Summary
Enhanced postoperative recovery programmes (ERAS) were developed about 20 years ago based on improved understanding of the pathophysiology of postoperative recovery within an integrated ...multidisciplinary approach. The results across surgical procedures have been extremely positive with a reduction in hospitalisation and medical complications, without increased re‐admission rates. However, several challenges lie ahead including improved implementation of existing scientific evidence, increased focus on post‐discharge recovery problems and a need for improved design of future ERAS studies. However, the most important challenges lie within a better understanding and control of undesirable peri‐operative pathophysiological responses with subsequent risk of organ dysfunction. These efforts should focus on: the inflammatory and neurohumoral surgical stress responses; fluid management; pain management; blood management; mechanisms of orthostatic intolerance; postoperative cognitive dysfunction; risk factors for thrombo‐embolic complications; and mechanisms and prevention of postoperative ileus. Finally, more focus should be made on the different barriers to post‐discharge functional recovery and the choice of (pre‐ and postoperative) rehabilitation. These efforts should be made on a procedure‐specific as well as on a patient‐specific basis.
In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We conducted a systematic review of randomized clinical ...trials investigating LIA for total knee arthroplasty (TKA) and total hip arthroplasty (THA) to evaluate the analgesic efficacy of LIA for early postoperative pain treatment. In addition, the analgesic efficacy of wound catheters and implications for length of hospital stay (LOS) were evaluated. Twenty-seven randomized controlled trials in 756 patients operated on with THA and 888 patients operated on with TKA were selected for inclusion in the review. In THA, no additional analgesic effect of LIA compared with placebo was reported in trials with low risk of bias when a multimodal analgesic regimen was administered perioperatively. Compared with intrathecal morphine and epidural analgesia, LIA was reported to have similar or improved analgesic efficacy. In TKA, most trials reported reduced pain and reduced opioid requirements with LIA compared with a control group treated with placebo/no injection. Compared with femoral nerve block, epidural or intrathecal morphine LIA provided similar or improved analgesia in the early postoperative period but most trials had a high risk of bias due to different systemic analgesia between groups. Overall, the use of wound catheters for postoperative administration of local anaesthetic was not supported in the included trials, and LOS was not related to analgesic efficacy. Despite the many studies of LIA, final interpretation is hindered by methodological insufficiencies in most studies, especially because of differences in use of systemic analgesia between groups. However, LIA provides effective analgesia in the initial postoperative period after TKA in most randomized clinical trials even when combined with multimodal systemic analgesia. In contrast, LIA may have limited additional analgesic efficacy in THA when combined with a multimodal analgesic regimen. Postoperative administration of local anaesthetic in wound catheters did not provide additional analgesia when systemic analgesia was similar and LOS was not related to use of LIA with a fast-track set-up.
Summary
Standardised peri‐operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non‐traumatic pathologies have been shown to be inadequate and associated with high ...morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with ‘rescue’ interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal‐directed therapy and intensive or intermediary postoperative care for high‐risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure‐specific, evidence‐based interventions inside rigorously implemented patient pathways based on multidisciplinary co‐operation. The focus has been on attenuation of peri‐operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri‐operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri‐operative pathophysiology of the different main patient groups – intestinal obstruction and perforation – and the potentially differentiated impact of interventions is carried out. Procedure‐ and pathology‐specific knowledge is lacking on key elements of peri‐operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri‐operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity‐ and procedure‐specific enhanced recovery protocols as seen in elective surgery.
Major surgery is still associated with undesirable sequelae such as pain, cardiopulmonary, infective and thromboembolic complications, cerebral dysfunction, nausea and gastrointestinal paralysis, ...fatigue and prolonged convalescence. The key pathogenic factor in postoperative morbidity, excluding failures of surgical and anaesthetic technique, is the surgical stress response with subsequent increased demands on organ function. These changes in organ function are thought to be mediated by trauma-induced endocrine metabolic changes and activation of several biological cascade systems (cytokines, complement, arachidonic acid metabolites, nitric oxide, free oxygen radicals, etc). To understand postoperative morbidity it is therefore necessary to understand the pathophysiological role of the various components of the surgical stress response and to determine if modification of such responses may improve surgical outcome. While no single technique or drug regimen has been shown to eliminate postoperative morbidity and mortality, multimodal interventions may lead to a major reduction in the undesirable sequelae of surgical injury with improved recovery and reduction in postoperative morbidity and overall costs.
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