In Intervention group , the nasopharyngeal temperature was remaining at ∼36.5 ° C , indicating the feasibility and efficiency of the underbody warming system in preventing intraoperative hypothermia during laparoscopic gastrointestinal surgery . Moreover , with anesthesia and operation time increased , there was no significant change of coagulation function , hemoglobin level as well as less intraoperative hemorrhage , less postoperative shivering and lower visual analog scale score in Intervention group comparing to Control group . Multivariate logistic regression analysis revealed that anesthesia time and volume of CO2 were independent risk factors for perioperative hypothermia . CONCLUSIONS Cutaneous warming with an underbody warming system is a feasible and effective method to prevent intraoperative hypothermia during laparoscopic gastrointestinal surgery BACKGROUND Most surgeons routinely place a nasogastric tube at the time of a pancreatic resection . The goal of the present study was to evaluate the outcome when a pancreatic resection is performed without routine post-operative nasogastric suction . METHODS One hundred consecutive patients underwent a pancreatic resection ( 64 a pancreaticoduodenectomy , 98 % pylorus sparing and 36 a distal pancreatectomy ) . In the first cohort ( 50 patients ) , a nasogastric tube was routinely placed at the time of surgery and in the second cohort ( 50 patients ) the nasogastric was removed in the operating room . Outcomes for these two cohorts were recorded in a prospect i ve data base and compared using the χ(2 ) or Fisher 's exact test and Wilcoxon 's rank-sum test . RESULTS Demographical , surgical and pathological details were similar between the two cohorts . A post-operative complication occurred in 22 ( 44 % ) in each group ( P= 1.000 ) . There were no statistically significant differences in the frequency or severity of complications , or length of stay between groups . The spectrum of complications experienced by the two cohorts was similar including complications that could potentially be related to the use of nasogastric suction such as delayed gastric emptying , anastomotic leak , wound dehiscence and pneumonia . There was no difference between the two groups in the number of patients who required post-operative nasogastric tube placement ( or replacement ) [ 2 ( 4 % ) vs. 4 ( 8 % ) , P= 0.678 ] . CONCLUSION It may be safe to place a nasogastric tube post-operatively in a minority of patients after a pancreatic resection and spare the majority the discomfort associated with routine post-operative nasogastric suction BACKGROUND Pasireotide is a newer generation somatostatin analogue that led to a significant reduction in pancreatic fistula after pancreatectomy in a single-center r and omized controlled trial . We sought to determine if pasireotide reduces the incidence of pancreatic fistula and other complications after pancreaticoduodenectomy at our high volume center . STUDY DESIGN All patients undergoing pancreaticoduodenectomy between April 2011 and January 2017 were prospect ively followed , and their complications were grade d using the Modified Accordion Grading System ( MAGS ) in our institutional complications data base . For 18 months , 5 pancreatic surgeons used pasireotide routinely in patients undergoing pancreaticoduodenectomy . Patients receiving pasireotide were then propensity score-matched to patients who did not receive pasireotide , and their outcomes were compared . RESULTS There were 459 patients who underwent pancreaticoduodenectomy , and 127 patients ( 28 % ) received pasireotide .  Patients who received pasireotide were significantly more likely to have dilated pancreatic ducts and have a drain left at the time of surgery . Patients who received pasireotide had no difference in pancreatic fistula , overall complications , 90-day readmission , or 90-day mortality . However , patients who received pasireotide had a significantly reduced rate of postoperative bleeding/anemia ( 8.7 % vs 16.9 % , p = 0.03 ) . Among 112 propensity score-matched pairs , patients who received pasireotide did not have significantly different rates of pancreatic fistula , and the rates of severe ( MAGS grade s 3 to 6 ) pancreatic fistula were identical between the 2 groups ( 7.1 % vs 7.1 % , p = 1.00 ) . Matched patients who received pasireotide had significantly decreased postoperative bleeding/anemia ( 9.8 % vs 19.6 % , p = 0.04 ) . CONCLUSIONS Pasireotide did not reduce the incidence or severity of pancreatic fistulas after pancreaticoduodenectomy , but was associated with a decrease in postoperative bleeding/anemia . A multicenter r and omized trial is needed to accurately define the role of pasireotide in the postoperative management of pancreaticoduodenectomy patients Background Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . Methods An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated “ high ” , “ moderate ” , “ low ” or “ very low ” . Recommendations were grade d as “ strong ” or “ weak ” . Results Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . Conclusions The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials AIMS To evaluate the impact of prophylactic octreotide on gastric emptying in patients undergoing pancreaticoduodenectomy . Postoperative pancreatic fistula ( POPF ) and delayed gastric emptying ( DGE ) are common complications after pancreaticoduodenectomy . Whereas several prospect i ve r and omized trials propose the prophylactic use of octreotide to prevent pancreatic fistula formation , somatostatin has , however , been associated with delayed gastric emptying after partial duodenopancreatectomy . METHODS In this prospect i ve , r and omized , double-blinded , placebo-controlled trial we analyzed the influence of prophylactic octreotide on delayed gastric empting after pancreaticoduodenectomy . Patients were r and omized to the placebo group ( n=32 ) and the octreotide group ( n=35 ) . Primary endpoint was the incidence of delayed gastric emptying , secondary endpoints included perioperative morbidity other than DGE . DGE was measured by clinical signs , gastric scintigraphy and the hydrogen breath test . Risk factors for DGE other than octreotide were analyzed by univariate and multivariate analyses . RESULTS DGE measured by clinical signs was similar between both groups studied ( approximately 20 % of the patients ) . Gastric scintigraphy ( T(1/2 ) ) was 76.3+/-15.2 min in the octreotide group and 86.7+/-18.0 min in controls at day 7 , respectively . The H(2 ) breath test was 65.0+/-6.5 min in octreotide treatment group and 67.0+/-5.7 min in controls at day 8 . POPF grade C occurred in approximately 3 % of the patients , although prophylactic treatment of octreotide did not reduce the incidence of POPF . Multivariate analysis showed that postoperative intraabdominal bleeding and infection were independent risk factors for DGE . Furthermore preoperative biliary stenting reduced postoperative DGE after partial duodenopancreatectomy . CONCLUSION Prophylactic octreotide has no influence on gastric emptying and does not decrease the incidence of postoperative pancreatic fistula after pancreaticoduodenectomy
target: A well-implemented ERAS protocol with good compliance is associated with a reduction in medical complications and length of hospital stay .
background: Enhanced recovery after surgery ( ERAS ) pathways are now implemented worldwide with strong evidence that adhesion to such protocol reduces medical complications , costs and hospital stay .
  This concept has been applied for pancreatic surgery since the first published guidelines in 2012 .
  This study presents the up date d ERAS recommendations for  pancreatoduodenectomy ( PD )  based on the best available evidence and on expert consensus .