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Marco V. Corniola, Bertrand Debono, Holger Joswig, Jean-Michel Lemée, and Enrico Tessitore

T he concept of Enhanced Recovery After Surgery (ERAS), also known as “fast-track surgery,” was introduced by Kehlet in 1997. 16 It conceptualizes a multidisciplinary and multimodal perioperative care approach that aims to hasten the recovery of patients undergoing surgery. Since then, ERAS has quickly been recognized worldwide and is now promoted by both national and international dedicated surgical societies and hospitals. 20 The ERAS concepts were first applied to abdominal surgery when minimally invasive laparoscopy was shown to be superior to laparotomy

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Bertrand Debono, Marco V. Corniola, Raphael Pietton, Pascal Sabatier, Olivier Hamel, and Enrico Tessitore

, Kalkman CJ , Meissner W : Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures . Anesthesiology 118 : 934 – 944 , 2013 23392233 10.1097/ALN.0b013e31828866b3 12 Gralla O , Haas F , Knoll N , Hadzidiakos D , Tullmann M , Romer A , : Fast-track surgery in laparoscopic radical prostatectomy: basic principles . World J Urol 25 : 185 – 191 , 2007 17171563 10.1007/s00345-006-0139-2 13 Grasu RM , Cata JP , Dang AQ , Tatsui CE , Rhines LD , Hagan KB , : Implementation of an

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Zach Pennington, Ethan Cottrill, Daniel Lubelski, Jeff Ehresman, Nicholas Theodore, and Daniel M. Sciubba

I n an effort to reduce variability, improve outcomes, and reduce cost in spinal surgery, there has been a recent drive to identify care pathways that result in consistently good, cost-effective outcomes for patients. This drive has led to the development of Enhanced Recovery After Surgery (ERAS) pathways, which were first described as “fast-track surgery” in the cardiac surgery literature in the 1990s. 1 ERAS pathways are defined by the ERAS Society as any perioperative care pathway designed to accelerate patient recovery after major surgery. 2 Elements of

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G. Damian Brusko, John Paul G. Kolcun, Julie A. Heger, Allan D. Levi, Glen R. Manzano, Karthik Madhavan, Timur Urakov, Richard H. Epstein, and Michael Y. Wang

(ERAS) movement began in Denmark as a practice concept integrating multidisciplinary, perioperative care programs. Previously known as “fast-track surgery” or “enhanced recovery programs,” ERAS became popularized in the 1990s to reduce the length of stay (LOS) after elective surgery through integrated approaches. 3–7 Core ERAS tenets included 1) a focus on the patient’s journey through surgery; 2) a multidisciplinary team approach; 3) interventions designed to reduce pain, morbidity, and recovery time; and 4) a data-driven iterative improvement process. The success

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Zach Pennington, Ethan Cottrill, Daniel Lubelski, Jeff Ehresman, Kurt Lehner, Mari L. Groves, Paul Sponseller, and Daniel M. Sciubba

OBJECTIVES

More than 7500 children undergo surgery for scoliosis each year, at an estimated annual cost to the health system of $1.1 billion. There is significant interest among patients, parents, providers, and payors in identifying methods for delivering quality outcomes at lower costs. Enhanced recovery after surgery (ERAS) protocols have been suggested as one possible solution. Here the authors conducted a systematic review of the literature describing the clinical and economic benefits of ERAS protocols in pediatric spinal deformity surgery.

METHODS

The authors identified all English-language articles on ERAS protocol use in pediatric spinal deformity surgery by using the following databases: PubMed/MEDLINE, Web of Science, Cochrane Reviews, EMBASE, CINAHL, and OVID MEDLINE. Quantitative analyses of comparative articles using random effects were performed for the following clinical outcomes: 1) length of stay (LOS); 2) complication rate; 3) wound infection rate; 4) 30-day readmission rate; 5) reoperation rate; and 6) postoperative pain scores.

RESULTS

Of 950 articles reviewed, 7 were included in the qualitative analysis and 6 were included in the quantitative analysis. The most frequently cited benefits of ERAS protocols were shorter LOS, earlier urinary catheter removal, and earlier discontinuation of patient-controlled analgesia pumps. Quantitative analyses showed ERAS protocols to be associated with shorter LOS (mean difference −1.12 days; 95% CI −1.51, −0.74; p < 0.001), fewer postoperative complications (OR 0.37; 95% CI 0.20, 0.68; p = 0.001), and lower pain scores on postoperative day (POD) 0 (mean −0.92; 95% CI −1.29, −0.56; p < 0.001) and POD 2 (−0.61; 95% CI −0.75, −0.47; p < 0.001). There were no differences in reoperation rate or POD 1 pain scores. ERAS-treated patients had a trend toward higher 30-day readmission rates and earlier discontinuation of patient-controlled analgesia (both p = 0.06). Insufficient data existed to reach a conclusion about cost differences.

CONCLUSIONS

The results of this systematic review suggest that ERAS protocols may shorten hospitalizations, reduce postoperative complication rates, and reduce postoperative pain scores in children undergoing scoliosis surgery. Publication biases exist, and therefore larger, prospective, multicenter data are needed to validate these results.

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Michael Y. Wang, Peng-Yuan Chang, and Jay Grossman

T he Enhancing Recovery After Surgery (ERAS) movement began in Denmark as a practice concept integrating multidisciplinary, perioperative care programs. Previously known as “fast-track surgery” or “enhanced recovery programs,” it started to gain ground in the 1990s by aiming to reduce the length of hospitalization after elective abdominal surgery through integrated approaches to maintain cardiovascular, pulmonary, neurological, gastrointestinal, and endocrine homeostatic functions. 9 , 10 Traditionally, a patient's surgical journey has been broken into

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Beate Poblete, Christoph Konrad, and Karl F. Kothbauer

. Neurosurgery 49 : 1124 – 1128 , 2001 17 Jones SE , Beasley JM , Macfarlane DW , Davis JM , Hall-Davies G : Intrathecal morphine for postoperative pain relief in children . Br J Anaesth 56 : 137 – 140 , 1984 18 Kehlet H : Fast-track surgery-an update on physiological care principles to enhance recovery . Langenbecks Arch Surg 396 : 585 – 590 , 2011 19 Kothbauer K , Schmid UD , Liechti S , Rösler KM : The effect of ketamine anesthetic induction on muscle responses to transcranial magnetic cortex stimulation studied in man

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Andrew B. Harris, Floreana Kebaish, Lee H. Riley III, Khaled M. Kebaish, and Richard L. Skolasky

: Patients’ satisfaction with fast-track surgery in gynaecological oncology . Eur J Cancer Care (Engl) 24 : 567 – 573 , 2015 17 Pilkonis PA , Choi SW , Reise SP , Stover AM , Riley WT , Cella D : Item banks for measuring emotional distress from the Patient-Reported Outcomes Measurement Information System (PROMIS®): depression, anxiety, and anger . Assessment 18 : 263 – 283 , 2011 18 Purvis TE , Andreou E , Neuman BJ , Riley LH III , Skolasky RL : Concurrent validity and responsiveness of PROMIS health domains among patients

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Ebru Tarıkçı Kılıç, Tuncay Demirbilek, and Sait Naderi

– 284 , 2013 10.1007/s00268-012-1772-0 23052794 8 Joshi GP , Bonnet F , Kehlet H : Evidence-based postoperative pain management after laparoscopic colorectal surgery . Colorectal Dis 15 : 146 – 155 , 2013 23350836 10.1111/j.1463-1318.2012.03062.x 9 Kehlet H , Wilmore DW : Evidence-based surgical care and the evolution of fast-track surgery . Ann Surg 248 : 189 – 198 , 2008 10.1097/SLA.0b013e31817f2c1a 18650627 10 Kim J , Burke SM , Kryzanski JT , Roberts RJ , Roguski M , Qu E , : The role of liposomal bupivacaine in reduction

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Mazin Elsarrag, Sauson Soldozy, Parantap Patel, Pedro Norat, Jennifer D. Sokolowski, Min S. Park, Petr Tvrdik, and M. Yashar S. Kalani

, and immune dysfunction can be attenuated. 25 , 32 , 47 Components and workflow of a typical ERAS pathway are demonstrated in Fig. 1 . Fig. 1. Components and workflow of a typical ERAS pathway. Copyright American Association of Nurse Anesthetists. Published with permission. Although Fearon et al. 13 became the first to formalize such protocols, similar systematic approaches to perioperative care were espoused as early as the 1990s. Initially described as “fast-track surgery” designed to expedite recovery and decrease length of stay (LOS), ERAS has since evolved in