title: Initial Experiences of an Enhanced Recovery Protocol in Esophageal Surgery The experiences of and the nursing care for breast cancer patients undergoing immediate breast reconstruction. Risk analysis and stratification of surgical morbidity after immediate breast reconstruction. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. A Randomized, Double-blinded Placebo-controlled Clinical Trial of the Routine Use of Preoperative Antibiotic Prophylaxis in Modified Radical Mastectomy Pulsed Electromagnetic Fields Reduce Postoperative Interleukin-1&bgr;, Pain, and Inflammation: A Double-Blind, Placebo-Controlled Study in TRAM Flap Breast Reconstruction Patients Preoperative oral carbohydrate administration reduces postoperative insulin resistance. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Enhanced recovery in colorectal surgery: a multicentre study Randomized trial of antimicrobial-coated sutures to prevent surgical site infection after breast cancer surgery. A randomized, double-blind, placebo-controlled trial of preemptive analgesia with bupivacaine in patients undergoing mastectomy for carcinoma of the breast A Comparison of the Combination of Aprepitant and Dexamethasone Versus the Combination of Ondansetron and Dexamethasone for the Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Craniotomy Perforator flap magnetic resonance angiography for reconstructive breast surgery: a review of 25 deep inferior epigastric and gluteal perforator artery flap patients. Impact of obesity on outcomes in breast reconstruction: analysis of 15,937 patients from the ACS-NSQIP datasets. Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Effect of perioperative intravenous flurbiprofen axetil on chronic postmastectomy pain. Thoracic Paravertebral Block and Its Effects on Chronic Pain and Health-Related Quality of Life After Modified Radical Mastectomy Randomized clinical trial on enhanced recovery versus standard care following open liver resection Evaluation of a New Wound Closure Device for Linear Surgical Incisions: 3M Steri-Strip S Surgical Skin Closure versus Subcuticular Closure Warmed irrigation fluid does not decrease perioperative hypothermia during arthroscopic shoulder surgery. Cosmetic outcome and surgical site infection rates of antibacterial absorbable (Polyglactin 910) suture compared to Chinese silk suture in breast cancer surgery: a randomized pilot research. Reduction of Skin Closure Time Without Loss of Healing Quality An evaluation of underbody forced‐air and resistive heating during hypothermic, on‐pump cardiac surgery * Pre-consultation educational group intervention to improve shared decision-making for postmastectomy breast reconstruction: a pilot randomized controlled trial Dextran-Related Complications in Head and Neck Microsurgery: Do the Benefits Outweigh the Risks? A Prospective Randomized Analysis Evaluation of Efficacy of the Perioperative Administration of Venlafaxine or Gabapentin on Acute and Chronic Postmastectomy Pain Evidence-Based Protocol for Infection Control in Immediate Implant-Based Breast Reconstruction Pre‐operative carbohydrate loading may be used in type 2 diabetes patients Changes in central venous saturation after major surgery, and association with outcome Preoperative dexamethasone reduces postoperative pain, nausea and vomiting following mastectomy for breast cancer Dressing wear time after breast reconstruction: study protocol for a randomized controlled trial Strengths of early physical rehabilitation programs in surgical breast cancer patients: results of a randomized control study Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial Amino acid infusions started after development of intraoperative core hypothermia do not affect rewarming but reduce the incidence of postoperative shivering during major abdominal surgery: a randomized trial British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP) – Cassandra’s view Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. What influence does intermittent pneumatic compression of the lower limbs intraoperatively have on core hypothermia? Efficacy of intravenous ketoprofen for pre-emptive analgesia. Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model Intra‐operative rewarming with Hot Dog® resistive heating and forced‐air heating: a trial of lower‐body warming Computed Tomographic Angiography in Planning Abdomen-Based Microsurgical Breast Reconstruction: A Comparison with Color Duplex Ultrasound A Comparison of a New Skin Closure Device and Intradermal Sutures in the Closure of Full-Thickness Surgical Incisions The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively--a randomised clinical trial. A Randomized Comparison of Intraoperative PerfecTemp and Forced-Air Warming During Open Abdominal Surgery Atrophy and impaired muscle protein synthesis during prolonged inactivity and stress. Effect of paravertebral nerve blocks on narcotic use after mastectomy with reconstruction. Evaluation of a New Skin Closure Device in Surgical Incisions Associated With Breast Procedures A randomized study of the effects of single-dose gabapentin versus placebo on postoperative pain and morphine consumption after mastectomy. The Effect of Intravenous Dopamine and Dobutamine on Blood Circulation During a Microvascular TRAM Flap Operation The effects of preanesthetic oral clonidine on total requirement of propofol for general anesthesia. Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial Does perioperative administration of rofecoxib improve analgesia after spine, breast and orthopaedic surgery? Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial A single dose of preoperative gabapentin for pain reduction and requirement of morphine after total mastectomy and axillary dissection: randomized placebo-controlled double-blind trial. A Carbohydrate-Rich Drink Reduces Preoperative Discomfort in Elective Surgery Patients Early rehabilitation after surgery improves functional outcome in inpatients with brain tumours Processes of Care in Autogenous Breast Reconstruction with Pedicled TRAM Flaps: Expediting Postoperative Discharge in an Ambulatory Setting Abstinence From Smoking Reduces Incisional Wound Infection: A Randomized Controlled Trial Comparison of Sevoflurane versus Propofol under Auditory Evoked Potential Monitoring in Female Patients Undergoing Breast Surgery [Antibiotic prophylaxis in breast surgery. Preliminary resuls of a multicenter randomized study on 1400 cases]. A prospective, randomized, controlled clinical trial of tissue adhesive (2-octylcyanoacrylate) versus standard wound closure in breast surgery. [Hypothermia prevention during surgery: comparison between thermal mattress and thermal blanket]. Anesthetic Technique for Radical Prostatectomy Surgery Affects Cancer Recurrence: A Retrospective Analysis Preoperative fluid and electrolyte management with oral rehydration therapy Preoperative small-dose ketamine has no preemptive analgesic effect in patients undergoing total mastectomy. Prewarming operating rooms for prevention of intraoperative hypothermia during total knee and hip arthroplasties. Long-Acting versus Short-Acting Cephalosporins for Preoperative Prophylaxis in Breast Surgery:A Randomized Double-Blin d Trial Involving 1,766 Patients Incidence of Hematoma Complication with Heparin Venous Thrombosis Prophylaxis after TRAM Flap Breast Reconstruction Pregabalin reduces post‐operative pain after mastectomy: a double‐blind, randomized, placebo‐controlled study Anaesthesia for day case excisional breast biopsy: propofol–remifentanil compared with sevoflurane–nitrous oxide The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap Early rehabilitation reduces the onset of complications in the upper limb following breast cancer surgery. The epidemiology of wound infection. A 10-year prospective study of 62,939 wounds. Aprepitant’s Prophylactic Efficacy in Decreasing Postoperative Nausea and Vomiting in Morbidly Obese Patients Undergoing Bariatric Surgery Is pain prophylaxis in minor gynaecological surgery of clinical value? a double-blind placebo controlled study of paracetamol 1 g versus lornoxicam 8 mg given orally. Effect of Intraoperative Fluid Management on Outcome after Intraabdominal Surgery Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery. Effect of active airway warming on body core temperature during adult liver transplantation. Oral administration of aprepitant to prevent postoperative nausea in highly susceptible patients after gynecological laparoscopy Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery Magnesium sulfate infusion prevents shivering during transurethral prostatectomy with spinal anesthesia: a randomized, double-blinded, controlled study. Systemic magnesium to improve quality of post-surgical recovery in outpatient segmental mastectomy: a randomized, double-blind, placebo-controlled trial. Use of 2-Octyl-Cyanoacrylate Skin Adhesive (Dermabond) for Wound Closure following Reduction Mammaplasty: A Prospective, Randomized Intervention Study The Role of Chronic and Perioperative Glucose Management in High-Risk Surgical Closures: A Case for Tighter Glycemic Control Analgesic efficacy of diclofenac in combination with morphine and paracetamol after mastectomy and immediate breast reconstruction [Efficacy of a novel warming blanket: prospective randomized trial]. Warming with an underbody warming system reduces intraoperative hypothermia in patients undergoing laparoscopic gastrointestinal surgery: a randomized controlled study. A randomised trial of nursing interventions supporting recovery of the postmastectomy patient. Interactive Digital Education Aid in Breast Reconstruction   Prospective, Randomized, Double-Blind Trial of Local Anesthetic Infusion and Intravenous Narcotic Patient-Controlled Anesthesia Pump for Pain Management after Free TRAM Flap Breast Reconstruction Aprepitant plus Ondansetron Compared with Ondansetron Alone in Reducing Postoperative Nausea and Vomiting in Ambulatory Patients Undergoing Plastic Surgery Effect of anaesthetic technique on the natural killer cell anti-tumour activity of serum from women undergoing breast cancer surgery: a pilot study. Postoperative nausea and vomiting prophylaxis: A comparative study of ondansetron, granisetron and granisetron and dexamethasone combination after modified radical mastectomy
abstract: Background A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery ( ERAS ) programs . Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce . We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease . Methods The ERAS program was initiated in 2009 . Patients who underwent esophagectomy and were treated according to the ERAS program were included . Items of ERAS included preoperative nutrition , early extubation , early removal of nasogastric tube , and early mobilization . Primary outcome parameters were hospital stay and the incidence of postoperative complications . Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol . A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient . Results Between 2008 and August 2010 , 181 patients in our department underwent esophagectomy .  Of these , 103 patients were included in the ERAS program ( ERAS+ group ) and were compared to 78 patients who had undergone an esophagectomy in 2008 ( ERAS– group ) .  Overall hospital stay was 14 days versus 15 days ( ERAS+ and ERAS– , respectively ; p = 0.013 ) . There were no significant differences in the incidence of postoperative complications in either group . The percentage of achieved items varied between 42 and 93 % per item . Conclusions The implementation of an ERAS program in esophageal surgery was feasible and result ed in a small but significant reduction in overall hospital stay , whereas overall morbidity was not affected This study explores the experiences of and the nursing care for nine women with breast cancer undergoing immediate breast reconstruction ( IBR ) with a TRAM-flap . The study was prospect i ve and descriptive and source and method triangulation was used . Source triangulation consisted of the patients ' and nurses ' perspectives , whilst method triangulation combined interviews , question naires and medical records . One result is that the meaning of IBR for the women operated is related to feelings of hope , normality and ' wholeness ' . Another result is that not all the needs of the patients are assessed and met ; the nursing care during admission is mainly focused on the physical care and after dismissal the patients are left in a situation characterized by vulnerability and a sense of emptiness . The study points to some implication s in the means of quality development and rehabilitation BACKGROUND  Surgical complications after breast reconstruction can be associated with significant morbidity , dissatisfaction , and cost . We used the ACS-NSQIP data sets from 2005 to 2011 to derive predictors of morbidity and to stratify risk after immediate breast reconstruction ( IBR ) . STUDY DESIGN Surgical complications after implant and autologous reconstruction were assessed using the ACS-NSQIP 2005 to 2011 data sets . Patient demographics , clinical characteristics , and operative factors were associated with the likelihood of experiencing a surgical complication . A " model cohort " of 12,129 patients was r and omly selected from the study cohort to derive predictors . Weighted odds ratios derived from logistic regression analysis were used to create a composite risk score and to stratify patients . The remaining one-third of the cohort ( n = 6,065 ) were used as the " validation cohort " to assess the accuracy value of the risk model . RESULTS On adjusted analysis , autologous reconstruction ( odds ratio [ OR ] 1.41 , p < 0.001 ) , American Society of Anesthesiologists physical status ≥ 3 ( OR 1.25 , p = 0.004 ) , class I obesity ( OR 1.38 , p < 0.001 ) , class II obesity ( OR 1.91 , p < 0.001 ) , class III obesity ( OR 1.70 , p < 0.001 ) , and active smoking ( OR 1.46 , p < 0.001 ) were associated with complications . Risk factors were weighted and patients were stratified into low ( 0 to 2 , n = 9,133 , risk = 7.14 % ) , intermediate ( 3 to 4 , n = 1,935 , risk = 10.90 % ) , high ( 5 to 7 , n = 1,024 , risk = 16.70 % ) , and very high ( 8 to 9 , n = 37 , risk = 27.02 % ) risk categories based on their total risk score ( p < 0.001 ) . Internal validation of the " model cohort " using the " validation cohort " was performed demonstrating accurate prediction of risk across groups : low ( 7.1 % vs 7.1 % , respectively , p = 0.9 ) , intermediate ( 10.9 % vs 12.0 % , respectively , p = 0.38 ) , high ( 16.7 % vs 16.8 % , respectively , p = 0.95 ) , and very high ( 27.0 % vs 30.0 % , respectively , p = 1.0 ) . CONCLUSIONS Surgical complications after IBR are related to preoperatively identifiable factors that can be used to accurately risk stratify patients , which may assist with counseling , selection , and perioperative decision-making BACKGROUND Mild perioperative hypothermia , which is common during major surgery , may promote surgical-wound infection by triggering thermoregulatory vasoconstriction , which decreases subcutaneous oxygen tension . Reduced levels of oxygen in tissue impair oxidative killing by neutrophils and decrease the strength of the healing wound by reducing the deposition of collagen . Hypothermia also directly impairs immune function . We tested the hypothesis that hypothermia both increases susceptibility to surgical-wound infection and lengthens hospitalization . METHODS Two hundred patients undergoing colorectal surgery were r and omly assigned to routine intraoperative thermal care ( the hypothermia group ) or additional warming ( the normothermia group ) . The patient 's anesthetic care was st and ardized , and they were all given cefam and ole and metronidazole . In a double-blind protocol , their wounds were evaluated daily until discharge from the hospital and in the clinic after two weeks ; wounds containing culture-positive pus were considered infected . The patients ' surgeons remained unaware of the patients ' group assignments . RESULTS The mean ( + /- SD ) final intraoperative core temperature was 34.7 + /- 0.6 degrees C in the hypothermia group and 36.6 + /- 0.5 degrees C in the normothermia group ( P < 0.001 ) Surgical-wound infections were found in 18 of 96 patients assigned to hypothermia ( 19 percent ) but in only 6 of 104 patients assigned to normothermia ( 6 percent , P = 0.009 ) . The sutures were removed one day later in the patients assigned to hypothermia than in those assigned to normothermia ( P = 0.002 ) , and the duration of hospitalization was prolonged by 2.6 days ( approximately 20 percent ) in hypothermia group ( P = 0.01 ) . CONCLUSIONS Hypothermia itself may delay healing and predispose patients to wound infections . Maintaining normothermia intraoperatively is likely to decrease the incidence of infectious complications in patients undergoing colorectal resection and to shorten their hospitalizations Background The effectiveness of antibiotic prophylaxis for prevention of surgical site infection ( SSI ) following specific types of breast cancer surgery remains uncertain . This study assessed the effectiveness of prophylaxis in modified radical mastectomy  ( MRM ) . Methods Women undergoing MRM for breast cancer were recruited . Women were excluded who had diabetes mellitus , severe malnutrition or known allergy to cephalosporins ; were receiving corticosteroid therapy or were treated with antibiotics within one week prior to surgery ; were scheduled for simultaneous breast reconstruction or bilateral oophorectomy ; had existing local infection . Participants were r and omized to receive either intravenous cefazolin 1 g or placebo within 30 min prior to skin incision . St and ard skin preparation and operative technique for MRM were carried out . Wounds were assessed for SSI and other complications weekly for 30 days . Results A total of 254 women were recruited . Age , clinical stage , prior chemotherapy , and operative time were similar for antibiotic and placebo groups . The overall incidence of SSI was 14.2 % . There were no significant differences in the infection rate over the 30-day follow-up period between the placebo and antibiotic groups ( 15 % vs 13.4 % ; p = 0.719 ) or at each week . The majority of SSI were either cellulitis or superficial infection for both groups . There were no significant differences between groups in treatments required for SSI , incidence of hematoma or seroma . Conclusions The findings of this study , alone and when meta-analyzed with data from studies in similar surgical population s , do not support the use of antibiotic prophylaxis in MRM Background : Pulsed electromagnetic fields have been shown to reduce postoperative pain , inflammation , and narcotic requirements after breast reduction and augmentation surgical procedures . This study examined whether pulsed electromagnetic field therapy could produce similar results in patients undergoing unilateral transverse rectus abdominis myocutaneous ( TRAM ) flap breast reconstruction , a significantly more complex and painful surgical procedure . Methods : In this double-blind , placebo-controlled , r and omized study , 32 patients undergoing unilateral TRAM flap breast reconstruction received active or sham pulsed electromagnetic field therapy .  Pain levels were measured by using a visual analogue scale ; narcotic use and wound exu date volume were recorded starting 1 hour postoperatively . Wound exu date s were analyzed for interleukin-1&bgr;. Results : Mean visual analogue scale pain scores were 2-fold higher in the sham cohort at 5 hours and 4-fold higher at 72 hours ( p < 0.01 ) , along with a concomitant 2-fold increase in narcotic use in sham patients ( p < 0.01 ) . Wound exu date volume was 2-fold higher in the sham cohort at 24 hours ( p < 0.01 ) , and mean interleukin-1&bgr ; concentration in wound exu date s of sham patients was 5-fold higher at 24 hours ( p < 0.001 ) . Conclusions : Pulsed electromagnetic field therapy significantly reduced postoperative pain , inflammation , and narcotic use following TRAM flap breast reconstruction , paralleling its effect in breast reduction patients . Both studies also report a significant reduction of interleukin-1&bgr ; in the wound exu date , supporting a mechanism involving a pulsed electromagnetic field effect on nitric oxide/cyclic guanosine monophosphate signaling , which modulates the body ’s antiinflammatory pathways . Adjunctive pulsed electromagnetic field therapy could impact the speed and quality of wound repair in many surgical procedures . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , 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 OBJECTIVES To study the impact of different adherence levels to the enhanced recovery after surgery ( ERAS ) protocol and the effect of various ERAS elements on outcomes following major surgery . DESIGN Single-center prospect i ve cohort study before and after reinforcement of an ERAS protocol . Comparisons were made both between and across periods using multivariate logistic regression . All clinical data ( 114 variables ) were prospect ively recorded . SETTING Ersta Hospital , Stockholm , Sweden . PATIENTS Nine hundred fifty-three consecutive patients with colorectal cancer : 464 patients treated in 2002 to 2004 and 489 in 2005 to 2007 . MAIN OUTCOME MEASURES The association between improved adherence to the ERAS protocol and the incidence of postoperative symptoms , complications , and length of stay following major colorectal cancer surgery was analyzed . RESULTS Following an overall increase in preoperative and perioperative adherence to the ERAS protocol from 43.3 % in 2002 to 2004 to 70.6 % in 2005 to 2007 , both postoperative complications ( odds ratio , 0.73 ; 95 % confidence interval , 0.55 - 0.98 ) and symptoms ( odds ratio , 0.53 ; 95 % confidence interval , 0.40 - 0.70 ) declined significantly . Restriction of intravenous fluid and use of a preoperative carbohydrate drink were major independent predictors . Across periods , the proportion of adverse postoperative outcomes ( 30-day morbidity , symptoms , and readmissions ) was significantly reduced with increasing adherence to the ERAS protocol ( > 70 % , > 80 % , and > 90 % ) compared with low ERAS adherence ( < 50 % ) . CONCLUSION Improved adherence to the st and ardized multimodal ERAS protocol is significantly associated with improved clinical outcomes following major colorectal cancer surgery , indicating a dose-response relationship Background Major colorectal surgery usually requires a hospital stay of more than 12 days . Inadequate pain management , intestinal dysfunction and immobilisation are the main factors associated with delay in recovery . The present work assesses the short and medium term results achieved by an enhanced recovery program based on previously published protocol s. Methods This prospect i ve study , performed at 12 Spanish hospitals in 2008 and 2009 , involved 300 patients . All patients underwent elective colorectal resection for cancer following an enhanced recovery program .  The main elements of this program were : preoperative advice , no colon preparation , provision of carbohydrate-rich drinks one day prior and on the morning of surgery , goal directed fluid administration , body temperature control during surgery , avoiding drainages and nasogastric tubes , early mobilisation , and the taking of oral fluids in the early postoperative period . Perioperative morbidity and mortality data were collected and the length of hospital stay and protocol compliance recorded . Results The median age of the patients was 68 years . Fifty-two % of the patients were women . The distribution of patients by ASA class was : I 10 % , II 50 % and III 40 % . Sixty-four % of interventions were laparoscopic ; 15 % required conversion to laparotomy . The majority of patients underwent sigmoidectomy or right hemicolectomy .  The overall compliance to protocol was approximately 65 % , but varied widely in its different components . The median length of postoperative hospital stay was 6 days . Some 3 % of patients were readmitted to hospital after discharge ; some 7 % required repeat surgery during their initial hospitalisation or after readmission . The most common complications were surgical ( 24 % ) , followed by septic ( 11 % ) or other medical complications ( 10 % ) . Three patients ( 1 % ) died during follow-up . Some 31 % of patients suffered symptoms that delayed their discharge , the most common being vomiting or nausea ( 12 % ) , dyspnoea ( 7 % ) and fever ( 5 % ) . Conclusion The following of this enhanced recovery program posed no risk to patients in terms of morbidity , mortality and shortened the length of their hospital stay . Overall compliance to protocol was 65 % . The following of this program was of benefit to patients and reduces costs by shortening the length of hospital stay . The implantation of such programmes is therefore highly recommended BACKGROUND Surgical site infection ( SSI ) is the fourth commonest healthcare-associated infection and complicates at least 5 % of open operations . In a r and omized clinical trial , antimicrobial-coated sutures were compared with their conventional counterparts , polyglactin and poliglecaprone , for skin closure after breast cancer surgery to assess their role in reducing the rate of SSI . METHODS Between November 2008 and February 2011 , 150 female patients presenting with breast cancer to a single center were r and omized to skin closure with antimicrobial-coated or plain sutures . Postoperatively , SSI was defined using the U.S. Centers for Disease Control and Prevention ( CDC ) definitions and scored using the ASEPSIS or Southampton systems by trained , blinded observers with close post-discharge surveillance and patient diaries . Surgeons and patients were blinded to the type of suture used . RESULTS Using CDC criteria , the overall rate of SSI was 18.9 % at six weeks . Six patients ( 4.7 % ) needed intervention or readmission for SSI . Skin closure with antimicrobial sutures showed a non-statistically significant reduction in the SSI rate , to 15.2 % , compared with conventional sutures ( 22.9 % ) . A uniform tendency for fewer SSIs in the antimicrobial-coated suture group was found using ASEPSIS and Southampton scores , but again , the difference was not statistically significant . CONCLUSION The previously reported high rate of SSI related to breast surgery was confirmed . Using statistical modeling and earlier reports , the study was powered to show a difference using ASEPSIS scores , but the modification used in this trial failed to find a difference . Finding a statistically significant difference would have needed two to three times the number of patients recruited . Further evaluation of antimicrobial-coated sutures is merited , particularly if used as part of a care bundle to reduce SSI after breast cancer surgery Summary Background In this prospect i ve , r and omized , placebo-controlled , double-blinded clinical trial we tested the hypothesis that preemptive analgesia with bupivacaine applied in the area of the surgical incision in patients undergoing mastectomy for breast cancer would reduce post-operative acute pain and would reduce the amount of analgesics used during surgery and in the post-operative period . Material / Methods Participants were assigned into 1 of 2 groups – with bupivacaine applied in the area of surgical incision or with placebo . We assessed the intraoperative consumption of fentanyl , the postoperative consumption of morphine delivered using a PCA method , and the subjective pain intensity according to VAS score reported by patients in the early post-operative period . Results Out of 121 consecutive cases qualified for mastectomy , 112 women were allocated r and omly to 1 of 2 groups – group A ( bupivacaine ) and group B ( placebo ) . The final study group comprised 106 breast cancer cases . Between the groups , a statistically significant difference was observed with respect to : lower fentanyl consumption during surgery ( p=0.011 ) , lower morphine ( delivered by means of a PCA ) consumption between the 4–12th postoperative hours ( p=0.02 ) and significantly lower pain intensity assessed according to VAS score at the 4th and 12th hours after surgery ( p=0.004 and p=0.02 respectively ) for the group A patients . Conclusions Preemptive analgesia application in the form of infiltration of the area of planned surgical incisions with bupivacaine in breast cancer patients undergoing mastectomy decreases post-operative pain sensation , limits the amount of fentanyl used during surgery , and reduces the dem and for opiates in the hours soon after surgery BACKGROUND : Postoperative nausea and vomiting ( PONV ) occur commonly after craniotomy . In patients receiving prophylaxis with ondansetron and dexamethasone  , vomiting occurred in 45 % of patients at 48 hours . In addition to causing patient discomfort , the physical act of vomiting may increase intracranial pressure or cerebral intravascular pressure , jeopardizing hemostasis and cerebral perfusion . Aprepitant is a neurokin-1 receptor antagonist with a long duration of action and no sedative side effect . In a large multicenter study in patients undergoing abdominal surgery , aprepitant was significantly more effective than was ondansetron in preventing vomiting at 24 and 48 hours postoperatively . We hypothesized that the combination of aprepitant with dexamethasone will decrease the incidence of postoperative vomiting when compared with the combination of ondansetron and dexamethasone in patients undergoing craniotomy under general anesthesia . METHODS : Patients scheduled to undergo craniotomy under general anesthesia were enrolled in this prospect i ve , double-blind , r and omized study . Patients were r and omized to receive oral aprepitant 40 mg ( or matching placebo ) 1 to 3 hours before induction of anesthesia or ondansetron 4 mg IV ( or placebo ) within 30 minutes of the end of surgery . All patients received dexamethasone 10 mg after induction of anesthesia . The anesthetic technique was st and ardized . Data were collected at regular intervals by blinded personnel for 48 hours after surgery . Statistical analysis was performed using Wilcoxon 's ranked sum test and & khgr;2 test . P < 0.05 was considered statistically significant . RESULTS : One hundred four patients completed the study . The cumulative incidence of vomiting at 48 hours was 16 % in the aprepitant group and 38 % in the ondansetron group ( P = 0.0149 ) . The incidence of vomiting was also decreased in the aprepitant group at 2 hours ( 6 % vs. 21 % , P = 0.0419 ) and 24 hours ( 14 % vs. 36 % , P = 0.0124 ) . From 0 to 48 hours , there was no difference between the aprepitant and ondansetron groups in the incidence of nausea ( 69 % vs. 60 % ) , nausea scores , need for rescue antiemetics ( 65 % vs. 60 % ) , complete response ( no PONV and no rescue , 22 % vs. 36 % ) , or patient satisfaction with the management of PONV . CONCLUSION : The combination of aprepitant and dexamethasone was more effective than was the combination of ondansetron and dexamethasone for prophylaxis against postoperative vomiting in adult patients undergoing craniotomy under general anesthesia .  However , there was no difference between the groups in the incidence or severity of nausea , need for rescue antiemetics , or in complete response between the groups PURPOSE To evaluate the accuracy of magnetic resonance angiography ( MRA ) for preoperative mapping of rectus and gluteal muscle perforating arteries prior to autologous flap breast reconstruction . MATERIAL S AND METHODS Preoperative MRA on 25 consecutive patients undergoing perforator artery-based autologous breast reconstruction  was performed at 1.5 T using 3D liver accelerate volume acquisition ( LAVA ) of abdominal or gluteal regions acquired during injection of 20 mL of gadobenate dimeglumine with bolus timing optimized using MR fluoroscopy or SmartPrep . Perforator artery size and coordinates relative to umbilicus or top of gluteal crease on 3D MRA were compared to findings at surgery . Reconstructed breast volume estimates from MRA were also compared to weights at harvesting . RESULTS In all , 132 perforator arteries were found at surgery to be located within 1 cm of the coordinates measured on MRA and were surgically verified to be suitable for flap perfusion . Surgery verified the arterial course and caliber through the rectus and gluteal muscles visualized on MRA in 48 of 49 arteries . Volume rendering of 3D MRA predicted a breast reconstruction volume with a mean difference of 47 g compared to measurements at harvesting . CONCLUSION MRA accurately maps rectus and gluteal muscle perforator arteries for preoperative planning of autologous flaps for breast reconstruction BACKGROUND Obesity is a growing epidemic in the United States ( US ) affecting more than 33 % of adults . We aim ed to use the World Health Organization ( WHO ) obesity stratification scheme to assess the overall risk of obese patients undergoing breast reconstruction using the ACS-NSQIP data base from 2005 to 2010 . STUDY DESIGN We review ed the 2005 to 2010 ACS-NSQIP data bases identifying encounters for Current Procedural Terminology ( CPT ) codes including either implant-based reconstruction ( immediate , delayed , and tissue exp and er ) or autologous reconstruction ( pedicled transverse rectus abdominis myocutaneous [ pTRAM ] , free TRAM , and latissimus dorsi flap with or without implant ) .  Patients were classified and compared based on WHO obesity criteria : nonobese ( body mass index [ BMI ] = 20 to 29.9 kg/m(2 ) ) , class I ( BMI = 30 to 34.9 kg/m(2 ) ) , class II ( BMI = 35 to 39.9 kg/m(2 ) ) , and class III ( BMI > 40 kg/m(2 ) ) . RESULTS During the study period 15,937 breast reconstructions were performed . The majority of reconstructions were immediate reconstructions ( 85.0 % ) and implant-based ( 79.1 % ) . The incidence of obesity was 27.1 % , with 16.3 % defined as class I obese , 6.9 % defined as class II obese , and 4.0 % defined as class III obese . The WHO-classified obese patients tended to have a progressively higher incidence of comorbid conditions , higher American Society of Anesthesiologists ( ASA ) physical status ( p < 0.001 ) , longer operative times ( p = 0.0001 ) , and greater lengths of hospital stay ( p = 0.0001 ) . Progressively higher BMI s were associated with higher rates of complications , including wound ( p < 0.001 ) , medical ( p < 0.001 ) , infections ( p < 0.001 ) , major surgical ( p < 0.001 ) , graft and prosthesis loss ( p < 0.001 ) , and return to the operating room ( p < 0.001 ) . CONCLUSIONS This study characterized the effect of progressive obesity on the incidence of surgical and medical complications after breast reconstruction using a large , prospect i ve multicenter data set . Increasing obesity is associated with increased perioperative morbidity . Data derived from this cohort study can be used to risk-stratify patients , enhance risk counseling , and advocate for institutional reimbursement in obese patients undergoing breast reconstruction Background This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery , and to provide grade d recommendations for items for an evidence d-based enhanced recovery protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omized 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 ( evidence grade : high or moderate ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , European Society for Clinical Nutrition and Metabolism ( ESPEN ) and International Association for Surgical Metabolism and Nutrition ( IASMEN ) present a comprehensive evidence -based consensus review of perioperative care for rectal surgery OBJECTIVE To explore whether perioperative intravenous flurbiprofen axetil can reduce the incidence and intensity of chronic pain for breast cancer after surgical treatment . METHODS This r and omized , double-blind , controlled trial enrolled 60 patients undergoing mastectomy and axillary lymph node dissection under general anesthesia . All patients accepted Hospital Anxiety and Depression Scale ( HAD ) tests the day before the surgery to evaluate depression and anxiety . The patients were r and omly assigned to receive either 50 mg flurbiprofen axetil intravenously 15 minutes before the surgical incision and 6 hours later ( group F ) or intravenous 5 mL intralipid as a control ( group C ) . All patients received patient-controlled intravenous analgesia ( PCIA ) with fentanyl postoperatively . Peripheral venous blood sample s were drawn before the surgery , at 4 and 24 h after the surgery to detect the plasma level of PGE2 and tumor necrosis factor-α ( TNF-α ) . Postoperative fentanyl consumption , Numerical Rating Scale ( NRS ) scores and adverse effects were recorded at 2 , 6 , 12 , 24 and 48 h after the surgery . The duration and intensity of pain were followed up by telephone at the 2nd-12th month after the surgery . RESULTS The incidence of pain at 2 , 4 , 6 , and 12 months after the breast surgery was 33 % , 20 % , 15 % , and 10 % , respectively , and the average pain score was 0.77 , 0.57 , 0.28 , and 0.18 , respectively . Compared with group C , the scores of pain in group F were significantly lower at 2 , 4 , 6 and 12 months postoperatively ( F=7.758 , P=0.007 ) . The incidence of pain in group F was significantly lower at 2 , 4 and 6 months postoperatively ( P<0.05 ) . There was no significant difference in the incidence of pain between the groups at 12 months postoperatively ( P>0.05 ) . Preoperatively and at 4 and 24 h after the surgery , there was no significant difference in the level of TNF-α between the two groups ( F=0.530 , P=0.470 ) ; but plasma concentration of PGE2 in group F was significantly lower than that in group C ( F=5.646 , P=0.021 ) . No patients developed abnormal bleeding , peptic ulcer , impaired liver or renal function and respiratory depression . CONCLUSION Perioperative intravenous infusion of 100 mg flurbiprofen axetil can decrease the intensity and incidence of chronic pain for breast cancer after surgical treatment Background and Objectives Patients undergoing breast cancer surgery frequently experience chronic postoperative pain . The primary objective of this r and omized study was to determine if thoracic paravertebral block ( TPVB ) reduced the incidence of chronic pain after a modified radical mastectomy ( MRM ) when compared with general anesthesia ( GA ) . Methods One hundred eighty women undergoing MRM were r and omized to 1 of 3 study groups : group 1 : st and ardized GA , group 2 : GA with a single-injection TPVB and placebo paravertebral infusion , and group 3 : GA with a continuous TPVB . Outcomes assessed postoperatively included acute postoperative pain and analgesic consumption and , at 3 and 6 months , the incidence and severity of chronic pain and physical and mental health-related quality of life ( HRQOL ) . Results There was no significant difference in the incidence of chronic pain at 3 months ( P = 0.13 ) and 6 months ( P = 0.79 ) after the MRM between the study groups . The relative risk of developing chronic pain ( P = 0.25 ) was also similar between the groups . There was no difference in acute pain ( P = 0.22 ) or postoperative analgesic consumption ( P = 0.67 ) between the groups . Nevertheless , differences were observed in chronic pain – related secondary outcome variables . The TPVB groups reported lower chronic pain scores ( P < 0.05 ) , exhibited fewer symptoms and signs of chronic pain ( P ⩽ 0.01 ) , and also experienced better physical and mental HRQOL than did the GA group . Chronic pain scores also decreased with time in all study groups ( P < 0.05 ) . Conclusions There is no significant difference in the incidence or relative risk of chronic pain at 3 and 6 months after an MRM when TPVB is used in conjunction with GA . Nevertheless , patients who receive a TPVB report less severe chronic pain , exhibit fewer symptoms and signs of chronic pain , and also experience better physical and mental HRQOL Enhanced recovery programmes ( ERPs ) have been shown to reduce length of hospital stay ( LOS ) and complications in colorectal surgery . Whether ERPs have the same benefits in open liver resection surgery is unclear , and r and omized clinical trials are lacking Background : Technological innovations are often adopted before scientific comparison to an accepted st and ard . The authors ' study compared suture with a new coaptive film device , 3 M Steri-Strip S Surgical Skin Closure , on linear incisions . Methods : Patients undergoing Wise-pattern breast reduction or abdominal procedures had paired incisions r and omly assigned to Steri-Strip S or suture closure . Key outcome measures were closure time , patient comfort , and scar quality at 6 months by patients and surgeons using a new scar evaluation tool , visual assessment of linear scars . Statistical differences between the two closure techniques were assessed by Wilcoxon signed rank test . Results : Of 59 patients , eight were excluded from r and omization ( a surgeon judged Steri-Strip S to be a nonviable closure technique for mismatched wound edges ) . Fifty-one patients ( breast , n = 24 ; abdomen , n = 27 ) were r and omized .  Operative time with Steri-Strip S for breast was 2.0 minutes ( SD = 1.1 ) versus suture closure at 4.6 minutes ( SD = 1.5 ; p < 0.001 ) . Similarly , Steri-Strip S versus suture for the abdomen was faster ( p < 0.001 ; 4.9 minutes , SD = 2.3 versus 10.1 minutes , SD = 3.4 ) . Comfort scores did not differ between closures [ 5.8 ( SD = 2.7 ) versus 6.9 ( SD = 2.0 ) , respectively , on breast ( p = 0.142 ) and 7.7 ( SD = 1.8 ) versus 7.7 ( SD = 2.3 ) on abdomen ( p = 0.903 ) ] . Complication rates did not differ between closure types . Patients ' visual assessment of linear scars rating of breasts was 3.8 ( SD = 2.9 ) for Steri-Strip S and better at 2.6 ( SD = 2.9 ) for suture ( p = 0.008 ) . One surgeon rated breast Steri-Strip S scars worse than suture scars ( 4.3 versus 3.7 ; p = 0.014 ) . For abdominal scars , there was no difference in the patient or surgeon ratings . Conclusions : Steri-Strip S permits faster wound closure than suture . On the basis of patient reports of comfort and scar quality , surgeons increase efficiency and maintain quality with the use of Steri-Strip S on abdominal wounds but not on breast wounds PURPOSE To compare the clinical efficacy of warmed irrigation fluid and room-temperature fluid in decreasing perioperative hypothermia during arthroscopic rotator cuff surgery . METHODS In this prospect i ve , r and omized , comparative study , warmed ( 36 ° C ) arthroscopic irrigation fluid ( group W , n = 36 ) or room-temperature irrigation fluid ( group RT , n = 36 ) was used without intraoperative warming devices  during arthroscopic shoulder surgery in 72 patients . The serial core body temperature and the last and lowest core body temperatures were measured by use of an esophageal stethoscope with a thermometer and a digital tympanic thermometer at 15-minute intervals during the operation and recovery period , respectively . When patients arrived in the postanesthesia care unit ( PACU ) after surgery , they were warmed immediately and monitored thereafter for body temperature and development of hypothermia-related adverse effects such as postoperative shivering and cardiac events . We evaluated the changes in the patients ' weight and prothrombin time on postoperative day 1 and the hemoglobin level and visual analog scale pain score immediately after the operation and on postoperative day 1 . RESULTS The 2 groups did not differ in demographic and surgical data and incidence of intraoperative hypothermia ( 33 of 36 [ 91.6 % ] in group RT and 34 of 36 [ 94.4 % ] in group W , P = .276 ) . The core body temperatures decreased throughout the surgery and increased linearly in the PACU , without any intergroup differences ( P > .05 ) . All patients were normothermic within 1 hour of arrival in the PACU . The 2 groups did not differ in postoperative weight change , prothrombin time , hemoglobin level , or postoperative visual analog scale pain score ( all P > .05 ) . Postoperative shivering occurred in 3 patients and 1 patient in group RT and group W , respectively . No cardiac events occurred in either group . CONCLUSIONS Warmed irrigation fluid was not superior to room-temperature irrigation fluid in reducing the occurrence of perioperative hypothermia during arthroscopic shoulder surgery . LEVEL OF EVIDENCE Level I , r and omized controlled trial BACKGROUND The primary objective of this multicenter post-market study was to compare the cosmetic outcome of triclosan-coated VICRYL Plus sutures with Chinese silk sutures for skin closure of modified radical mastectomy . A secondary objective was to assess the incidence of surgical site infection ( SSI ) . METHODS Patients undergoing modified radical mastectomy were r and omly assigned to coated VICRYL Plus antibacterial ( Polyglactin 910 ) suture or Chinese silk suture .  Cosmetic outcomes were evaluated postoperatively at days 12 ( ± 2 ) and 30 ( ± 5 ) , and the evidence of SSI was assessed at days 3 , 5 , 7 , 12 ( ± 2 ) , 30 ( ± 5 ) , and 90 ( ± 7 ) . Cosmetic outcomes were independently assessed via visual analogue scale ( VAS ) score evaluations of blinded incision photographs ( primary endpoint ) and surgeon-assessed modified Holl and er Scale ( mHCS ) scores ( secondary endpoint ) . SSI assessment s used both CDC criteria and ASEPSIS scores . RESULTS Six Chinese hospitals r and omized 101 women undergoing modified radical mastectomy to closure with coated VICRYL Plus suture ( n = 51 ) or Chinese silk suture ( n = 50 ) . Mean VAS cosmetic outcome scores for antibacterial suture ( 67.2 ) were better than for Chinese silk ( 45.4 ) at day 30 ( P < 0.0001 ) ) . Mean mHCS cosmetic outcome total scores , were also higher for antibacterial suture ( 5.7 ) than for Chinese silk ( 5.0 ) at day 30 ( P = 0.002 ) . CONCLUSIONS Patients using coated VICRYL Plus suture had significantly better cosmetic outcomes than those with Chinese silk sutures . Patients using coated VICRYL Plus suture had a lower SSI incidence compared to the Chinese silk sutures , although the difference did not reach statistical significance The authors report the results of a multicenter prospect i ve study evaluating a novel technology : dermal suture using absorbable staples composed of polylactic and polyglycolic acids . From January to June 2009 , 59  dermal sutures  were performed with Insorb absorbable staples and 41 with absorbable thread .  All patients in the study underwent abdominal dermolipectomy ( N = 65 ) or surgery for breast hypertrophy ( N = 35 ) . The purpose of the study was to compare the closure time and healing quality obtained with the 2 methods . Ninety-five patients were reexamined by the surgeon after 1 year of follow-up to assess scar width , suppleness , inflammation , and hypertrophy . The overall results were good and quite similar for the 2 groups . Thus , the use of Insorb staples reduced closure time while ensuring good healing quality We conducted a r and omised controlled trial to compare the efficacy of underbody forced‐air warming ( Arizant Healthcare Inc , Eden Prairie , MN , USA ) with an underbody resistive heating mattress ( Inditherm Patient Warming System , Rotherham , UK ) and passive insulation in 129 patients having hypothermic cardiac surgery with cardiopulmonary bypass . Patients were separated from cardiopulmonary bypass at a core temperature of 35 ° C and external warming continued until the end of surgery . Before cardiopulmonary bypass , the temperature‐vs‐time slopes were significantly greater in both active warming groups than in the passive insulation group ( p < 0.001 for each ) . However , the slopes of forced‐air and resistive warming did not differ ( p = 0.55 ) . After cardiopulmonary bypass , the rate of rewarming was significantly greater with forced‐air than with resistive warming or passive insulation ( p < 0.001 for each ) , while resistive warming did not differ from passive insulation ( p = 0.14 ) . However , absolute temperature differences among the groups were small Purpose Breast cancer survivors who make preference-sensitive decisions about postmastectomy breast reconstruction often have large gaps in knowledge and undergo procedures that are misaligned with their treatment goals . We evaluated the feasibility and effect of a pre-consultation educational group intervention on the decision-making process for breast reconstruction . Methods We conducted a pilot r and omized controlled trial ( RCT ) where participants were r and omly assigned to the intervention with routine education or routine education alone .  The outcomes evaluated were decisional conflict , decision self-efficacy , satisfaction with information , perceived involvement in care , and uptake of reconstruction following surgical consultation . Trial feasibility and acceptability were evaluated , and effect sizes were calculated to determine the primary outcome for the full-scale RCT . Results Of the 41 patients enrolled , recruitment rate was 72 % , treatment fidelity was 98 % , and retention rate was 95 % . The Cohen ’s d effect size in reduction of decisional conflict was moderate to high for the intervention group compared to routine education ( 0.69 , 95 % CI = 0.02–1.42 ) , while the effect sizes of increase in decision self-efficacy ( 0.05 , 95 % CI = −0.60–0.71 ) and satisfaction with information ( 0.11 , 95 % CI = −0.53–0.76 ) were small . A higher proportion of patients receiving routine education signed informed consent to undergo breast reconstruction ( 14/20 or 70 % ) compared to the intervention group ( 8/21 or 38 % ) P = 0.06 . Conclusions A pre-consultation educational group intervention  improves patients ’ shared decision-making quality compared to routine preoperative patient education . A full-scale definitive RCT is warranted based on high feasibility outcomes , and the primary outcome for the main trial will be decisional conflict Increased experience with free-tissue transfer has minimized flap loss secondary to microvascular thrombosis , yet pharmacologic antithrombotic prophylaxis continues to be used routinely . Currently there is no consensus on the ideal pharmacologic agent , dosing , or efficacy . Low-molecular-weight dextran has been widely used for prophylaxis due to its properties of volume expansion and enhanced microrheology . Significant systemic morbidity ( pulmonary morbidity , cardiac morbidity , anaphylaxis ) is known to occur with use of low-molecular-weight dextran . The purpose of this study was to evaluate morbidity associated with postoperative low-molecular-weight dextran and aspirin prophylaxis in head and neck microsurgery patients . This study was a r and omized prospect i ve analysis of 100 consecutive patients undergoing microvascular reconstruction for head and neck malignancy during a 2-year period . Patients were r and omized into one of three postoperative antithrombotic prophylaxis treatment groups : low-molecular-weight dextran 20 cc/hour for 48 hours ( n = 35 ) , low-molecular-weight dextran 20 cc/hour for 120 hours ( n = 32 ) , or aspirin 325 mg/day for 120 hours ( n = 27 ) . Six patients were excluded intraoperatively due to the need for systemic heparin therapy . Treatment groups were compared for age , sex , prior medical problems , duration of anesthesia , and intraoperative fluid intake . Flap outcome and the incidence of local and systemic complications were evaluated in the treatment groups . Patient ages ranged from 12 to 84 years ( mean age , 58 years ) . No significant difference was found among the treatment groups with respect to age , sex , prior medical problems , duration of anesthesia , intraoperative fluid intake , and the distribution of donor and recipient sites . There were no total flap losses and two partial flap losses in this series . Three flaps were reexplored and all were salvaged . The incidence of systemic complications ( congestive heart failure , myocardial infa rct ion , pulmonary edema , pleural effusion , and pneumonia ) was as follows : low-molecular-weight dextran 120 hours , 51 percent ; low-molecular-weight dextran 48 hours , 29 percent ; and aspirin , 7 percent . Analysis of these data suggests that the method of prophylaxis had no effect on overall flap survival . However , the incidence of systemic complications was significantly related to the method of prophylaxis , with patients receiving low-molecular-weight dextran 120 hours and 48 hours at a 7.2 and 3.9 times greater relative risk , respectively , of developing a systemic complication compared with patients receiving aspirin . The results of this study have eliminated the routine use of low-molecular-weight dextran prophylaxis at our institution in an effort to reduce morbidity in head and neck microsurgical reconstruction Objectives Postmastectomy pain syndrome is a neuropathic pain syndrome that is known to develop after breast surgery . Preemptive analgesia has been shown to be efficacious in reducing postoperative pain , and may be effective in reducing the incidence of certain types of neuropathic pain . We investigated the analgesic efficacy of Venlafaxine and gabapentin on acute and chronic pain associated with cancer breast surgery . Patients and Methods The study was carried out on 150 patients scheduled for either partial or radical mastectomy with axillary dissection . They were r and omized in a double-blinded manner to receive , extended release Venlafaxine 37.5 mg/d , gabapentin 300 mg/d , or placebo for 10 days starting the night before operation . Pain scores were recorded at rest and movement ( visual analog scale ) at 4 , 12 , and 24 hours on the first day postoperatively , daily from the second to tenth day postoperatively and visual analog scale in addition to pain character 6 months later . Analgesic requirements were compared between the 3 groups . Results Pain after movement was reduced by gabapentin from the second to tenth postoperative day and venlafaxine group in the last 3 days but no difference was found between the groups regarding pain during rest . Gabapentin reduced morphine consumed in the first 24 hours postoperatively . The analgesic requirements from the second to tenth days for codeine and paracetamol were reduced in venlafaxine and gabapentin groups compared to the control group . Six months later , the incidence of chronic pain , its intensity , and need for analgesics were reduced in venlafaxine compared to gabapentin and the placebo group . However , burning pain was more frequent in the control groups than in the gabapentin . Conclusion Venlafaxine 37.5 mg/d extended release or gabapentin 300 mg/d have equipotent effects ( except on the first day in venlafaxine group ) in reducing analgesic requirements , although gabapentin is more effective in reducing pain after movement . Venlafaxine significantly reduced the incidence of postmastectomy pain syndromes ( chronic pain ) 6 months in women having breast cancer surgery . Gabapentin had no effect on chronic pain except decreasing incidence of burning pain Abstract Immediate breast implant reconstruction has among the highest incidence of infections in plastic surgery . A literature search returned key articles that showed a significant decrease in surgical-site infections by performing nasal swab evaluation to treat methicillin-sensitive and methicillin-resistant Staphylococcus aureus before surgery with mupirocin nasal ointment and 5 days of chlorhexidine scrub to the surgical area . Additional Level 1 data supported the use of chlorhexidine-alcohol over povidone-iodine solutions for skin preparation . Intraoperative data on breast pocket irrigation showed the benefits of povidone-iodine as well as a triple antibiotic solution . Nasal swabs from 120 patients showed no methicillin-resistant S. aureus but did identify 10 patients with methicillin-sensitive S. aureus , 1 with streptococcus , and 3 with gram-negative rods , which changed perioperative antibiotic management . On the basis of the previously mentioned data , an evidence -based protocol for infection control was developed to potentially decrease infection rates . Further cost and efficacy data are warranted 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 Introduction Despite recent interest in measurement of  central venous oxygen saturation ( ScvO2 ) , there are no published data describing the pattern of ScvO2 changes after major general surgery or any relationship with outcome . Methods  ScvO2 and other biochemical , physiological and demographic data were prospect ively measured for 8 hours after major  surgery  .  Complications and deaths occurring within 28 days of enrolment were included in the data analysis . Independent predictors of complications were identified with the use of logistic regression analysis . Optimum cutoffs for ScvO2 were identified by receiver operator characteristic analysis . Results Data from 118 patients was analysed ; 123 morbidity  episodes occurred in 64 these patients . There were 12 deaths ( 10.2 % ) . The mean ± SD age was 66.8 ± 11.4 years . Twenty patients ( 17 % ) underwent emergency surgery and 77 patients ( 66 % ) were male . The mean ± SD P-POSSUM ( Portsmouth Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity ) score was 38.6 ± 7.7 , with a predicted mortality of 16.7 ± 17.6 % . After multivariate analysis , the lowest cardiac index value ( odds ratio ( OR ) 0.58 ( 95 % confidence intervals 0.37 to 0.9 ) ; p = 0.018 ) , lowest ScvO2 value ( OR 0.94 ( 0.89 to 0.98 ) ; p = 0.007 ) and P-POSSUM score ( OR 1.09 ( 1.02 to 1.15 ) ; p = 0.008 ) were independently associated with post-operative complications . The optimal ScvO2 cutoff value for morbidity prediction was 64.4 % . In the first hour after surgery , significant reductions in ScvO2 were observed , but there were no significant changes in CI or oxygen delivery index during the same period . ConclusionS ignificant fluctuations in ScvO2 occur in the immediate post-operative period . These fluctuations are not always associated with changes in oxygen delivery , suggesting that oxygen consumption is also an important determinant of ScvO2 . Reductions in ScvO2 are independently associated with post-operative complications Background Dexamethasone has been reported to reduce postoperative symptoms after different surgical procedures . We evaluated the efficacy of preoperative dexamethasone in ameliorating postoperative nausea and vomiting ( PONV ) , and pain  after mastectomy . Methods In this prospect i ve , double-blind , placebo-controlled study , 70 patients scheduled for mastectomy with axillary lymph node dissection were analyzed after r and omization to treatment with 8 mg intravenous dexamethasone ( n = 35 ) or placebo ( n = 35 ) . All patients underwent st and ardized procedures for general anesthesia and surgery . Episodes of PONV and pain score were recorded on a visual analogue scale . Analgesic and antiemetic requirements were also recorded . Results Demographic and medical variables were similar between groups . The incidence of PONV was lower in the dexamethasone group at the early postoperative evaluation ( 28.6 % vs. 60 % ; p = 0.02 ) and at 6 h ( 17.2 % vs. 45.8 % ; p = 0.03 ) . More patients in the placebo group required additional antiemetic medication ( 21 vs. 8 ; p = 0.01 ) . Dexamethasone treatment significantly reduced postoperative pain just after surgery ( VAS score , 4.54 ± 1.55 vs. 5.83 ± 2.00 ; p = 0.004 ) , at 6 h ( 3.03 ± 1.20 vs. 4.17 ± 1.24 ; p < 0.0005 ) and at 12 h ( 2.09 ± 0.85 vs. 2.54 ± 0.98 ; p = 0.04 ) . Analgesics were required in more patients of the control group ( 21 vs. 10 ; p = 0.008 ) . There were no adverse events , morbidity or mortality . Conclusions Preoperative intravenous dexamethasone ( 8 mg ) can significantly reduce the incidence of PONV and pain in patients undergoing mastectomy with axillary dissection for breast cancer . Trial registration Background One of the major risk variables for surgical site infection is wound management . Underst and ing infection risk factors for breast operations is essential in order to develop infection-prevention strategies and improve surgical outcomes . The aim of this trial is to assess the influence of  dressing wear time on surgical site infection rates and skin colonization . Patients ’ perception at self- assessment will also be analyzed . Methods / Design This is a two-arm r and omized controlled trial . Two hundred breast cancer patients undergoing immediate or delayed breast reconstruction will be prospect ively enrolled . Patients will be r and omly allocated to group I ( dressing removed on postoperative day one ) or group II ( dressing removed on postoperative day six ) . Surgical site infections will be defined by st and ard criteria from the Centers for Disease Control and Prevention ( CDC ) . Skin colonization will be assessed by culture of sample s collected at predefined time points . Patients will score dressing wear time with regard to safety , comfort and convenience . Discussion The evidence to support dressing st and ards for breast surgery wounds is empiric and scarce . CDC recommends protecting , with a sterile dressing for 24 to 48 hours postoperatively , a primarily closed incision , but there is no recommendation to cover this kind of incision beyond 48 hours , or on the appropriate time to shower or bathe with an uncovered incision . The results of the ongoing trial may support st and ard recommendations regarding dressing wear time after breast reconstruction . Trial registration Clinical Trials.gov identifier : http://www . clinical trials.gov/ct2/ results ? term = NCT01148823 BACKGROUND In the immediate postoperative period surgical breast cancer patients can face many problems including functional limitation of the shoulder , edema , pain and depression . Although those symptoms can alleviate during the stages of the therapeutic route , most of the time concur significantly to the everyday life discomforts decreasing sharply the quality of life . Therefore , is essential to pay attention to the functional problems of breast cancer patients in order to ensure a quick and complete physical and psychosocial recovery . AIM Aim of this study , comparing 2 groups of patients , one that underwent to  early physical rehabilitation program ( EPRP ) and one as a control group , is to evaluate : functional improvements of the glenohumeral joint mobility , antalgic effect of EPRP , improvements and /or worsening of quality of life . DESIGN R and omized controlled study . SETTING Inpatient and outpatient clinic , Breast Unit , " San Giuseppe Moscati " Hospital , Avellino , Italy . POPULATION Seventy women planned for Madden 's modified radical mastectomy or for segmental mastectomy with axillary dissection in the period from March 2010 to February 2011 . METHODS Patients were r and omly assigned to treated and control group . All participants were evaluated before surgery and postoperatively at fifth day , first , sixth and twelfth month . Patients of the treated group , underwent first , to assisted cautious mobilization of h and , wrist and elbow and after drainage removal , to twenty physiotherapy sessions under the guide of a physiotherapist . RESULTS Within group statistical analysis evidence d that TG regained normal function at 1 year after surgery while CG was unable to do so for flexion , abduction and internal rotation movements . TG manifested general and statistically significative improvements in QoL. Improvements in the grade of pain perceived were observed starting from the first postoperative month . CONCLUSION Postoperative early physical rehabilitation programme in surgical breast cancer patients surgically treated significantly improves glenohumeral joint mobility , reduces pain and widely improves the quality of life . CLINICAL REHABILITATION IMPACT Early rehabilitation plays a key role in the physical and psycho-social recovery for breast cancer patients surgically treated with axillary dissection BACKGROUND Smokers are at higher risk of cardiopulmonary and wound-related postoperative complications than non-smokers . Our aim was to investigate the effect of preoperative smoking intervention on the frequency of postoperative complications in patients undergoing hip and knee replacement . METHODS We did a r and omised trial in three hospitals in Denmark . 120 patients were r and omly assigned 6 - 8 weeks before scheduled surgery to either the  control ( n=60 ) or smoking intervention ( 60 ) group .  Smoking intervention was counselling and nicotine replacement therapy , and either smoking cessation or at least 50 % smoking reduction . An assessor , who was masked to the intervention , registered the occurrence of cardiopulmonary , renal , neurological , or surgical complications and duration of hospital admittance . The main analysis was by intention to treat . FINDINGS Eight controls and four patients from the intervention group were excluded from the final analysis because their operations were either postponed or cancelled . Thus , 52 and 56 patients , respectively , were analysed for outcome . The overall complication rate was 18 % in the smoking intervention group and 52 % in controls ( p=0.0003 ) . The most significant effects of intervention were seen for wound-related complications ( 5 % vs 31 % , p=0.001 ) , cardiovascular complications ( 0 % vs 10 % , p=0.08 ) , and secondary surgery ( 4 % vs 15 % , p=0.07 ) . The median length of stay was 11 days ( range 7 - 55 ) in the intervention group and 13 days ( 8 - 65 ) in the control group . INTERPRETATION An effective smoking intervention programme 6 - 8 weeks before surgery reduces postoperative morbidity , and we recommend , on the basis of our results , this programme be adopted Purpose Previous studies have demonstrated that amino acid infusions exert enhanced thermogenic effects during general anesthesia . This study was conducted to investigate whether amino acid infusions started after development of intraoperative core hypothermia can accelerate rewarming . Methods Twenty-two patients scheduled for major abdominal surgery were included in this study . When tympanic temperature reached 35.5 ° C , patients were r and omly assigned to receive amino acids ( amino acid group ; n = 11 ) or saline ( saline group ; n = 11 ) . A continuous infusion of a mixture of 18 amino acids or saline was started at 200 ml h−1 . Tympanic , forearm , and digit temperatures were recorded . Forearm minus fingertip skin-surface temperature gradients ( temperature gradient ) were calculated . Postoperative shivering was also evaluated . Results Tympanic membrane temperature and temperature gradient were similar between the two groups at each time point during the study period . Temperature gradient at extubation in the amino acid group was significantly lower than in the saline group although tympanic temperature at extubation was similar between the two groups . Postoperative shivering score was significantly lower in the amino acid group than in the saline group . Conclusions Amino acid infusions started after development of intraoperative core hypothermia failed to accelerate rewarming . However , amino acid infusions reduced the incidence of postoperative shivering . Use of amino acid infusions to reduce thermoregulatory vasoconstriction at emergence might contribute to a decrease in the development of postoperative shivering Not enough fluid and too much fluid are both bad . That is the one great irrefutable truth in fluid management in anaesthesia and in the critically ill . For almost every other question in fluid therapy there is ‘ current opinion ’ . The big questions are when , where , which and why but of greater moment than all of these is ‘ how much ’ . The current drift towards the use of smaller volumes of fluid in major surgery suggests that the right amount at the right time is probably the way to go , so volume and timing are seemingly linked . This ties in neatly with the rediscovery of the notion that early fluid resuscitation in the emergency room is better than late and dovetails with the concept that adequate resuscitation , or optimisation , improves outcome in high risk surgery . New gadgets that help to achieve this end abound since the pulmonary artery catheter fell from grace . The recent discovery of hyperchloraemic acidosis as a new iatrogenic disease entity has focused attention on the importance of the fundamental constituents of the fluids that are given [ 1 ] . The meta-analytical cloud that the Cochrane collaboration placed over albumin was dissipated by the SAFE study only to be replaced by a different evidential cloud drifting over the world of starches [ 2 ] . This has reawakened interest in the potentially malevolent nature of synthetic molecules . As the dynamics of the questions and current answers change , it is easy to become confused . The publication of the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients could therefore not be more timely [ 3 ] . The authors have asked a very large number of relevant questions , assessed a vast array of available information and measured it with an evidence -based score to produce recommendations bundled into guidelines . There are no less than 28 evidence -scored recommendations to assist in fluid management . This major work should be m and atory reading for anyone involved in fluid management for a range of reasons that will come clear . The recommendations , all 28 of them , each has an evidence level of between 1 and 5 , although some have several evidence levels for different parts of the same question . In brief ; level 1 is very good , 1a – a systematic review or 1b a r and omised control trial , while level 4 is a case series and level 5 is expert opinion without critical appraisal , so ‘ 1 – good and 5 – bad ’ . The first recommendation dismisses normal saline from routine use because it causes hyperchloraemic acidosis , and advocates balanced solutions . The evidence level is 1b and appears to be very good using no fewer than seven papers . On closer scrutiny some of these are small r and omised controlled trials which demonstrate mild acidosis [ 4–9 ] . Saline and hyperchloraemic acidosis are associated and by implication this is harmful , although any evidence for harm is circumstantial and inconsequential [ 10 ] . The recommendation , supportive of balanced solutions , is inappropriate given the limited evidence ( this author ’s opinion – level 5 ) . Sensible maybe , but evidence -based ? To be fair , many of the recommendations have been st and ard practice for years and , paradoxically , several of these are level 5 . The pre-operative recommendations may raise eyebrows . Most anaesthetists know that fluids can be given orally up to 2 h pre-operatively but how many actively encourage it despite the evidence level of 1a ? The implication is there should be a general and active move to 2-h fluid fasting . These guidelines are based on three references , two of which are themselves guidelines and one being a Cochrane review . The fact that fluids make patients feel better is supported by trials and rates an evidence level of 2a . Curiously , the guidelines contain useful tips on the current position of bowel preparation , grade d level 1a , while the predicted fluid and electrolyte disturbance which it causes only achieves level 5 . Mind you , using a parachute when jumping out of an aircraft presumably only gets a score of 4 [ 11 ] . It is curious that the Geigy Scientific tables for the electrolyte content of secretions rates level 5 while the Hartmann ’s vs saline question in the replacement of gastric losses rates level 2a , again largely because saline is associated with hyperchloraemic acidosis . No-one would argue that balanced crystalloid or a colloid can be used for the treatment of hypovolaemia but , of the 11 references quoted , nine involve starches , a curious selection from a very extensive literature , while balanced crystalloid is once again recommended because of the supposed risks of hyperchloraemic acidosis , if such risks exist . The recommendations move on to the diagnosis of hypovolaemia and the use of incremental 200-ml boluses of either crystalloid or colloid . This is level 1b evidence based on two small trials [ 12 , 13 ] . While one must question whether this constitutes substantial evidence , it does make sense . Orthopaedic and abdominal surgery are singled out to recommend stroke volume measurement to guide fluid management peri-operatively ( level 1b ) . In orthopaedic surgery this is based on two well known studies , each of which can be interpreted either to indicate that the intervention reduced hospital stay or that the control group could have been better managed . The former is more widely accepted . In non-elective surgery , in the same specialities , this management should continue for 8 h and , in these circumstances , low dose dopexamine , which performed well in a meta- analysis , is Anaesthesia , 2009 , 64 , pages 235–238 OBJECTIVE To investigate the effect of a restricted intravenous fluid regimen versus a st and ard regimen on complications after colorectal resection . SUMMARY BACKGROUND DATA Current fluid administration in major surgery causes a weight increase of 3 - 6 kg . Complications after colorectal surgery are reported in up to 68 % of patients . Associations between postoperative weight gain and poor survival as well as fluid overload and complications have been shown . METHODS We did a r and omized observer-blinded multicenter trial . After informed consent was obtained , 172 patients were allocated to either a restricted or a st and ard intraoperative and postoperative intravenous fluid regimen . The restricted regimen aim ed at maintaining preoperative body weight ; the st and ard regimen resembled everyday practice . The primary outcome measures were complications ; the secondary measures were death and adverse effects . RESULTS The restricted intravenous fluid regimen significantly reduced postoperative complications both by intention-to-treat ( 33 % versus 51 % , P = 0.013 ) and per- protocol ( 30 % versus 56 % , P = 0.003 ) analyses . The numbers of both cardiopulmonary ( 7 % versus 24 % , P = 0.007 ) and tissue-healing complications ( 16 % versus 31 % , P = 0.04 ) were significantly reduced . No patients died in the restricted group compared with 4 deaths in the st and ard group ( 0 % versus 4.7 % , P = 0.12 ) . No harmful adverse effects were observed . CONCLUSION The restricted perioperative intravenous fluid regimen aim ing at unchanged body weight reduces complications after elective colorectal resection Background Intermittent pneumatic compression ( IPC ) devices have been widely used for thrombosis prophylaxis in laparoscopic colorectal surgery . However , periodic compression using an IPC device may inject augmented boluses of cool blood from the lower limbs into the central circulation repetitively , thereby causing a reduction in core temperature . The authors therefore conducted a prospect i ve , r and omized , double-blind , controlled study to compare the effects of intraoperative IPC on core temperature in patients undergoing laparoscopic colorectal surgery . Methods For this study , 56 patients ages 18–60 years and scheduled to undergo laparoscopic resection for colorectal cancer under general anesthesia were r and omly assigned to receive either no IPC ( control group ) or calf-thigh-length IPC in both legs using the SCD Express ( IPC group ) . Anesthetic , thermal , and pneumoperitoneum management were st and ardized . Esophageal temperature , as an indicator of core temperature , was measured at 15-min intervals for 2 h after induction of anesthesia . Results A total of 47 subjects ( 23 control and 24 IPC subjects ) were included in the analysis . The core temperature drop in the IPC group was significantly greater than in the control group , starting from 45 min after induction of anesthesia ( P < 0.05 ) . As a result , the total temperature drop during the 2-h study period was significantly greater in the IPC group ( 1.2 ± 0.3 ° C ) than in the control group ( 0.9 ± 0.3 ° C ) ( P = 0.004 ) . Conclusions Because intraoperative application of IPC carries an increased risk of a core temperature drop , appropriate temperature monitoring and active thermal management are required for surgical patients receiving IPC AIM To determine whether intravenous ketoprofen is effective as pre-emptive analgesia for breast surgery . DESIGN R and omised , controlled , double blind study . PATIENTS AND METHODS 50 patients undergoing breast surgery under general anaesthesia r and omised to receive either 100 mg intravenous ketoprofen 30 minutes before ( Group I ) , or immediately after surgical incision ( Group II ) . Postoperatively , pain scores ( Visual Analogue Scale , VAS ) and time to rescue analgesic were recorded by an independent , blinded observer . The study was terminated when rescue analgesic was required ( VAS > or = 4 or dem and for analgesic ) . STATISTICAL ANALYSIS Continuous variables were analysed by the unpaired ' t ' test , discrete variables with the chi square test , and survival curves by the log-rank test . RESULTS Pain scores were significantly lower in Group I till 10 hours after surgery . The number of patients requiring analgesia at 4 , 6 , 8 and 10 hours was significantly lower in group I ( 0 % vs. 47 % [ P < 0.0001 ] , 0 % vs. 44 % [ P < 0.003 ] , 0 % vs. 80 % [ P < 0.0001 ] , 0 % vs. 100 % [ P < 0.0001 ] respectively ) . The mean time for rescue analgesic was 15.47 -/+ 2.87 hours in group I versus 4.22 -/+ 2.55 hours in group II ( P < 0.0001 ) . CONCLUSION Pre-emptive analgesia with Intravenous ketoprofen ( 100 mg ) produces better postoperative pain-relief in patients undergoing breast surgery Background : Enhanced recovery after surgery was compared with traditional recovery after surgery for postmastectomy alloplastic breast reconstruction . Methods : Length of stay , emergency room visits , and complications within 30 days of surgery were compared among three groups : traditional recovery after surgery , transition ( some elements of enhanced recovery protocol , not transitioned to outpatient care ) , and enhanced recovery after surgery ( day surgery , provided with st and ardized perioperative education and multimodal analgesia ) . Prospect i ve data collection allowed quality -of-recovery assessment using a vali date d question naire for enhanced recovery/transition groups . Results were statistically analyzed ( analysis of variance/chi-square ) . Results : The traditional recovery , transition , and enhanced recovery cohorts comprised 29 , 11 , and 29 patients , respectively . No significant differences were present regarding age , smoking status , preoperative radiation , single stage direct-to-implant versus tissue exp and er , bilateral versus unilateral surgery , or immediate versus delayed reconstruction among groups . Average length of stay was 1.6 nights in both the traditional recovery and transition groups , compared with 0 nights in the enhanced recovery group ( p < 0.001 ) . Enhanced recovery patients had less severe pain ( p = 0.02 ) and nausea ( p = 0.01 ) , and better enjoyed their food ( p = 0.0002 ) and felt more rested ( p = 0.02 ) than their transition counterparts . There were no differences in the number of emergency room visits among the three groups ( p = 0.88 ) . There was no difference in the rate of hematoma ( p = 0.36 ) , infection requiring intravenous antibiotics ( p = 0.36 ) , or infection requiring explantation ( p = 0.36 ) among the three groups . Conclusion : An enhanced recovery protocol for alloplastic breast reconstruction treated patients safely , with improved patient satisfaction and same-day discharge and with no increase in complications . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , III Resistive heating is an alternative to forced‐air warming which is currently the most commonly used intra‐operative warming system . We therefore tested the hypothesis that rewarming rates are similar with Hot Dog ® ( Augustine Biomedical ) resistive and Bair Hugger ® ( Arizant ) forced‐air heating systems . We evaluated 28 patients having major maxillary tumour surgery . During the establishment of invasive monitoring , patients became hypothermic , dropping their core temperature to about 35 ° C . They were then r and omly assigned to rewarming with lower‐body resistive ( n = 14 ) or forced‐air ( n = 14 ) heating , with each system set to ‘ high ’ . Our primary outcome was the rewarming rate during active heating over a core temperature range from 35 to 37 ° C . Morphometric characteristics were comparable in both groups . Temperature increased at twice the rate in patients assigned to forced‐air warming , with an estimated mean ( SE ) slope of 0.49 ( 0.03 ) ° C.h−1 vs 0.24 ( 0.02 ) ° C.h−1 ( p < 0.001 ) . Resistive heating warmed at half the rate of forced air Background : To plan abdominal perforator-based microsurgical breast reconstruction , duplex ultrasound is often employed to preoperatively identify the location of abdominal wall perforating vessels . Recently , several groups have published the use of computed tomography angiography for preoperative planning in perforator flap breast reconstruction . The purpose of this study was to compare the accuracy of computed tomography angiography in locating clinical ly useful abdominal wall perforators with that of duplex ultrasound . Methods : A prospect i ve study was conducted of 22 consecutive patients undergoing 30 abdomen-based microsurgical breast reconstructions using both preoperative computed tomography angiography and duplex ultrasound .  Perforator data were obtained with both computed tomography angiography and ultrasound . The two largest perforators were chosen per abdominal side for comparison between studies . In addition , the locations of perforators were confirmed at surgery . Results : Computed tomography angiography preoperatively identified 83 of the largest perforators , while only 55 of these large perforators ( 66.3 percent ) were preoperatively identified on ultrasound . No superficial inferior epigastric arteries were identified by ultrasound . However , in all eight breast reconstructions performed with the superficial inferior epigastric system , the superficial inferior epigastric arteries were identified preoperatively as adequate size for microsurgical transfers , with an average diameter of 1.6 mm . Conclusions : There are many advantages to preoperative computed tomography angiography for planning abdominal perforator-based microsurgical breast reconstruction , including accurate identification of perforating vessels , the underlying branching pattern of the deep inferior epigastric artery , and the presence of the superficial inferior epigastric vessels . This study demonstrates the superiority of computed tomography angiography over duplex ultrasound as a tool for preoperative planning of perforator-based breast reconstruction Background : A novel topical skin adhesive system was developed to close the outermost layer of skin in an expeditious manner . To determine its clinical utility , a clinical investigation was undertaken to demonstrate equivalence of a new adhesive skin closure system ( Prineo Skin Closure System ) to intradermal sutures in wound closure . Methods : The investigation included 83 patients who underwent elective abdominoplasty , circumferential body lift procedures , and breast reconstruction with deep inferior epigastric perforator flaps . Incisions were divided in half , and each half was r and omized to wound closure with the new skin closure system , including a pressure-sensitive adhesive mesh tape for wound edge approximation and next-generation cyanoacrylate or intradermal sutures . Postoperative evaluations took place at 24 hours , 7 days , 12 to 25 days , 90 days , 6 months , and 12 months . Results : The new skin closure system was found to be equivalent to intradermal sutures for the continuous approximation of wounds . The upper limit of the two-sided 90 percent confidence interval for difference in proportions was 10.9 percent . The mean time to closure for the new skin closure system was 1.46 minutes , approximately 5 minutes faster than that for intradermal sutures ( p < 0.0001 ) . Both treatments had similar incision healing and cosmetic outcomes . No quantitative or qualitative differences of clinical significance were evident between the treatment groups . Conclusions : The Prineo Skin Closure System can be considered equivalent to intradermal sutures for full-thickness surgical incisions with regard to safety and effectiveness . The ease and speed of application contribute to shortened operative times ( 4.5 times faster than intradermal sutures ) . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , II 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 BACKGROUND : The PerfecTemp is an underbody resistive warming system that combines servocontrolled underbody warming with viscoelastic foam pressure relief . Clinical efficacy of the system has yet to be formally evaluated . We therefore tested the hypothesis that intraoperative distal esophageal ( core ) temperatures with the PerfecTemp ( underbody resistive ) warming system are noninferior to upper-body forced-air warming in patients undergoing major open abdominal surgery under general anesthesia . METHODS : Adults scheduled for elective major open abdominal surgery ( liver , pancreas , gynecological , and colorectal surgery ) under general anesthesia were enrolled at 2 centers . Patients were r and omly assigned to underbody resistive or forced-air warming . Resistive heating started when patients were transferred to the operating room table ; forced-air warming started after patients were draped . The primary outcome was noninferiority of intraoperative time-weighted average core temperature , adjusted for baseline characteristics and using a buffer of 0.5 ° C . RESULTS : Thirty-six patients were r and omly assigned to underbody resistive heating and 34 to forced-air warming . Baseline and surgical characteristics were generally similar . We had sufficient evidence ( P = 0.018 ) to conclude that underbody resistive warming is not worse than ( i.e. , noninferior to ) upper-body forced-air warming in the time-weighted average intraoperative temperature , with a mean difference of −0.12 ° C [ 95 % confidence interval ( CI ) −0.37 to 0.14 ] . Core temperatures at the end of surgery averaged 36.3 ° C [ 95 % CI 36 to 36.5 ] in the resistive warming patients and 36.6 ° C [ 95 % CI 36.4 to 36.8 ] in those assigned to forced-air warming for a mean difference of −0.34 ° C [ 95 % CI −0.69 to 0.01 ] . CONCLUSIONS : Mean intraoperative time-weighted average core temperatures were no different , and significantly noninferior , with underbody resistive heating in comparison with upper-body forced-air warming . Underbody resistive heating may be an alternative to forced-air warming CONTEXT We recently demonstrated that 28-d bed rest in healthy volunteers results in a moderate loss of lean leg mass and strength . OBJECTIVE The objective of this study was to quantify changes in muscle protein kinetics , body composition , and strength during a clinical bed rest model reflecting both physical inactivity and the hormonal stress response to injury or illness . DESIGN Muscle protein kinetics were calculated during a primed , continuous infusion ( 0.08 micromol/kg.min ) of 13C6-phenylalanine on d 1 and 28 of bed rest . SETTING The setting for this study was the General Clinical Research Center at the University of Texas Medical Branch . PARTICIPANTS Participants were healthy male volunteers ( n = 6 , 28 + /- 2 yr , 84 + /- 4 kg , 178 + /- 3 cm ) . INTERVENTION During bed rest , hydrocortisone sodium succinate was administered iv ( d 1 and 28 ) and orally ( d 2 - 27 ) to reproduce plasma cortisol concentrations consistent with trauma or illness ( approximately 22 microg/dl ) . MAIN OUTCOME MEASURES We hypothesized that inactivity and hypercortisolemia would reduce lean muscle mass , leg extension strength , and muscle protein synthesis .  RESULTS Volunteers experienced a 28.4 + /- 4.4 % loss of leg extension strength ( P = 0.012 ) and a 3-fold greater loss of lean leg mass ( 1.4 + /- 0.1 kg ) ( P = 0.004 ) compared with our previous bed rest-only model . Net protein catabolism was primarily due to a reduction in muscle protein synthesis [ fractional synthesis rate , 0.081 + /- 0.004 ( d 1 ) vs. 0.054 + /- 0.007%/h ( d 28 ) ; P = 0.023 ] . There was no change in muscle protein breakdown . CONCLUSION Prolonged inactivity and hypercortisolemia represents a persistent catabolic stimulus that exacerbates strength and lean muscle loss via a chronic reduction in muscle protein synthesis INTRODUCTION Pain control outcomes using local anesthetic delivery systems vs usual narcotics at our institution revealed that use of local anesthetic delivery systems decreased narcotic use greater than 40 % in patients with no reconstruction but had very little effect in patients receiving reconstruction . As part of our quality improvement program , the anesthesiology department trained and began offering paravertebral blocks ( PVBs ) to patients having reconstruction . We review ed pain control outcomes to underst and how the use of paravertebral nerve blocks affected narcotic use in reconstructed patients . METHODS Retrospective review of prospect ively collected data on patients undergoing mastectomy with or without reconstruction in the 6-month period after introduction of PVB analgesia .  Patients received preoperative single-shot paravertebral nerve blocks at T2 to T3 and T5 to T6 with bupivacaine .5 % and epinephrine 1:200,000 ( 7.5 mL per injection ) . Patients who had a bilateral mastectomy with reconstruction received bilateral paravertebral nerve blocks at the same locations . Narcotic doses were converted to morphine equivalents ( MSEs ) to allow comparison . RESULTS There were 102 patients with mastectomy during that period and 91 were evaluable . Fifty-one had no reconstruction with an average MSE use of 37.9 . There were 40 with reconstruction , 33 had PVB with average MSE of 42.6 , and 7 patients had reconstruction with no PVB with average MSE of 71.1 . There were no major complications . CONCLUSIONS Institution of the PVB for patients undergoing mastectomy with reconstruction lowered average MSE use . We will continue to offer paravertebral blocks in this cohort of patients Background A novel topical skin adhesive system was developed to close the outermost layer of skin in an expeditious manner . To determine its clinical utility in breast procedures , a prospect i ve clinical investigation was undertaken to demonstrate equivalence of a new adhesive ( PRINEO ™ Skin Closure System ) to intradermal sutures in wound closure . Methods The investigation comprised 79 patients who underwent elective surgery for bilateral breast procedures . Each breast incision was r and omized to wound closure with the PRINEO ™ Skin Closure System or intradermal sutures ( used in accordance with st and ard local practice ) . Postoperative evaluations took place at 24 hours , 7 days , 12–25 days , 90 days , 6 months , and 12 months . Data were collected on the continuous approximation of the skin edges , the time required to close the include final skin layer , the evaluation of incision healing , and cosmesis outcomes . Safety evaluations were related to the incidence and extent of local acute inflammatory reactions , clinical infection , skin blistering , and adverse events . Results PRINEO ™ Skin Closure System was found to be equivalent to intradermal sutures for the continuous approximation of wounds associated with breast procedures . The upper limit of the one-sided 95 % confidence interval for difference in proportions was less than the predetermined 12 % , at 5.9 % . The mean time to closure for the PRINEO ™ Skin Closure System was 2.56 minutes , which was 13.66 minutes faster than that for intradermal sutures ( 16.22 minutes , P < 0.0001 ) . Time savings may be less if 2 operators close simultaneously . On the other h and , because the device can be applied by 1 operator , the assistant ’s time may be freed up to attend to other tasks . Both treatments had similar incision healing and cosmetic outcomes . No quantitative or qualitative differences of clinical significance were evident between the treatment groups for local acute inflammatory reactions , clinical infection , or skin blistering . The number of serious adverse events was low , although the number of adverse events was higher , with 54/79 patients experiencing at least 1 adverse event . Conclusion PRINEO ™ Skin Closure System can be considered equivalent to intradermal sutures for full-thickness surgical incisions associated with breast procedures , with regard to safety and effectiveness . It was also 6.3 times faster than intradermal sutures for wound closure BACKGROUND The anticonvulsant gabapentin has proven effective for neuropathic pain in three large placebo-controlled clinical trials . Experimental and clinical studies have demonstrated antihyperalgesic effects in models involving central neuronal sensitization . It has been suggested that central neuronal sensitization may play an important role in postoperative pain . The aim of the study was to investigate the effect of gabapentin on morphine consumption and postoperative pain in patients undergoing radical mastectomy . METHODS In a r and omized , double-blind , placebo-controlled study , 70 patients received a single dose of oral gabapentin ( 1,200 mg ) or placebo 1 h before surgery . Patients received patient-controlled analgesia with morphine at doses of 2.5 mg with a lock-out time of 10 min for 4 h postoperatively . Pain was assessed on a visual analog scale at rest and during movement , and side effects were assessed on a four-point verbal scale 2 and 4 h postoperatively . RESULTS Thirty-one patients in the gabapentin group and 34 patients in the placebo group completed the study . Gabapentin reduced total morphine consumption from a median of 29 ( interquartile range , 21 - 33 ) to 15 ( 10 - 19 ) mg ( P < 0.0001 ) . Pain during movement was reduced from 41 ( 31 - 59 ) to 22 ( 10 - 38 ) mm at 2 h postoperatively ( P < 0.0001 ) and from 31 ( 12 - 40 ) to 9 ( 3 - 34 ) mm at 4 h postoperatively ( P = 0.018 ) . No significant differences between groups were observed with regard to pain at rest or side effects . CONCLUSION A single dose of 1,200 mg oral gabapentin result ed in a substantial reduction in postoperative morphine consumption and movement-related pain after radical mastectomy , without significant side effects . These promising results should be vali date d in other acute pain models involving central neuronal sensitization A study was conducted to assess the effect of intraoperatively administered inotropic agents on blood flow in the recipient and donor vessels , during breast reconstruction with a muscle sparing free TRAM flap . Twenty-one consecutive patients were r and omized into 3 groups receiving either dopamine , dobutamine , or placebo . When the flap and all vessels had been fully dissected but not yet divided , the study drug was administered intravenously for 15 minutes . Hemodynamic parameters and transit-time flow of the thoracodorsal and inferior epigastric arteries were monitored . Both dobutamine and dopamine infusions result ed in significant raises in cardiac output and mean arterial pressure . However , while dobutamine result ed in a higher cardiac output ( P = 0.001 ) and a decrease in systemic vascular resistance ( P = 0.028 ) , the increase in mean arterial pressure was greater with dopamine ( P = 0.002 ) . Only the dobutamine group showed increased blood flow , in both the thoracodorsal ( P = 0.043 ) and the inferior epigastric ( P = 0.043 ) arteries . If vasoactive agents are needed during microvascular anesthesia , dobutamine seems to be more advantageous than dopamine STUDY OBJECTIVE To investigate the effects of preanesthetic oral clonidine on total  propofol  requirement for uniform minor surgery ( breast conservative surgery : breast cancer removal with axillary lymph node dissection ) , and to compare the action of clonidine with that of preanesthetic oral diazepam , a commonly used benzodiazepine . DESIGN R and omized double-blinded study . SETTING Operating room ASA physical status I and II room and recovery room of the cancer center . PATIENTS 80 breast cancer patients scheduled for surgery . INTERVENTIONS Patients were r and omized to one of four treatment groups ( placebo , clonidine 75 micrograms , or 150 micrograms of clonidine , or 10 mg of diazepam were orally administered 60 min before induction of anesthesia ) ; n = 20 per group . After evaluating the sedation and anxiety levels of patients using a visual analog scale , anesthesia was induced with propofol ( 1.5 mg/kg ) , and maintained with oxygen ( O2 ) : nitrous oxide ( N2O ) ( 30:70 ) with a continuous infusion of propofol . The propofol infusion was started at 10 mg/kg/h for 10 minutes , then decreased to 8 mg/kg/h , and 6 mg/kg/h thereafter , and the rate of infusion was adjusted to obtain adequate anesthesia ( maintaining hemodynamic parameters within 20 % of that prior to premedication ) . Fentanyl 0.2 mg ( each 0.1 mg was given for intubation and axillary lymph node dissection , respectively ) was administered . MEASUREMENTS AND MAIN RESULTS Preanesthetic oral clonidine ( 150 micrograms ) and diazepam ( 10 mg ) induced anxiolysis without sedation . The total requirement ( the mean infusion rates ) of propofol in placebo , clonidine 75 micrograms , clonidine 150 micrograms , and 10 mg of diazepam groups were 841 + /- 70 ( 9.0 + /- 0.3 ) , 720 + /- 63 ( 7.1 + /- 0.4 ) , 491 + /- 39 ( 5.6 + /- 0.2 ) , and 829 + /- 77 mg ( 7.9 + /- 0.4 mg/kg/h ) , respectively . The cost of propofol in these groups was $ 51.0 + /- 3.8 , $ 45.5 + /- 3.2 , $ 33.5 + /- 2.3 , and $ 50.5 + /- 4.4 , respectively . CONCLUSIONS Preanesthetic oral clonidine ( 150 micrograms ) but not diazepam ( 10 mg ) reduced the total requirement of propofol while stabilizing hemodynamic parameters . In addition , 150 micrograms of oral clonidine attenuates the hemodynamic responses associated with tracheal intubation Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety Background and objective : Data on the effectiveness of cyclooxygenase 2 inhibitors in postoperative pain therapy vary widely . We tested in a prospect i ve , placebo‐controlled , r and omized , double‐blind trial the hypotheses that perioperative ( i.e. preoperative and postoperative ) administration of the cyclooxygenase 2 inhibitor rofecoxib decreases pain scores and morphine consumption after spine , breast and orthopaedic surgery . Methods : Five hundred and forty patients scheduled for spine , breast or orthopaedic surgery were r and omly assigned to receive in combination with postoperative morphine via patient controlled analgesia pump for 4 days either rofecoxib 50 mg administered perioperatively , rofecoxib 50 mg administered only postoperatively , or placebo . Primary outcome criteria were pain score at rest ( numeric rating scale 0–4 ) and morphine consumption . Results : Perioperative rofecoxib significantly decreased pain score 0 ( 0–1 ) vs. 1 ( 0–2 ) ( median ( interquartile range ) ) , and morphine consumption 18 ( 6–33 ) vs. 22.5 ( 12–38 ) compared with placebo . In contrast , rofecoxib when administered only postoperatively did not significantly improve analgesic effects or side‐effects at time of assessment of the main criteria ( 24 h after skin closure ) , but during the follow‐up period at 48 h and 72 h after skin closure pain scores and morphine consumption were improved compared to placebo . The analgesic effects of rofecoxib were independent from the type of surgery . Conclusions : Perioperative administration of the cyclooxygenase 2 inhibitor rofecoxib decreases pain scores and morphine consumption after orthopaedic , breast and spine surgery . However , the benefit of preoperative administration of the cyclooxygenase 2 inhibitor seems to be only moderate , suggesting that early postoperative administration may be a useful alternative approach . There is no evidence that the type of surgery influences analgesic effects of cyclooxygenase 2 inhibitors 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 BACKGROUND Gabapentin has been recently found to be useful for reducing acute postoperative pain when administered preoperatively . Although various dose regimens have been tried in different surgical setting s , the minimum effective dose is not established . AIMS We aim ed to evaluate the analgesic efficacy of single low dose gabapentin in patients undergoing total mastectomy and axillary dissection . SETTING S AND DESIGN Prospect i ve r and omized placebo-controlled double-blind trial in a tertiary care teaching hospital . MATERIAL S AND METHODS Fifty women scheduled for total mastectomy and axillary dissection were r and omized to receive either gabapentin 600 mg or placebo orally 1 h preoperatively . The intraoperative and postoperative management was st and ardized . Postoperative pain was assessed at rest and on movement for 12 h using the numerical rating scale ( NRS ) .  Morphine  was administered if NRS exceeded 30 . Primary outcome measure was total morphine consumption . STATISTICAL ANALYSIS The morphine consumption was compared using independent t test while pain and sedation scores were analyzed using Mann-Whitney U test . RESULTS Forty-six patients completed the trial . The postoperative morphine consumption was significantly less ( 5.8 + /- 4.2 vs. 11.0 + /- 3.4 mg ; P 0.001 ) and the median [ IQR ] time to first analgesic was significantly longer ( 90 [ 37.5 - 120 ] vs. 0 [ 0 - 90 ] min ; P 0.001 ) in the gabapentin group than in the placebo group . The incidence of side effects was similar in the two groups . CONCLUSIONS A single low dose of 600 mg gabapentin administered 1 h prior to surgery produced effective and significant postoperative analgesia after total mastectomy and axillary dissection without significant side effects 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 Clinical experience suggests that application of the fundamental principles of rehabilitation medicine can improve the care of patients with cancer . Despite the high incidence of neurological and functional deficits in patients affected by brain tumours ( BTs ) , rehabilitation treatment of this population is not as well established as it is for patients with other neurological conditions . To assess functional outcome in brain tumour in patients who underwent early rehabilitation after surgery . 75 patients who had undergone neurosurgery for primary BTs and 75 patients affected by stroke were enrolled in a case-control study . All patients were evaluated by means of a core set of clinical scales ( Functional Independence Measure , Sitting Balance score , St and ing Balance score , Hauser Index , Massachusetts General Hospital Functional Ambulation Classification ) . Patients were evaluated before the beginning ( T0 ) and at the end ( T1 ) of rehabilitation treatment . The neurorehabilitation programme consisted of individual 60-min sessions of treatment , administered once a day , six days a week , for four consecutive weeks . Speech therapy was included when aphasia was diagnosed . All the measures of outcome were indicative of substantial improvements for neuro-oncological and for stroke patients ( P = 0.000 ) . Analysis of subgroups showed that patients affected by meningioma achieved better results ( in efficiency terms ) as regards independence in activities of daily living ( P = 0.02 ) and mobility ( P = 0.04 ) compared with patients affected by glioblastoma or stroke . Rehabilitation after surgery can improve functional outcome , justifying the delivery of rehabilitation services , even during the acute phase , to BTs in patients , irrespective of tumour type Background : A multidisciplinary patient care plan was developed to facilitate early discharge following autogenous breast reconstruction and included ( 1 ) preadmission patient education , ( 2 ) perioperative multimodal pain management , ( 3 ) intraoperative nerve blocks , and ( 4 ) postdischarge telephone advice . This study evaluated the success of this care plan in the first 18 months after its implementation . Methods : A retrospective cohort study of all consecutive women undergoing pedicled transverse rectus abdominis myocutaneous ( TRAM ) flap breast reconstruction ( November of 2009 to May of 2011 ) was performed . The primary outcome was time to discharge ; secondary outcomes included complications , readmission , and self-report pain at discharge . Predictors of discharge time were analyzed using stepwise multivariable regression modeling . Results : Ninety-one women ( mean age , 50.0 ± 8.5 years ) underwent pedicled TRAM flap reconstruction ( 76 percent unilateral and 81 percent delayed ) , with 77 percent receiving the intended multimodal analgesia protocol . Mean time to discharge was 38.7 ± 27.6 hours . Overall , 40 percent of patients were discharged within 24 hours , but successful early discharge increased significantly over the study period . Key predictors of shorter time to discharge were use of multimodal analgesia , lower American Society of Anesthesiologists class , and surgery more than 6 months after implementation of the care plan . Conclusions : The authors ’ initial experience has supported the safety and feasibility of expedited discharge following pedicled TRAM flap breast reconstruction , with adherence to the authors ’ care plan improving steadily over the study period . Multimodal pain management proved a key modifiable factor in facilitating early discharge . A prospect i ve study is currently underway to evaluate patient-reported quality of recovery following ambulatory surgery in this population . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , IV Objective Clinical studies show that the incidence of postoperative wound complications is higher in smokers than nonsmokers . In this study , we evaluated the effect of abstinence from smoking on incisional wound infection . Methods Seventy-eight healthy subjects ( 48 smokers and 30 never-smokers ) were included in the study and followed for 15 weeks . In the first week of the study , the smokers smoked 20 cigarettes per day . Subsequently , they were r and omized to continuous smoking , abstinence with transdermal nicotine patch ( 25 mg per day ) , or abstinence with placebo patch . At the end of the first week and 4 , 8 , and 12 weeks after r and omization , incisional wounds were made lateral to the sacrum to excise punch biopsy wounds . At the same time identical wounds were made in 6 never-smokers . In 24 never-smokers a wound was made once . All wounds were followed for 2 weeks for development of wound complications . Results A total of 228 wounds were evaluated . In smokers the wound infection rate was 12 % ( 11 of 93 wounds ) compared with 2 % ( 1 of 48 wounds ) in never-smokers ( P < 0.05 ) . Wound infections were significantly fewer in abstinent smokers compared with continuous smokers after 4 , 8 , and 12 weeks after r and omization . No difference between transdermal nicotine patch and placebo was found . Conclusions Smokers have a higher wound infection rate than never-smokers and 4 weeks of abstinence from smoking reduces the incidence of wound infections Background : General anesthesia is used for most major surgeries , and the most common side effects include headache , nausea , vomiting , and sore throat . Major breast surgery is associated with a high incidence of postoperative nausea and vomiting ( PONV ) . We compared the postoperative nausea and vomiting of propofol-based total intravenous anesthesia ( TIVA ) and sevoflurane ( SEVO ) anesthesia under auditory evoked potential ( AEP ) monitoring in female patients undergoing breast surgery . Methods : A total of 84 patients scheduled to undergo elective breast surgery from 1 to 4 h in duration from March 2011 to December 2011 were prospect ively included in the study . All participants were r and omly assigned to TIVA or SEVO group . The AEP index was maintained at 15 - 25 . After completing the surgery , the duration of surgery , emergence time , and the side effects of PONV were recorded . Results : Patient characteristics , intraoperative and postoperative data , and the amounts of intraoperative analgesic drugs used were not significantly different between the TIVA and SEVO groups . The incidence of PONV was significantly higher in the SEVO group than in the TIVA group ( 50 % and 14.3 % , respectively ; p < 0.001 ) , and the total cost was significantly lower in the TIVA group than in the SEVO group ( 648 ± 185 and 850 ± 197 , respectively ) . Conclusion : We observed that when compared with sevoflurane , propofol given for the maintenance of general anesthesia improves the postoperative patient well-being and reduces the incidence of PONV . Furthermore , total intravenous anesthesia with propofol result ed in significant cost reductions UNLABELLED Breast surgery is classified among the procedures performed in clean surgery and is associated with a low incidence of wound infection ( 3 - 15 % ) . The objective of this study was to evaluate the advantages antibiotic prophylaxis  in patients undergoing breast surgery .  A multicenter r and omized controlled study was performed between January 2008 and November 2008 . One thous and four hundred patients were enrolled in prospect i ve r and omized study ; surgical wound infection was found in 41 patients ( 2.93 % ) . In our RCT we have shown that in breast surgery antibiotic prophylaxis does not present significant advantages in patients with potential risk of infection ( 17 patients , 2.42 % , subjected to antibiotic prophylaxis vs 24 patients , 3.43 % , without antibiotic prophylaxis ) ( P = 0.27 ) . In patients with drainage there is a significant minor incidence of wound infections in patients receiving antibiotic prophylaxis ( 5 patients , 0.92 % , subjected to antibiotic prophylaxis vs 14 patients , 3.09 % , without antibiotic prophylaxis ) ( P = 0.02 ) . CONCLUSION This study is only a preliminary RCT to be followed by a study which should be enrolled more patients in order to get the results as statistically significant BACKGROUND Recent studies suggest that the use of tissue adhesive for closure of both traumatic lacerations and incisional surgical wounds leads to cosmetic outcome comparable to conventional sutures . To date , no studies have investigated tissue adhesive in breast surgery and costs . Our aim was to compare the tissue adhesive 2-octylcyanoacrylate ( OCA ) with st and ard suture in breast surgery . METHODS A prospect i ve r and omized study was conducted in which 151 patients were assessed for eligibility , and 133 were r and omly allocated to skin closure with OCA adhesive or monofilament suture .  Cosmetic outcome with blinded assessment , wound management by the patients , complication rates , and economic outcome were recorded . RESULTS There was no difference in cosmetic score in the 2 groups , nor in complications at the early , 6-month , and 1-year follow-up . Patient satisfaction with the wound closed with OCA was rated significantly higher when compared with st and ard suture ( P < .0001 ) . The application of the tissue adhesive was significantly faster than that for st and ard suture ( P < .001 ) . In economic terms total costs were less in the tissue adhesive group , mainly due to lower postoperative costs of physician and assistant services ( P < .001 ) . CONCLUSIONS OCA is effective and reliable in skin closure for breast surgery , yielding similar cosmetic results to st and ard suture . OCA is faster than st and ard wound closure and offers several practical advantages over suture repair for patients . Cost analysis has found that OCA adhesive can significantly decrease health care costs This study aim ed to compare the efficiency of the thermal blanket and thermal mattress in the prevention of hypothermia during surgery .  Thirty-eight r and omized patients were divided into two groups ( G1 - thermal blanket and G2 - thermal mattress ) . The variables studied were : length of surgery , length of stay in the post-anesthetic care unit , period without using the device after thermal induction , transport time from the operating room to post-anesthetic care unit , intraoperative fluid infusion , surgery size , anesthetic technique , age , body mass index , esophageal , axillary and operating room temperature . In G2 , length of surgery and starch infusion longer was higher ( both p=0.03 ) , but no hypothermia occurred . During the surgical anesthetic procedure , the axillary temperature was higher at 120 minutes ( p=0.04 ) , and esophageal temperature was higher at 120 ( p=0.002 ) and 180 minutes ( p=0.03 ) and at the end of the procedure ( p=0.002 ) . The thermal mattress was more effective in preventing hypothermia during surgery Background : Regional anesthesia and analgesia attenuate or prevent perioperative factors that favor minimal residual disease after removal of the primary carcinoma . Therefore , the authors evaluated prostate cancer recurrence in patients who received either general anesthesia with epidural anesthesia/analgesia or general anesthesia with postoperative opioid analgesia .  Methods : In a retrospective review of medical records , patients with invasive prostatic carcinoma who underwent open radical prostatectomy between January 1994 and December 2003 and had either general anesthesia – epidural analgesia or general anesthesia – opioid analgesia were evaluated through October 2006 . The endpoint was an increase in postoperative prostate-specific antigen . Results : After adjusting for tumor size , Gleason score , preoperative prostate-specific antigen , margin , and date of surgery , the epidural plus general anesthesia group had an estimated 57 % ( 95 % confidence interval , 17–78 % ) lower risk of recurrence compared with the general anesthesia plus opioids group , with a corresponding hazard ratio of 0.43 ( 95 % confidence interval , 0.22–0.83 ; P = 0.012 ) in a multivariable Cox regression model . Gleason score and tumor size ( percent of prostate involved ) were also independent predictors of recurrence ( hazards ratios of 1.19 [ 1.08 , 1.52 ] , P = 0.004 , and 1.17 [ 1.03 , 1.34 ] for 10 % size difference , P = 0.01 , respectively ) . A similar association between epidural use and recurrence was obtained by comparing patients matched on the propensity to receive epidural versus general anesthesia . Conclusions : Open prostatectomy surgery with general anesthesia , substituting epidural analgesia for postoperative opioids , was associated with substantially less risk of biochemical cancer recurrence . Prospect i ve r and omized trials to evaluate this association seem warranted Purpose We hypothesized that oral rehydration therapy using an oral rehydration solution may be effective for preoperative fluid and electrolyte management in surgical patients before the induction of general anesthesia , and we investigated the safety and effectiveness of oral rehydration therapy as compared with intravenous therapy . Methods Fifty female patients who underwent breast surgery were r and omly allocated to two groups . Before entry to the operation room and the induction of general anesthesia , 25 patients drank 1000 ml of an oral rehydration solution ( “ oral group ” ) and 25 patients were infused with 1000 ml of an intravenous electrolyte solution ( “ intravenous group ” ) . Parameters such as electrolyte concentrations in serum and urine , urine volume , vital signs , vomiting and aspiration , volumes of esophageal-pharyngeal fluid and gastric fluid ( EPGF ) , and patient satisfaction with the therapy ( as surveyed by a question naire ) were assessed . Results After treatment , the serum sodium concentration and the hematocrit value , which both declined within the normal limits , were significantly higher in the oral group than in the intravenous group ( sodium , 140.8 ± 2.9 mEq·l−1 in the oral group and 138.7 ± 1.9 mEq·l−1 in the intravenous group ; P = 0.005 ; hematocrit , 39.03 ± 4.16 % in the oral group and 36.15 ± 3.41 % in the intravenous group ; P = 0.01 ) . No significant difference was observed in serum glucose values . Urine volume was significantly larger in the oral group ( 864.9 ± 211.5 ml ) than in the intravenous group ( 561.5 ± 216.0 ml ; P < 0.001 ) . The fractional excretion of sodium ( FENa ) , as an index of renal blood flow , was increased in both groups following treatment ( 0.8 ± 0.5 in the oral group and 0.8 ± 0.3 in the intravenous group ) . Patient satisfaction with the therapy favored the oral rehydration therapy , as judged by factors such as “ feeling of hunger ” , “ occurrence of dry mouth ” , and “ less restriction in physical activity ” . The volume of EPGF collected following the induction of anesthesia was significantly smaller in the oral group than in the intravenous group ( 6.03 ± 9.14 ml in the oral group and 21.76 ± 30.56 ml in the intravenous group ; P < 0.001 ) . No adverse events or adverse reactions were observed in either group . Conclusion The results suggest that the oral rehydration therapy with an oral rehydration solution before surgery is superior to the current preoperative intravenous therapy for the provision of water , electrolytes , and carbohydrates , and this therapy should be considered as an alternative to the intravenous therapy for preoperative fluid and electrolyte management in selected surgical patients in whom there is no reason to suspect delayed gastric emptying UNLABELLED We evaluated the preemptive analgesic effect of a small dose of ketamine given before or immediately after surgery in a r and omized , double-blinded study performed in 128 women undergoing total mastectomy . Group 1 patients received ketamine 0.15 mg/kg as a 5-mL i.v . injection 5 min before surgery and isotonic saline 5 mL i.v . at the time of skin closure . Group 2 received 5 mL i.v . of isotonic saline , then 0.15 mg/kg i.v . ketamine . A st and ard general anesthesia procedure including sufentanil was used . In the recovery room , patient-controlled analgesia i.v . morphine was used for postoperative analgesia . Postoperative pain was assessed by measuring morphine consumption and visual analog scale pain scores . No significant intergroup differences were seen in the pain scores . Patient-controlled analgesia morphine consumption was lower during the first 2 h after surgery in patients given ketamine at the time of skin closure . No patient complained of hallucinations or nightmares . The incidence of adverse effects was not different between the two groups . In conclusion , administering ketamine at the end of surgery is more effective in reducing morphine consumption than it is when given before surgery . IMPLICATION S We administered the same small dose of ketamine before or after surgery . The preoperative administration of 0.15 mg/kg ketamine in patients undergoing total mastectomy did not elicit a preemptive analgesic effect . Ketamine given at closure reduced the patient-controlled analgesia morphine requirement in the first 2 h after surgery Prewarming operating rooms has been shown to limit hypothermia in pediatric surgical patients but may be associated with extreme discomfort for surgeons . We examined the effect of prewarming operating rooms on core temperatures during knee and hip arthroplasties . Sixty-six patients were r and omized to the  prewarmed group at 24 ° C or control group at 17 ° C . The prewarmed group core temperature ( mean , 36.14 ° C ) before active warming was significantly higher ( P = .018 ) than that of the control group ( mean , 35.83 ° C ) . By the start of surgery , the difference was 36.01 ° C prewarmed vs 35.83 ° C control , P = .038 . There was no significant difference in the last recorded mean temperatures between groups : 36.35 ° C ( prewarmed ) vs 36.16 ° C ( control ) . A prewarmed operating room for adults undergoing knee or hip arthroplasty had minimal effect on preventing intraoperative hypothermia Postoperative infectious complications after breast surgery may result in significant morbidity , psychological trauma , and additional costs . We assessed the efficacy of preoperative antibiotic prophylaxis for surgery in a r and omized , double-blind trial of 1,766 patients undergoing breast surgery . From January 1 , 1996 to August 31 , 1997 , all eligible patients were assigned r and omly to receive a single dose of ceftriaxone ( 2 g ) or ceftazidime ( 2 g ) given intravenously at the induction of anesthesia , with no further doses . The groups were similar with respect to age , operative procedure , operative time and time to discharge after operation . The patients who received ceftriaxone prophylaxis had 54.4 % fewer overall infections than those who received ceftazidime prophylaxis . Wound infection occurred in 0.45 % of the ceftriaxone recipients ( 2 of 883 ) and 0.91 % of the ceftazidime recipients ( 8 of 883 ) . This prospect i ve r and omized double-blind study showed that the long-acting regimen containing ceftriaxone is more cost-effective than the short-acting ceftazidime in preventing postoperative infections in patients subjected to breast surgery Background : R and omized controlled studies provide ample evidence that heparin is effective in reducing the risk of thromboembolic complications . Nevertheless , plastic surgeons are often reluctant to use heparin chemoprophylaxis for fear of postoperative bleeding . The authors investigated whether heparin chemoprophylaxis was associated with postoperative hematoma that required evacuation in patients who underwent transverse rectus abdominis myocutaneous ( TRAM ) flap breast reconstruction . Methods : A multicenter retrospective review of consecutive TRAM flap cases identified 679 patients , 392 in the heparin-treated group and 287 in the control group .  The post hoc sample sizes were adequate to detect a 5 percent difference in hematoma rate with 89 percent power at an alpha level of 5 percent ( p < 0.05 ) . Outcome measures of reoperative hematoma , deep vein thrombosis , and pulmonary embolism were recorded . Results : Reoperative hematoma occurred in 0.5 percent of patients in the heparin-treated group and 1.0 percent of patients in the control group ; this difference was not statistically significant ( p = 0.66 ) . Thromboembolic events were detected at a low rate ( 0.8 percent in the heparin-treated group versus 1.4 percent in the untreated group ; p = 0.46 ) . Conclusions : The use of heparin for venous thrombotic prophylaxis did not increase the risk of reoperative hematoma after breast reconstruction with abdominal tissue . The authors propose a risk assessment that balances a statistical hematoma rate of 0.5 to 5 percent ( clinical ly observed rate , 0.5 percent ) with use of heparin prophylaxis against a rare ( clinical ly observed rate , 1.4 percent ) but morbid occurrence of thromboembolic complications when chemoprophylaxis is omitted Background : Pregabalin is used for the treatment of neuropathic pain and has shown analgesic efficacy in post‐operative pain . The aim of this r and omized , double‐blinded , placebo‐controlled trial ( Clinical Trials.gov ID NCT00938548 ) was to investigate the efficacy and safety  of pregabalin for reducing post‐operative pain in patients after mastectomy Background and objective A r and omized and prospect i ve study was performed to compare anaesthetic characteristics and stress hormone responses of two anaesthetic techniques . Methods Forty‐two patients undergoing day case excisional biopsy of breast mass were r and omly assigned to receive propofol – remifentanil or sevoflurane – N2O . Anaesthesia was induced and maintained either with sevoflurane and 50 % N2O in oxygen or with target‐controlled remifentanil and propofol in 50 % oxygen and air . Anaesthetic depth was monitored by the bispectral index . Results The times for induction ( 2.9 vs. 1.7 min ) and for laryngeal mask insertion ( 5.7 vs. 3.3 min ) were longer in the sevoflurane – N2O group than in the propofol – remifentanil group . However , apnoea ( 57.1 % vs. 9.5 % ) and bradycardia ( 23.8 % vs. 0 % ) were more prevalent with propofol – remifentanil . In the sevoflurane – N2O group , the emergence times to a verbal response ( 10.6 vs. 3.7 min ) , to extubation ( 11.8 vs. 4.0 min ) and to orientation ( 14.7 vs. 4.8 min ) were longer than in the propofol – remifentanil group . There were significantly more nausea ( 38.1 % vs. 4.8 % ) and vomiting ( 19.2 % vs. 0 % ) in the sevoflurane – N2O group than in the propofol – remifentanil group . The time to discharge was similar although there was less postoperative pain in the sevoflurane – N2O group . There were no differences in the perioperative cortisol responses in the two groups . Conclusions Smoother induction of anaesthesia was seen with sevoflurane – N2O . Propofol – remifentanil showed a quicker emergence with less nausea/vomiting . There were similar perioperative cortisol responses in the two anaesthetic techniques Background : Immediate breast reconstruction using the transverse rectus abdominis musculocutaneous ( TRAM ) flap is associated with multiple risk factors for pulmonary thromboembolism , the incidence of which has been reported to be as high as 6.3 percent . The authors conducted a prospect i ve study of the efficacy of prophylactic use of low-molecular-weight heparin to prevent pulmonary thromboembolism . Methods : Six hundred fifty consecutive patients who underwent immediate breast reconstruction with TRAM flaps between August of 2001 and April of 2007 were included in this study .  No medical prophylaxis was administered for the former 450 consecutive patients ( group 1 ) . Since February of 2006 , enoxaparin was routinely given to the latter 200 consecutive patients ( group 2 ) for 7 days , from the day of surgery . Fifty-four patients in group 1 ( group 1c ) and 68 patients in group 2 ( group 2c ) were routinely examined for asymptomatic pulmonary thromboembolism . Incidences of symptomatic and asymptomatic pulmonary thromboembolism , decreases in hemoglobin , and bleeding-related complications were compared . Results : Although the incidence of symptomatic pulmonary thromboembolism did not differ significantly between groups 1 and 2 ( 1.8 percent versus 0 percent ; p = 0.107 ) , that of asymptomatic pulmonary thromboembolism was significantly higher in group 1c than in group 2c ( 16.7 percent versus 0 percent ; p = 0.009 ) . The hemoglobin decrease was significantly different ( 2.5 g/dl in group 1 versus 2.8 g/dl in group 2 ; p = 0.001 ) , but the incidences of transfusion , hematoma , and seroma showed no statistically significant difference . Conclusion : Prophylactic use of low-molecular-weight heparin was effective in preventing pulmonary thromboembolism without increasing problematic bleeding-related complications in TRAM flap immediate breast reconstruction patients BACKGROUND Breast cancer ( BC ) is currently the most frequent tumor in women . Through the years , BC management has evolved towards conservative surgery . However , even minimally invasive surgery can cause neuromotor and /or articular impairments which can lead to permanent damage , if not adequately treated . AIM To clinical ly evaluate upper ipsilateral limb function and the impact of certain post-surgical consequences arising after invasive or breast-conserving surgery for early BC , by intervening , or not intervening , with an early rehabilitation program . To investigate physical morbidity after sentinel ( SLND ) or axillary lymph node dissection ( ALND ) and after reconstructive surgery in the treatment of early BC . DESIGN Observational prospect i ve trial . SETTING Inpatient and outpatient treatment . POPULATION Eighty-three females participated in the study : 25 patients did not begin physiotherapy during hospitalization ( Group A ) , 58 patients received early rehabilitation treatment ( Group B ) . METHODS The patients of Groups A and B were compared with respect to the following criteria : shoulder-arm mobility , upper limb function , and presence of lymphedema . All patients were assessed at 15 - 30 , 60 and 180 days after surgery . RESULTS Statistically significant differences , in favor of Group B , were encountered at the 180-day follow-up visit , especially with respect to articular and functional limitation of the upper limb . CONCLUSION AND CLINICAL REHABILITATION IMPACT The results of the present study show that early assisted mobilization ( beginning on the first postoperative day ) and home rehabilitation , in conjunction with written information on pre caution ary hygienic measures to observe , play a crucial role in reducing the occurrence of postoperative side-effects of the upper limb A 10-year prospect i ve study undertaken at Foothills Hospital in Canada used the infection of wounds  to measure the rate of infection on the surgical services . The authors consider the effects of the following factors on the rate of infection : length of preoperative stay , preparation of the patient for surgery , identification of patients at risk , surgical technique and choice of procedure , and acquainting staff with statistics of wound infection rates Background Postoperative nausea and vomiting is a major cause of patient dissatisfaction towards surgery . For bariatric surgery , increased vomiting/retching is detrimental to surgical anastomosis . The present study evaluated the efficacy of aprepitant ( neurokinin-1 inhibitor ) as a prophylactic antiemetic in morbidly obese patients for laparoscopic bariatric surgery . Methods After institutional review board approval , 125 morbidly obese patients were recruited into this double-blind placebo-controlled trial . On r and om division , the patients received a tablet of aprepitant ( 80 mg ) in group A , or a similar-appearing placebo in group P , an hour prior to surgery . All patients received intravenous ondansetron ( 4 mg ) intraoperatively . Postoperatively , the patients were evaluated for nausea and vomiting by a blinded evaluator at 30 min , 1 , 2 , 6 , 24 , 48 , and 72 h. Results Both groups were evenly distributed for age , body mass index , type , and length of surgery . Cumulative incidence of vomiting at 72 h was significantly lower in group A ( 3 % ) compared to group P ( 15 % ; p = 0.021 ) . Odds ratio for vomiting in group P compared to group A was 5.47 times . On Kaplan – Meier plot , time to first vomiting was also significantly delayed in group A ( p = 0.019 ) . A higher number of patients showed complete absence of nausea or vomiting in group A compared to group P ( 42.18 vs. 36.67 % ) . On the other h and , nausea scores were unaffected by aprepitant , and no significant difference between groups was found at any of the measured time points . Conclusions In morbidly obese patients undergoing laparoscopic bariatric surgery , addition of aprepitant to ondansetron can significantly delay vomiting episodes simultaneously lowering the incidence of postoperative vomiting Methods : In a prospect i ve r and omised placebo controlled double-blind study 210 ASA I-II women scheduled for elective termination of pregnancy received 1 g paracetamol , 8 mg lornoxicam or placebo orally 60 min before anaesthesia which was st and ardised with propofol , fentanyl and oxygen in nitrous oxide 1:2 .  Postoperative pain was assessed by VAS-score at 30 and 60 min after end of surgery and at discharge as primary endpoints . Need for rescue medication and time to discharge were secondary endpoints . Results : All patients had an uncomplicated course .  Overall pain intensity was low , however , the patients pretreated with lornoxicam had significantly less pain after surgery , no difference could however , be seen in need for rescue medication or time to discharge between the three groups . Conclusion : General pain prophylaxis may be argued in minor gynaecological surgical procedures where postoperative pain is of low intensity . If general prophylaxis is to be given in minor gynaecological surgery , a non steroidal anti-inflammatory ( NSAID ) such as lornoxicam , seems more efficacious as compared to a st and ard dose of 1 g paracetamol 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 OBJECTIVE A postoperative regimen using a multimodal approach with enforced mobilization and early oral nutrition has been reported to improve convalescence but has not been compared with other postoperative regimens . METHODS Forty patients undergoing elective colorectal surgery were r and omly allocated to an intervention group receiving comprehensive information on the importance of mobilization , balanced anesthesia , and postoperative analgesia including epidural local anesthetics and enforced postoperative mobilization or a control group receiving anesthesia without epidural local anesthetics , postoperative analgesia with epidural morphine , and mobilization without fixed goals . All patients were offered early oral nutrition . The regimens were compared by means of ambulation time and physical activity , voluntary muscle strength , pulmonary function , and body composition . RESULTS The ambulation time improved substantially within 22 h in the intervention group versus 3 h in the control group on day 1 ( P = 0.0004 ) and within 8 h versus 2 h on day 4 ( P = 0.0003 ) . The voluntary strength of the quadriceps muscle decreased by 3 % in the intervention group versus 15 % in the control group on day 7 ( P = 0.04 ) . Two months postoperatively , the difference between groups was the same ( P = 0.02 ) . CONCLUSION This active per- and postoperative regimen based on a multimodal approach improved ambulation time and muscle function during admission and late convalescence INTRODUCTION Active inspired gas humidification ( AH ) preserves body heat and maintains normothermia intraoperatively . However , it is unclear whether AH shows comparable influences during liver transplantation ( OLT ) , which may be affected by both large internal heat loss and external heat supply . Thus , the aim of this study was to evaluate the effect of AH compared with passive humidification ( PH ) on body temperature in OLT . MATERIAL S AND METHODS Thirty-four adult patients undergoing living donor OLT were r and omly enrolled into two groups : those given AH using a heated humidifier ( HH group , n = 17 ) and those using a heat- and -moisture exchanger ( HME group , n = 17 ) . Both core and skin temperatures ( Tc and Ts ) , as well as respiratory parameters , including static/dynamic lung compliances and PaO(2 ) , were recorded at predetermined times . RESULTS Both Tc and Ts were consistently higher among the HH versus the HME group after 2 hours of anesthesia . Differences in Tc and Ts between the two groups increased gradually over time . The overall Tc during surgery was higher among the HH than the HME group ( P = .023 ) . The incidences of hypothermia were lower in the HH group at 3 hours of anesthesia , 1 and 3 hours of reperfusion , and at the end of surgery ( P = .037 , 0.024 , 0.005 , and 0.010 respectively ) . The duration of hypothermia was lower in the HH than the HME group ( 3.9 ± 3.5 hours versus 6.7 ± 3.3 hours , P = .025 ) . Both groups showed no significant intraoperative changes in respiratory parameters ; there were no postoperative respiratory complications . CONCLUSION Active humidification warms the patient 's body effectively , lessening the incidence and duration of hypothermia during OLT with no respiratory risks Purpose The use of opioids following surgery is associated with a high incidence of postoperative nausea and vomiting ( PONV ) . We conducted a prospect i ve , r and omized , double-blind , placebo-controlled study to investigate the effect of orally administered aprepitant , a neurokinin-1 receptor antagonist , for reducing PONV in patients with fentanyl-based , patient-controlled analgesia ( PCA )  given intravenously after gynecological laparoscopy . Methods One hundred and twenty female patients ( ages 21–60 ) undergoing laparoscopic hysterectomy were r and omly allocated to receive 80 mg ( A80 group , n = 40 ) or 125 mg aprepitant ( A125 group , n = 40 ) or placebo ( control group , n = 40 ) orally 2 h before anesthesia induction . Anesthesia was maintained with isoflurane and remifentanil , and PCA IV using fentanyl and ketorolac were provided for 48 h after surgery . Incidences of nausea , vomiting/retching , and use of rescue antiemetics were recorded at 2 , 24 , and 48 h after surgery . Complete response was defined as no PONV and no need for rescue treatment . Results The incidence of complete response was significantly lower in the A80 and A125 groups than in controls , 56 % and 63 % , vs. 28 % , respectively , P = 0.007 and P = 0.003 , respectively , during the first 48 h , and 65 % and 65 % vs. 38 % , respectively , both P = 0.025 , during the first 2 h. However , there were no statistically significant differences between A80 and A125 groups in the incidences of complete response and PONV during the study period . Conclusions Aprepitant 80 mg orally was effective in lowering the incidence of PONV in the first 48 h after anesthesia in patients receiving fentanyl-based PCA  after gynecological laparoscopy Background : Surgery is succeeded by long‐lasting state of relative peripheral insulin resistance , which is reduced by giving glucose infusion or oral carbohydrate‐rich drinks immediate before operating instead of fasting . The aim of the present study was to investigate whether oral carbohydrate or carbohydrate with peptide drinks preoperatively instead of fasting would improve postoperative voluntary muscle strength , nutritional intake and ambulation , decrease postoperative fatigue , anxiety and discomfort , and reduce the endocrine response to surgery STUDY OBJECTIVE To determine whether magnesium sulfate ( MgSO(4 ) ) infusion during surgery reduces shivering during spinal anesthesia . DESIGN Double-blinded placebo-controlled , r and omized trial . SETTING Operation room of a university hospital . PATIENTS 60 patients , aged 40 to 70 years , scheduled for elective transurethral resection of the prostate ( TURP ) during spinal anesthesia . INTERVENTIONS Subarachnoid anesthesia consisting of hyperbaric bupivacaine three mL 0.5 % was injected using a 25-G Quincke spinal needle . Patients received either saline ( Group C , n = 30 ) or MgSO(4 ) ( Group Mg , n = 30 ) . Group Mg received an intravenous ( IV ) bolus of MgSO(4 ) 80 mg/kg via syringe pump over a 30-minute period , followed by a two g/hr infusion during the intraoperative period . Group C received an equal volume of saline . MEASUREMENTS Motor blockade was evaluated by Bromage motor scale . Sensory block level was assessed by pinprick test . Shivering was assessed after the completion of subarachnoid drug injection . Side effects were recorded . MAIN RESULTS Hypothermia was observed in all patients ( 100 % ) in Group Mg and in 24 patients ( 80 % ) in Group C ( P = 0.024 ) . The decrease in core temperature in Group Mg was significantly greater ( P < 0.005 ) . Shivering was observed in two patients ( 6.7 % ) in Group Mg and 20 patients ( 66.7 % ) in Group C ( P = 0.0001 ) . CONCLUSIONS MgSO(4 ) infusion in the perioperative period significantly reduced shivering during TURP with spinal anesthesia . MgSO(4 ) infusion prevents shivering in patients receiving spinal anesthesia but increases the risk of hypothermia BACKGROUND It remains to be determined if perioperative systemic magnesium can improve postoperative quality of recovery of patients undergoing ambulatory procedures . The main objective of the current investigation was to evaluate the effect of systemic magnesium on postoperative quality of recovery in patients undergoing outpatient segmental mastectomies . METHODS The study was a prospect i ve r and omized , double-blind , placebo-controlled , clinical trial . Female subjects were r and omized to receive intravenous magnesium ( MgSO4 50mg/kg in 100 mL of normal saline over 15 min before anesthesia induction , followed by an infusion of 15 mg/kg/hour ) or the same volume of saline . The primary outcome was the Quality of Recovery 40 ( QOR-40 ) question naire at 24 hours after surgery . RESULTS 50 subjects were recruited and 46 completed the study . Patients in the magnesium group had better global Quality of Recovery scores compared with the saline group , with a median difference of 24 ( 99 % CI , 3 to 33 ) , P<0.001 . After discharge from hospital , subjects in the magnesium group required less oral opioids , median ( IQR ) of 10 ( 0 to 20 ) ( oral milligrams of morphine equivalents ) than the saline group , 30 ( 20 to 40 ) ( P<0.001 ) . The postoperative systemic magnesium concentrations were substantially higher in the magnesium group , 1.25 ± 0.28 mmol/L compared to control , 0.71 ± 0.11 mmol/L , P<0.0001 . Simple linear regression demonstrated a direct linear relationship between the postoperative systemic magnesium concentrations and 24 hour postoperative quality of recovery scores ( P = 0.004 ) , and also an inverse relationship with pain burden in the postoperative care unit ( P = 0.01 ) . CONCLUSIONS Systemic magnesium improves postoperative quality of recovery in patients undergoing outpatient segmental mastectomy .  Systemic magnesium is a safe , inexpensive , efficacious strategy to improve quality of recovery after ambulatory surgery Background : 2-Octyl-cyanoacrylate skin adhesive may be used for surgical wound closure . However , its use in plastic surgery has not been properly assessed . Methods : The authors conducted a prospect i ve , r and omized , controlled clinical intervention study in which the scar characteristics after use of skin adhesive were compared with those after suture closure .  Bilateral reduction mammaplasty was performed in 50 patients . The method of closure ( sutures versus skin adhesive ) applied to each breast was determined r and omly , using each patient as her own control . Scars were assessed by the patient and by a blinded panel , at 1 week , 6 weeks , and 6 months after surgery , using a visual analogue scale , the modified Holl and er Wound Evaluation Scale , and the Patient and Observer Scar Assessment Scale . Results : Both patients and panelists expressed an overall preference for the adhesive side as of 1 week after surgery . Patients ’ visual analogue scale scores for scar comfort and scar appearance and panelists ’ visual analogue scale scores for aesthetic outcome were significantly better for the adhesive side after 6 weeks and 6 months ( p < 0.05 ) , as was the total Holl and er Wound Evaluation Scale score of the panelists after 6 weeks ( p < 0.02 ) . The total Patient and Observer Scar Assessment Scale score after 6 months was significantly better for the adhesive side according to the patients ( p < 0.01 ) , but not according to the panelists ( p = 0.11 ) . Conclusion : The authors conclude that 2-octyl-cyanoacrylate is a sound alternative for wound closure Background : The exact risk that poor glucose control introduces to patients undergoing surgical closure has yet to be fully defined . Methods : The authors retrospectively analyzed a prospect ively collected data base of patients seen at their wound care center to evaluate the effects of chronic and perioperative glucose control in high-risk patients undergoing surgical wound closure .  Hemoglobin A1c and blood glucose levels for the 5 days before and after surgical closure were recorded and compared with the primary endpoints of dehiscence , infection , and reoperation . Univariate and multivariate analyses were performed . Results : Seventy-nine patients had perioperative glucose levels and 64 had hemoglobin A1C levels available for analysis . Preoperative and postoperative hyperglycemia ( defined as any blood glucose measurement above 200 mg/dl ) as well as elevated A1C levels ( above 6.5 percent or 48 mmol/ml ) were significantly associated with increased rates of dehiscence ( odds ratio , 3.2 , p = 0.048 ; odds ratio , 3.46 , p = 0.028 ; and odds ratio , 3.54 , p = 0.040 , respectively ) . Variability in preoperative glucose ( defined as a range of glucose levels exceeding 200 points ) was significantly associated with increased rates of reoperation ( odds ratio , 4.14 , p = 0.025 ) and trended toward significance with increased rates of dehiscence ( p = 0.15 ) . In multivariate regression , only perioperative hyperglycemia and elevated A1c were significantly associated with increased rates of dehiscence . Conclusions : In primary closure of surgical wounds in high-risk patients , poor glycemic control is significantly associated with worse outcomes . Every effort should be made to ensure tight control in both the chronic and subacute perioperative periods . CLINICAL QUESTION /LEVEL OF EVIDENCE : Risk , II Background : Breast cancer treatment with mastectomy and immediate breast reconstruction ( IBR ) is associated with intense pain in the primary post‐operative period . The present prospect i ve , placebo‐controlled and double‐blind study aim ed to evaluate the analgesic efficacy of diclofenac , a non‐steroid anti‐inflammatory drug ( NSAID ) , in combination with paracetamol and opioids . This was done by 64‐h assessment of post‐operative pain intensity , opioid consumption , blood loss , nausea and tiredness BACKGROUND Perioperative hypothermia is a common complication of general anesthesia and occurs in up to 50 % of patients during ear , nose and throat ( ENT ) surgery . In this prospect i ve , r and omized controlled study the hypothesis that a new conductive warming blanket ( Barrier ® EasyWarm ® , Mölnlycke Health Care Erkrath , Germany ) is better in reducing the incidence of perioperative hypothermia in ENT surgery than insulation with a conventional hospital duvet alone was tested . MATERIAL S AND METHODS After approval of the local ethics committee and written informed consent 80 patients with a planned procedure time between 1 and 3 h were recruited .  Anesthesia was induced and maintained using propofol , remifentanil and rocuronium and the core temperature was measured using an esophageal temperature probe . Patients in the study group were warmed at least 30 min prior to induction of anesthesia using the novel warming blanket ( Barrier ® EasyWarm ® ) and patients in the control group were insulated with a st and ard hospital duvet . Data were tested using Fisher 's exact test , Student 's t-test or the Mann-Whitney U-test as appropriate . Time-dependent changes in core temperature were evaluated using repeated measures analysis of variance ( ANOVA ) and post hoc Scheffé 's test . Results are expressed as mean ± SD or as median and interquartile range ( IQR ) as appropriate . A p < 0.05 was considered to be statistically significant . RESULTS The ANOVA did not identify a significantly higher core temperature in the study group at any time point . Furthermore , Fisher 's exact test showed no differences in the incidence of intraoperative ( 12 out of 29 versus 10 out of 32 patients , p = 0.44 ) or postoperative hypothermia ( 12 out of 29 versus 9 out of 32 patients , p = 0.30 ) between the groups . No adverse effects were observed . CONCLUSIONS In the studied patient group the new conductive warming blanket ( Barrier ® EasyWarm ® ) showed no superiority compared to conventional thermal insulation alone BACKGROUND Intraoperative hypothermia is a common event during laparoscopic abdominal surgery . On one h and , intraoperative hypothermia can delay the metabolism and prevent tissue damage . One the other h and , long-term and severe intraoperative hypothermia may also lead to perioperative complications , such as increasing of peripheral resistance , coagulation dysfunction , intraoperative hemorrhage and postoperative shivering . Maintenance of normothermia during surgical procedures may improve the quality of patient care . OBJECTIVES This study investigated the feasibility and efficacy of intraoperative cutaneous warming with an underbody warming system during laparoscopic gastrointestinal surgery . METHODS 110 patients undergoing laparoscopic surgery for gastrointestinal cancer between January and December 2011 were r and omized into the laparoscopic control ( Control ) group and laparoscopic intervention ( Intervention ) group . Nasopharyngeal temperature , prothrombin time , activated partial thromboplastin time , and thrombin time were measured before and during surgery , intraoperative and postoperative complications , as well as shivering after anesthesia and visual analog scale score for pain evaluation after surgery were also recorded . Clinical risk factors that may cause intraoperative hypothermia during laparoscopic surgery were also analyzed by correlation analysis . RESULTS The two groups were comparable at the baseline . Intraoperative hypothermia was observed in 29 patients ( 52.7 % ) in Control group and 3 ( 5.5 % ) in Intervention group . Nasopharyngeal temperature in Control group was significantly decreased since 30min after the start of operation until the end of surgery comparing to that at the start of anesthesia , but there was no difference in the Intervention group . In Intervention group , the nasopharyngeal temperature was remaining at ∼36.5 ° C , indicating the feasibility and efficiency of the underbody warming system in preventing intraoperative hypothermia during laparoscopic gastrointestinal surgery . Moreover , with anesthesia and operation time increased , there was no significant change of coagulation function , hemoglobin level as well as less intraoperative hemorrhage , less postoperative shivering and lower visual analog scale score in Intervention group comparing to Control group . Multivariate logistic regression analysis revealed that anesthesia time and volume of CO2 were independent risk factors for perioperative hypothermia . CONCLUSIONS Cutaneous warming with an underbody warming system is a feasible and effective method to prevent intraoperative hypothermia during laparoscopic gastrointestinal surgery AIMS AND OBJECTIVES This ABC to recovery study evaluated the combined and separate components of preoperative education and the effectiveness of wearing the Papilla Gown . BACKGROUND Surgical removal of the breast may lead to activity limitation , self-image issues , discomfort and later complication of lymphoedema . Design . This study used experimental and longitudinal design . METHODS One hundred and forty-five women undergoing mastectomies for stages two and three breast cancer were r and omised into four groups : education and Papilla Gown , education only , gown only and control . The outcomes of activity ( A ) , body image ( B ) , comfort ( C ) , knowledge and lymphoedema were assessed at baseline and /or 1 week and 6 months using three measures . All 145 participants completed the study question naires at first two measures , and forty-six of these participants completed the question naires at 6 months postoperatively . The setting for the study included two clinics and hospitals . To examine statistical significance at each time point after surgery , 2-way anovas were performed on ABC , knowledge and tape measurement to see whether there were any statistically significant differences between the four groups . All reported p-values are two sided . All statistical analyses were performed using sas 9.2 for Windows . RESULTS The mean age of the sample was 55 years . The study revealed that women who received the combined intervention demonstrated greater activity . Women who wore the gown only had a greater comfort level and decreased lymphoedema . Women that received preoperative education experienced increased knowledge . CONCLUSIONS Outcomes suggest that the combined intervention ( ABCs to recovery ) can improve recovery following mastectomy . Relevance to clinical practice . The results will be used to further modify the intervention and to increase awareness of nurse practitioners and other healthcare professionals of the specific needs of postmastectomy patients Background : An interactive digital education aid for breast reconstruction patients was developed because of a perceived need to provide patients with more education regarding the treatment so that they can make better informed treatment decisions . A prospect i ve r and omized study was conducted to assess its effectiveness . Methods : Breast cancer patients who were c and i date s for breast reconstruction were recruited and r and omized into a control group and a study group . Both groups received routine assessment and education in the plastic surgery clinic , but the study group also watched the interactive digital education aid .  Question naires assessing knowledge , anxiety , and satisfaction were administered ( 1 ) before the initial plastic surgery consultation , ( 2 ) immediately before surgery , and ( 3 ) 1 month after surgery . Results : A total of 133 women participated , 66 in the control group and 67 in the study group . Women in both groups showed decreased anxiety , increased knowledge , and enhanced satisfaction with their decision-making ability associated with preoperative instructions about reconstructive surgery . However , the study group was significantly more satisfied than the control group with the method of receiving information and showed a less steep learning curve regarding the different techniques of breast reconstruction . They also tended to have a reduced mean level of anxiety and increased satisfaction with the treatment choice compared with the control group . Conclusions : An interactive digital education aid is a beneficial educational adjunct for patients contemplating breast reconstruction . Patients who use an interactive digital education aid demonstrate greater factual knowledge , reduced anxiety , and increased postoperative satisfaction compared with patients given preoperative instructions using st and ard methods alone . The benefit of an interactive digital education aid is expected to be higher in a broad-based practice setting outside of a comprehensive cancer center Background : This study assessed the efficacy of a continuous infusion pump system for postoperative pain control at muscle-sparing transverse rectus abdominis musculocutaneous ( TRAM ) flap donor sites . Methods : In this prospect i ve , r and omized , double-blind trial , a dual-catheter continuous infusion pump system was placed in the muscle-sparing TRAM flap donor-site area in all patients .  Bupivacaine ( 0.375 % ; continuous infusion pump group ) or isotonic saline ( control group ) was infused at 4 ml/hour . All patients also had a patient-controlled anesthesia system delivering intravenous narcotics on dem and .  Pain scores , patient satisfaction , narcotic use , milestones of surgical recovery , and side effects of narcotics were compared between the two groups . Results : Forty-eight patients were included in the study ( 23 continuous infusion pump patients and 25 control patients ) . The continuous infusion patients used less mean patient-controlled anesthesia narcotic during the first 2 postoperative days ( 78.0 mg versus 42.7 mg ; p = 0.019 ) and transitioned earlier to oral narcotics than did control patients . Patients ’ overall pain satisfaction scores were significantly better in the continuous infusion group than in the control group . There were no significant differences between groups with regard to overall abdominal pain intensity scores , total narcotic use , length of hospitalization , incidence of narcotic side effects , or milestones of surgical recovery . Conclusions : The continuous infusion pump system appears to be a safe and effective method for postoperative donor-site pain management in TRAM flap breast reconstruction patients and should be considered for postoperative donor-site pain management . However , continuous infusion pump local anesthetic delivery to the muscle-sparing TRAM flap donor site did not eliminate narcotic use for pain control Background : Postoperative nausea and vomiting is a major challenge in the perioperative setting . The incidence can be as high as 80 percent , and the majority of the symptoms among out patients occur after discharge . This study evaluated the efficacy of a neurokinin-1 receptor antagonist ( aprepitant ) in reducing postoperative symptoms for up to 48 hours in patients undergoing outpatient plastic surgery . Methods : A prospect i ve , double-blinded , r and omized , two-arm evaluation of 150 ambulatory plastic surgery patients receiving a st and ardized general anesthetic , including postoperative nausea and vomiting prophylaxis with ondansetron and either aprepitant or placebo  , was performed . The main outcome measures were the occurrence of vomiting and the severity of nausea for up to 48 hours postoperatively . Results : Overall , 9.3 percent of patients who received aprepitant versus 29.7 percent in group B had vomiting , with the majority of vomiting episodes occurring after hospital discharge . The Kaplan-Meier plot of the hazards of vomiting revealed an increased incidence of emesis in patients receiving ondansetron alone compared with the combination of ondansetron and aprepitant ( p = 0.006 ) . The incidence of nausea was not significantly different in the two groups . Severity of nausea , however , was significantly higher in those receiving ondansetron alone compared with those receiving ondansetron and aprepitant , as measured by a peak nausea score ( p = 0.014 ) and by multivariate analysis of variance results comparing repeated verbal rating scale scores over 48 hours after surgery ( p = 0.024 ) . Conclusion : In patients undergoing plastic surgery , the addition of aprepitant to ondansetron significantly decreases postoperative vomiting rates and nausea severity for up to 48 hours postoperatively . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , II BACKGROUND Animal models and retrospective clinical data suggest that certain anaesthetic techniques can attenuate immunosuppression and minimize metastasis after cancer surgery . Natural killer ( NK ) T cells are a critical component of the anti-tumour immune response . We investigated the effect of serum from women undergoing primary breast cancer surgery , r and omized to propofol-paravertebral block ( PPA ) or sevoflurane-opioid ( GA ) anaesthetic techniques  , on healthy human donor NK cell function and cytotoxicity against oestrogen and progesterone receptor-positive breast cancer cells ( HCC1500 ) . METHODS Ten subjects who donated serum before operation and 24 h after operation in an ongoing r and omized prospect i ve trial ( NCT 00418457 ) were r and omly selected . Serum from PPA ( n=5 ) and GA ( n=5 ) subjects was co-cultured with HCC1500 and healthy primary NK cells . NK cell activating receptors ( NKp30 , NKp44 , NKp46 , 2b4 , CD16 , NKG2D ) , cytokine production , NK CD107a expression , and cytotoxicity towards HCC1500 were examined . RESULTS Serum from PPA subjects did not alter normal NK marker expression or secretion of cytokines . Serum from GA subjects reduced NK cell activating receptor CD16 [ from mean ( sem ) , 82 (2)% to 50 (4)% , P=0.001 ] , IL-10 [ from 1700 ( 80 ) to 1200 ( 92 ) pg ml(-1 ) , P=0.001 ] , and IL-1β [ from 68 ( 12 ) to 19 ( 4 ) pg ml(-1 ) , P=0.01 ] . An increase in NK cell CD107a [ 23 (2)% to 37(3)% , P=0.007 ] and apoptosis of HCC1500 [ 11 (1)% to 21 (2)% , P=0.0001 ] was observed with PPA serum , but not GA serum , treated NK cells . CONCLUSION Serum from women with breast cancer undergoing surgical excision who were r and omized to receive a PPA anaesthetic technique led to greater human donor NK cell cytotoxicity in vitro compared with serum from women who received GA . CLINICAL TRIAL REGISTRATION NCT 041857 Background : Post-operative nausea and vomiting ( PONV ) is commonly seen after modified radical mastectomy ( MRM ) . In this r and omized double-blind prospect i ve study we compared the efficacy of ondansetron , granisetron and granisetron and dexamethasone combination for prevention of PONV following MRM in female patients . Material s and Methods : A total of 75 patients ( 20 - 60 years of age ) undergoing elective MRM were r and omly allocated to one of the three groups of 25 patients each . Group O received ondansetron 4 mg , Group G received granisetron 40 mcg/kg and group granisetron and dexamethasone ( G + D ) received granisetron 40 mcg/kg + dexamethasone 8 mg prior to induction . All episodes of PONV within 24 h after induction of anesthesia were recorded . Statistical Analysis : Statistical analysis was done using Kruskal-Wallis test ( nonparametric ANOVA ) . Results : The incidence of complete response ( no PONV , no rescue medication ) was 96 % with G+D , as compared with 86 % with granisetron and 4 % with ondansetron during 0 - 3h after surgery which was clinical ly significant ( P < 0.05 ) . Similarly clinical ly significant response was seen during 3 - 6 , 6 - 9 , 9 - 12 and 12 - 24 h of surgery . Conclusion : Granisetron and dexamethasone combination is more effective for prevention of PONV in comparison to individual ondansetron and granisetron in MRM
target: Key recommendations support use of  opioid-sparing perioperative medications  , minimal preoperative fasting and early feeding , use of anesthetic techniques that decrease postoperative nausea and vomiting and pain , use of measures to prevent intraoperative hypothermia , and support of early mobilization after surgery .
background: Background : Enhanced recovery following surgery can be achieved through the introduction of evidence -based perioperative maneuvers .
  This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery  and to provide evidence -based recommendations for an enhanced perioperative protocol .