Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

There is some evidence to suggest that enhanced recovery after surgery programs are better than traditional perioperative care, but evidence from a larger, better quality randomized controlled trial is necessary.

Laparoscopic repair of ventral and incisional hernia is at least as effective, if not superior to, the open approach in a number of outcomes.

Remote telesimulation is an effective method for teaching the Fundamentals of Laparoscopic Surgery in Africa, achieving a 100% FLS skills pass rate. This training platform provides a cost-effective method of teaching in resource-restricted countries and could be used to teach laparoscopic skills anywhere in the world with internet access.

The intestinal immune system is emerging as an important contributor to obesity-related insulin resistance, but the role of intestinal B cells in this context is unclear. Here, we show that high fat diet (HFD) feeding alters intestinal IgA + immune cells and that IgA is a critical immune regulator of glucose homeostasis. Obese mice have fewer IgA + immune cells and less secretory IgA and IgA-promoting immune mediators. HFD-fed IgA-deficient mice have dysfunctional glucose metabolism, a phenotype that can be recapitulated by adoptive transfer of intestinal-associated pan-B cells. Mechanistically, IgA is a crucial link that controls intestinal and adipose tissue inflammation, intestinal permeability, microbial encroachment and the composition of the intestinal microbiome during HFD. Current glucose-lowering therapies, including metformin, affect intestinal-related IgA + B cell populations in mice, while bariatric surgery regimen alters the level of fecal secretory IgA in humans. These findings identify intestinal IgA + immune cells as mucosal mediators of whole-body glucose regulation in diet-induced metabolic disease.

On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.

In hospitals with variable uptake of ERAS strategies, preoperative counseling, intraoperative fluid restriction, use of a laparoscopic approach, immediate initiation of clear fluids after surgery, and early discontinuation of the Foley catheter are all independently associated with shortened length of stay.

Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach.