Search Results (197)

Axillary lymph node staging remains a cornerstone of the surgical management of breast cancer. Conventional axillary lymph node dissection (ALND) has historically been the standard procedure for evaluating nodal involvement; however, it is associated with significant morbidity, including lymphedema, sensory disturbances, and reduced shoulder mobility. Over the past few decades, minimally invasive surgery has demonstrated clear benefits in multiple surgical fields, particularly in reducing postoperative morbidity, improving recovery, and enhancing cosmetic outcomes. In breast surgery, these principles have been progressively incorporated into clinical practice. Endoscopic techniques were first introduced in the late 1990s as a minimally invasive alternative to axillary lymph node dissection. Early studies have demonstrated the technical feasibility of endoscopic axillary lymphadenectomy (EALND), reporting adequate lymph node retrieval and acceptable perioperative outcomes. Although the widespread adoption of sentinel lymph node biopsy and the progressive de-escalation of axillary surgery have limited the diffusion of this approach, the potential advantages of minimally invasive techniques appear to be applicable to axillary surgery. In recent years, minimally invasive approaches, including endoscopic and robot-assisted procedures, have been expanded in breast surgery and are now being explored for axillary management. Advances in instrumentation, optics, and imaging technologies, such as fluorescence, have improved surgical visualization and may facilitate safer and more precise dissection of axillary structures. This review summarizes the historical development, technical evolution, and current evidence regarding endoscopic axillary lymphadenectomy for breast cancer. Furthermore, we discuss the potential role of this approach in the modern era of axillary de-escalation and highlight the emerging technologies that may contribute to the future development of minimally invasive axillary surgery. Full article

Background: Enhanced Recovery After Surgery (ERAS) pathways have become the standard of care in elective colorectal surgery. However, implementation remains heterogeneous across institutions, and the relative contribution of ERAS pathways and minimally invasive surgery to improved postoperative outcomes remains uncertain. This study evaluated the association between ERAS implementation and short-term outcomes in two university-affiliated colorectal units with different levels of ERAS adoption. Methods: A retrospective bi-centre observational study was conducted, and comprised 802 consecutive patients who underwent elective colorectal resection between January 2016 and December 2024. Patients managed according to a standardized ERAS pathway (Group 1, n = 406) were compared with patients who received conventional perioperative care (Group 2, n = 396). Primary endpoints included postoperative morbidity, anastomotic leakage, and length of hospital stay (LOS). Secondary endpoints included mortality, readmission, postoperative complications, and hospitalization-related costs. Multivariable logistic regression was performed, adjusting for age, sex, ASA score, tumour stage, and tumour location. Results: Baseline demographic characteristics were largely comparable between groups, although patients in the conventional care group had a higher proportion of ASA III–IV status. Overall postoperative morbidity was significantly lower in the ERAS cohort (8.6% vs. 20.9%, p < 0.001), together with a lower incidence of anastomotic leakage (1.2% vs. 4.5%, p < 0.001). Median LOS was reduced from 9 to 8 days overall and, among patients who underwent laparoscopic surgery, from 6 to 4 days (p = 0.010). After multivariable adjustment, conventional perioperative management remained independently associated with higher postoperative morbidity (OR 2.62, 95% CI 1.60–4.09; p < 0.001) and anastomotic leakage (OR 1.92, 95% CI 1.01–4.98; p = 0.048). Mortality, surgical site infections, intra-abdominal abscesses, and other postoperative complications were comparable between groups. Based on regional reimbursement tariffs, ERAS implementation was associated with an estimated annual reduction of 567 hospital bed-days. Conclusions: Implementation of a standardized ERAS pathway was associated with reduced postoperative morbidity, lower anastomotic leakage rates, and shorter hospital stay after elective colorectal surgery. These benefits persisted after adjustment for major clinical confounders, supporting the effectiveness of standardized perioperative care. The greatest reduction in hospital stay was observed when ERAS was combined with minimally invasive surgery, emphasizing the complementary role of these strategies in optimizing postoperative recovery. Full article

Total-knee arthroplasty (TKA) is associated with substantial acute postoperative pain. While the adductor canal block (ACB) is widely used to provide motor-sparing anterior knee analgesia, effective management of posterior knee pain remains an important clinical challenge. The infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) block was developed to address posterior capsular pain but may be associated with technical and ergonomic limitations. More recently, the popliteal plexus block (PPB) has emerged as a novel motor-sparing alternative. This narrative review summarizes the anatomical basis, current clinical evidence, and practical considerations of combining the ACB with the PPB, with particular emphasis on its potential role as an alternative to the IPACK block within Enhanced Recovery After Surgery (ERAS) pathways. Current anatomical and early clinical evidence suggests that the PPB selectively targets the terminal articular branches around the adductor hiatus while preserving the major motor nerve trunks. Available randomized clinical trials indicate that the PPB provides analgesia comparable to IPACK while maintaining motor function, with additional practical advantages including shorter procedural time and, in individual studies, reduced postoperative opioid consumption and postoperative nausea. Overall, the combined ACB and PPB approach appears to be a promising motor-sparing strategy for perioperative analgesia after TKA. However, the current evidence is derived predominantly from cadaveric studies, early-phase randomized trials, and single-center clinical investigations. Therefore, larger multicenter studies with longer follow-ups are needed to establish its long-term efficacy, safety, and role relative to the established IPACK technique. Full article

Background and Objectives: Over recent decades, germline genetic testing has become increasingly integrated into breast cancer care, yet its precise effect on the timing of surgical workflows remains incompletely defined. This study investigates the implementation of nationally reimbursed genetic testing programs and examines how the scheduling of multigene germline testing relates to surgical timing. Materials and Methods: In this retrospective cohort analysis, we examined 502 breast cancer cases from the institutional registry of the “Ion Chiricuță” Oncology Institute (IOCN), with a mean age of 52 years, a high rate of neoadjuvant therapy (82.3%) and a majority of them in T2 (52%) and N1 (43%), N2 (29%) clinical stage: 263 patients from an earlier private-practice pay testing era (pre-reimbursement) as a comparison sample and 239 patients from the period when reimbursement programs were in operation. We then evaluated the benefits of state-funded genetic testing initiatives, computing three intervals: diagnosis to genetic test, genetic test to surgery, and diagnosis to surgery. Patients were categorized by timing of multigene testing (preoperative vs. postoperative), receipt of neoadjuvant systemic therapy (NACT), mutation status, and funding source for testing (national PNS program funded by the Romanian Ministry of Health; PNRR European Recovery and Resilience Facility funds; or self-funded private testing). Nonparametric statistics (Mann–Whitney U, Spearman correlation) and effect-size metrics (Cliff’s delta, Theil–Sen slope) were employed. Results: The median diagnosis-to-surgery interval was 203 days (IQR 179–230). Patients tested preoperatively had longer intervals than those tested postoperatively (216 vs. 182.5 days; p = 0.000153; Cliff’s δ = −0.486), a pattern driven by shared pathways involving NACT rather than by testing-induced delays. NACT was the principal determinant of surgical timing (211 vs. 43 days; p = 302.55 × 10⁻¹¹). Within the preoperative subgroup, time to multigene testing correlated strongly with time to surgery (Spearman ρ = 0.54; p = 4.75 × 10⁻⁷; Theil–Sen slope = 0.37, 95% CI = 0.22–0.53). However, the no-NACT group included only four patients. The presence of a pathogenic variant did not significantly change surgical timing (p = 0.982). The PNS national reimbursement program achieved the highest preoperative integration rate for multigene genetic testing after adjustment for NACT confounder (76.7%), outperforming PNRR (61%) and private practice (56%). Conclusions: While genetic testing timing correlates with surgical workflow, neoadjuvant systemic therapy pathways and program structure exert greater influence than testing per se. Structured national programs enhance preoperative testing uptake without causing delays beyond those inherent to NACT pathways. Full article

Postoperative complications following colorectal surgery—including anastomotic leak (AL), surgical site infection (SSI), perioperative haemorrhage and colovesical fistula—represent major causes of patient morbidity and mortality, prolonged hospitalisation, and healthcare expenditure. This review summarises contemporary evidence across two key domains of complication management—prevention and diagnosis—applied to four major complications (AL, SSI, perioperative haemorrhage, and colovesical fistula), drawn from a comprehensive literature review of recent randomised controlled trials, systematic reviews, meta-analyses, and prospective cohort studies. Preventive strategies discussed include optimisation of surgical techniques (minimally invasive and robotic approaches, indocyanine green perfusion assessment, self-expanding metal stent bridge-to-surgery, and negative pressure wound therapy), modification of patient factors where possible (obesity, anaemia, malnutrition, and immunosuppression), and system-level interventions including Enhanced Recovery After Surgery (ERAS) protocols, perioperative beta-blockade, prehabilitation, and structured quality improvement bundles. Diagnostic strategies have evolved to incorporate biomarker surveillance (CRP and procalcitonin), drain fluid pH analysis, CT imaging (including angiography), endoscopy, and novel digital health tools including wearable monitoring and mobile health applications. Reducing the risk of postoperative complications should involve a multidisciplinary, protocolised approach combining intraoperative technique optimisation with structured perioperative care bundles and close post-discharge surveillance, and centralisation to specialist colorectal surgical units. Full article

Background/Objectives: Intraoperative oliguria has long been considered a marker of impaired renal perfusion, but its prognostic value for postoperative acute kidney injury (AKI) remains controversial, particularly within Enhanced Recovery After Surgery (ERAS) protocols. We investigated the association between intraoperative oliguria and postoperative AKI in patients undergoing major hepatobiliary and pancreatic surgery within an ERAS protocol. Methods: Patients who underwent major hepatobiliary and pancreatic surgery within an institutional ERAS protocol were retrospectively analyzed. Intraoperative oliguria was defined as urine output < 0.3 mL kg⁻¹ h⁻¹. Postoperative AKI was defined according to the KDIGO serum creatinine criterion within 7 days after surgery. The association was assessed using multivariable logistic regression and sensitivity analyses were performed using an alternative oliguria threshold of <0.5 mL kg⁻¹ h⁻¹ and incorporating additional surgical covariates. Results: Among 816 patients, intraoperative oliguria occurred in 51 (6.3%), and postoperative AKI developed in 60 (7.4%). AKI incidence did not differ between the oliguria and non-oliguria groups (11.8% vs. 7.1%, p = 0.332), and median intraoperative urine output was comparable between the AKI and non-AKI groups (0.7 [0.5–1.1] vs. 0.8 [0.6–1.4] mL kg⁻¹ h⁻¹, p = 0.069). In multivariable analysis, intraoperative oliguria was not independently associated with AKI (OR 1.68, 95% CI 0.60–4.01; p = 0.276). Oral carbohydrate loading, thoracic epidural analgesia, and total intraoperative fluid volume were not associated with AKI. Results were consistent across both sensitivity analyses. Conclusions: In patients undergoing hepatobiliary and pancreatic surgery within the ERAS protocol, intraoperative oliguria was not associated with postoperative AKI, although modest association cannot be excluded given the limited number of AKI and oliguria events. These findings suggest that intraoperative urine output alone may not be a reliable indication for additional fluid administration, and larger prospective studies are needed to confirm this. Full article

Enhanced Recovery After Surgery (ERAS) pathways have improved perioperative outcomes by standardizing evidence-based interventions across the surgical continuum. However, substantial variability in postoperative recovery persists, even within well-implemented ERAS programs. This heterogeneity reflects differences in clinical risk, functional reserve, biological response to surgical stress, treatment responsiveness, and contextual factors that are not fully captured by uniform protocols. Precision medicine provides a potential framework for refining ERAS by integrating patient-specific data into perioperative risk assessment, intervention selection, patient monitoring, and recovery planning. Nevertheless, most precision medicine tools remain insufficiently validated for routine ERAS implementation, and their clinical utility is limited by heterogeneous evidence, data integration challenges, costs, workflow complexity, and equity concerns. Future progress will require prospective validation, pragmatic implementation studies, interoperable data systems, and evaluation of patient-centered outcomes. This narrative review examines the emerging role of precision medicine tools in perioperative practice and proposes an idealized conceptual model of “precision ERAS” in which standardized evidence-based care is preserved as the foundation, while selected interventions are adapted according to individual risk, biological phenotype, and recovery trajectory. Full article

Background/Objectives: Enhanced Recovery After Surgery (ERAS) protocols improved outcomes in colorectal surgery, but global implementation remains heterogeneous. In centers without structured ERAS programs, the lack of standardized discharge criteria could lead to conservative decisions and prolonged hospital stays. This study aimed to evaluate the feasibility and safety of early discharge (ED) on postoperative day (POD) 3 using the five Tavernier’s criteria in a real-world setting without formal ERAS pathways. Methods: This retrospective analysis of a prospectively maintained database included all consecutive adult patients undergoing elective laparoscopic colorectal resection between February 2025 and February 2026 at a high-volume tertiary center. Patients were stratified into the EARLY group (discharged on POD 3 upon fulfilling all five Tavernier criteria: C-reactive protein < 150 mg/L, temperature < 38 °C, passage of flatus, Visual Analogue Scale score < 5, and oral diet tolerance) and the STANDARD group (discharged after POD 3). The primary endpoint was the safety and negative predictive value (NPV) of the five-criteria bundle regarding 30-day complications. Results: Seventy-seven patients were included (EARLY: n = 44; STANDARD: n = 33). In the STANDARD group, the primary barriers to discharge were prolonged intravenous analgesic requirements (81.8%) and delayed bowel function (36.4%). The five-criteria bundle demonstrated an NPV of 84.1%, a sensitivity of 68.2%, and a specificity of 67.3% for identifying patients at low risk of complications. The overall 30-day complication rate was significantly lower in the EARLY group compared to the STANDARD group (15.9% vs. 45.5%; p = 0.010). No major complications (Clavien–Dindo ≥ III) occurred in the EARLY group compared to 6.1% in the STANDARD group. Conclusions: This exploratory feasibility analysis suggests that early discharge on POD 3 guided by the five Tavernier criteria is potentially safe and feasible in a real-world clinical setting without formal ERAS pathways. However, given the small sample size and inherent methodological biases, these findings remain preliminary, and larger prospective multi-center trials are strictly required to validate the safety and formal impact of this strategy. Full article

Background: Liver cancer is a major public health problem in Thailand due to its high incidence and mortality. Although hepatectomy is a potentially curative treatment, it is a complex procedure with a high risk of postoperative complications, necessitating a structured and systematic approach to care. Objectives: This study aimed to develop a clinical practice guideline (CPG) for patients with liver cancer undergoing hepatectomy and to evaluate the feasibility of its implementation in relation to outcomes for healthcare providers, the organization, and patients. Methods: This implementation research was conducted in three phases: (1) an evidence-triggered phase, (2) an evidence-supported phase, and (3) an evidence-observed phase. The CPG covered five stages of care: preoperative, intraoperative, postoperative, discharge planning, and post-discharge follow-up. It was implemented through a multidisciplinary approach, with an advanced practice nurse (APN) facilitating adherence to Enhanced Recovery After Surgery (ERAS) components. Data were analyzed using descriptive statistics. Results: Healthcare personnel demonstrated high adherence to the CPG and reported high feasibility of implementation. After implementation, favorable trends were observed in postoperative complications, length of hospital stay, hospitalization costs, and patient satisfaction compared with the historical pre-implementation period. The CPG also appeared to support clearer care standards and multidisciplinary coordination. Conclusions: The developed CPG was feasible and contextually appropriate for ERAS-based hepatectomy care in this setting. Preliminary findings suggest favorable trends in care processes and selected outcomes. Larger controlled studies with longer follow-up are needed to determine effectiveness and sustainability. Full article

Objective: To characterize the structural organization of Enhanced Recovery After Surgery (ERAS) component implementation in gynecologic oncology and determine whether ERAS elements operate as an interconnected perioperative system during early pathway integration. Methods: This study represents a secondary analysis of the prospective multicenter Enhanced Recovery in Gynecologic Oncology (ERGO) cohort, including the first 300 consecutive patients undergoing surgery for gynecologic malignancy across five tertiary institutions. Components with prevalence between 5% and 95% were included in a regularized Ising network model to estimate conditional dependencies between pathway elements. Node-level centrality metrics and global network characteristics were calculated to identify structurally influential ERAS components and to describe the overall implementation architecture. Results: Thirteen central ERAS components met the predefined prevalence criterion (5–95%) and were included in the conditional dependency network. The estimated network demonstrated substantial inter-component connectivity, indicating that ERAS practices were frequently implemented in coordinated patterns rather than as isolated interventions. Centrality analysis identified postoperative laxatives or chewing gum, tranexamic acid administration, perioperative intravenous fluid management, and avoidance of drain placement as highly connected elements within the network. Early nutritional advancement and postoperative bowel stimulation measures also demonstrated relatively central positions within the recovery-related component cluster. Community detection analysis revealed distinct modules of co-adopted ERAS practices spanning multiple perioperative phases. Conclusions: ERAS implementation in gynecologic oncology appears to follow a structured architecture characterized by interconnected perioperative practices rather than independent protocol elements. Understanding these implementation structures may help guide targeted quality-improvement strategies aimed at optimizing ERAS integration in routine clinical practice. Full article

Enhanced Recovery After Surgery (ERAS^®) is a multimodal perioperative framework designed to mitigate the physiological stress response to major surgery. While ERAS protocols consistently reduce length of hospital stay, overall complication rates, and healthcare costs compared to conventional care, their specific impact on surgical site infections (SSIs) remains poorly defined. This review explores the potential synergistic benefits of integrating ERAS protocols with established infection prevention bundles. By evaluating the current clinical evidence, we analyze how the co-implementation of these two evidence-based strategies can collectively reduce the incidence of SSIs. Full article

Background and Objectives: Perioperative nutrition is a core component of Enhanced Recovery After Surgery (ERAS) pathways. Understanding the patient experience of nutrition recommendations provides insight into the acceptability of perioperative nutrition care and facilitates the achievement of ERAS targets. This systematic review aimed to synthesise patients’ experiences of nutrition within ERAS pathways for colorectal surgery. Methods: A systematic search of Ovid MEDLINE, Embase, Emcare, and CINAHL was conducted to identify studies published up until July 2025. Eligible studies included qualitative, mixed-methods, or descriptive survey designs. Data were extracted and synthesised using an inductive thematic analysis. Methodological quality was assessed using the Mixed Methods Appraisal Tool. Results: Fifteen studies were included (40% qualitative, 33% quantitative, 27% mixed-methods), representing data from 1431 patients. Eleven studies met all quality criteria. Five themes were identified. Information gaps and misconceptions about nutrition (Theme 1) resulted from unclear advice across care settings. Oral intake post-surgery (Theme 2) was limited by nausea, reduced appetite, early satiety, and dissatisfaction with hospital food. Experiences with oral nutritional supplements (Theme 3) were variable, with palatability affecting acceptability. Healthcare professionals (Theme 4) were central in shaping patient confidence in nutrition care. The transition to home (Theme 5) was a vulnerable period where follow-up support was highly valued. Heterogeneous reporting of nutrition in ERAS contexts was a limitation. Conclusions: Patient engagement with ERAS nutrition is shaped by individual and healthcare system factors. Addressing information gaps, providing nutrition support, and integrating patient perspectives through codesigned education and research initiatives may enhance perioperative nutrition experiences and optimise recovery outcomes. Full article

Background: Enhanced Recovery After Surgery (ERAS) programmes are structured perioperative care pathways in which clinical outcomes are closely linked to the degree of implementation fidelity. However, the interaction between ERAS adherence, care complexity, and postoperative outcomes in real-world settings remains insufficiently explored. Objective: To evaluate the association between ERAS adherence and postoperative length of stay in oncological colorectal surgery and to analyse whether Care Complexity Individual Factors (CCIFs) influence this relationship. Methods: A retrospective observational cohort study was conducted in two university hospitals in Barcelona, including 90 adult patients undergoing elective colorectal cancer surgery (2022). ERAS adherence was assessed globally and by phase (pre-, intra-, and postoperative) using structured indicators. CCIFs were classified into five domains. Associations between adherence, care complexity, and outcomes were analysed using bivariate methods. Results: Overall adherence was 64%. Higher adherence was associated with shorter hospital length of stay (median 4 vs. 5 days; p = 0.033) and greater compliance with expected length of stay (37.8% vs. 17.0%; p = 0.047). Adherence varied across perioperative phases, with higher compliance in the preoperative phase and lower compliance postoperatively. Care complexity was high (mean CCIF 2.62) and was not significantly associated with adherence or compliance with expected length of stay. Conclusions: Higher ERAS adherence is associated with shorter hospital stay in oncological colorectal surgery within a real-world context. These findings support the importance of implementation fidelity across the perioperative pathway. Further research incorporating multivariable analyses and patient-centred outcomes is needed to better understand the interaction between care complexity and recovery trajectories. Full article

Background/Objectives: Colorectal cancer (CRC) remains one of the most common malignancies worldwide. Despite advances in surgical techniques and the implementation of Enhanced Recovery After Surgery (ERAS) protocols, a substantial proportion of patients continue to experience postoperative complications and persistent functional impairment. Multimodal prehabilitation, combining physical exercise, nutritional optimization, and behavioral support, has been proposed as a strategy to enhance functional reserve prior to surgical treatment. The aim of this review was to provide a critical narrative evaluation of current clinical evidence regarding the effectiveness and safety of prehabilitation in patients with CRC. Methods: A targeted literature review was conducted in PubMed, Embase, CINAHL, Scopus, and Web of Science (2015–2025), identifying 23 primary studies, including 18 randomized and 5 non-randomized trials. Results: Most multimodal prehabilitation programs resulted in significant improvements in functional capacity prior to CRC resection. Functional outcomes were most commonly assessed using the six-minute walk test, cardiopulmonary fitness parameters, and measures of muscle strength, with good tolerance and high patient adherence. Several studies also demonstrated reductions in postoperative complication rates, shorter hospital stays, and faster recovery of independence, particularly among older patients, those with frailty, or reduced baseline functional capacity, although these effects were not fully consistent across studies. Conclusions: Available clinical evidence supports multimodal prehabilitation as a safe and feasible strategy that consistently preserves and enhances functional reserve prior to CRC surgery. However, its capacity to modify hard perioperative outcomes (such as complication rates and length of stay) remains inconsistent across current RCTs, showing clear efficacy predominantly in targeted high-risk, frail, or malnourished cohorts. Full article

Background: The ERAS (Enhanced Recovery After Surgery) protocol is a multidisciplinary perioperative care pathway aimed at improving postoperative recovery. Few studies have investigated their effectiveness in thyroid surgery. The aim of this study was to evaluate the potential clinical benefits of a structured ERAS protocol applied to thyroid surgery in a tertiary referral center. Methods: We conducted a single-center retrospective study on consecutive series of patients undergoing thyroid surgery for benign or malignant disease before (January 2018–December 2022) and after (May 2024–July 2024) the introduction of the ERAS protocol. A propensity score matching (PSM) analysis was used, matching the groups for age, gender, BMI and type of surgery. Results: After PSM, 64 matched patient pairs were analyzed. ERAS patients showed a significant reduction in length of hospital stay (p < 0.001), postoperative nausea and vomiting (3.1% vs. 12.5%, p = 0.04), and pain with an NRS > 5 12 h after surgery (9.4% vs. 26.6%, p = 0.01). Patients in the ERAS group showed significantly higher calcium levels at 6 h (9.09 vs. 8.7 mg/dL, p < 0.001) and 24 h (8.8 vs. 8.6 mg/dL, p = 0.008) postoperatively, with a reduction in the need for intravenous calcium therapy (0% vs. 12.5%, p = 0.003). Conclusions: This study showed significant clinical benefits and reduced length of stay were achieved in thyroid surgery patients after the implementation of a structured ERAS protocol with potential implications for healthcare cost reduction. Full article