Background Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non‐steroidal anti‐inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods A prospective multicentre cohort study was delivered by an international, student‐ and trainee‐led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre‐specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results A total of 4164 patients were included, with a median age of 68 (i.q.r. 57–75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1–3, of whom 1061 (92·0 per cent) received non‐selective cyclo‐oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

Background Laparoscopic sleeve gastrectomy (LSG) is a common weight loss operation that is increasingly being managed on an outpatient or overnight stay basis. The aim of this systematic review was to evaluate the available literature and develop recommendations for optimal pain management after LSG. Methods A systematic review utilizing preferred reporting items for systematic reviews and meta‐analysis with PROcedure SPECific Postoperative Pain ManagemenT methodology was undertaken. Randomized controlled trials (RCTs) published in the English language from inception to September 2018 assessing postoperative pain using analgesic, anesthetic, and surgical interventions were identified from MEDLINE, EMBASE and Cochrane Databases. Results Significant heterogeneity was identified in the 18 RCTs included in this systematic review. Gabapentinoids and transversus abdominis plane blocks reduced LSG postoperative pain. There was limited procedure‐specific evidence of analgesic effects for acetaminophen, non‐steroidal anti‐inflammatory drugs, dexamethasone, magnesium, and tramadol in this setting. Inconsistent evidence was found in the studies investigating alpha‐2‐agonists. No evidence was found for intraperitoneal local anesthetic administration or single‐port laparoscopy. Conclusions The literature to recommend an optimal analgesic regimen for LSG is limited. The pragmatic view supports acetaminophen and a non‐steroidal anti‐inflammatory drug, with opioids as rescue analgesics. Gabapentinoids should be used with caution, as they may amplify opioid‐induced respiratory depression. Although transversus abdominis plane blocks reduced pain, port‐site infiltration may be considered instead, as it is a simple and inexpensive approach that provides adequate somatic blockade. Further RCTs are required to confirm the influence of the recommended analgesic regimen on postoperative pain relief.

Background: Emergency laparotomy (EL) is a common procedure with high mortality leading to several efforts to record and reduce mortality. Risk scores currently used by quality improvement programmes either require intraoperative data or are not specific to EL. To be of utility to clinicians/patients, estimation of preoperative risk of mortality is important. We aimed to explore individual preoperative risk factors that might be of use in developing a preoperative mortality risk score. Methods: Two independent reviewers identified relevant articles from searches of MEDLINE, EMBASE and Cochrane databases from January 1980 to January 2018. We selected studies that evaluated only preoperative predictive factors for mortality in EL patients. Results: The search yielded 6648 articles screened, with 22 studies included examining 157 728 patients. The combined post-operative 30-day mortality was 13%. All, but one small study, were at low risk of bias. A meta-analysis of results was not possible due to the heterogeneity of populations and outcomes. Age, American Society of Anesthesiologists, preoperative sepsis, dependency status, current cancer and comorbidities were associated with increased mortality. Acute physiological derangements seen in renal, albumin and complete blood count assays were strongly associated with mortality. Delay to surgery and diabetes did not influence mortality. Higher body mass index was protective. Conclusion: Preoperatively, risk factors identified can be used to develop and update risk scores specific for EL mortality. This scoping review focused on the preoperative setting which helps tailor treatment decisions. It highlights the need for further research to test the relevance of newer risk factors such as frailty and nutrition.

Background Excisional haemorrhoidectomy has been traditionally performed under general or regional anaesthesia. However, these modes are associated with complications such as nausea, urinary retention and motor blockade. Local anaesthesia (LA) alone has been proposed to reduce side effects as well as to expedite ambulatory surgery. This systematic review aims to assess LA versus regional or general anaesthesia for excisional haemorrhoidectomy. Methods A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, EMBASE and CENTRAL databases were searched to 13 January 2020. All randomised controlled trials comparing LA only versus regional or general anaesthesia in patients who received excisional haemorrhoidectomy were included. The main outcomes included pain, adverse effects and length of stay. Results Nine trials, consisting of six studies comparing local versus regional anaesthesia and three comparing LA versus general anaesthesia, were included. Meta-analysis showed a significantly lower relative risk for need of rescue analgesia (RR 0.32 [95% CI 0.16-0.62]), intra-operative hypotension (RR 0.17 [95% CI 0.04-0.76]), headache (RR 0.13 [0.02-0.67]) and urinary retention (RR 0.17 [95% CI 0.09-0.29]) for LA when compared with regional anaesthesia. There was mixed evidence for both regional and general anaesthesia in regard to post-operative pain. Conclusions LA alone may be considered as an alternative to regional anaesthesia for excisional haemorrhoidectomy with reduced complications and reduction in the amount of post-operative analgesia required. The evidence for LA compared to general anaesthesia for haemorrhoidectomy is low grade and mixed.