Postoperative colonic motility and tone in patients after colorectal surgery

PURPOSE: Colonic motility is crucial for the resolution of postoperative ileus. However, few data are available on postoperative colonic motility and no data on postoperative colonic tone. We aimed to characterize postoperative colonic tone and motility in patients. METHODS: Nineteen patients were investigated with combined barostat and manometry recordings after left colonic surgery. During surgery a combined recording catheter was placed in the colon with two barostat bags and four manometry channels cephalad to the anastomosis. Recordings were performed twice daily from Day 1 to Day 3 after surgery. RESULTS: Manometry showed an increasing colonic motility index, which was a mean (± standard error of the mean) of 37±5 mmHg/minute on Day 1, 87±19 mmHg/minute on Day 2, and 102±13 mmHg/minute on Day 3 (P<0.05 for Day 1vs. Day 2 and Day 2vs. Day 3). Low barostat bag volumes indicating a high colonic tone were observed on Day 1 after surgery and increased subsequently (barostat bag I was 19±4, 32±6, and 32±6 ml; barostat bag II was 13±1, 19±3, and 22±5 ml on Days 1, 2, and 3, respectively; for both barostat bagsP<0.05 for Day 1vs. Day 2 but not Day 2vs. Day 3). CONCLUSIONS: Colonic motility increased during the postoperative course. The low barostat bag volumes indicated a high colonic tone postoperatively which would correspond to a contracted rather than to a distended colon. High colonic tone postoperatively may be relevant for pharmacologic treatment of postoperative ileus.Supported by grants to Dr. Kreis from the University of Tübingen (fortüne 23) and the Deutsche Forschungsgemeinschaft (Kr 1816/1-1). Dr. Huge is supported by the Deutsche Forschungsgemeinschaft (Zi 415/4-1).Published in part in abstract form inGastroenterology 1998;114:G3167.     

Safety of fast-track rehabilitation after gastrointestinal surgery: Systematic review and meta-analysis

AIM: To compare the safety of fast-track rehabilitation protocols (FT) and conventional care strategies (CC), or FT and laparoscopic surgery (LFT) and FT and open surgery (OFT) after gastrointestinal surgery.METHODS: We searched MEDLINE, WHO International Trial Register, Embase and The Cochrane Central Register of Controlled Trials up to 2014 for randomized controlled trials (RCTs) comparing FT and CC or comparing LFT and OFT, with 10 or more randomized participants and about 30 d follow-up. Two reviewers independently extracted data on complications, anastomotic leak, obstruction, wound infection, re-admission between FT and CC or LFT and OFT after gastrointestinal surgery.RESULTS: Twenty-four RCTs of FT vs CC or LFT vs OFT were included. Compared with CC, FT reduced overall complications and wound infection. However, anastomotic leak, obstruction and re-admission were not significantly reduced. The pooled risk ratio (RR) of 0.69 (95%CI: 0.60-0.78; P < 0.001), pooled RR of 0.71 (95%CI: 0.57-0.88; P < 0.001), pooled RR of 0.93 (95%CI: 0.68-1.25; P > 0.05), a pooled RR of 0.87 (95%CI: 0.67-1.15; P > 0.05) and pooled RR of 0.94 (95%CI: 0.73-1.22; P > 0.05) respectively. Compared with OFT, LFT reduced complications, with a pooled RR of 0.66 (95%CI: 0.54-0.81; P < 0.001).CONCLUSION: FTs are safe after gastrointestinal surgery. Additional large, prospective RCTs should be conducted to establish further the safety of this approach.     

Postoperative colonic motility after tropisetron and a standardized meal in patients undergoing conventional colorectal surgery

Background Early postoperative enteral nutrition is advantageous for the recovery of colonic motility but may be limited by abdominal distension, nausea, and vomiting. We aimed to investigate the tolerance of a standardized meal after pretreatment with the 5-hydroxytryptamine-3-receptor antagonist tropisetron and to study the concomitant colonic motility. Methods Colonic motility and tone were recorded on postoperative day 1 to 3 with a combined manometry/barostat recording catheter in 12 patients who underwent open colorectal surgery with an anastomosis in the distal colon or rectum. The study protocol consisted of 30 min of baseline recordings followed by 5 mg of tropisetron intravenously. Then, motility was recorded for another 30 min before patients ingested a standardized meal to trigger the gastrocolonic response. Postprandial motility was recorded for the subsequent 60 min. Results The colonic motility index increased after administration of tropisetron on all three postoperative days (day 1: 34±11 vs 122±48, day 2: 55±19 vs 101±25, and day 3: 42±16 vs 93±33 mmHg/min; p<0.05). No further increase of the motility index was observed postprandially. Frequency and amplitude of contractions were virtually unaffected by tropisetron and the meal. Barostat bag volume decreased postprandially in the proximal bag on the third, and in the distal bag on the first and second postoperative day (p<0.05). Patients’ condition was unaffected by the standardized meal after tropisetron administration. Conclusions Tropisetron may enhance colonic motility in the early postoperative period; however, the gastrocolonic response was impaired thereafter. High caloric food intake is well tolerated early after surgery after tropisetron pretreatment. This work was presented as an oral presentation at the Ross Residence Conference during the annual meeting of the Society for Surgery of the Alimentary Tract in 2001 and is published in abstract form (Gastroenterology 2001; 120(Suppl 1):A473).     

Multivariate analysis of the risk for pulmonary complication after gastrointestinal surgery

AIM: To identify the risk factors for postoperative pulmonary complications (PPC) after gastrointestinal surgery. METHODS: A total of 1 002 patients undergoing gastrointestinal surgery in the Second Affiliated Hospital, Sun Yat-Sen University, during December 1999 and December 2003, were retrospectively studied. RESULTS: The overall incidence of PPC was 22.8% (228/ 1 002). Multivariate logistic analysis identified nine risk factors associated with PPC, including age odds ratio (OR = 1.040) history of respiratory diseases (OR = 2.976), serum albumin (OR = 0.954), chemotherapy 2 wk before operation (OR = 3.214), volume of preoperative erythrocyte transfusion (OR = 1.002), length of preoperative antibiotic therapy (OR = 1.072), intraoperative intratracheal intubation (OR = 1.002), nasogastric intubation (OR = 1.050) and postoperative mechanical ventilation (OR = 1.878). Logistic regression equation for predicting the risk of PPC was P(1) =q/[1+e-(-3.488+0.039×+1.090×Rd+0.001×Rbc-0.0047×Alb+0.002×Lii+ 0.049×Lni+0.630×Lmv+0.070×Dat+1.168×a)].     

Early enteral infusion of traditional Chinese medicine preparation can effectively promote the recovery of gastrointestinal function after esophageal cancer surgery

Objective

To evaluate the effectiveness and safety of the enteral infusion of traditional Chinese medicine (TCM) preparation in promoting the recovery of gastrointestinal function in patients who have received surgery for esophageal cancer.

Methods

Of patients who received surgeries for their esophageal cancers in the Sun Yat-Sen University Cancer Center from October 2009 to July 2011, 100 patients were enrolled and randomly divided into TCM group (n=50) and control group (n=50): in the TCM group, 200 ml home-made TCM preparation was administered via the enteral feeding tube after the enteral nutrition was provided once daily one day after surgery. In the control group, 200 ml normal saline was administered via the enteral feeding tube after the enteral nutrition was provided one day after surgery. Both groups were infused until the gastrointestinal function returned normal. The time to first audible bowel sounds, bowel sound recovery time, time to first flatus, time to first stool, and abdominal symptom score were compared between these two groups.

Results

The time to first audible bowel sounds, bowel sound recovery time, time to first flatus, and time to first stool were 34.68±6.92 h, 60.56±9.188 h, 58.52±8.986 h, and 90.38±15.379 h in the TCM group and 43.04±8.214 h, 68.72±10.180 h, 64.64±10.198 h, and 99.28±15.456 h in the control group (p=0.002, p=0.005, p<0.001, p<0.001, respectively).

Conclusions

Early enteral injection of TCM preparation via the enteral feeding tube can effectively and safely promote the recovery of gastrointestinal function after esophageal cancer surgery.     

Evidence or eminence in abdominal surgery: Recent improvements in perioperative care

Repeated surveys from Europe, the United States, Australia, and New Zealand have shown that adherence to an evidence-based perioperative care protocol, such as Enhanced Recovery After Surgery(ERAS), has been generally low. It is of great importance to support the implementation of the ERAS protocol as it has been shown to improve outcomes after a number of surgical procedures, including major abdominal surgery. However, despite an increasing awareness of the importance of structured perioperative management, the implementation of this complex protocol has been slow. Barriers to implementation involve both patient- and staff-related factors as well as practice-related issues and resources. To support efficient and successful implementation, further educational and structural measures have to be made on a national or regional level to improve the standard of general health care. Besides postoperative morbidity, biological and physiological variables have been quite commonly reported in previous ERAS studies. Little information, however, has been obtained on cost-effectiveness, long-term outcomes, quality of life and patient-related outcomes, and these issues remain important areas of research for future studies.     

Readmission and mortality in patients undergoing off-pump coronary artery bypass surgery with fast-track recovery protocol

The development of less invasive methods for myocardial revascularization such as “off-pump” cardiac surgery, and new methods of anesthesia and postoperative care protocols such as “fast-track recovery” (FTRC), have contributed to a significant reduction in postoperative intensive care unit (ICU) and hospital length of stay after cardiac surgical procedures. The objectives of this study were to identify perioperative risk factors of prolonged hospital stay, hospital mortality, and readmission rates in off-pump coronary artery bypass surgery (CABG) patients undergoing the FTRC protocol. Eighty consecutive patients undergoing off-pump coronary artery bypass surgery with FTRC protocol were included in the study. For the first purpose of this protocol, early extubation is defined as removal of the endotracheal tube within 6 h of arrival at the surgical ICU. The second purpose was to obtain a minimal length of stay in the ICU (<24 h) and hospital discharge within 5 days. We analyzed the influence of the preoperative, intraoperative, and postoperative variables on prolonged hospital stay, hospital mortality, and hospital readmission. Three patients died during hospitalization, giving a hospital mortality rate of 3.75%. The causes of hospital death were massive stroke and sepsis. Using multivariate logistic regression analysis, hypertension (P = 0.0185), postoperative stroke (P = 0.0001), and sternal infection (P = 0.0007) were identified as independent predictors of hospital mortality. Mean hospital length of stay was 4.23 ± 0.75 days. Univariate and multivariate logistic regression analysis revealed that postoperative blood use (P = 0.0095) was the major independent predictor of prolonged hospital stay. During the 30-day observation period, seven patients were readmitted. One of these patients died on postoperative day 45 from mediastinitis and sepsis. Multivariate logistic regression analysis identified age (P = 0.0033) and hypertension (P = 0.045) as independent predictors of hospital readmission. FTRC protocols can be performed safely in patients with off-pump CABG, and the mortality and readmission rates following this protocol were found to be within acceptable ranges.     

Effect of lipopolysaccharide on diarrhea and gastrointestinal transit in mice： Roles of nitric oxide and prostaglandin E2

AIM: To investigate the effect of lipopolysaccharide (LPS) on the diarrheogenic activity, gastrointestinal transit (GIT), and intestinal fluid content and the possible role of nitric oxide (NO) and prostaglandin E2 (PGE2) in gastrointestinal functions of endotoxin-treated mice. METHODS: Diarrheogic activity, GIT, and intestinal fluid content as well as nitric oxide and PGE2 products were measured after intraperitoneal administration of LPS in mice. RESULTS: LPS dose-dependently accumulated abundant fluid into the small intestine, induced diarrhea, but decreased the GIT. Both nitric oxide and PGE2 were found to increase in LPS-treated mice. Western blot analysis indicated that LPS significantly induced the protein expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 in mice intestines. Pretreatment with NG-nitro-L-arginine-methyl ester (L-NAME, a non-selective NOS inhibitor) or indomethacin (an inhibitor of prostaglandin synthesis) significantly attenuated the effects of LPS on the diarrheogenic activity and intestine content, but reversed the GIT. CONCLUSION: The present study suggests that the pathogenesis of LPS treatment may mediate the stimulatory effect of LPS on nitric oxide and PGE2 production and NO/ prostaglandin pathway may play an important role on gastrointestinal function.     

西甲硅油改善肥胖症患者腹腔镜下袖状胃切除术后胃肠道功能的研究

目的探讨西甲硅油对肥胖症患者在腹腔镜袖状胃切除术（LSG）后胃肠道功能恢复的影响。 方法选取2018年1月至2018年7月于西南交通大学附属医院（成都市第三人民医院）行LSG的50例肥胖症患者,随机分组,抽取25例行LSG的肥胖症患者作为实验组,术后常规服用西甲硅油;另取25例同样术式的肥胖症患者作为对照,术后未服西甲硅油,观察术后两组患者腹胀、呕吐、腹痛程度,肛门排气时间。 结果实验组患者术后腹胀、呕吐、腹痛症状明显轻于对照组,肛门排气时间也早于对照组（P<0.05）。 结论行LSG的肥胖症患者,术后常规服用西甲硅油可有效促进患者术后肠道功能的恢复。     

Hypovolemia after traditional preoperative care in patients undergoing colonic surgery is underrepresented in conventional hemodynamic monitoring

Background and aims Hypovolemia after bowel preparation as well as capnoperitoneum (CP) may compromise hemodynamic function during laparoscopic colonic surgery. A fall in arterial pressure after induction of anesthesia is often answered by generous fluid administration, which might impair “fast-track” rehabilitation. Intraoperative assessment of the needed infusion volume is difficult because of a lack of data regarding the volume status in these patients.Patients and methods Nineteen patients scheduled for laparoscopic colonic surgery after bowel preparation were prospectively monitored using the PULSION COLD Z-021 system and central venous catheter. Intrathoracic blood volume index (ITBVI), mean arterial pressure (MAP), cardiac index (CI), central venous pressure (CVP), and heart rate (HR) were measured after induction of anesthesia (M1), during CP in head-down position with an intraabdominal pressure (IAP) of 20 mmHg (M2) and 12 mmHg (M3).Results Although MAP (87 mmHg), HR (64 min⁻¹), and CVP (8 mmHg) were within normal ranges at the induction of surgery, ITBVI (834 ml m⁻²), and CI (2.66 l m⁻²) were decreased, indicating a relative hypovolemia. CP with 12 mmHg increased ITBVI (p<0.05) and CI (p<0.01), while an IAP of 20 mmHg reduced CI (p<0.05) compared to 12 mmHg (M3). Mean infusion during the measurements was 1,355 ml.Conclusion Combination of CP with 12 mmHg, head-down position, and infusion of 1,500 ml fluids compensated relative hypovolemia during colonic surgery. With conventional monitoring, intravascular volume status might be underestimated after traditional preoperative care.     

Bacterial translocation in patients undergoing major gastrointestinal surgery and its role in postoperative sepsis

Bacteria of the human intestinal microflora have a dual role. They promote digestion and are part of a defense mechanism against pathogens. These bacteria could become potential pathogens under certain circumstances. The term “bacterial translocation” describes the passage of bacteria of the gastrointestinal tract through the intestinal mucosa barrier to mesenteric lymph nodes and other organs. In some cases, the passage of bacteria and endotoxins could result in blood stream infections and in multiple organ failure. Open elective abdominal surgery more frequently results in malfunction of the intestinal barrier and subsequent bacterial translocation and blood stream infections than laparoscopic surgery. Postoperative sepsis is a common finding in patients who have undergone non-elective abdominal surgeries, including trauma patients treated with laparotomy. Postoperative sepsis is an emerging issue, as it changes the treatment plan in surgical patients and prolongs hospital stay. The association between bacterial translocation and postoperative sepsis could provide novel treatment options.     

Short- and long-term outcomes associated with enhanced recovery after surgery protocol vs conventional management in patients undergoing laparoscopic gastrectomy

BACKGROUND At present, the enhanced recovery after surgery(ERAS) protocol is widely implemented in the field of gastric surgery. However, the effect of the ERAS protocol on the long-term prognosis of gastric cancer has not been reported.AIM To compare the effects of ERAS and conventional protocols on short-term outcomes and long-term prognosis after laparoscopic gastrectomy.METHODS We retrospectively analyzed the data of 1026 consecutive patients who underwent laparoscopic gastrectomy between 2012 and 2015. The patients were divided into either an ERAS group or a conventional group. The groups were matched in a 1:1 ratio using propensity scores based on covariates that affect cancer survival. The primary outcomes were the 5-year overall and cancer-specific survival rates. The secondary outcomes were the postoperative short-term outcomes and inflammatory indexes.RESULTS The patient demographics and baseline characteristics were similar between the two groups after matching. Compared to the conventional group, the ERAS group had a significantly shorter postoperative hospital day(7.09 d vs 8.67 d, P 0.001), shorter time to first flatus, liquid intake, and ambulation(2.50 d vs 3.40 d, P 0.001; 1.02 d vs 3.64 d, P 0.001; 1.47 d vs 2.99 d, P 0.001, respectively), and lower medical costs($7621.75 vs $7814.16, P = 0.009). There was a significantly higher rate of postoperative complications among patients in the conventional group than among those in the ERAS group(18.1 vs 12.3, P = 0.030). Regarding inflammatory indexes, the C-reactive protein and procalcitonin levels on postoperative day 3/4 were significantly different between the two groups(P 0.001 and P = 0.025, respectively). The ERAS protocol was associated with significantly improved 5-year overall survival and cancer-specific survival rates compared with conventional protocol(P = 0.013 and 0.032, respectively). When stratified by tumour stage, only the survival of patients with stage III disease was significantly different between the two groups(P = 0.044).CONCLUSION Adherence to the ERAS protocol improves both the short-term outcomes and the 5-year overall survival and cancer-specific survival of patients after laparoscopic gastrectomy.     

体外循环心脏术后消化系统并发症的防治进展

体外循环心脏术后消化系统并发症虽然发生率不高,但病死率却极高.体外循环期间多种因素导致消化系统血液供应减少、组织损伤、炎性介质大量释放,从而引起包括胃肠道出血、消化性溃疡、缺血性肠炎、胰腺炎、胆囊炎、肝衰竭等在内的消化系统并发症.严密观察患者临床表现并早期诊断予以干预,对患者的预后有重要帮助.本文就近年来体外循环心脏术后消化系统并发症的机制、危险因素及诊断治疗的进展予以综述.     

The effects of fast-track surgery on inflammation and immunity in patients undergoing colorectal surgery

Objective

The objective of this study is to explore the effects of the fast-track surgery (FTS) program on inflammation and immunity in patients undergoing colorectal surgery.

Methods

From August 2014 to March 2015, a prospective and randomized controlled trial of 230 patients who underwent colorectal surgery was performed. The patients were randomly assigned to an FTS group (116 patients) or a traditional group (114 patients). Inflammatory mediators, immunological indicators, postoperative recovery indexes, and complications were compared between the two groups.

Results

The inflammatory mediators (CRP, IL-6, TNF-α) were lower in the FTS group than in the traditional group (P?<?0.05) on postoperative day (POD) 1, POD 4, and POD 6, and the immunological indicators (IgG, IgA, C3, C4) of the FTS group were superior to those of the traditional group (P?<?0.05) on POD 4 and POD 6. The time to first aerofluxus, defecation, oral intake, and ambulation after surgery was shorter in the FTS group than in the traditional group (P?<?0.05); however, the duration of postoperative hospitalization did not differ significantly between the two groups (P?>?0.05). The total complications were significantly lower in the FTS group than in the traditional group (P?<?0.05).

Conclusion

The FTS program can decrease inflammation, maintain immune homeostasis, and improve rehabilitation effects in colorectal surgery patients.

     

A study of pulmonary embolism after abdominal surgery in patients undergoing prophylaxis

AIM： To determine risk factors for pulmonary embolism and estimate effects and benefits of prophylaxis. METHODS： We included 78 patients who died subsequently to a pulmonary embolism after major abdominal surgery from 1985 to 2003. A first, retrospective analysis involved 41 patients who underwent elective surgery between 1985 and 1990 without receiving any prophylaxis. In the prospectively evaluated subgroup, 37 patients undergoing major surgery between 1991 and 2003 were enrolled： all of them had received a prophylaxis consisting in lowmolecular weight heparin, given subcutaneously at a dose of 2850 IU AXa/0.3 mL （body weight 〈 50 kg） or 5700 IU AXa/0.6 mL （body weight ≥ 50 kg）. RESULTS： A higher incidence of thromboembolism （43.9% and 46.34% in the two groups, respectively） was found in older patients （〉 60 years）. The incidence of pulmonary embolism after major abdominal surgery in patients who had received the prophylaxis was significantly lower compared to the subjects with the same condition who had not received any prophylaxis （P 〈 0.001, OR = 2.825; 95% CI, 1.811-4.408）. Furthermore, the incidence of pulmonary embolism after colorectal cancer surgery was significantly higher compared to incidence of pulmonary embolism after other abdominal surgical procedures. Finally, the incidence of pulmonary embolism after colorectal cancer surgery among the patients who had received the prophylaxis （11/4316, 0.26%） was significantly lower compared to subjects undergoing a surgical procedure for the same indication but without prophylaxis （10/1562, 0.64%） （P 〈 0.05, OR = 2.522; 95% Ct, 1.069-5.949）. CONCLUSION： Prophylaxis with low molecular weight heparin is highly recommended during the preoperative period in patients with diagnosis of colorectal cancer due to high risk of pulmonary embolism after elective surgery.     

The implementation of an enhanced recovery after surgery (ERAS) program following pancreatic surgery in an academic medical center of China

IntroductionThe experience of implementing enhanced recovery after surgery (ERAS) programs in pancreatic surgery is limited. The aim of this study was to evaluate the feasibility of ERAS program in pancreatic surgery in an academic medical center of China.MethodsBetween May 2014 and August 2015, 124 patients managed with an ERAS program following pancreatic surgery (ERAS group), were compared to a historical cohort of 63 patients, treated with traditional perioperative care between August 2013 and April 2014 (no-ERAS group). Postoperative hospital stay (POPH), unplanned reoperation, unplanned readmissions, mortality and complications were compared between the two groups.ResultsMean POPH of all patients was significantly reduced (p = 0.007) from 17.1 days (no-ERAS group) to 11.7 days (ERAS group). Especially, mean POPH was reduced significantly in ERAS group of patient with no (7.0 vs. 8.7, p = 0.020) or grade I–II (10.6 vs. 14.4, p = 0.001) complications. There was no difference of complication grades and types between two groups, as well as the rate of mortality, unplanned reoperation and readmission.ConclusionThe ERAS program is safe and feasible for patients undergoing pancreatic surgery, and it can decrease the postoperative hospital stay.     

曲马多复合不同剂量舒芬太尼用于胃肠外科患者术后静脉自控镇痛效果比较

目的评价曲马多复合不同剂量舒芬太尼用于胃肠外科患者术后静脉自控镇痛(patient controlled intravenous analgesia,PCIA)的效果。方法选择ASAⅠ或Ⅱ级择期行胃肠外科手术患者60例,按入院先后分为三组。A组:曲马多300 mg+舒芬太尼50μg;B组:曲马多300 mg+舒芬太尼100μg;C组:曲马多300 mg+舒芬太尼150μg。三组镇痛药物均加入氟哌啶2.5 mg,用生理盐水稀释至100 ml。手术结束前连接自控镇痛泵(PCA),镇痛模式为负荷剂量2 ml,背景输注剂量1.2 ml/h,单次给药剂量2 ml,锁定时间为20 min,全程观察24 h。分别于术后2~4 h、8~10 h、12~20 h、22~24 h记录患者视觉模拟评分法(VAS)评分、Ramsay镇静评分和不良反应。结果术后24 h各时段B、C两组VAS评分均低于A组(P=0.000);与B组比较,C组8~10 h、12~20 h VAS评分均降低(P=0.000);三组患者各时段Ramsay镇静评分差异无统计学意义(P0.05)。结论 300 mg曲马多复合150μg舒芬太尼用于胃肠外科手术后PCIA,效果较好,而且安全可靠。     

Enhanced recovery after surgery programs in patients undergoing hepatectomy: A meta-analysis

AIM:To evaluate the impact of enhanced recovery after surgery(ERAS) programs in comparison with traditional care on liver surgery outcomes.METHODS:The Pub Med,EMBASE,CNKI and Cochrane Central Register of Controlled Trials databases were searched for randomized controlled trials(RCTs) comparing the ERAS program with traditional care in patients undergoing liver surgery. Studies selected for the meta-analysis met all of the following inclusion criteria:(1) evaluation of ERAS in comparison to traditional care in adult patients undergoing elective open or laparoscopic liver surgery;(2) outcome measures including complications,recovery of bowel function,and hospital length of stay; and(3) RCTs. The following exclusion criteria were applied:(1) the study was not an RCT;(2) the study did not compare ERAS with traditional care;(3) the study reported on emergency,non-elective or transplantation surgery; and(4) the study consisted of unpublished studies with only the abstract presented at a national or international meeting. The primary outcomes were complications. Secondary outcomes were length of hospital stay and time to first flatus.RESULTS:Five RCTs containing 723 patients were included in the meta-analysis. In 10/723 cases,patients presented with benign diseases,while the remaining 713 cases had liver cancer. Of the five studies,three were published in English and two were published in Chinese. Three hundred and fifty-four patients were in the ERAS group,while 369 patients were in the traditional care group. Compared with traditional care,ERAS programs were associated with significantly decreased overall complications(RR = 0.66; 95%CI:0.49-0.88; P = 0.005),grade?Ⅰ?complications(RR = 0.51; 95%CI:0.33-0.79; P = 0.003),and hospitallength of stay [WMD =-2.77 d,95%CI:-3.87-(-1.66); P 0.00001]. Similarly,ERAS programs were associated with decreased time to first flatus [WMD =-19.69 h,95%CI:-34.63-(-4.74); P 0.0001]. There was no statistically significant difference in grade Ⅱ-Ⅴ complications between the two groups.CONCLUSION:ERAS is a safe and effective program in liver surgery. Future studies should define the active elements to optimize postoperative outcomes for liver surgery.     

Applicability of the Rockall score in patients undergoing endoscopic therapy for upper gastrointestinal bleeding

BACKGROUND: The Rockall score is used to assess the prognosis of patients with upper gastrointestinal bleeding. AIM: To assess the applicability of the Rockall score in patients undergoing endoscopic therapy for upper gastrointestinal bleeding. METHODS: Retrospective evaluation of the Rockall score in the period 1995-2001. To evaluate the applicability of the Rockall system, two groups were created: group I (Rockallor=6 points). RESULTS: Two hundred and twenty-two patients were included. The median age of patients was 65 +/ -17 years. Hypotension and associated diseases were present in 20 and 50% of patients, respectively. Re-bleeding occurred in 50 patients (23%) whose median score was 7, whereas the median score of patients without re-bleeding was 6 (p=0.14). There were 20 deaths (9%) with a median score of 8, whilst the median score of surviving patients was 6 (p<0.001). Sixteen patients in group I (18.4%) and 34 in group II (25.2%) re-bled (p=0.25). All the patients who died belong to group II with a Rockall score>or=6 (15% versus 0% in groups II and I, respectively, p<0.001). CONCLUSION: The Rockall score can be used in patients who undergo therapeutic endoscopy for upper gastrointestinal bleeding to identify those with high risk for mortality.