Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include: • integration of nutrition into the overall management of the patient • avoidance of long periods of preoperative fasting • re-establishment of oral feeding as early as possible after surgery • start of nutritional therapy early, as soon as a nutritional risk becomes apparent • metabolic control e.g. of blood glucose • reduction of factors which exacerbate stress-related catabolism or impair gastrointestinal function • minimized time on paralytic agents for ventilator management in the postoperative period • early mobilisation to facilitate protein synthesis and muscle function The guideline presents 37 recommendations for clinical practice.

Background: Transanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal IPAA (Ta-IPAA), considering postoperative complications and medium-term functional outcomes. Methods: Our Center has experienced the transanal approach for proctectomy and IPAA since October 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Results: Until March 2019, 8 patients underwent Ta-IPAA. In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively by a validated questionnaire (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, restriction in work and social genitourinary and sexual functions were also investigated. Conclusions: In our experience, Ta-IPAA provided good short and medium-term functional results in UC. Background Restorative proctocolectomy is widely adopted in the treatment of ulcerative colitis ,, , as well as in other inflammatory and neoplastic conditions, requiring an ileal pouch-anal anastomosis (IPAA) to reconstruct gastrointestinal continuity to the anus. Conventionally, either the laparoscopic or the open approach can be employed to gain rectal dissection and creation of ileal pouch-anal anastomosis. Pouch-anal anastomosis is usually made using a stapler, leaving a 2 cm rectal cuff in order to preserve continence and to reduce the risk of inflammatory recurrence or dysplasia. The dissection of the last centimeters of the rectum, rectum resection and ileal pouch-anal anastomosis could be demanding from a technical point of view due to narrow pelvic space and cross stapling of the distal part of the rectum is often challenging for surgeons. Transanal total mesorectal excision (TaTME) has been recently described in rectal cancer treatment, with potential technical and oncologic advantages compared to transabdominal approach. The transanal approach for the proctectomy has been described also in IPAA since 2015, showing feasibility and potential technical advantages; some series ,,, and initial comparative studies have been published , , showing a not increased rate of postoperative morbidity, equivalent quality of life and functional results. The aim of our study is to analyze a single centre experience of transanal IPAA (Ta-IPAA), examining e...

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Background Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus. Methods A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations. Results A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia. Conclusions The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

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Enhanced recovery is cost-effective, with savings evident even in the initial implementation period.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.