title: Nutritional supplements after hip fracture: poor compliance limits effectiveness. Urinary Bladder Catheter Drainage Following Pelvic Surgery—Is It Necessary for That Long? Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. Drainage After Elective Hepatic Resection A Randomized Trial Rectal Cancer Surgery With or Without Bowel Preparation: The French Greccar III Multicenter Single-Blinded Randomized Trial Randomized clinical trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care Toll-like receptors in the inflammatory response during open and laparoscopic colectomy for colorectal cancer Preoperative oral carbohydrate administration reduces postoperative insulin resistance. Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty A randomised controlled trial evaluating the use of enteral nutritional supplements postoperatively in malnourished surgical patients Impact of Age on Perioperative Complications and Length of Stay in Patients Undergoing Noncardiac Surgery Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection An audit of results of a no-drainage practice policy after hepatectomy. Perioperative increase in global blood flow to explicit defined goals and outcomes after surgery: a Cochrane Systematic Review. Clinical characteristics and management of cancer-associated acute venous thromboembolism: findings from the MASTER Registry The surgical stress response and postoperative immune function after laparoscopic or conventional total mesorectal excision in rectal cancer: a randomized trial Epidural Anesthesia, Hypotension, and Changes in Intravascular Volume Detailed evaluation of functional recovery following laparoscopic or open surgery for colorectal cancer within an enhanced recovery programme Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Antioxidant-enriched enteral nutrition and immuno-inflammatory response after major gastrointestinal tract surgery. Preoperative oral carbohydrate treatment attenuates immediate postoperative insulin resistance. The effect of pharmacological modification of gastric emptying and mouth-to-caecum transit time on the absorption of sugar probe marker molecules of intestinal permeability in normal man. A Prospective, Randomized, Controlled Trial Comparing Intermittent Portal Triad Clamping Versus Ischemic Preconditioning With Continuous Clamping for Major Liver Resection Postoperative mortality and morbidity in French patients undergoing colorectal surgery: results of a prospective multicenter study. Pre‐operative carbohydrate loading may be used in type 2 diabetes patients Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. A randomised controlled trial of
  transverse skin crease vs. vertical midline incision for right
  hemicolectomy Optimal duration of urinary drainage after rectal resection: a randomized controlled trial. Perioperative gastric emptying is not a predictor of early postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. Laparoscopic-Assisted and Open High Anterior Resection within an ERAS Protocol Is Urinary Drainage Necessary During Continuous Epidural Analgesia After Colonic Resection? Immunologic Response After Laparoscopic Colon Cancer Operation Within an Enhanced Recovery Program Early oral feeding after colorectal resection: a randomized controlled study The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively--a randomised clinical trial. Systemic and Peritoneal Inflammatory Response After Laparoscopic or Conventional Colon Resection in Cancer Patients Reproducibility and normal ranges for gastric emptying in normal volunteers using a test meal designed for post-operative patients† Development of postoperative insulin resistance is associated with the magnitude of operation. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial The effect of anesthetic technique on early postoperative gastric emptying: comparison of propofol-remifentanil and opioid-free sevoflurane anesthesia Randomized clinical trial comparing epidural anaesthesia and patient‐controlled analgesia after laparoscopic segmental colectomy Preoperative Gastric Emptying Effects of Anxiety and Oral Carbohydrate Administration A Carbohydrate-Rich Drink Reduces Preoperative Discomfort in Elective Surgery Patients Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients Prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Prognostic Significance of Postoperative In-Hospital Complications in Elderly Patients. I. Long-Term Survival The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Major colorectal cancer resection should not be denied to the elderly. The effect of unselected post-operative nutritional supplementation on nutritional status and clinical outcome of orthopaedic patients. Inflammatory response after laparoscopic and conventional colorectal resections – results of a prospective randomized trial A clinical pathway to accelerate recovery after colonic resection. Preoperative oral carbohydrate treatment attenuates endogenous glucose release 3 days after surgery. In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery: A Randomized Clinical Trial (LAFA-study) Shorter hospital stay associated with fastrack postoperative care pathways and laparoscopic intestinal resection are not associated with increased physical activity Midline or transverse abdominal incision for right‐sided colon cancer—a randomized trial Fast track hysterectomy. Comparison of immunologic outcomes of laparoscopic vs open approaches in clinical stage III colorectal cancer Rectal cancer surgery without mechanical bowel preparation A comparison in five European Centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery. Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy General anesthesia combined with epidural anesthesia ameliorates the effect of fast-track surgery by mitigating immunosuppression and facilitating intestinal functional recovery in colon cancer patients A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer Drainage is unnecessary after elective liver resection. The Impact of Open Versus Laparoscopic Resection for Colon Cancer on C-Reactive Protein Concentrations as a Predictor of Postoperative Infective Complications Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Scintigraphic validation of a magnetic resonance imaging method to study gastric emptying of a solid meal in humans Two phase randomised controlled clinical trial of postoperative oral dietary supplements in surgical patients. Recovery after open and laparoscopic right hemicolectomy: a comparison. Short term benefits of post-operative oral dietary supplements in surgical patients. Randomized controlled trial of preoperative oral carbohydrate treatment in major abdominal surgery Effect of Intraoperative Fluid Management on Outcome after Intraabdominal Surgery Randomised trial of glutamine-enriched enteral nutrition on infectious morbidity in patients with multiple trauma Long-Term Morbidity and Oncologic Outcomes of Laparoscopic-Assisted Anterior Resection for Upper Rectal Cancer: Ten-Year Results of a Prospective, Randomized Trial Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection Effect of preoperative suggestion on postoperative gastrointestinal motility. Labeled acetate to assess intestinal absorption in critically ill patients Nutritional approach in malnourished surgical patients: a prospective randomized study. Application of Fibrin Glue Sealant After Hepatectomy Does Not Seem Justified: Results of a Randomized Study in 300 Patients Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial Surgical Stress Response and Postoperative Immune Function After Laparoscopy or Open Surgery With Fast Track or Standard Perioperative Care: A Randomized Trial Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations
abstract: BACKGROUND Undernutrition and weight loss are important determinants of clinical outcome in older patients after hip fracture but the effectiveness of nutritional support programs in routine clinical practice remains controversial . AIMS OF THE PROJECT : To determine if oral nutritional supplements given daily for 28 days after hip fracture surgery could prevent weight loss and /or lead to improved clinical outcomes ( mortality rates , discharge destination , activities of daily living or length of hospital stay ) in non-malnourished community-dwelling older women with hip fracture . METHODS One hundred and nine women with BMI range 20 - 30 kg/m(2 ) were allocated to either nutritional supplements ( 352 kcal/day ) or usual hospital nutrition using a quasi-r and omisation technique . Body weight changes were monitored at 4 and 8 weeks and clinical outcomes were recorded at discharge and at 6 months . RESULTS No significant differences in weight change or clinical outcomes were seen between the two groups . Compliance with consuming the nutritional supplements was quite variable and there was a significant negative correlation between the amount of supplement consumed and subsequent weight change ( r=-0.36 , P=0.019 ) . CONCLUSIONS Poor compliance with oral nutritional supplements is an important determinant of the effectiveness of oral nutritional interventions in preventing weight loss after hip fracture . Whilst this may explain the lack of clinical improvements seen , our data do not support the routine use of oral nutritional supplements in non-malnourished hip fracture patients PURPOSE : Urinary bladder drainage for several days after pelvic surgery is a common surgical practice , despite insufficient evidence supporting its routine use . The aim of this study was to prospect ively evaluate the utility of urinary bladder drainage after pelvic colorectal surgery . METHODS : Patients undergoing pelvic surgery were prospect ively r and omly assigned to 3 groups . In group A , the Foley catheter was removed on postoperative day 1 , and in groups B and C it was removed on postoperative days 3 and 5 , respectively . Male patients with severe prostatic symptoms were excluded from the study . The main outcome criterion was acute urinary retention requiring reinsertion of the Foley catheter . RESULTS : A total of 118 patients ( 68 males ) at a mean age of 55 years were included in this study ( group A , 41 patients ; group B , 38 ; and group C , 39 ) . Overall , urinary retention after removal of the Foley catheter occurred in 12 ( 10 % ) of the patients : 6 ( 14.6 % ) in group A , 2 ( 5.3 % ) in group B , and 4 ( 10.5 % ) in group C ( P = .39 ) . Symptomatic urinary tract infection was diagnosed in 5 patients in group A , 3 in group B , and 9 in group C , but this difference did not reach statistical significance . Likewise , there were no significant differences in anastomotic leak and intra-abdominal abscess rates among the 3 groups . CONCLUSIONS : Routine prolonged urinary bladder catheterization after pelvic surgery may not be required , and the Foley catheter may be safely removed on postoperative day 1 . Larger studies are needed to confirm the findings of this study 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 Objective This prospect i ve r and omized study determined the influence of closed-suction drainage on the incidence of postoperative complications after elective hepatic resection . Summary Background Data Routine drainage is no longer advocated after several intra-abdominal surgical procedures . Methods A series of 81 patients who underwent elective hepatic resection were r and omly allocated to either a nondrainage group ( n = 39 ) and a drainage group with closed-suction drainage ( n = 42 ) . Indications for resection were 42 benign lesions and 39 malignant tumors , including 19 with cirrhosis . Major hepatic resection was performed in 25 patients and minor resection , in 56 . All patients underwent ultrasonography with puncture for bacteriologic cultures of all fluid collection s within the first 5 postoperative days . Results One patient died in each group . Ultrasonography found a significantly higher rate of subphrenic collection s in the drainage group compared with the nondrainage group ( respectively , 36 % vs. 15 % , p < 0.05 ) . These collection s were more frequently infected in the drainage group ( n = 6 ) than in the nondrainage group ( n = 2 ) . After major liver resection , the rate of intra-abdominal postoperative complications ( i.e. , subphrenic fluid collection s , hematomas , and bilomas ) was similar between the two groups . Conclusion Minor liver resection is safer without drainage . Major liver resection can be performed with or without abdominal drainage Objective : To assess with a single-blinded , multicenter , r and omized trial , the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation ( MBP ) .  Background : The collective evidence from literature strongly suggests that MBP , before elective colonic surgery , is of no benefit in terms of postoperative morbidity . Very few data and no r and omized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP . Methods : From October 2007 to January 2009 , patients scheduled for elective rectal cancer sphincter-saving resection were r and omized to receive preoperative MBP ( ie , retro grade enema and oral laxatives ) or not . Primary endpoint was the overall 30-day morbidity rate . Secondary endpoints included mortality rate , anastomotic leakage rate , major morbidity rate ( Dindo III or more ) , degree of discomfort for the patient , and hospital stay . Results : A total of 178 patients ( 103 men ) , including 89 in both groups ( no-MBP and MBP groups ) , were included in the study . The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group , 44 % versus 27 % , P = 0.018 , and 34 % versus 16 % , P = 0.005 , respectively . Regarding both anastomotic leakage and major morbidity rates , there was no significant difference between no-MBP and MBP group : 19 % versus 10 % ( P = 0.09 ) and 18 % versus 11 % ( P = 0.69 ) , respectively . Moderate or severe discomfort was reported by 40 % of prepared patients . Mortality rate ( 1.1 % vs 3.4 % ) and mean hospital stay ( 16 vs 14 days ) did not differ significantly between both groups . Conclusions : This first r and omized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate . Thus , it suggests continuing to perform MBP before elective rectal resection for cancer . This study is registered with clinical trials.gov , number NCT00554892 Postoperative oral nutritional supplementation has been shown to be of clinical benefit . This study examined the clinical effects and cost of administration of oral supplements both before and after surgery Background Surgical interventions activate a cascade of reactions that result in an aseptic inflammatory reaction . This inflammatory response initiates the organism ’s innate immunity . Laparoscopic surgery reduces the trauma , and patients benefit from diminished surgical trauma and maintained immune function . Cytokine levels and C-reactive protein ( CRP ) are related to the magnitude of surgical trauma and surgical stress . Toll-like receptors ( TLRs ) 2 and 4 are the first sensor-recognition receptors of the invading pathogens for the innate immune response . This study aim ed to compare the inflammatory response and then the stress response during laparoscopic and open colectomy for cancer by calculating TLR-2 and TLR-4 as the first sensor-recognition receptors together with interleukin-6 ( IL-6 ) , tumor necrosis factor-α ( TNF-α ) , and high-sensitivity CRP ( hsCRP ) . Methods A total 40 patients with colorectal cancer were r and omized in two groups : group A ( open colectomy , n = 20 ) and group B ( laparoscopic colectomy , n = 20 ) .  An epidural catheter was placed in all patients 1 h preoperatively . Rupivocaine was administered perioperatively and 48 h postoperatively . Blood sample s were taken for calculation of IL-6 , TNF-α , hsCRP , TLR-2 , and TLR-4 preoperatively and 5 min after deflation of pneumoperitoneum ( group B ) or 5 min after division of the colon ( group A ) , then 6 and 24 h postoperatively . Results The mean operative time was 115 for group A and 142 min for group B. The mean blood loss was respectively 240 and 105 ml ( P < 0.001 ) , and the mean hospital stay was respectively 8 and 5 days ( P < 0.05 ) . The IL-6 level was significant higher in group A than in group B at 6 and 24 h postoperatively ( P < 0.0001 ) , and the hsCRP level was significant higher in group A than in group B at 24 h postoperatively ( P < 0.001 ) . The TNF-α values did not differ between the two groups . The TLR-2 level was significantly higher in group A than in group B at 5 min ( P = 0.013 ) and 24 h ( P = 0.007 ) postoperatively . The TLR-4 level was significant higher in group A than in group B at 5 min postoperatively ( P = 0.03 ) . Conclusion The inflammatory response and the result ant stress response are significantly less during laparoscopic colectomy than during open colectomy for colorectal cancer . This is an obvious short-term clinical benefit for the patient , providing tinder for further study to investigate the long-term results of laparoscopic colectomy versus open colectomy for colorectal cancer ( Registered clinical trial no. NCT00942461 ; www . clinical trials.gov ) UNLABELLED Infusions of carbohydrates before surgery reduce  postoperative insulin resistance . We in-vestigated the effects of a carbohydrate drink , given shortly before surgery , on postoperative metabolism . METHOD Insulin sensitivity , glucose turnover ( [ 6,6 , 2H2]-D-glucose ) and substrate utilization were measured using hyperinsulinemic normoglycemic clamps and indirect calorimetry in two matched groups of patients before and after elective colorectal surgery . The drink group ( n = 7 ) received 800 ml of an isoosmolar carbohydrate rich beverage the evening before the operation ( 100 g carbohydrates ) , as well as another 400 ml ( 50 g carbohydrates ) 2 h before the initiation of anesthesia . The fasted group ( n = 7 ) was operated after an overnight fast . RESULTS After surgery , energy expenditure increased in both groups . Endogenous glucose production was higher after surgery and the difference was significant during low insulin infusion rates in both groups ( P < 0.05 ) . The supressibility of endogenous glucose production by the two step insulin infusion was similar pre- and postoperatively in both groups . At the high insulin infusion rate postoperatively , whole body glucose disposal was more reduced in the fasted group ( -49 + /- 6 % vs -26 + /- 8 % , P < 0.05 vs drink ) . Furthermore , during high insulin infusion rates , glucose oxidation decreased postoperatively only in the fasted group ( P < 0 . 05 ) and postoperative levels of fat oxidation were greater in the fasted group ( P < 0.05 vs drink ) . Only minor postoperative changes in cortisol and glucagon were found and no differences were found between the treatment groups . CONCLUSIONS Patients given a carbohydrate drink shortly before elective colorectal surgery displayed less reduced insulin sensitivity after surgery as compared to patients who were operated after an overnight fast BACKGROUND In-vitro studies indicate that platelet function and the coagulation cascade are impaired by hypothermia . However , the extent to which perioperative hypothermia influences bleeding during surgery remains unknown . Accordingly , we tested the hypothesis that mild hypothermia increases blood loss and allogeneic transfusion requirements during hip arthroplasty . METHODS Blood loss and transfusion requirements were evaluated in 60 patients undergoing primary , unilateral total hip arthroplasties who were r and omly assigned to normothermia ( final intraoperative core temperature 36.6 [ 0.4 ] degrees C ) or mild hypothermia ( 35.0 [ 0.5 ] degrees C ) .  Crystalloid , colloid , scavenged red cells , and allogeneic blood were administered by strict protocol . FINDINGS Intra- and postoperative blood loss was significantly greater in the hypothermic patients : 2.2 ( 0.5 ) L vs 1.7 ( 0.3 ) L , p < 0.001 ) . Eight units of allogeneic packed red cells were required in seven of the 30 hypothermic patients , whereas only one normothermic patient required a unit of allogeneic blood ( p < 0.05 for administered volume ) . A typical decrease in core temperature in patients undergoing hip arthroplasty will thus augment blood loss by approximately 500 mL. INTERPRETATION The maintenance of intraoperative normothermia reduces blood loss and allogeneic blood requirements in patients undergoing total hip arthroplasty BACKGROUND Patients who undergo surgery are at risk of malnutrition due to periods of starvation , the stress of surgery , and subsequent increase in metabolic rate . There are limited data on nutritional outcome of surgical patients . AIMS To investigate changes in nutritional status and the influence of oral supplements on nutritional status , morbidity , and quality of life in postoperative surgical patients . METHODS Entry was determined by the presence of malnutrition , as defined by a body mass index ( BMI ) ⩽20 kg/m2 , anthropometric measurements ⩽15th percentile on admission , or initiation of oral diet postoperatively and /or a weight loss of 5 % or more during the operative period . We studied 101 patients : 52 were r and omised to the treatment group ( TG ) and prescribed a 1.5 kcal/ml nutritional supplement ; 49 patients were r and omised to the control group ( CG ) and continued with routine nutritional management .  Nutritional status was assessed by weight , anthropometry , and grip strength , with measurements taken at two weekly intervals for 10 weeks . Complications , namely wound infection , chest infection , and antibiotic use were documented . Quality of life ( QOL ) was assessed using the UK SF-36 question naire . RESULTS Patients in the control group lost a maximum mean ( SD ) of 5.96 ( 4.21 ) kg in weight over a period of eight weeks while patients in group TG lost less weight overall ( maximum mean ( SD ) 3.40 ( 0.89 ) kg ( p<0.001 ) occurring at four weeks and progressively regained weight from week 4 ) . Anthropometry , grip strength , and QOL were similarly significantly different between groups ( p<0.001 ) . Fewer patients in the treatment group ( 7/52 ) required antibiotic prescriptions compared with the control group ( 15/49 ) . CONCLUSIONS Nutritional status declined for two months after discharge . Postoperative nutritional supplementation improved nutritional status , QOL , and morbidity in these patients As the U.S. population ages , major surgical procedures are being performed in elderly patients with increasing frequency ( 1 ) , but few data are available to guide preoperative risk stratification . Several studies have described correlates of cardiac morbidity and mortality in patients undergoing noncardiac surgery  ( 2 - 8 ) , but the number of elderly patients in most series has been small . Furthermore , few data are available on noncardiac complications , the overall complication rate , and length of stay . We describe the influence of age on perioperative complication and mortality rates in a large cohort of patients undergoing noncardiac surgery .  As discussed elsewhere , age was not an independent correlate of major cardiac complications in this cohort ( 7 ) . This analysis tests the hypothesis that advanced age is a correlate of the overall rate of complications , after adjustment for functional status . Methods Patients All patients 50 years of age or older who underwent major nonemergent noncardiac procedures at Brigham and Women 's Hospital , Boston , Massachusetts , from 18 July 1989 to 28 February 1994 were eligible for the study . Major noncardiac procedures were defined as those with an expected length of stay of 2 or more days . Procedures were electively scheduled or were performed nonemergently during inpatient admissions . Eligibility criteria included the ability to speak English and adequate cognitive function to give informed consent . The enrollment and clinical data collection protocol s were approved by the institutional review board of Brigham and Women 's Hospital . The full study protocol included preoperative interviews by clinical study personnel ( physicians or research nurses ) . Of the 4315 patients who provided informed consent to participate , 621 ( 14.4 % ) did not provide consent before surgery for the serial interview portion of the study , which included interviews 1 and 6 months after surgery . Patients who were not interviewed before surgery were not excluded on the basis of age or clinical status , but solely according to the availability of study personnel . Data Collection The data collection protocol is described elsewhere ( 7 , 9 , 10 ) . In brief , patients who provided informed consent to the full study protocol underwent preoperative evaluation by clinical investigators ( physicians or research nurses ) using a structured data form . These evaluations included detailed medical histories , physical examinations , and laboratory tests . For patients who did not undergo this evaluation because they could not be approached or because they declined participation in the interview portion of the study , we obtained clinical data from the structured evaluation by the anesthesiologist found in the medical record . This data source was also used to obtain American Society of Anesthesiologists classification for all patients . Hence , prospect ively recorded clinical data were available for all patients . Consenting patients agreed to postoperative sampling of creatine kinase and , if total creatine kinase levels were elevated , measurement of creatine kinaseMB immediately after surgery , at 8 p.m. on the evening of surgery , and on the next two mornings . In all other enrolled patients , creatine kinaseMB was measured according to the physician 's orders . Among all participants , the mean ( SD ) number of cardiac enzyme sample s obtained was 4.0 2.2 . Electrocardiography was performed in the recovery room and on the first , third , and fifth postoperative days if the patient remained hospitalized . The Charlson Comorbidity Index , a weighted comorbidity score based on the number and the severity of 16 selected medical diseases , was used to quantify the burden of medical comorbid conditions ( 11 ) . The mean number of other common comorbid conditions in this population was calculated for all patients . Preoperative functional status was assessed in 3890 patients by performing structured interviews using the  Specific Activity Scale , an ordinally scaled , four-class instrument based on metabolic expenditure in various personal care , housework , occupational , and recreational activities ( 12 , 13 ) . This group included 196 patients who consented to preoperative interviews but did not consent to the full study protocol , including long-term follow-up . Classification of Outcomes The occurrence of major cardiac events postoperatively was classified by a single review er who was blinded to preoperative clinical data and who evaluated only postoperative clinical information , including cardiac enzyme measurements , electrocardiograms , and clinical events . Myocardial infa rct ion was diagnosed on the basis of creatine kinaseMB levels and electrocardiographic findings ( 10 ) . Major cardiac complications were unstable angina ( postoperative typical chest pain associated with ischemic electrocardiographic changes ) , myocardial infa rct ion , cardiogenic pulmonary edema , documented ventricular tachycardia , ventricular fibrillation or primary cardiac arrest , and sustained complete heart block requiring pacemaker . Major noncardiac events were pulmonary embolism documented by autopsy , angiography , or a high-probability ventilationperfusion scan ; respiratory failure requiring intubation for more than 2 days or reintubation ; noncardiogenic pulmonary edema ; lobar pneumonia confirmed by chest radiography and requiring antibiotic therapy ; acute renal failure requiring dialysis ; or cerebrovascular accident with new neurologic deficit . In-hospital mortality was also recorded , and the combined end point of major cardiac or noncardiac complications or death was used in these analyses . Statistical Analysis To evaluate the impact of age on postoperative complications , we performed analyses in which age was considered as a continuous variable and as four categories ( 50 to 59 years , 60 to 69 years , 70 to 79 years , and 80 years ) . Because age was not linearly associated with the risk for outcomes , categorized age variables are used throughout this report . Univariate correlations between clinical characteristics and age category were analyzed by using the chi-square test and the Fisher exact test for categorical variables and a t-test or Wilcoxon test for continuous variables . Because several clinical and laboratory variables are associated with age and because it is difficult to exclude the association of age with the event of interest , we included all relevant clinical variables in the multivariate analysis . Logistic regression analysis was used to determine the independent association of age with postoperative complications while controlling for the presence of comorbid conditions , sex , ethnicity , functional status as measured by Specific Activity Scale class , type of procedure , and preoperative laboratory data . Patients for whom data on selected variables were missing were excluded from the model . Clinical ly relevant variables from the regression model were analyzed for potential interactions , and potentially significant interaction terms were considered in the regression models . A two-sided P value less than 0.05 was considered statistically significant in all analyses . Linear regression models were used to estimate the independent variation in length of stay attributable to age , controlling for sex , ethnicity , preoperative clinical characteristics , American Society of Anesthesiologists classification , type of procedure , postoperative events , and in-hospital mortality . The logarithmic transformation of length of stay was used because of the non-normal distribution of this variable . The percentage change in the geometric mean of length of stay in the final model was used to estimate the numbers of adjusted hospital days attributable to age groups . All analyses were performed by using SAS statistical software for Windows , version 6.12 ( SAS Institute , Inc. , Cary , North Carolina ) . Role of the Funding Source The funding source had no role in data collection and analysis or in subsequent decisions about publication of manuscripts . Results Patients The study sample constituted 4315 patients who had a mean age of 67 9 years ; 2096 patients ( 48 % ) were male and 3903 ( 90 % ) were white . Twenty-four percent ( 1015 patients ) were younger than 59 years , 38 % ( 1646 patients ) were 60 to 69 years of age , 31 % ( 1341 patients ) were 70 to 79 years of age , and 7 % ( 313 patients ) were older than 80 years of age . These patients undergoing elective surgery had a low prevalence of comorbid conditions , and 3187 ( 74 % ) patients had Charlson Comorbidity Index scores of 0 through 2 . The types of procedures performed were orthopedic ( 35 % ) , intrathoracic ( 12 % ) , abdominal ( 12 % ) , abdominal aortic aneurysm ( 5 % ) , other vascular ( 17 % ) , and other general surgical procedures ( 33 % ) . In the oldest age group , significantly fewer patients were male and nonwhite compared with the younger age groups ( Table 1 ) . The number of comorbid conditions and the average Charlson Comorbidity Index scores increased with increasing age . The distribution of Specific Activity Scale class and American Society of Anesthesiology class was also significantly worse in the older age groups ; a greater proportion of patients 70 to 79 years of age and 80 years of age was classified as class 3 or 4 . As expected , the type of surgical procedure performed varied among age groups . Higher percentages of older patients underwent orthopedic procedures , aortic aneurysm repair , and other vascular surgeries ( Table 1 ) . Table 1 . Patient Characteristics Perioperative Complications Major or fatal perioperative complications occurred in 44 ( 4.3 % ) patients younger than 59 years of age , 93 ( 5.7 % ) patients 60 to 69 years of age , 129 ( 9.6 % ) patients 70 to 79 years of age , and 39 ( 12.5 % ) patients 80 years of age or older ( P<0.001 ) ( Figure ) . Age was significantly associated with a higher risk for cardiogenic pulmonary edema , myocardial infa rct ion , ventricular arrhythmias , bacterial pneumonia , respiratory failure requiring intubation , and in-hospital mortality . All other major complications The aim of this trial was to compare  multimodal optimization  with  conventional perioperative management  in a consecutive series of patients undergoing a wide range of colorectal procedures BACKGROUND It was hypothesized that routine operative drainage is unnecessary for elective hepatic resection . METHODS A review was made of the clinical records of patients undergoing liver resection at a tertiary referral hepatobiliary surgery center since the conclusion in April of 1994 of our previous r and omized drainage trial . The main outcome measures were  operative drainage versus no operative drainage  assessed for possible association with diagnoses , extent of hepatectomy , hospital course , and postoperative radiologic percutaneous drainage procedures . RESULTS Of 1,165 patients , 184 were operatively drained with closed drains according to specific practice criteria and 981 were not subject to operative drainage .  Patients who were not operatively drained had length of stay ( 10.1 days ) , mortality ( 2 % ) , and complication rate ( 34 % ) comparable with the nondrained patients in the previous r and omized trial . Ten percent of these patients required postoperative percutaneous drainage . Patients who were operatively drained were a group who were at higher risk for biliary leakage or infections and consequently had a significantly longer hospital stay , greater mortality , higher complication rate , and required a greater number of percutaneous abdominal drainages . CONCLUSIONS The 84 % of patients not operatively drained had no greater adverse outcome . After hepatic resection , routine drainage of the abdomen is unnecessary This systematic review and meta- analysis summarizes the clinical effects of increasing perioperative blood flow using fluids with or without inotropes/vasoactive drugs to explicit defined goals in adults . We included r and omized controlled trials of adult patients ( aged 16 years or older ) undergoing surgery . We included 31 studies of 5292 participants . There was no difference in mortality at the longest follow-up : 282/2615 ( 10.8 % ) died in the control group and 238/2677 ( 8.9 % ) in the treatment group , RR of 0.89 ( 95 % CI : 0.76 - 1.05 ; P=0.18 ) . However , the results were sensitive to analytical methods and withdrawal of studies with method ological limitations . The intervention reduced the rate of three morbidities ( renal failure , respiratory failure , and wound infections ) but not the rates of arrhythmia , myocardial infa rct ion , congestive cardiac failure , venous thrombosis , and other types of infections . The number of patients with complications was also reduced by the intervention . Hospital length of stay was reduced in the treatment group by 1.16 days . There was no difference in critical care length of stay . The primary analysis of this review showed no difference between groups but this result was sensitive to the method of analysis , withdrawal of studies with method ological limitations , and was dominated by a single large study . Patients receiving this intervention stayed in hospital 1 day less with fewer complications . It is unlikely that the intervention causes harm . The balance of current evidence does not support widespread implementation of this approach to reduce mortality but does suggest that complications and duration of hospital stay are reduced MASTER is a multicenter registry of consecutively recruited patients with symptomatic , objective ly confirmed , acute venous thromboembolism . One fifth of the patients enrolled had cancer . In these patients , venous thromboembolism has peculiar features , and its management is more problematic . Background Clinical characteristics and management of acute deep vein thrombosis and pulmonary embolism ( PE ) have been reported to be different in patients with and without cancer . The aim of this paper was to provide information on clinical characteristics and management of acute venous thromboembolism in patients with cancer by means of a large prospect i ve registry . Design and Methods MASTER is a multicenter registry of consecutively recruited patients with symptomatic , objective ly confirmed , acute venous thromboembolism . Information about clinical characteristics and management was collected by an electronic data network at the time of the index event . Results A total of 2119 patients were enrolled , of whom 424 ( 20 % ) had cancer . The incidence of bilateral lower limb deep vein thrombosis was significantly higher in patients with cancer than in patients without cancer ( 8.5 % versus 4.6 % ; p<0.01 ) , as were the rates of iliocaval thombosis ( 22.6 % versus 14 % ; p<0.001 ) , and upper limb deep vein thrombosis ( 9.9 % versus 4.8 % ; p<0.001 ) . Major bleeding ( 3.3 % versus 1.1 % ; p=0.001 ) , in-hospital treatment ( 73.3 % versus 66.6 % ; p=0.02 ) and inferior vena cava filter implantation ( 7.3 % versus 4.1 % ; p=0.005 ) were significantly more frequent in patients with cancer , in whom oral anticoagulants were less often used ( 64.2 % versus 82 % ; p<0.0001 ) . Conclusions The clinical presentation of acute venous thromboembolism is different and often more extensive in cancer patients than in patients free from malignancy . Moreover , the management of the acute phase of venous thromboembolism is more problematic in cancer patients , especially because of a higher rate of major bleeding and the need for implantation of inferior vena cava filters Purpose This study evaluated differences in stress response and immunological function following laparoscopic and conventional total mesorectal excision ( TME ) for rectal cancer . Methods Patients with non-metastasized rectal cancer were prospect ively r and omized to open ( n = 18 ) or laparoscopic ( n = 22 ) TME .  Blood sample s were taken preoperatively ( baseline ) , 2 , 24 , and 72 h following surgery . Systemic white blood cell and monocyte count , C-reactive protein , interleukin-6 ( IL-6 ) , interleukin-8 ( IL-8 ) , HLA-DR expression on monocytes , growth hormone , prolactin , and cortisol were measured . Results Forty patients with a median age of 66 years ( interquartile range , 60–74 years ) were included . Eighteen patients ( 45 % ) were r and omized to  open surgery and 22 patients ( 55 % ) to laparoscopic surgery . Patient demographics in terms of gender , age , BMI , ASA classification , localization of the tumor , and type of neoadjuvant therapy were comparable for both groups . Laparoscopic surgery result ed in a significantly better short-term preservation of postoperative immune function . HLA-DR expression on monocytes was significantly higher ( 64 % vs 50 % , P = 0.014 ) and IL-6 level increase was significantly lower ( 4.6 vs 10.8 , P = 0.003 ) 2 h after laparoscopic surgery . No differences between the open and laparoscopic technique were observed in postoperative white blood cell count , monocyte count , C-reactive protein , IL-8 , growth hormone , prolactin , and cortisol levels . ConclusionS hort-term postoperative immune and inflammatory functions tended to be better after laparoscopic rectal surgery . However , the differences were not consistent at all time intervals , making a definitive conclusion difficult . Better preserved inflammatory function 2 h after surgery may reflect a reduction in operative trauma when the laparoscopic technique is compared with open rectal procedures Background The most common side effect of epidural or spinal anesthesia is hypotension with functional hypovolemia prompting fluid infusions or administration of vasopressors . Short-term studies ( 20 min ) in patients undergoing lumbar epidural anesthesia  suggest that plasma volume may increase when hypotension is present , which may have implication s for the choice of treatment of hypotension . However , no long-term information or measurements of plasma volumes with or without hypotension after epidural anesthesia are available . Methods In 12 healthy volunteers , the authors assessed plasma ( 125I-albumin ) and erythrocyte ( 51Cr-EDTA ) volumes before and 90 min after administration of 10 ml bupivacaine , 0.5 % , via a thoracic epidural catheter ( T7–T10 ) . After 90 min ( t = 90 ) , subjects were r and omized to administration of fluid ( 7 ml/kg hydroxyethyl starch ) or a vasopressor ( 0.2 mg/kg ephedrine ) , and 40 min later ( t = 130 ) , plasma and erythrocyte volumes were measured . At the same time points , mean corpuscular volume and hematocrit were measured . Systolic and diastolic blood pressure , heart rate , and hemoglobin were measured every 5 min throughout the study . Volume kinetic analysis was performed for the volunteers receiving hydroxyethyl starch . Results Plasma volume did not change per se after thoracic epidural anesthesia despite a decrease in blood pressure . Plasma volume increased with fluid administration but remained unchanged with vasopressors despite that both treatments had similar hemodynamic effects . Hemoglobin concentrations were not significantly altered by the epidural blockade or ephedrine administration but decreased significantly after hydroxyethyl starch administration . Volume kinetic analysis showed that the infused fluid exp and ed a rather small volume , approximately 1.5 l. The elimination constant was 56 ml/min . Conclusions Thoracic epidural anesthesia per se does not lead to changes in blood volumes despite a reduction in blood pressure . When fluid is infused , there is a dilution , and the fluid initially seems to be located central ly . Because administration of hydroxyethyl starch and ephedrine has similar hemodynamic effects , the latter may be preferred in patients with cardiopulmonary diseases in which perioperative fluid overload is undesirable Background and aims Evidence demonstrating improved short-term outcomes with laparoscopic surgery compared with open surgery for colorectal cancer is accumulating . In addition , programmes optimising peri-operative care for major abdominal surgery are becoming widespread . Evaluating laparoscopic surgery and enhanced recovery programmes usually focuses on short-term recovery . The aim of this study was to compare recovery after laparoscopic and open surgery for colorectal cancer up to 1 year post-operatively , using a combination of self-report and observer data . Patients / Methods From January 2002 to March 2004 , 62 patients were r and omised ( 2:1 ) to receive laparoscopic ( n = 43 ) or open surgery ( n = 19 ) within an enhanced recovery programme .  Functional outcomes up to 1 year were assessed using interview-administered question naires . Results / Findings Question naire and health-related quality of life data were obtained in over 85 % of patients . Patients undergoing laparoscopic surgery  felt fully recovered and resumed driving more quickly than those having open surgery ( p = 0.016 and p = 0.048 respectively ) . Fifty-eight percent of patients having open surgery felt fully recovered by 12 months versus 88 % of laparoscopic patients .Interpretation/ Conclusion Within an enhanced recovery programme , patients undergoing laparoscopic surgery  recovered more quickly than after open resection . Both approaches however , were associated with slow recovery despite a relatively short hospital stay BACKGROUND The safety and short-term benefits of laparoscopic colectomy for cancer remain debatable . The multicentre COLOR ( COlon cancer Laparoscopic or Open Resection ) trial was done to assess the safety and benefit of laparoscopic resection compared with open resection for curative treatment of patients with cancer of the right or left colon . METHODS 627 patients were r and omly assigned to laparoscopic surgery and 621 patients to open surgery .  The primary endpoint was cancer-free survival 3 years after surgery . Secondary outcomes were short-term morbidity and mortality , number of positive resection margins , local recurrence , port-site or wound-site recurrence , metastasis , overall survival , and blood loss during surgery . Analysis was by intention to treat . Here , clinical characteristics , operative findings , and postoperative outcome are reported . FINDINGS Patients assigned laparoscopic resection had less blood loss compared with those assigned open resection ( median 100 mL [ range 0 - 2700 ] vs 175 mL [ 0 - 2000 ] , p<0.0001 ) , although laparoscopic surgery lasted 30 min longer than did open surgery ( p<0.0001 ) . Conversion to open surgery was needed for 91 ( 17 % ) patients undergoing the laparoscopic procedure . Radicality of resection as assessed by number of removed lymph nodes and length of resected oral and aboral bowel did not differ between groups . Laparoscopic colectomy was associated with earlier recovery of bowel function ( p<0.0001 ) , need for fewer analgesics , and with a shorter hospital stay ( p<0.0001 ) compared with open colectomy .  Morbidity and mortality 28 days after colectomy did not differ between groups . INTERPRETATION Laparoscopic surgery can be used for safe and radical resection of cancer in the right , left , and sigmoid colon Major surgery induces an immuno-inflammatory response accompanied by oxidative stress that may impair cellular function and delay recovery . The objective of the study was to investigate the effect of an enteral supplement , containing glutamine and antioxidants , on circulating levels of immuno-inflammatory markers after major gastrointestinal tract surgery . Patients ( n 21 ) undergoing major gastrointestinal tract surgery were r and omised in a single-centre , open-label study . The effects on circulating levels of immuno-inflammatory markers were determined on the day before surgery and on days 1 , 3 , 5 and 7 after surgery . Major gastrointestinal surgery increased IL-6 , TNF receptor 55/60 ( TNF-R55 ) and C-reactive protein ( CRP ) . Surgery reduced human leucocyte antigen-DR ( HLA-DR ) expression on monocytes . CRP decrease was more pronounced in the first 7 d in the treatment group compared with the control group . In the treatment group , from the moment Module AOX was administered on day 1 after surgery , TNF receptor 75/80 ( TNF-R75 ) level decreased until the third post-operative day and then stabilised , whereas in the control group the TNF-R75 level continued to increase . The results of the present pilot study suggest that enteral nutrition enriched with glutamine and antioxidants possibly moderates the immuno-inflammatory response ( CRP , TNF-R75 ) after surgery 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 present study examined the hypothesis that altered motility of the gastrointestinal tract affects absorption of probe markers of intestinal permeability .  Seven healthy subjects , aged 32 - 44 years , received saline , 600 micrograms atropine or 10 mg metoclopramide in r and omized order at weekly intervals . After 10 min they ingested a test solution containing 5 g lactulose , 5 g mannitol and 2 g 3-O-methyl glucose in 100 ml tap water . The molarity of the solution was 542 mmol l-1 and the dose administered was 80 ml m-2 body surface area . Gastric emptying was measured by ultrasound , mouth-to-caecum transit time by breath hydrogen analysis and sugar concentrations by gas-liquid chromatography . Gastric emptying half-times ( min ) were [ mean ( 95 % confidence intervals ) ] 14.9 ( 11:4 - 18.5 ) after saline , 22 ( 18.7 - 25.2 ) after atropine and 10.3 ( 7.0 - 12.6 ) after metoclopramide ( P less than 0.002 ) . Transit times ( min ) were 68.9 ( 52 - 85.2 ) after saline , 143 ( 126 - 159 ) after atropine and 38 ( 21.2 - 54.5 ) after metoclopramide ; P less than 0.0001 . Analysis of plasma levels of mannitol and 3-O-methyl glucose showed a significant within-subject effect of drug with time ( P less than 0.03 ) . Urinary excretion of mannitol in the first 5 h after ingestion of the test solution was 1256 ( 974 - 1620 ) mg after saline , 1560 ( 1210 - 2013 ) mg after atropine and 955 ( 740 - 1232 ) mg after metoclopramide ( P less than 0.03 ) . There were no significant differences in lactulose and 3-O-methyl glucose urinary excretion between drug treatments . ( ABSTRACT TRUNCATED AT 250 WORDS Objective : To evaluate whether ischemic preconditioning ( IP ) with continuous clamping or intermittent clamping ( IC ) of the portal triad confers better protection during liver surgery . Summary Background Data : IP and IC are distinct protective approaches against ischemic injury . Since both strategies proved to be superior in r and omized controlled trials ( RCTs ) to continuous inflow occlusion alone , we design ed a RCT to compare IP and IC in patients undergoing major liver resection . Methods : Noncirrhotic patients undergoing major liver resection were r and omized to receive IP with inflow occlusion ( n = 36 ) or IC ( n = 37 ) . Primary endpoints were postoperative liver injury and intraoperative blood loss . Postoperative liver injury was assessed by peak values of AST ( alanine aminotransferase ) and ALT ( aspartate aminotransferase ) , as well as the area under the curve ( AUC ) of the postoperative transaminase course . Secondary endpoints included resection time , the need of blood transfusion , ICU , and hospital stay as well as postoperative complications and mortality . Results : Both groups were comparable regarding demographics , ASA score , type of hepatectomy , duration of inflow occlusion ( range , 30–75 minutes ) , and resection surface . The transection-related blood loss was 146 versus 250 mL ( P = 0.008 ) , and when st and ardized to the resection surface 1.2 versus 1.8 mL/cm2 ( P = 0.01 ) for IP and IC , respectively . Although peak AST , AUCAST , and AUCALT were lower for IC , the differences did not reach statistical significance . Overall ( 42 % vs. 38 % ) and major ( 33 vs. 27 % ) postoperative complications as well as median ICU ( 1 vs. 1 day ) and hospital stay ( 10 vs. 11 days ) were similar between both groups . Conclusions : Both IP and IC appear to be equally effective in protecting against postoperative liver injury in noncirrhotic patients undergoing major liver resection . However , IP is associated with lower blood loss and shorter transection time . Therefore , both strategies can be recommended for noncirrhotic patients undergoing liver resection HYPOTHESIS Better knowledge of independent risk factors might decrease mortality and morbidity rates following colorectal surgery . DESIGN Prospect i ve multicenter study . INTERVENTIONS From June to September 2002 , consecutive patients undergoing open or laparoscopic surgery ( electively or on an emergent basis ) for colorectal cancers or diverticular disease were prospect ively included . Exclusion criteria were colectomy for other causes ( eg , inflammatory bowel diseases , benign polyps ) . The structured sheet of data collection included more than 200 items on all perioperative data concerning the patient , the disease , and the operating surgeons . Postoperative mortality and morbidity were defined as in-hospital death and complications . RESULTS Among 1421 patients , the in-hospital death rate was 3.4 % and the overall  morbidity  rate was 35 % . Four independent preoperative risk factors of mortality were found : emergency surgery , loss of more than 10 % of weight , neurological comorbidity , and age older than 70 years . Six independent risk factors of morbidity were found : age older than 70 years , neurologic comorbidity , hypoalbuminemia , cardiorespiratory comorbidity , long duration of operation , and peritoneal contamination . CONCLUSION Colorectal resection in France is associated with a 3.4 % mortality rate and a 35 % morbidity rate . Knowledge of the risk factors could help surgeons manage cases Background : Post‐operative insulin resistance and hyperglycaemia are associated with an impaired outcome after surgery . Pre‐operative oral carbohydrate loading ( CHO ) reduces post‐operative insulin resistance with a reduced risk of hyperglycaemia during post‐operative nutrition . Insulin‐resistant diabetic patients have not been given CHO because the effects on pre‐operative glycaemia and gastric emptying are unknown BACKGROUND Occult hypovolaemia is a key factor in the aetiology of postoperative morbidity and may not be detected by routine heart rate and arterial pressure measurements . Intraoperative gut hypoperfusion during major surgery is associated with increased morbidity and postoperative hospital stay . We assessed whether using intraoperative oesophageal Doppler guided fluid management to minimize hypovolaemia would reduce postoperative hospital stay and the time before return of gut function after colorectal surgery . METHODS This single centre , blinded , prospect i ve controlled trial r and omized 128 consecutive consenting patients undergoing colorectal resection to oesophageal Doppler guided or central venous pressure (CVP)-based ( conventional ) intraoperative fluid management .  The intervention group patients followed a dynamic oesophageal Doppler guided fluid protocol whereas control patients were managed using routine cardiovascular monitoring aim ing for a CVP between 12 and 15 mm Hg . RESULTS The median postoperative stay in the Doppler guided fluid group was 10 vs 11.5 days in the control group P<0.05 . The median time to resuming full diet in the Doppler guided fluid group was 6 vs 7 for controls P<0.001 . Doppler patients achieved significantly higher cardiac output , stroke volume , and oxygen delivery . Twenty-nine ( 45.3 % ) control patients suffered gastrointestinal morbidity compared with nine ( 14.1 % ) in the Doppler guided fluid group P<0.001 , overall morbidity was also significantly higher in the control group P=0.05 . CONCLUSIONS Intraoperative oesophageal Doppler guided fluid management was associated with a 1.5-day median reduction in postoperative hospital stay . Patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity Abstract . Background : A transverse skin crease incision for right hemicolectomy may result in more rapid recovery than traditional vertical midline incision . This hypothesis was tested with a prospect i ve r and omised trial . Methods : Patients from 2 centres undergoing right hemicolectomy were r and omised to received a  midline or transverse incision . Incision lengths were sufficient to enable unrestricted resection of the right colon . Patients and carers were blinded to the incisions using strategically placed dressings . Analgesia and oral intake were controlled by the patient . Operative details and recovery parameters were compared . Results : A total of 28 patients were r and omised . Demographic data and tumour characteristics of the two treatment groups were similar . The transverse incision group had a slightly shorter median wound ( 10 cm vs. 11 cm , p<0.05 ) . Operative time , analgesia requirements , recovery parameters ( time to discharge , 6.5 vs. 6.5 days ) and frequency of complications were otherwise comparable . Conclusions : A transverse skin crease incision for right hemicolectomy results in a slightly smaller wound but no other advantages were demonstrated compared with a traditional vertical midline incision BACKGROUND Voiding dysfunction is frequently observed after  rectal resection  and justifies urinary drainage . However , there is no agreement about the optimal duration of this postoperative drainage . The aim of this controlled trial was to compare 1 versus 5 days of transurethral catheterization after rectal resection , with special reference to urinary tract infection and bladder retention . METHODS One hundred twenty-six patients undergoing rectal resection  were included in a prospect i ve r and omized study design ed to compare the results for patients undergoing 1 day of transurethral catheterization after rectal resection  ( 1-day group ) with those for patients undergoing 5 days ' catheterization  ( 5-day group ) . RESULTS Patients were r and omly assigned to the 1-day and 5-day groups ( n = 64 and 62 , respectively ) . Clinical findings and surgical procedures were comparable in both groups . Acute urinary retention occurred in 16 patients ( 25 % ) in the 1-day group versus 6 ( 10 % ) in the 5-day group ( P < .05 ) . Urinary tract infection was observed in 13 of 64 patients ( 20 % ) in the 1-day group versus 26 of 62 ( 42 % ) in the 5-day group ( P < .01 ) . Multivariate analysis revealed that after 1 day of catheterization carcinoma of the low rectum and lymph node metastasis were significant risk factors for acute urinary retention ( P < .05 for both factors ) . After selection of patients without low rectum carcinoma , the acute urinary retention rate was comparable in both groups ( 14 % in the 1-day group versus 7 % in the 5-day group ) , but the urinary tract infection rate was significantly lower in the 1-day group versus the 5-day group ( 14 % vs 40 , P < .01 ) . CONCLUSIONS Our controlled study showed that after rectal resection 1 day of urinary drainage can be recommended for most patients . Five-day drainage should be reserved for patients with low rectal carcinoma UNLABELLED It is not known whether patients with postoperative nausea and vomiting ( PONV ) have delayed gastric emptying compared with patients without PONV . We compared the perioperative rate of gastric emptying in patients experiencing PONV with the rate in those without PONV immediately after laparoscopic cholecystectomy .  Gastric emptying was studied by the acetaminophen method . Acetaminophen is not absorbed from the stomach but is rapidly absorbed from the small intestine , and the rate of gastric emptying therefore determines the rate of absorption of acetaminophen administered into the stomach . Forty patients ( ASA physical status I and II ) were included in the study . After the induction of anesthesia , a gastric tube was positioned in the stomach and 1.5 g of acetaminophen dissolved in 200 mL of water was administered . Venous blood sample s for the determination of serum acetaminophen concentrations were taken before and at 15-min intervals during a period of 180 min after the administration of acetaminophen .  Twenty-six patients experienced nausea during the first 4 h postoperatively . The other 14 patients had no nausea . There were no statistically significant differences in the maximal acetaminophen concentration , the time taken to reach the maximal concentration , or the area under the serum acetaminophen concentration time curves from 0 to 60 , 0 - 120 , and 0 - 180 min between the groups of patients with or without PONV . We did not find any relationship between postoperative gastric emptying and PONV , and therefore gastric emptying is not a predictor of PONV . IMPLICATION S The incidence of postoperative nausea and vomiting is frequent after laparoscopic cholecystectomy . This study has shown that perioperative gastric emptying is not a predictor of early postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy Background Due to potentially superior short-term outcomes compared with open colorectal surgery , laparoscopic surgery is currently being implemented in clinical practice worldwide . In parallel , enhanced recovery after surgery ( ERAS ) programs are shown to improve postoperative recovery in open colorectal surgery . This study reports outcomes in laparoscopic versus open surgery in conjunction with compliance to the ERAS protocol . Methods The association between surgical approach ( laparoscopic or open surgery ) , compliance to the ERAS protocol , postoperative symptoms , complications , and length of stay after surgery was studied . Between January 2007 to December 2010 , 114 consecutive patients underwent elective high anterior resection with laparoscopic-assisted ( n = 55 ) or open resection ( n = 59 ) . All clinical data ( 114 variables ) were prospect ively recorded . Results The overall preoperative ERAS- protocol compliance was 77 % for both the laparoscopic and open group . Laparoscopic surgery result ed in shorter total length of stay ( median 4 vs. 6 days , p = 0.04 ) , earlier pain control ( median 2 vs. 3 days , p = 0.008 ) , shorter need for intravenous infusions , improved mobilization on the first postoperative day ( POD1 ) , and lower inflammatory response ( CRP ( POD1 ) 54 ± 24 vs. 67 ± 31 mg/l , p = 0.017 ) compared with open resection . The trends in fewer postoperative complications ( 9.1 vs. 16.9 % ; odds ratio ( OR ) 0.55 ; 95 % confidence interval ( CI ) 0.17–1.81 ) and overall postoperative symptoms delaying recovery ( 20 vs. 30.5 % ; OR 0.63 ; 95 % CI 0.22–1.34 ) in laparoscopic surgery were not statistically significant . Conclusions The use of laparoscopy in colorectal surgery within an ERAS protocol results in faster recovery compared with open resection Background and Objectives Postoperative urinary retention may occur in between 10 % and 60 % of patients after major surgery . Continuous lumbar epidural analgesia , in contrast to thoracic epidural analgesia , may inhibit urinary bladder function . Postoperative urinary drainage has been common in patients with continuous epidural analgesia , despite the lack of scientific evidence for its indication after thoracic epidural analgesia . This study describes 100 patients who underwent elective colonic resection with 48 hours of continuous thoracic epidural analgesia and only 24 hours of urinary drainage .  Methods This is a prospect i ve , uncontrolled study with well-defined general anesthesia , postoperative analgesia , and nursing care programs in patients with a planned 2-day hospital stay , urinary catheter removal on the first postoperative morning , and epidural catheter removal on the second postoperative morning . Follow-up in the outpatient clinic was on days 8 and 30 . Results Nine patients needed bladder recatheterization , 8 as a single procedure and 1 patient a second recatheterization with removal on day 7 . This patient had urinary infection on day 10 and was readmitted for 5 days because of urosepsis and , subsequently , for cystitis and left-sided epididymitis . Three patients had uncomplicated urinary infection . No patients had urological complaints at 30 days follow-up ( 95 % confidence limit , 0 % to 3.6 % ) . Conclusion The low incidence of urinary retention ( 9 % ) and urinary infection ( 4 % ) suggests that routine bladder catheterization beyond postoperative day 1 may not be necessary in patients with ongoing continuous low-dose thoracic epidural analgesia Objective It has been demonstrated that colon operation combined with fast-track ( FT ) surgery and laparoscopic technique can shorten the length of hospital stay , accelerate recovery of intestinal function , and reduce the occurrence of post-operative complications . However , there are no reports regarding the combined effects of FT colon operation and laparoscopic technique on humoral inflammatory cellular immunity . Methods This was a prospect i ve , controlled study . One hundred sixty-three colon cancer patients underwent the traditional protocol and open operation ( traditional open group , n = 42 ) , the traditional protocol and laparoscopic operation ( traditional laparoscopic group , n = 40 ) , the FT protocol and open operation ( FT open group , n = 41 ) , or the FT protocol and laparoscopic operation ( FT laparoscopic group , n = 40 ) .  Blood sample s were taken prior to operation as well as on days 1 , 3 , and 5 after operation . The number of lymphocyte sub population s was determined by flow cytometry , and serum interleukin-6 and C-reactive protein levels were measured . Post-operative hospital stay , post-operative morbidity , readmission rate , and in-hospital mortality were recorded . Results Compared with open operation , laparoscopic colon operation effectively inhibited the release of post-operative inflammatory factors and yielded good protection via post-operative cell immunity . FT surgery had a better protective role with respect to the post-operative immune system compared with traditional peri-operative care . Inflammatory reactions , based on interleukin-6 and C-reactive protein levels , were less intense following FT laparoscopic operation compared to FT open operation ; however , there were no differences in specific immunity ( CD3 + and CD4 + counts , and the CD4+/CD8 + ratio ) during these two types of surgical procedures . Post-operative hospital stay in patients r and omized to the FT laparoscopic group was significantly shorter than in the other three treatment groups ( P < 0.01 ) . Post-operative complications in patients who underwent FT laparoscopic treatment were less than in the other three treatment groups ( P < 0.05 ) . There were no significant differences between the four treatment groups regarding readmission rate and in-hospital mortality . Conclusions The laparoscopic technique and FT surgery rehabilitation program effectively inhibited release of post-operative inflammatory factors with a reduction in peri-operative trauma and stress , which together played a protective role on the post-operative immune system . Combining two treatment measures during colon operation produced better protective effects via the immune system . The beneficial clinical effects support that the better-preserved post-operative immune system may also contribute to the improvement of post-operative results in FT laparoscopic patients Background : Nasogastric ( NG ) intubation is widely used following elective abdominal operations although it is associated with morbidity and discomfort . The present study is a r and omised controlled trial on the effect of early oral feeding without NG decompression  following elective colorectal resection for cancer AIM Recent evidence suggests that the provision of energy-containing fluids is safe and may impact positively on markers of recovery . The aims of this study were to assess the tolerance of preoperative carbohydrate fluid administration and to determine its effect on postoperative metabolic and clinical responses . METHODS Patients admitted to the Royal Infirmary of Edinburgh for major , elective abdominal surgery were recruited to this double-blind , r and omised study and received either a placebo drink or carbohydrate ( 12.6g/100ml ) drink ( CHOD ) . Patients consumed 800 ml of their drink on the evening before surgery and 400 ml on the day of surgery 2 - 3 h before the induction of anaesthesia . Nutritional status was determined using body mass index ( BMI ) and upper arm anthropometry ; all measurements were taken preoperatively , postoperatively and at discharge . Blood glucose and insulin concentrations were also measured preoperatively and on the first post operative day . Length of hospital stay ( LOS ) and postoperative complications were recorded . RESULTS Seventy-two patients were recruited and 65 ( 34 male:31 female ) completed this study . Thirty-four patients were r and omised to receive the placebo drink ( control group ) and 31 patients to receive the carbohydrate drink ( CHOD group ) . Groups were well-matched in terms of gender and age . There were no differences between the two groups at baseline for BMI ( control : -25.1+/-1.7 kg/m2 ; CHOD -25.2+/-1.2 kg/m2 ) , upper arm anthropometry or surgical procedure . At discharge loss of muscle mass ( arm muscle circumference ) was significantly greater in the control group when compared with the CHOD group ( control : -1.1+/-0.15 cm ; CHOD : -0.5+/-0.16 cm ; P<0.05 ) . Baseline insulin ( control : 20.7+/-4.9 mU/l ; CHOD : 24.6+/-6.2 mU/l ) and glucose ( control : 6.0+/-1.4 mmol/l ; CHOD 5.7+/-1.4 mmol/l ) were comparable in the two groups and did not differ postoperatively . No complications were recorded as a result of preoperative fluid consumption . Postoperative morbidity occurred in six patients from each group . Median LOS in the control group was 10 days ( IQR=6 ) , and 8 days ( IQR=4 ) in the CHOD group . CONCLUSION Preoperative consumption of carbohydrate-containing fluids is safe . Provision of a carbohydrate energy source prior to surgery may attenuate depletion of muscle mass after surgery . Further studies are required to determine if this preservation of muscle mass is reflected in improved function and reduced rehabilitation time Abstract PURPOSE : This study was design ed to evaluate differences in both the peritoneal and systemic immune response after laparoscopic and conventional surgical approaches . METHODS : Patients with a primary carcinoma were prospect ively r and omized to curative laparoscopic ( n = 12 ) or conventional ( n = 14 ) colon resection . The proinflammatory cytokines interleukin-6 , interleukin-8 , and tumor necrosis factor-alpha were measured in the peritoneal drain fluid and in the serum . C-reactive protein and leukocyte counts and the differences in leukocyte sub population s and expression of human leukocyte antigen-DR on monocytes were measured perioperatively . RESULTS : Significantly higher levels of proinflammatory cytokine were found in the peritoneal drain fluid than in the circulation after both procedures . Serum interleukin-6 and interleukin-8 levels were significantly lower 2 hours after laparoscopic surgery than with the conventional procedure . Postoperative cellular immune counts and human leukocyte antigen-DR expression normalized earlier after the laparoscopic approach . CONCLUSIONS : The systemic proinflammatory concentrations after both surgical approaches represent only a small fragment of what is generated in the peritoneal drain fluid . Even if the immediate levels of proinflammatory cytokines in the serum are significantly lower in the laparoscopic group , the same cytokines locally produced showed no differences , which suggests that the two intra-abdominal approaches are equally traumatic . No differences in cellular response were observed between the groups Scintigraphy is the current gold st and ard for the quantification of gastric emptying ; however , results vary with meal composition . We modified a dual phase meal for administration to patients in the early post-operative period and aim ed to test the reproducibility of the method , to obtain normal ranges and to compare these with previous data . Twenty healthy volunteers ( 10 male , 10 female ) , studied prospect ively , were compared with 10 historical male volunteers . Each volunteer was studied twice ( Test 1 at day 0 and Test 2 at day 7 - 10 ) . After an overnight fast , subjects had Meal A consisting of a 60 g pancake labelled with 3 MBq of non-absorbable 99mTc-ion exchange resin and 100 ml of water labelled with 0.5 MBq of non-absorbable 111In-diethylenetriamine pentaacetic acid ( 111In-DTPA ) . Anterior and posterior gamma camera images of the stomach were obtained every 20 min for 3 h. The time for 50 % emptying ( T50 ) was derived from time-activity curves . Data obtained for males were compared with historical data using a similar technique with Meal B , consisting of two pancakes and a 200 ml milkshake labelled with identical amounts of radioisotopes . The mean ( 95 % CI ) T50 values for solid phase emptying for males and females using Meal A , and for historical males using Meal B , were 51.1 min ( 44.1 - 58.1 ) , 58.6 min ( 52.7 - 64.5 ) and 128.9 min ( 112.8 - 145.1 ) , respectively . Corresponding figures for the liquid phase were 33.2 min ( 26.1 - 40.3 ) , 50.2 min ( 38.4 - 62.1 ) and 30.7 min ( 21.4 - 39.9 ) . Bl and -Altman plots for each phase showed good agreement between Tests 1 and 2 for Meal A. The modified test meal gave reproducible results in healthy volunteers ; however , solid phase emptying was significantly faster than that of the bulkier test meal in historical subjects OBJECTIVE To study the development of insulin resistance and changes in stress hormone concentrations in patients undergoing elective operations of different magnitude . DESIGN Prospect i ve open study . SETTING University hospital , Sweden . SUBJECTS 12 otherwise healthy patients , undergoing elective surgery for cholecystectomy ( n = 6 ) and inguinal hernia repair ( n = 6 ) . INTERVENTIONS Insulin sensitivity was measured by the normoglycaemic , hyperinsulinaemic glucose clamp technique before operation ( control ) and on the first postoperative day . MAIN OUTCOME MEASURE Relative insulin sensitivity ( compared with preoperative ) on the day after each operation . Changes in stress hormone concentrations in relation to the relative change in insulin sensitivity . RESULTS After hernia repair , mean ( SEM ) insulin sensitivity was reduced by 32 (4)% , p < 0.05 compared with baseline , and after open cholecystectomy by 56 (3)% , ( p < 0.05 ) . The difference between the two groups was highly significant ( p < 0.01 ) . The changes in concentrations of catecholamines , glucagon , cortisol and growth hormone after operation were only small , and did not correlate with the relative changes in insulin sensitivity . CONCLUSIONS Insulin resistance develops even after a minor elective operation , ( inguinal hernia repair ) . The degree of postoperative insulin resistance was more pronounced after open cholecystectomy . The alteration in insulin sensitivity could not be related to simultaneous changes in the hormones studied BACKGROUND Low concentrations of albumin in serum and long gastric emptying times have been returned to normal in dogs by salt and water restriction , or a high protein intake . We aim ed to determine the effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection in human beings . METHODS We r and omly allocated ten patients to receive postoperative intravenous fluids in accordance present hospital practice ( > or = 3 L water and 154 mmol sodium per day ) and ten to receive a restricted intake ( < or = 2 L water and 77 mmol sodium per day ) . All patients had no disease other than colonic cancer . The primary endpoint was solid and liquid-phase gastric emptying time , measured by dual isotope radionuclide scintigraphy on the fourth postoperative day . Secondary endpoints included time to first bowel movement and length of postoperative hospital stay . Analysis was by intention to treat . FINDINGS Median solid and liquid phase gastric emptying times ( T(50 ) ) on the fourth postoperative day were significantly longer in the st and ard group than in the restricted group ( 175 vs 72.5 min , difference 56 [ 95 % CI 12 - 132 ] , p=0.028 ; and 110 vs 73.5 min , 52 [ 9 - 95 ] , p=0.017 , respectively ) . Median passage of flatus was 1 day later ( 4 vs 3 days , 2 [ 1 - 2 ] , p=0.001 ) ; median passage of stool 2.5 days later ( 6.5 vs 4 days , 3 [ 2 - 4 ] , p=0.001 ) ; and median postoperative hospital stay 3 days longer ( 9 vs 6 days , 3 [ 1 - 8 ] , p=0.001 ) in the st and ard group than in the restricted group . One patient in the restricted group developed hypokalaemia , whereas seven patients in the st and ard group had side-effects or complications ( p=0.01 ) . INTERPRETATION Positive salt and water balance sufficient to cause a 3 kg weight gain after surgery delays return of gastrointestinal function and prolongs hospital stay in patients undergoing elective colonic resection Purpose A postoperative decrease in the gastric emptying ( GE ) rate may delay the early start of oral feeding and alter the bioavailability of orally administered drugs . The aim of this study was to compare the effect on early gastric emptying between two anesthetic techniques . Methods Fifty patients ( age , 19–69 years ) undergoing day-case laparascopic cholecystectomy were r and omly assigned to received either total intravenous anesthesia with propofol/remifentanil/rocuronium ( TIVA ; n = 25 ) or inhalational opioid-free anesthesia with sevoflurane/rocuronium ( mask induction ; GAS ; n = 25 ) . Postoperative gastric emptying was evaluated by the acetaminophen method . After arrival in the recovery unit , acetaminophen ( paracetamol ) 1.5 g was given through a nasogastric tube , and blood sample s were drawn during a 2-h period . The area under the serum-acetaminophen concentration curve from 0–60 min ( AUC60 ) , the maximal concentration ( Cmax ) , and the time to reach C-max ( Tmax ) were calculated . Results Twelve patients were excluded due to surgical complications ( e.g. , conversion to open surgery ) and difficulty in drawing blood sample s ( TIVA , n = 7 ; GAS , n = 5 ) . Gastric emptying parameters were ( mean ± SD ) : TIVA , AUC60 , 2458 ± 2775 min·µmol·l−1 ; Cmax , 71 ± 61 µmol·l−1 ; and Tmax , 81 ± 37 min ; and GAS , AUC60 , 2059 ± 2633 min·µmol·l−1 ; Cmax , 53 ± 53 µmol·l−1 ; and Tmax , 83 ± 41 min . There were no significant differences between groups . Conclusion There was no major difference in early postoperative gastric emptying between inhalation anesthesia with sevoflurane versus total intravenous anesthesia with propofol-remifentanil . Both groups showed a pattern of delayed gastric emptying , and the variability in gastric emptying was high . Perioperative factors other than anesthetic technique may have more influence on gastric emptying This r and omized clinical trial compared the use of thoracic epidural anaesthesia – analgesia ( TEA ) with morphine patient‐controlled analgesia ( PCA ) for pain relief after laparoscopic colectomy Background Overnight fasting is routine before elective surgery . This may not be the optimal way to prepare for surgical stress , however , because intravenous carbohydrate supplementation instead of fasting has recently been shown to reduce postoperative insulin resistance . In the current study , gastric emptying of a carbohydrate-rich drink was investigated before elective surgery and in a control situation . Methods Twelve patients scheduled for elective surgery were r and omly given 400 mL of either a carbohydrate-rich drink ( 285 mOsm/kg , 12.0 % carbohydrates , n = 6 ) or water 4 hours before being anesthetized . Gastric emptying was measured ( gamma camera , 99Tcm ) . Each patient repeated the protocol postoperatively as a control . All values were presented as the mean ± SEM by means of a nonparametric statistical evaluation . Results Despite the increased anxiety experienced by patients before surgery ( p < 0.005 ) , gastric emptying did not differ between the experimental and control situations . Initially , water emptied more rapidly than carbohydrate . However , after 90 minutes , the stomach was emptied regardless of the solution administered ( 3.2 ± 1.1 % [ mean ± SEM ] remaining in the stomach in the carbohydrate group versus 2.3 ± 1.2 % remaining in the stomach in the water group ) . Conclusions Preoperative anxiety does not prolong gastric emptying . The stomach had been emptied 90 minutes after Ingestion of both the carbohydrate-rich drink and water , thereby indicating the possibility of allowing an intake of iso-osmolar carbohydrate-rich fluids before surgery We studied the effects of different preoperative oral fluid protocol s on preoperative discomfort , residual gastric fluid volumes , and gastric acidity .  Two-hundred-fifty-two elective abdominal surgery patients ( ASA physical status I – II ) were r and omized to preparation with a 12.5 % carbohydrate drink ( CHO ) , placebo ( flavored water ) , or overnight fasting . The CHO and Placebo groups were double-blinded and were given 800 mL to drink on the evening before and 400 mL on the morning of surgery . Visual analog scales were used to score 11 different discomfort variables . CHO did not increase gastric fluid volumes or affect acidity , and there were no adverse events . The visual analog scale scores in a control situation were not different between groups . During the waiting period before surgery , the CHO-treated group was less hungry and less anxious than both the other groups ( P ≤ 0.05 ) . CHO reduced thirst as effectively as placebo ( P < 0.0001 versus Fasted ) . Trend analysis showed consistently decreasing thirst , hunger , anxiety , malaise , and unfitness in the CHO group ( P < 0.05 ) . The Placebo group experienced decreasing unfitness and malaise , whereas nausea , tiredness , and inability to concentrate increased ( P < 0.05 ) . In the Fasted group , hunger , thirst , tiredness , weakness , and inability to concentrate increased ( P < 0.05 ) . In conclusion , CHO significantly reduces preoperative discomfort without adversely affecting gastric contents Purpose To determine whether , in obese [ body mass index ( BMI ) > 30 kg·m2 ] patients , oral intake of 300 mL clear liquid two hours before elective surgery affects the volume and pH of gastric contents at induction of anesthesia . Methods A single-blind , r and omized study of 126 adult patients , age ≥18 yr , ASA physical status I or II , BMI > 30 kg·m2 who were scheduled for elective surgery under general anesthesia . Patients were excluded if they had diabetes mellitus , symptoms of gastroesophageal reflux , or had taken medication within 24 hr that affects gastric secretion , gastric fluid pH or gastric emptying . All patients fasted from midnight and were r and omly assigned to fasting or fluid group . Two hours before their scheduled time of surgery , all patients drank 10 mL of water containing phenol red 50 mg . Those in the fluid group followed with 300 mL clear liquid of their choice . Immediately following induction of general anesthesia and tracheal intubation , gastric contents were aspirated through a multiorifice Salem sump tube . The fluid volume , pH and phenol red concentration were recorded . Results Median ( range ) values in fasting vs fluid groups were : gastric fluid volume 26 ( 3–107 ) mL vs 30 ( 3–187 ) mL , pH 1.78 ( 1.31–7.08 ) vs 1.77 ( 1.27–7.34 ) and phenol red retrieval 0.1 (0–30)% vs 0.2 (0–15)% . Differences between groups were not statistically significant . Conclusion Obese patients without comorbid conditions should follow the same fasting guidelines as non-obese patients and be allowed to drink clear liquid until two hours before elective surgery , inasmuch as obesity per se is not considered a risk factor for pulmonary aspiration . RésuméObjectifDéterminer si , chez des patients obèses [ indice de masse corporelle ( IMC ) > 30 kg·m2 ] , la prise orale de 300 mL de liquide clair deux heures avant de subir une opération réglée a un effet sur le volume et le pH du contenu gastrique lors de l’induction anesthésique . MéthodeUne étude r and omisée , à simple insu , a été menée auprès de 126 patients adultes , ≥18 ans , d’état physique ASA I ou II , d’IMC > 30 kg·m2 , devant subir une intervention chirurgicale réglée sous anesthésie générale . La présence de diabète , ou de symptômes de reflux gastro-œsophagien ou la prise de médicaments , dans les 24 h avant l’opération , pouvant affecter la sécrétion gastrique , le pH du liquide gastrique ou l’évacuation gastrique entraînaient l’exclusion du patient . Tous les patients , à jeun depuis minuit , ont été répartis en deux groupes : jeûne ou liquide . Deux heures avant l’heure prévue de l’opération , tous les patients ont bu 10 mL d’eau contenant 50 mg de rouge de phénol . Les patients du groupe « liquide » ont pris ensuite 300 mL d’un liquide clair de leur choix . Immédiatement après l’induction de l’anesthésie et l’intubation endotrachéale , le contenu gastrique a été aspiré au moyen d’une sonde multiorifice Salem . Le volume de liquide , le pH et les concentrations de rouge de phénol ont été notés . RésultatsLes valeurs moyennes ( étendue ) du groupe de jeûne vs le groupe « liquide » ont été : volume de liquide gastrique 26 ( 3–107 ) mL vs 30 ( 3–187 ) mL , pH 1,78 ( 1,31–7,08 ) vs 1,77 ( 1,27–7,34 ) et repérage du rouge de phénol 0,1 ( 0–30 ) % vs 0,2 ( 0–15 ) % . Il n’y avait pas de différence intergroupe significative . Conclusion Les patients obèses , sans symptômes comorbides , devraient suivre les mêmes directives de jeûne que les patients non obèses . Ils peuvent boire un liquide clair jusqu’à deux heures avant une opération réglée , étant donné que l’obésité en elle-même n’est pas considérée comme un facteur de risque d’aspiration pulmonaire INTRODUCTION Postoperative traditional feeding protocol s are not based on scientific studies , but rather on anecdotal evidence . We present the first prospect i ve trial of aggressive postoperative bowel stimulation following radical hysterectomy in an attempt to determine its effect on the length of hospital stay . METHODS Twenty consecutive patients undergoing radical hysterectomy were entered onto a prospect i ve trial of aggressive postoperative bowel stimulation , which consisted of 30 cc milk of magnesia p.o . b.i.d . starting on postoperative day 1 and biscolic suppositories q.d . starting on day 2 . A clear liquid diet was begun following flatus or bowel movement and patients were discharged 12 h after tolerating a clear liquid diet . Diet was slowly advanced at home . RESULTS Median time to flatus was 3 days , bowel movement 3 days , and clear liquid diet 3 days . Median time to discharge was 4 days . No patients developed ileus or bowel obstructions and there were no readmissions for bowel complications . Our median time to discharge of 4 days represents a 50 % reduction in hospital stay compared to our previous prospect i ve study using traditional postoperative bowel management ( 8 days ) , which was statistically significant at P = 0.001 . CONCLUSION Aggressive bowel stimulation with milk of magnesia and biscolic suppositories result ed in early return of bowel function and early discharge with no noticeable complications BACKGROUND There is a need for an accurate measure of surgical outcomes so that hospitals and surgeons can be compared properly regardless of case mix . POSSUM ( Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity ) uses a physiological score and an operative severity score to calculate risks of mortality and morbidity . In a previous small study it was found that Portsmouth POSSUM ( P-POSSUM ; a modification of the POSSUM system ) provided a more accurate prediction of mortality . METHODS Some 10000 general surgical interventions ( excluding paediatric and day cases ) were studied prospect ively between August 1993 and November 1995 . The POSSUM mortality equation was applied to the full 10000 surgical episodes . The 10000 patients were arranged in chronological order and the first 2500 were used as a training set to produce the modified P-POSSUM predictor equation . This was then applied prospect ively to the remaining 7500 patients arranged chronologically in five groups of 1500 . RESULTS The original POSSUM logistic regression equation for mortality overpredicts the overall risk of death by more than twofold and the risk of death for patients at lowest risk ( 5 per cent or less ) by more than sevenfold . The P-POSSUM equation produced a very close fit with the observed in-hospital mortality . CONCLUSION P-POSSUM provides an accurate method for comparative surgical audit To determine the impact of in-hospital postoperative complications on long-term survival , we prospect ively studied consecutive patients ≥70 yr of age undergoing noncardiac surgery .  Potential clinical risk factors were measured and evaluated for their association with the occurrence of long-term postoperative mortality . Long-term survival was determined by using the Kaplan-Meier method . Multivariate correlates of survival were analyzed with the Cox proportional hazards model . The survival of the study group was also compared with the age- and gender-matched general United States population . Five hundred seventeen patients who survived the initial hospitalization were studied . The mean follow-up duration was 28.6 ± 12.8 mo . One hundred sixty-four of 517 patients ( 31.7 % ) were deceased at the time of follow-up . A history of cancer ( hazard ratio [ HR ] 2.44 , 95 % confidence interval [ CI ] 1.78–3.38 , P < 0.0001 ) , ASA physical status > II ( HR 2.27 , 95 % CI 1.61–3.21 , P < 0.0001 ) , neurologic disease ( HR 1.59 , 95 % CI 1.13–2.24 , P = 0.008 ) , age ( HR 1.42 per decade , 95 % CI 1.11–1.81 , P = 0.005 ) , postoperative pulmonary complications ( HR 2.41 , 95 % CI 1.30–4.48 , P = 0.005 ) , and renal complications ( HR 6.07 , 95 % CI 2.23–16.52 , P < 0.0001 ) were significant independent predictors of decreased long-term survival . Compared with the United States population , patients with complications had a greater increase in mortality risk in the first 3 mo after surgery ( HR 7.3 versus general population ) than those without complications ( HR 2.9 , P = 0.023 ) . An effort to improve perioperative care delivery to elderly surgical patients must include measures to minimize in-hospital postoperative complications , particularly those involving the pulmonary and renal systems BACKGROUND The ERAS ( enhanced recovery after surgery ) care has been shown in r and omized clinical trials to improve outcome after colorectal surgery compared to traditional care . The impact of different levels of compliance and specific elements , particularly out with a trial setting , is poorly understood . OBJECTIVE This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection . METHODS The international , multicenter ERAS registry data , collected between November 2008 and March 2013 , was review ed . Patient demographics , disease characteristics , and perioperative ERAS protocol compliance were assessed . Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication . FINDINGS A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries .  Median length of stay for colorectal resections was 6 days , with readmissions in 216 ( 9.2 % ) , complications in 948 ( 40 % ) , and reoperation in 167 ( 7.1 % ) of 2352 patients . Laparoscopic surgery was associated with reduced complications [ odds ratio ( OR ) = 0.68 ; P < 0.001 ] and length of stay ( OR = 0.83 , P < 0.001 ) . Increasing ERAS compliance was correlated with fewer complications ( OR = 0.69 , P < 0.001 ) and shorter primary hospital admission ( OR = 0.88 , P < 0.001 ) . Shorter hospital stay was associated with preoperative carbohydrate and fluid loading ( OR = 0.89 , P = 0.001 ) , and totally intravenous anesthesia ( OR = 0.86 , P < 0.001 ) ; longer stay was associated with intraoperative epidural analgesia ( OR = 1.07 , P = 0.019 ) . Reduced postoperative complications were associated with restrictive perioperative intravenous fluids ( OR = 0.35 , P < 0.001 ) . CONCLUSIONS This analysis has demonstrated that in a large , international cohort of patients , increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome AIMS Adjuvant therapy after surgery for colorectal cancer is often denied to the elderly for various reasons . This study was to determine morbidity and mortality risk after surgery in the elderly and whether this is affected by adjuvant therapy . METHODS Data were collected prospect ively and entered on a data base for all patients undergoing resection of colorectal cancer between January 1994 and July 2000 . A total of 304 patients were included , 65 aged 80 years and over . RESULTS There were 84 deaths , 21 ( 30 % ) in the over 80s , and 63 ( 26 % ) in the under 80s ( P=0.51 ) . The ' in-hospital ' mortality was 10.1 % in the over 80s and 3.8 % in the under 80s ( P=0.056 ) . In the over 80s the colon was more affected than the rectum ( P=0.002 ) . The over 80s were less likely to be offered  adjuvant therapy  , 7.2 % vs 42.1 % ( P<0.001 ) . The 5 year survival ( all-cause mortality ) in the over 80s was 58.5 % and 47.6 % in the under 80s ( P=0.25 ) . Cox 's regression analysis of all patients identified the following factors to be independently related to overall survival : age>80 years , post-operative leak , increasing Dukes stage and distant recurrence of disease . CONCLUSION This study has demonstrated that surgery should not be denied to elderly patients with colorectal cancer as despite a higher post-operative morbidity and mortality rate and with the absence of adjuvant therapy , favourable long-term outcome can be achieved by resectional surgery alone BACKGROUND AND AIMS Nutritional supplements are widely administered in hospitals and can benefit clinical outcome . The aim here was to determine the effect of routine post-operative nutritional supplementation on the nutritional status and clinical outcome of adult orthopaedic patients . METHODS A prospect i ve controlled study was conducted on two adult orthopaedic wards . Patients in the study group were prescribed two nutritional supplements/day post-operatively . Nutritional and biochemical indices and incidence of clinical complications were observed . RESULTS Of 181 patients studied , 14 in the supplemented group and 34 in the control ( P=0.005 ) developed major complications . There were 22 occurrences of major complications in the supplemented group and 55 in the control ( P=0.0002 ) . There was no significant difference in the number of minor complications between the two groups ( P=0.2 ) . There was no statistical difference in changes in nutritional parameters or in albumin or CRP between the two groups . There were significantly greater reductions in transferrin ( P=0.002 ) and in haemoglobin ( P=0.002 ) in the control group at week 1 . The median costs of hospital stay were 2068 UK pounds in the supplemented group and 2199 UK pounds in the control . The median cost of additional treatments was 30.16 UK pounds in the supplemented group and 46.23 UK pounds in the control . CONCLUSION A significant reduction in major complications and in number and costs of additional treatments was seen in the supplemented group Abstract Background : Short-term benefits of laparoscopic relative to conventional colorectal resections have been demonstrated in r and omized controlled trials . It has been suggested that a diminished cytokine and acute-phase response may be responsible for these advantages . Methods : In a r and omized controlled trial , patients underwent laparoscopic ( n=30 ) or conventional ( n=30 ) resection of colorectal tumors .  Plasma levels of interleukin-1 receptor antagonist ( IL-1RA ) , interleukin-6 ( IL-6 ) , interleukin-10 ( IL-10 ) , and C-reactive protein ( CRP ) were analyzed repeatedly . Postoperative peak levels and area under the curve values were calculated and compared between groups using the Mann-Whitney U-test . Results : Patient characteristics , preoperative cytokine , and CRP plasma levels were not different between each group . Postoperative peak concentrations of IL-6 ( P=0.05 ) and CRP ( P<0.001 ) and the overall postoperative plasma concentrations of IL-6 ( P=0.03 ) and CRP ( P=0.002 ) were lower in the laparoscopic than in the conventional group . Peak and overall IL-1RA ( P=0.2 ; P=0.2 ) and IL-10 ( P=0.4 ; P=0.6 ) plasma concentrations , respectively , were not different between groups . Conclusions : IL-6 and CRP plasma levels were lower after laparoscopic than conventional colorectal resections . The less intense inflammatory response may be an indicator of the milder surgical trauma inflicted by laparoscopic than conventional colorectal resection OBJECTIVE To investigate the feasibility of a 48-hour postoperative stay program after colonic resection . SUMMARY BACKGROUND DATA Postoperative hospital stay after colonic resection is usually 6 to 12 days , with a complication rate of 10 % to 20 % . Limiting factors for early recovery include stress-induced organ dysfunction , paralytic ileus , pain , and fatigue . It has been hypothesized that an accelerated multimodal rehabilitation program with optimal pain relief , stress reduction with regional anesthesia , early enteral nutrition , and early mobilization may enhance recovery and reduce the complication rate . METHODS Sixty consecutive patients undergoing elective colonic resection  were prospect ively studied using a well-defined postoperative care program including continuous thoracic epidural analgesia and enforced early mobilization and enteral nutrition , and a planned 48-hour postoperative hospital stay . Postoperative follow-up was scheduled at 8 and 30 days . RESULTS Median age was 74 years , with 20 patients in ASA group III-IV . Normal gastrointestinal function ( defecation ) occurred within 48 hours in 57 patients , and the median hospital stay was 2 days , with 32 patients staying 2 days after surgery . There were no cardiopulmonary complications . The readmission rate was 15 % , including two patients with anastomotic dehiscence ( one treated conservatively , one with colostomy ) ; other readmissions required only short-term observation . CONCLUSION A multimodal rehabilitation program may significantly reduce the postoperative hospital stay in high-risk patients undergoing colonic resection . Such a program may also reduce postoperative ileus and cardiopulmonary complications . These results may have important implication s for the care of patients after colonic surgery and in the future assessment of open versus laparoscopic colonic resection BACKGROUND & AIMS Postoperative metabolism is characterised by insulin resistance and a negative whole-body nitrogen balance . Preoperative carbohydrate treatment reduces insulin resistance in the first day after surgery . We hypothesised that preoperative oral carbohydrate treatment attenuates insulin resistance and improves whole-body nitrogen balance 3 days after surgery . METHODS Fourteen patients undergoing total hip replacement were double-blindly r and omised to preoperative oral carbohydrate treatment ( 12.5 % , 800 + 400 ml , n = 8) or placebo ( n = 6 ) . Glucose kinetics ( 6,6-D2-glucose ) , substrate utilisation ( indirect calorimetry ) and insulin sensitivity ( hyperinsulinaemic-euglycaemic clamp ) were measured preoperatively and on the third day after surgery . Nitrogen losses were monitored for 3 days after surgery . Values are mean ( SEM ) . Analysis of variance ( ANOVA ) statistics were used . RESULTS Endogenous glucose release during insulin infusion increased after surgery in the placebo group . Preoperative carbohydrate treatment , as compared to placebo , significantly attenuated postoperative endogenous glucose release ( 0.69 ( 0.07 ) vs. 1.21 (0.13)mg kg(-1 ) x min(-1 ) , P < 0.01 ) , while whole-body glucose disposal and nitrogen balance were similar between groups . CONCLUSIONS While insulin resistance in the first day after surgery has previously been characterised by reduced glucose disposal , enhanced endogenous glucose release was the main component of postoperative insulin resistance on the third postoperative day . Preoperative carbohydrate treatment attenuated endogenous glucose release on the third postoperative day After more than two decades of nutritional awareness , we design ed a prospect i ve study to determine whether malnutrition is still a significant issue in hospitalized patients . Patients admitted to an intensive care unit ( ICU ) were divided into well-nourished and malnourished groups , according to their nutritional status as assessed by serum albumin level and weight/height ratio . Severity of illness , as assessed by the Therapeutic Intervention Scoring System ( TISS ) , was used to further stratify the study population . All patients were followed clinical ly until discharge or death and their outcome recorded . Of 129 patients studied , 43 % were malnourished .  Length of hospital stay ( p = n.s . ) , incidence of complications ( p < 0.01 ) , and number of patients not discharged from hospital ( p < 0.05 ) were greater in the malnourished patients than in the well-nourished . In patients with less severe degrees of illness , the existence of malnutrition led to a worse outcome than in sicker patients . To further assess the clinical setting in which hospital-related malnutrition develops or is exacerbated , postoperative patients admitted to the ICU ( n = 66 ) were also studied in a nutritional survey ; the results of this survey indicate that : ( a ) the incidence of malnutrition in the surgical population is similar to that in the whole study population , and ( b ) hospital-related malnutrition in surgical patients mainly develops during their preoperative stay in general wards . Whereas our conclusion that patients ' outcome is adversely affected by a poor nutritional status is not new or startling , malnutrition continues to be a persistent problem in hospitalized patients , which can be readily identified using simple and easily available indices and , furthermore , readily treated Objective : To investigate which perioperative treatment , ie , laparoscopic or open surgery combined with fast track ( FT ) or st and ard care , is the optimal approach for patients undergoing segmental resection for colon cancer . Summary Background Data : Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care , both focusing on faster recovery . Methods : In a 9-center trial , patients eligible for segmental colectomy were r and omized to laparoscopic or open colectomy , and to FT or st and ard care  , result ing in 4 treatment groups . Primary outcome was total postoperative hospital stay ( THS ) . Secondary outcomes were postoperative hospital stay ( PHS ) , morbidity , reoperation rate , readmission rate , in-hospital mortality , quality of life at 2 and 4 weeks , patient satisfaction and in-hospital costs .  Four hundred patients were required to find a minimum difference of 1 day in hospital stay . Results : Median THS in the laparoscopic/FT group was 5 ( interquar-tile range : 4–8 ) days ; open/FT 7 ( 5–11 ) days ; laparoscopic/st and ard 6 ( 4.5–9.5 ) days , and open/st and ard 7 ( 6–13 ) days ( P < 0.001 ) . Median PHS in the laparoscopic/FT group was 5 ( 4–7 ) days ; open/FT 6 ( 4.5–10 ) days ; laparoscopic/st and ard 6 ( 4–8.5 ) days and open/st and ard 7 ( 6–10.5 ) days ( P < 0.001 ) . Secondary outcomes did not differ significantly among the groups . Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity . Conclusions : Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program . If open surgery is applied , it is preferentially done in FT care . This study was registered under NTR222 ( www.trialregister.nl ) Objective Recent prospect i ve studies have shown that ‘ fast track ’ postoperative care protocol s ( FT ) can reduce hospitalization after major intestinal surgery to 4.5 days , as compared to the 7–10 days with traditional management ( TR ) and 2.5 days after laparoscopic surgery ( LC ) . We used computerized actigraphy ( CA ) to evaluate physical activity using TR , FT and LC approaches The influence of the type of abdominal incision on post‐operative pain and pulmonary function was investigated in patients operated upon for a right‐sided cancer of the large bowel OBJECTIVE To identify factors limiting early discharge after  laparoscopically assisted vaginal hysterectomy ( LAVH ) and abdominal hysterectomy  , in a fast track setting with emphasis on information , treatment of pain , early mobilization , and early food intake . STUDY DESIGN A prospect i ve , descriptive study of 32 unselected women allocated to either abdominal hysterectomy ( n=16 ) or LAVH ( n=16 ) . The patients received the same information , care , and advice for the perioperative period except for an assumed 1-day hospital stay in the LAVH-group and 2 days in the abdominal group . RESULTS Patients were discharged median 1 day ( 1 - 3 ) after LAVH and 2 days ( 2 - 4 ) after abdominal hysterectomy .  Work was resumed median 23 days after abdominal hysterectomy and 28 days after LAVH ( P > 0.05 ) . CONCLUSIONS The study questions the previously proposed advantages of shortened hospitalization and convalescence after LAVH compared with abdominal hysterectomy . Further studies with active rehabilitation are needed to demonstrate real differences between laparoscopic and open hysterectomy Purpose Improved survival in patients with stage III colon cancer after a laparoscopic colectomy ( LC )  has been reported by Lacy et al. ( Lancet 359:2224–2229 , 6 ) , and preserved immunity was suggested as the reason for the survival advantage . The aim of our study was to clarify the existence of an immunological benefit after laparoscopic colon cancer surgery ( LC ) compared to open colon surgery ( OC ) . Methods From January 2006 to November 2007 , 74 patients with clinical stage III colon cancer were prospect ively assigned to undergo a LC ( n = 35 ) or an OC ( n = 39 ) . The immune factors were examined preoperatively , and on the first and fifth days postoperatively ( POD1 and POD5 ) . Results The cellular immune factors were significantly decreased ; however , there was no significant difference between the LC and OC groups except for the mHLA-DR . The LC group had a better preserved mHLA-DR on POD5 than did the OC group ( p = 0.015 ) , in addition to a faster recovery ( p < 0.005 ) . Conclusion The mHLA-DR on POD5 was affected less by the LC compared to the OC . The LC demonstrated minimal immunological advantage when compared to the OC . However , further study is required to clarify the immunological benefits of the LC on colorectal cancer prognosis Eight r and omized clinical trials and two meta‐analyses recently question ed the value of preoperative mechanical bowel preparation ( MBP ) in colorectal surgery . However , very few patients having rectal surgery were included in these studies . The aim of this study was to assess whether rectal cancer surgery can be performed safely without MBP BACKGROUND & AIMS This study review ed the case mix , clinical management , and clinical outcomes of patients undergoing colorectal resection in five European centres performing different forms of conventional or ' fast-track ' perioperative care . METHODS The perioperative care programme and surgical practice in each centre was defined . Patient data were collected by case-note review on an internet-based audit system . Case mix was determined using ASA classification and the P-POSSUM scoring system . RESULTS A total of 451 consecutive patients from units practicing either conventional ( Sweden , n=109 ; UK , n=87 ; Netherl and s , n=76 , Norway , n=61 ) or fast-track surgery ( Denmark , n=118 ) , were studied between 1998 and 2001 . Elements of perioperative practice varied widely both between units practicing ' traditional ' care and the reference ' fast-track ' unit ( Denmark ) . Based on the P-POSSUM scores , the case mix was similar between centres . There were no differences in morbidity or 30-day mortality between the different centres . The median length of stay was 2 days in Denmark and 7 - 9 days in the other centres ( P<0.05 ) . The readmission rate was 22 % in Denmark and 2 - 16 % in the other centres ( P<0.05 ) . CONCLUSION Compared with traditional care , fast-track perioperative care results in a reduced length of hospital stay but may be associated with a higher readmission rate . Morbidity and mortality appears to be similar with either approach . Prospect i ve evaluation of the potential benefits of the fast-track approach in different European centres is merited A carbohydrate‐rich drink ( CHO ) has been shown to reduce preoperative discomfort . It was hypothesized that it may also reduce postoperative nausea and vomiting ( PONV ) Purpose The purpose of this study is to investigate the influence of anesthetic methods on markers of anti-tumor immunity and intestinal functions in fast-track surgery in colon cancer ( CC ) patients during the perioperative period . Patients and methods A total of 53 patients with American Society of Anesthesiologists ( ASA ) I-II status r and omly received general anesthesia ( G group , n = 27 ) or general anesthesia combined with epidural anesthesia ( E group , n = 26 ) for surgical tumor resection . The recovery times of intestinal function were evaluated in both groups postoperatively . The frequencies of different subsets of CD4 + T cells and myeloid-derived suppressor cells and C-reactive protein ( CRP ) were measured by flow cytometry and enzyme-linked immunosorbent assay , respectively , before anesthesia ( t0 ) , 1 h after the beginning of surgery ( t1 ) , 1 h after the end of surgery ( t2 ) , and on day 2 ( t3 ) and day 5 ( t4 ) post-surgery . Results There was no significant difference in demographic characteristics between the two groups , but the E group of patients received significantly lower amounts of morphine and sevoflurane . In comparison with those in the G group , significantly greater numbers of lymphocytes and elevated frequencies of Th1 cells were detected at t3 and t4 post-surgery in the E group ( p < 0.01 ) . Significantly lower percentages of Th2 cells and regulatory T cells were detected in the E group at t2–4 post-surgery . Whereas the levels of plasma CRP increased post-surgery in both groups , the levels of CRP were significantly lower in the E group than those in the G group at t3–4 post-surgery ( p < 0.05 ) . The times to the first flatus and to tolerate a full diet were significantly shorter in the E group than those in the G group ( p < 0.01 ) . Conclusion General anesthesia combined with epidural anesthesia plays an important role in fast-track surgery , mitigating the surgical stress-related impairment of anti-tumor immune responses and hastening the recovery of intestinal function . This combination might also help to improve long-term outcomes for CC patients Objective : A prospect i ve r and omized controlled trial ( RCT ) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer . Aims : This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT . Methods : Patients for elective resection for colorectal cancer were offered trial entry . Participants were stratified by sex and requirement for a total mesorectal excision and central ly r and omized .  Multimodal patients received intravenous fluid restriction , unrestricted oral intake with prokinetic agents , early ambulation , and fixed regimen epidural analgesia . Control patients received intravenous fluids to prevent oliguria , restricted oral intake until return of bowel motility , and weaning regimen epidural analgesia . Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets . Discharge decision was made using preagreed criteria . The primary endpoint was postoperative stay , and achievement of independence milestones . Secondary endpoints were postoperative complications , readmission rates , and mortality . Analysis was by intention to treat . Results : Seventy patients were recruited . Approximately one fourth underwent TME . Median ages were similar ( 69.3 vs. 73.0 years ) . The median stay was significantly reduced in the multimodal group ( 5 vs. 7 days ; P < 0.001 , Mann-Whitney U test ) . Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days . Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions . There were 2 deaths , both controls . Conclusions : This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery . Morbidity and mortality are not increased PURPOSE A prospect i ve , r and omized trial was performed to determine if intra-abdominal drainage catheters are necessary after elective liver resection . PATIENTS AND METHODS Between April 1992 and April 1994 , 120 patients subjected to liver resection , stratified by extent of resection and by surgeon , were  r and omized to receive or not receive operative closed-suction drainage . Operative blood loss was not an exclusion criteria , and no patient who consented to the study was excluded . RESULTS Eighty-seven patients ( 73 % ) had resection of one hepatic lobe or more ( 27 lobectomies , 54 trisegmentectomies , and 6 bilobar atypical resections ) and 33 had less than a lobectomy ( 8 wedge resections or enucleations , 9 segmentectomies , and 16 bisegmentectomies ) . Eighty-four patients ( 70 % ) had metastatic cancer and 36 patients ( 30 % ) had primary liver pathology . There were no differences in outcome , including length of hospital stay ( no drain , 13.4 + /- 0.9 days ; drain , 13.1 + /- 0.8 days ; P = not significant [ NS ] ) , mortality ( no drain , 3.3 % ; drain , 3.3 % ) , complication rate ( no drain , 43 % ; drain , 48 % ; P = NS ) , or requirement for subsequent percutaneous drainage ( no drain , 18 % ; drain , 8 % ; P = NS ) . All infected collection s ( n = 3 ) occurred in operatively drained patients . Two other complications were directly related to the operatively placed drains . One patient developed a subcutaneous abscess at the drain site , and a second developed a subcutaneous drain tract tumor recurrence as the only current site of recurrence . CONCLUSION In the first 50 consecutive resections performed since the conclusion of this trial , only 4 patients ( 8 % ) have required subsequent percutaneous drainage . We conclude that abdominal drainage is unnecessary after elective liver resection Abstract Background There is increasing evidence that C-reactive protein is a useful negative predictor of infective complications and anastomotic leak following surgery for colorectal cancer . In particular , C-reactive protein concentrations on postoperative days 3 and 4 have been proposed to be of clinical utility since they aid safe and early discharge of selected patients following colorectal surgery . However , it is not clear whether such thresholds are also applicable in laparoscopic surgery . The aim of the present study was to compare the value of daily C-reactive protein concentrations in the prediction of postoperative infective complications in patients undergoing open versus laparoscopic resection for colon cancer . Methods Patients with histologically proven colon cancer who were considered to have undergone potentially curative resection in one of two university teaching hospitals in Glasgow were included in the study ( n = 344 ) . Patient characteristics were collected in a prospect i ve surgical data base . All resections were elective cases and were performed using either open ( n = 191 ) or laparoscopic surgery ( n = 153 ) .  Daily blood sample s  to measure C-reactive protein concentrations  perioperatively were taken routinely . Patients were assessed for postoperative infective and non-infective complications . Results The majority of patients were aged 65 years or older ( 75 % ) , male ( 52 % ) , had left-sided tumors ( 54 % ) , node negative disease ( 77 % ) , and did not undergo neoadjuvant treatment ( 94 % ) . Patients undergoing open and laparoscopic resection  were similar in terms of age , sex , tumor site , TNM stage , comorbidity , and infective complications . In contrast , preoperative and postoperative days 1–3 C-reactive protein concentrations were lower following laparoscopic compared with open resection in the whole cohort ( n = 344 ; all p < 0.001 ) and in those who did not develop infective complications ( n = 251 ; all p < 0.001 ) . The median length of hospital stay was shorter in the laparoscopic resection ( p < 0.001 ) . During follow-up , 127 ( 37 % ) patients developed a postoperative complication , 93 ( 73 % ) of which were infective complications . In those who developed an infective complication , there was no significant difference in the C-reactive protein concentrations between open and laparoscopic resections on postoperative days 1–4 . C-reactive protein thresholds predictive of infective complications were the same on postoperative days 3 ( 180 mg/l ) and 4 ( 140 mg/l ) following both open and laparoscopic resection for colon cancer . Conclusions The results of the present study show that although the magnitude of the systemic inflammatory response , as evidence d by C-reactive protein , following surgery was greater in open compared with laparoscopic resection , the threshold concentrations of C-reactive protein for the development of postoperative infective complications were remarkably similar on days 3 and 4 BACKGROUND Bowel preparation prior to colonic surgery usually includes antibiotic therapy together with mechanical bowel preparation ( MBP ) . Mechanical bowel preparation may cause discomfort to the patient , prolonged hospitalization , and water and electrolyte imbalance . It was assumed that with the improvement in surgical technique together with the use of more effective prophylactic antibiotics , it was possible that MBP would no longer be necessary . HYPOTHESIS There is no statistical difference in the postoperative results of patients who undergo elective colon resection with MBP  as compared with those who have no MBP . DESIGN AND PATIENTS The study includes all patients who had elective large bowel resection at Campus Golda between April 1 , 1999 , and March 31 , 2002 . Emergency operations were not included . The patients were r and omly assigned to the 2 study groups ( with or without MBP ) according to identification numbers . All patients were treated with intravenous and oral antibiotics prior to surgery . The patients in the MBP group received Soffodex for bowel preparation . RESULTS A total of 329 patients participated in the study , 165 without MBP and 164 with MBP . The 2 groups were similar in age , sex , and type of surgical procedure . Two hundred sixty-eight patients ( 81.5 % ) underwent surgery owing to colorectal cancer and 61 patients ( 18.5 % ) owing to benign disease . The hospitalization period was longer in the bowel-prepared group ( mean + /- SD , 8.2 + /- 5.1 days ) as compared with the nonprepared group ( mean + /- SD , 8.0 + /- 2.7 days ) . However , this difference was not statistically significant . The time until the first bowel movement was similar between the 2 groups : a mean + /- SD of 4.2 + /- 1.3 days in the nonprepared group as compared with a mean + /- SD of 4.3 + /- 1.1 days in the prepared group ( P = NS ) . Four patients ( 1.2 % ) died in the postoperative course owing to acute myocardial infa rct ion and pulmonary embolism . Sixty-two patients ( 37.6 % ) of the non-MBP group suffered from postoperative complications as compared with 77 patients ( 46.9 % ) of the MBP group . CONCLUSION Our results suggest that no advantage is gained by preoperative MBP in elective colorectal surgery Background We have previously used a magnetic resonance imaging ( MRI ) method to study gastric emptying of liquids . So far , however , it has not possible to assess solid gastric emptying with this technique . Aims To vali date scintigraphically MRI as a method for measuring emptying of a mixed solid/liquid meal . Methods In eight healthy subjects , gastric emptying of a solid/liquid ( SM ) and a liquid meal ( LM ) of identical energy content and macronutrient composition was studied by scintigraphy and MRI for 120 minutes . Results MRI and scintigraphy agreed with respect to emptying profiles ( intraclass correlation coefficient ( RI ) SM : 0.988 , RI , LM : 0.917 ) , t1/2 ( SMMRI : 129 ( 9 ) , SMScinti : 123 ( 11 ) minutes , NS ; LMMRI : 100 ( 7 ) , LMScinti : 110 ( 8) minutes , NS ) and AUC ( SMMRI : 8999 ( 232 ) , SMScinti : 8788 ( 277 ) min% , NS ; LMMRI : 8819 ( 368 ) , LMScinti : 8891 ( 321 ) min% , NS ) . Conclusions MRI can be used to measure reliably gastric emptying not only of liquid but also of mixed solid/liquid meals in humans BACKGROUND : Previous work has shown that the administration of oral dietary supplements to patients who have undergone gastrointestinal surgery results in clinical ly significant short term benefits . AIMS : This study aim ed firstly to re-evaluate these short term effects , and secondly to establish whether there are any long term benefits . SUBJECTS : One hundred patients admitted for elective moderate or major gastrointestinal surgery . METHODS : In the inpatient phase , patients were r and omised to receive a normal ward diet postoperatively , or the same diet supplemented with an oral dietary supplement . In the outpatient phase , patients were further r and omised to receive their home diet , or their home diet supplemented with the oral dietary supplement for four months . RESULTS : During the inpatient phase , patients treated with oral supplements had a significantly improved nutritional intake and lost less weight ( 2.2 , 95 % confidence interval ( 95 % CI ) 0.9 kg ) compared with control patients ( 4.2 ( 0.78 ) kg , p < 0.001 ) . Supplemented patients maintained their h and grip strength whereas control patients showed a significant reduction in grip strength ( p < 0.01 ) . Subjective levels of fatigue increased significantly above preoperative levels in control patients ( p < 0.01 ) but not in the supplemented group . Twelve patients in the control group developed complications compared with four in the supplemented group ( p < 0.05 ) . In the outpatient phase , supplemented patients had improved nutrient intakes but there were no significant differences in indices of nutritional status or wellbeing between the groups . CONCLUSIONS : The prescription of oral dietary supplements to patients who have undergone gastrointestinal surgery results in clinical ly significant benefits . These benefits , however , are restricted to the inpatient phase BACKGROUND Enhanced Recovery after Surgery ( ERAS ) programs have gained popularity with potential to accelerate recovery and reduce morbidity after colectomy . We were interested in comparing recovery after open right colectomy within an ERAS program compared with laparoscopic right colectomy in a st and ard care perioperative environment . METHODS Between October 2005 and June 2009 , prospect i ve data were collected on consecutive patients undergoing elective open right colectomy within an established ERAS setting ( OpERAS ) . Similarly , between March 2008 and June 2009 , data were collected on consecutive patients undergoing laparoscopic right hemicolectomy with conventional care ( LapCon ) . Exclusion criteria for both groups were : ASA > or= 4 , formation of a stoma , and dementia or mental illness rendering the patient unable to comply with instructions . Perioperative variables were collected . The surgical recovery score ( SRS ) was used as a vali date d means to measure convalescence on d 1 , 3 , 7 , 30 , and 60 postoperatively . RESULTS There were 74 patients in the OpERAS and 39 patients in the LapCon groups . At baseline , there were no significant demographic differences except that more patients had malignancy in OpERAS group .  Mean operating time was longer in the LapCon group . Median day stay was 4 ( 3 - 28 ) in OpERAS and 5 ( 2 - 18 ) in LapCon ( P = 0.032 ) . There was no statistical difference in the incidence of complications or the severity of complications . There were no significant differences in SRS after surgery at any time point . CONCLUSION When perioperative care is optimized , recovery after elective open right hemicolectomy is comparable with laparoscopic resection . Studies looking at the combination of laparoscopy and ERAS are warranted The present study was undertaken to investigate the short term clinical efficacy of oral dietary supplements administered post-operatively to patients undergoing predetermined moderate to severe gastrointestinal surgery . Trial end points for comparison included effects of oral dietary supplements on nutritional intake , nutritional status and incidence of serious complications .  54 patients who were scheduled to undergo predetermined moderate to major gastrointestinal surgical procedures entered the study . They were r and omly assigned to receive a normal ward diet post-operatively or the same diet supplemented ad libitum by an oral nutritional sip feed . The study period was defined as commencing from the day patients were adjudged to be capable of ingesting ' free fluids ' to the day of hospital discharge . 40 patients ( 20 in each group ) completed the study . The mean daily energy intake ( KCal/day ) assessed from 7 day food diaries was significantly higher in the treatment group ( 1833 + /- SEM 99 ) than in the control group ( 1108 + /- 56 , p < 0.0001 ) . This increase occurred not only as a consequence of energy intake from the oral dietary supplements ( 470 + /- 30 ) but also because more energy was consumed from the ward diet by the treatment than the control patients ( 1353 + /- 92 vs 1108 + /- 56 , p < 0.02 ) . The mean daily protein intake g/day in the treatment group ( 66.0 + /- 3.4 ) was also greater than in the control group ( 52.9 + /- 29 p < 0.0001 ) . This difference was due solely to the intake in protein from the oral dietary supplements ( 15.7 + /- 1.0 ) , protein intake from the ward diet being similar in the treatment ( 50.1 + /- 3.2 ) and control ( 52.9 + /- 29 ) groups . Patients in the treatment group maintained their pre-operative weight where as control patients had lostsignificant amount of their pre-operative weight by study day 3 ( 4.5 + /- 12 kg and by discharge ( 4.7 + /- 1.2 kg , p < 0.02 ) . Pre-operative muscle function as evidence d by grip strength dynamometry decreased to a greater extent in the control than treatment group patients by study day 3 ( 14.6 + /- 2.2 KPa vs 2.8 + /- 2.4 < 0.03 ) and by discharge ( 10.4 + /- 3.1 KPa vs 0.10 + /- 1.9 p < 0.03 ) . The incidence of serious infections ( pneumonia , wound infection ) was significantly higher in the control group ( 10 ) than in the treatment group ( 3 , p < 0.02 ) . It is concluded that the prescription of oral dietary supplements on an ad libitum basis to post-operative patients undergoing moderate to major gastrointestinal surgery results in clinical ly significant short term benefits Major surgery is associated with postoperative insulin resistance which is attenuated by preoperative carbohydrate ( CHO ) treatment . The effect of this treatment on clinical outcome after major abdominal surgery has not been assessed in a double‐blind r and omized trial Background : The debate over the correct perioperative fluid management is unresolved . Methods : The impact of two intraoperative fluid regimes on postoperative outcome was prospect ively evaluated in 152 patients with an American Society of Anesthesiologists physical status of I – III who were undergoing elective intraabdominal surgery . Patients were r and omly assigned to receive intraoperatively either liberal ( liberal protocol group [ LPG ] , n = 75 ; bolus of 10 ml/kg followed by 12 ml · kg−1 · h−1 ) or restrictive ( restrictive protocol group [ RPG ] , n = 77 ; 4 ml · kg−1 · h−1 ) amounts of lactated Ringer 's solution . The primary endpoint was the number of patients who died or experienced complications . The secondary endpoints included time to initial passage of flatus and feces , duration of hospital stay , and changes in body weight , hematocrit , and albumin serum concentration in the first 3 postoperative days . Results : The number of patients with complications was lower in the RPG ( P = 0.046 ) . Patients in the LPG passed flatus and feces significantly later ( flatus , median [ range ] : 4 [ 3–7 ] days in the LPG vs. 3 [ 2–7 ] days in the RPG ; P < 0.001 ; feces : 6 [ 4–9 ] days in the LPG vs. 4 [ 3–9 ] days in the RPG ; P < 0.001 ) , and their postoperative hospital stay was significantly longer ( 9 [ 7–24 ] days in the LPG vs. 8 [ 6–21 ] days in the RPG ; P = 0.01 ) . Significantly larger increases in body weight were observed in the LPG compared with the RPG ( P < 0.01 ) . In the first 3 postoperative days , hematocrit and albumin concentrations were significantly higher in the RPG compared with the LPG . Conclusions : In patients undergoing elective intraabdominal surgery , intraoperative use of restrictive fluid management may be advantageous because it reduces postoperative morbidity and shortens hospital stay BACKGROUND Infections are an important cause of morbidity and mortality in patients with multiple trauma . Studies in both animals and human beings have suggested that glutamine-enriched nutrition decreases the number of infections . METHODS Patients with multiple trauma with an expected survival of more than 48 h , and who had an Injury Severity Score of 20 or more , were r and omly allocated glutamine supplemented enteral nutrition or a balanced , isonitrogenous , isocaloric enteral-feeding regimen along with usual care . Each patient was assessed every 8 h for infection , the primary endpoint . Data were analysed both per protocol , which included enteral feeding for at least 5 days , and by intention to treat . FINDINGS 72 patients were enrolled and 60 received enteral feeding ( 29 glutamine-supplemented ) for at least 5 days . Five ( 17 % ) of 29 patients in the glutamine-supplemented group had pneumonia compared with 14 ( 45 % ) of 31 patients in the control group ( p<0.02 ) . Bacteraemia occurred in two ( 7 % ) patients in glutamine group and 13 ( 42 % ) in the control group ( p<0.005 ) . One patient in the glutamine group had sepsis compared with eight ( 26 % ) patients in the control group ( p<0.02 ) . INTERPRETATION There was a low frequency of pneumonia , sepsis , and bacteraemia in patients with multiple trauma who received glutamine-supplemented enteral nutrition . Larger studies are needed to investigate whether glutamine-supplemented enteral nutrition reduces mortality PURPOSE : We have previously reported the five-year results of a r and omized trial comparing laparoscopic and open resection for cancer of the upper rectum and rectosigmoid junction . The aim of this follow-up study is to report on the long-term morbidity and ten-year oncologic outcomes among the subgroup of patients with upper rectal cancer . METHODS : From September 1993 to October 2002 , 153 patients with upper rectal cancer were r and omly assigned to receive either laparoscopic-assisted ( n = 76 ) or open ( n = 77 ) anterior resection .  Patients were last followed up in December 2007 . Long-term morbidity , survival , and disease-free interval were prospect ively recorded . Data were analyzed by intention-to-treat principle . RESULTS : The demographic data of the two groups were comparable . More patients in the open group developed adhesion-related bowel obstruction requiring hospitalization ( P = 0.001 ) and intervention . The overall long-term morbidity rate was also significantly higher in the open group ( P = 0.012 ) . After curative resection , the probabilities of cancer-specific survival at ten years of the laparoscopic-assisted and open groups were 83.5 percent and 78.0 percent , respectively ( P = 0.595 ) , and their probabilities of being disease-free at ten years were 82.9 percent and 80.4 percent , respectively ( P = 0.698 ) . CONCLUSION : Laparoscopic-assisted anterior resection for upper rectal cancer is associated with fewer long-term complications and similar ten-year oncologic outcomes when compared with open surgery Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery . This r and omized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery Autonomic behavior is subject to direct suggestion . We found that patients undergoing major operations benefit more from instruction than from information and reassurance . We compared the return of intestinal function after intra-abdominal operations in 2 groups of patients :  the suggestion group received specific instructions for the early return of gastrointestinal motility , and the control group received an equal-length interview offering reassurance and nonspecific instructions . The suggestion group had a significantly shorter average time to the return of intestinal motility , 2.6 versus 4.1 days . Time to discharge was 6.5 versus 8.1 days . Covariates including duration of operation , amount of intraoperative bowel manipulation , and amount of postoperative narcotics were also examined using the statistical model analysis of covariance . An average savings of $ 1,200 per patient result ed from this simple 5-minute intervention . In summary , the use of specific physiologically active suggestions given preoperatively in a beleivable manner can reduce the morbidity associated with an intra-abdominal operation by reducing the duration of ileus Objective To compare the absorption of  carbon-13 ( C ) acetate – enriched nutrients with D-xylose absorption . Design Prospect i ve cohort observational study . Setting Surgical intensive care unit of a university hospital . Patients A total of 24 critically ill patients requiring enteral nutritional support . InterventionThe patients were divided into three groups according to the route of C acetate administration : 1 ) gastric , 2 ) jejunal , and 3 ) intravenous . D-xylose was administered via the same route as enteral nutrition . Measurements and Main Results C acetate absorption and oxidation were reflected by pulmonary CO2 excretion . Breath CO2 isotopic enrichment was measured by mass spectrometry . C acetate absorption was rapid , and D-xylose absorption was depressed in all three groups , compared with the normal values ( p < .0001 ) . Breath CO2 isotopic enrichment was similar after intravenous and jejunal administration but slightly delayed during the first 240 mins after gastric administration ( p < .01 ) . Enteral feeding was well tolerated : mean energy delivery amounted to 77 % , 88 % , and 86 % of measured resting energy expenditure on days 1–3 . Conclusions Gastric and jejunal C acetate are rapidly absorbed in critically ill surgical patients requiring enteral nutrition , contrasting with a depressed or delayed D-xylose absorption . CO2 recovery kinetics was similar after jejunal or intravenous C acetate and slightly depressed after gastric administration . Further studies are required to determine the value of labeled nutrients to assess gastric emptying and intestinal absorption HYPOTHESIS Perioperative administration of a supplemented enteral formula may decrease postoperative morbidity . DESIGN R and omized clinical trial . SETTING Department of surgery at a university hospital . PATIENTS One hundred ninety-six registered malnourished patients ( weight loss > or = 10 % ) who were c and i date s for major elective surgery for malignancy of the gastrointestinal tract . INTERVENTION After r and omization ( n = 150 ) , one group received postoperative enteral feeding with a st and ard diet within 12 hours of surgery ( control group ; n = 50 ) . Another group orally received 1 L/d for 7 consecutive days of a liquid diet enriched with arginine , omega-3 fatty acids , and RNA ( preoperative group ; n = 50 ) . After surgery , patients were given the same st and ard enteral formula as the control group . A third group orally received 1 L/d for 7 consecutive days of the enriched liquid diet . After surgery , patients were given enteral feeding with the same enriched formula ( perioperative group ; n = 50 ) . MAIN OUTCOME MEASURES Postoperative complications and length of hospital stay . RESULTS The 3 groups were comparable for baseline demographics , biochemical markers , comorbidity factors , and surgical variables . The intent-to-treat analysis showed that the total number of patients with complications was 24 in the control group , 14 in the preoperative group , and 9 in the perioperative group ( P = .02 , control group vs perioperative group ) . Postoperative length of stay was significantly shorter in the preoperative ( 13.2 days ) and perioperative ( 12.0 days ) groups than in the control group ( 15.3 days ) ( P = .01 and P = .001 , respectively , vs the control group ) . CONCLUSION Perioperative immunonutrition seems to be the best approach to support malnourished patients with cancer Objective : To evaluate the efficacy , amount of hemorrhage , biliary leakage , complications , and postoperative evolution after fibrin glue sealant application in patients undergoing liver resection . Summary Background Data : Fibrin sealants have become popular as a means of improving perioperative hemostasis and reducing biliary leakage after liver surgery . However , trials regarding its use in liver surgery remain limited and of poor method ologic quality . Patients and Methods : A total of 300 patients undergoing hepatic resection were r and omly assigned to fibrin glue application or control groups .  Characteristics and debit of drainage and postoperative complications were evaluated . The amount of blood loss , measurements of hematologic parameters liver test , and postoperative evolution ( particularly involving biliary fistula and morbidity ) was also recorded . Results : Postoperatively , no differences were observed in the amount of transfusion ( 0.15 ± 0.66 vs. 0.17 ± 0.63 PRCU ; P = 0.7234 ) or in the patients that required transfusion ( 18 % vs. 12 % ; P = 0.2 ) , respectively , for the fibrin glue or control group . There were no differences in overall drainage volumes ( 1180 ± 2528 vs. 960 ± 1253 mL ) or in days of postoperative drainage ( 7.9 ± 5 vs. 7.1 ± 4.7 ) . Incidence of biliary fistula was similar in the fibrin glue and control groups , ( 10 % vs. 11 % ) . There were no differences regarding postoperative morbidity between groups ( 23 % vs. 23 % ; P = 1 ) . Conclusions : Application of fibrin sealant in the raw surface of the liver does not seem justified . Blood loss , transfusion , incidence of biliary fistula , and outcome are comparable to patients without fibrin glue . Therefore , discontinuation of routine use of fibrin sealant would result in significant cost saving Postoperative organ dysfunction contributes to morbidity , hospital stay and convalescence . Multimodal rehabilitation with epidural analgesia , early oral feeding , mobilization and laxative use after colonic resection has reduced ileus and hospital stay BACKGROUND Laparoscopic-assisted surgery for colorectal cancer has been widely adopted without data from large-scale r and omised trials to support its use . We compared short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer to predict long-term outcomes . METHODS Between July , 1996 , and July , 2002 , we undertook a multicentre , r and omised clinical trial in 794 patients with colorectal cancer from 27 UK centres . Patients were allocated to receive laparoscopic-assisted ( n=526 ) or open surgery ( n=268 ) . Primary short-term endpoints were positivity rates of circumferential and longitudinal resection margins , proportion of Dukes ' C2 tumours , and in-hospital mortality . Analysis was by intention to treat . This trial has been assigned the International St and ard R and omised Controlled Trial Number IS RCT N74883561 . FINDINGS Six patients ( two [ open ] , four [ laparoscopic ] ) had no surgery , and 23 had missing surgical data ( nine , 14 ) . 253 and 484 patients actually received open and laparoscopic-assisted treatment , respectively . 143 ( 29 % ) patients underwent conversion from laparoscopic to open surgery . Proportion of Dukes ' C2 tumours did not differ between treatments ( 18 [ 7 % ] patients , open vs 34 [ 6 % ] , laparoscopic ; difference -0.3 % , 95 % CI -3.9 to 3.4 % , p=0.89 ) , and neither did in-hospital mortality ( 13 [ 5 % ] vs 21 [ 4 % ] ; -0.9 % , -3.9 to 2.2 % , p=0.57 ) . Apart from patients undergoing laparoscopic anterior resection for rectal cancer , rates of positive resection margins were similar between treatment groups . Patients with converted treatment had raised complication rates . INTERPRETATION Laparoscopic-assisted surgery for cancer of the colon is as effective as open surgery in the short term and is likely to produce similar long-term outcomes . However , impaired short-term outcomes after laparoscopic-assisted anterior resection for cancer of the rectum do not yet justify its routine use Objective : To evaluate the effect of  laparoscopic or open colectomy with fast track or st and ard perioperative care on patient 's immune status and stress response after surgery . Methods : Patients with nonmetastasized colon cancer were r and omized to laparoscopic or open colectomy with fast track or st and ard care .  Blood sample s were taken preoperatively ( baseline ) , and 1 , 2 , 24 , and 72 hours after surgery . Systemic HLA-DR expression , C-reactive protein , interleukin-6 , growth hormone , prolactin , and cortisol were analyzed . Results : Nineteen patients were r and omized for laparoscopy and fast track care ( LFT ) , 23 for laparoscopy and st and ard care ( LS ) , 17 for open surgery and fast track care ( OFT ) , and 20 for open surgery and st and ard care ( OS ) . Patient characteristics were comparable . Mean HLA-DR was 74.8 in the LFT group , 67.1 in the LS group , 52.8 in the OFT group , and 40.7 in the OS group . Repeated- measures 2-way analysis of variance ( ANOVA ) showed this can be attributed to type of surgery and not aftercare ( P = 0.002 ) . Interleukin-6 levels were highest in the OS group . Repeated- measures 2-way ANOVA showed this can be attributed to type of surgery and not aftercare ( P = 0.001 ) . C-reactive protein levels were highest in the OS group . Following repeated- measures 2-way ANOVA , this can be attributed to type of surgery and not aftercare ( P = 0.022 ) . Growth hormone was lowest in the LFT group . Following repeated- measures 2-way ANOVA , this can be attributed to type of aftercare and not to type of surgery ( P = 0.033 ) . No differences between the groups were seen regarding prolactin or cortisol . No differences in ( infectious ) complication rates were observed between the groups . Conclusions : This r and omized trial showed that immune function of HLA-DR in patients undergoing laparoscopic surgery with fast track care remains highest . This can be attributed to type of surgery and not aftercare . These results may indicate a reason for the accelerated recovery of patients treated laparoscopically within a fast track program as described in the LAparoscopy and /or FAst track multimodal management versus st and ard care ( LAFA-Trial ) ( www.trialregister.nl , protocol NTR222 ) 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 Background This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery
target: The present systematic review shows that , with the exception of laparoscopic surgery , objective evidence of the effect of individual components of ERAS protocol s in reducing the stress response following colorectal surgery is limited
background: Abstract Enhanced Recovery or Fast Track Recovery after Surgery protocol s ( ERAS ) have significantly changed perioperative care following colorectal surgery and are promoted as reducing the stress response to surgery .