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Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery After Surgery, Perioperative Optimization and Prehabilitation: 2nd Edition

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "General Surgery".

Deadline for manuscript submissions: 25 September 2026 | Viewed by 6681

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Special Issue Editors

Dr. Carlos Cerdán Santacruz

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Guest Editor

1. Colorectal Surgery Unit, General Surgery Department, Hospital Universitario de la Princesa, Madrid, Spain
2. Colorectal Surgery Department, Clínica Santa Elena, 28003 Madrid, Spain
Interests: oncology; colorectal cancer; rectal cancer organ preservation; proctology; inflammatory bowel disease; functional disorders; fecal incontinence; minimally invasive surgery; robotic surgery; enhanced recovery after surgery; surgery prehabilitation
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Dr. María Rodríguez Pérez

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Guest Editor Assistant

Thoracic Surgery Department, Clinica Universidad de Navarra, Pamplona, Spain
Interests: thoracic surgery; lung cancer; lung metastases; minimally invasive surgery; robotic surgery

Special Issue Information

Dear Colleagues,

Following on from the success of our first Special Issue, entitled “Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery After Surgery, Perioperative Optimization and Prehabilitation” (https://www.mdpi.com/journal/jcm/special_issues/LHUCW4DOZ2), we are launching a second edition, which continues to report on clinical research.

The field of perioperative care has undergone a real revolution over the last 25 years. First, the rapid spread of enhanced perioperative recovery pathways, and later, the spread of prehabilitation, have revolutionized the rules of management of patients scheduled for surgery. Despite this, the implementation of such strategies in many centers is suboptimal, and there are still many issues on which evidence is lacking.

The aim of this Special Issue is to serve as a forum to critically address the most relevant and, above all, some of the most unexplored aspects of perioperative medicine, from education, strategies for implementation, maintenance, possible areas for future improvement, and, most importantly, the long-term outcomes and patient-reported outcome measures.

Priority is given to high-quality, original studies, but well-designed and conducted systematic reviews (with or without a meta-analysis) are welcome. In summary, the Special Issue aims to increase clinicians’ knowledge of poorly explored areas of perioperative care, as well as to provide a balanced, sound, and evidence-based overview of the advances and potential perspectives in the field.

Dr. Carlos Cerdán Santacruz
Guest Editor

Dr. María Rodríguez Pérez
Guest Editor Assistant

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

perioperative care
enhanced recovery after surgery
prehabilitation
minimally invasive surgery
patient-related outcome measures
colorectal surgery
general surgery
thoracic surgery
vascular surgery
optimal functional recovery

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Related Special Issue

Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery after Surgery, Perioperative Optimization and Prehabilitation in Journal of Clinical Medicine (6 articles)

Published Papers (6 papers)

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Research

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14 pages, 326 KB

Open AccessArticle

Perioperative Determinants of Postoperative Morbidity After Liver Resection: From Morphofunctional Vulnerability to Inflammatory Response

by Leticia Pérez-Santiago, Isabel Mora-Oliver, Marina Garcés-Albir, Elena Muñoz-Forner, Luis Sabater-Ortí and Dimitri Dorcaratto

J. Clin. Med. 2026, 15(10), 3581; https://doi.org/10.3390/jcm15103581 - 7 May 2026

Viewed by 147

Abstract

Background: Postoperative morbidity after liver resection remains considerable despite advances in surgical and perioperative care. Risk stratification has traditionally focused on surgical factors, although patient-related vulnerability and the postoperative inflammatory response may also play a critical role. This study aimed to evaluate the relative contribution of perioperative factors, including morphofunctional vulnerability (skeletal muscle index [SMI] and GLIM-defined malnutrition), surgical variables, and inflammatory biomarkers, in predicting postoperative outcomes after liver resection. Methods: We conducted a retrospective single-center study including patients who underwent liver resection between 2017 and 2021. Preoperative morphofunctional assessment included skeletal muscle index (SMI) measured at the L3 level on computed tomography and nutritional status defined according to GLIM criteria. Perioperative variables included surgical factors and postoperative inflammatory and immune biomarkers. Outcomes were overall complications within 90 days, major complications (Clavien–Dindo ≥ III), and severe morbidity defined by a Comprehensive Complication Index (CCI) ≥ 26.2. Multivariable logistic regression analyses were performed to identify independent predictors. Results: A total of 253 patients were analysed. Overall complications occurred in 35.6% of patients, with major complications in 14.6% and severe morbidity in 17.4%. Low SMI was present in 56.1% of patients. In multivariable analysis, low SMI independently predicted postoperative complications (OR 2.23, 95% CI 1.14–4.38; p = 0.02), along with the open surgical approach, operative time ≥ 193 min, and elevated C-reactive protein on postoperative day 3. For major complications (Clavien–Dindo ≥ III), low SMI remained a strong independent predictor (OR 4.28, 95% CI 2.76–10.40; p = 0.001), together with surgical factors and lymphopenia on postoperative day 3. In contrast, GLIM-defined malnutrition was independently associated with severe morbidity (CCI ≥ 26.2) (OR 2.95, 95% CI 1.44–6.06; p = 0.003). Conclusions: Postoperative morbidity after liver resection is determined by a combination of perioperative factors, including patient-related morphofunctional vulnerability, surgical complexity, and postoperative inflammatory response. Skeletal muscle depletion is primarily associated with the occurrence of complications, whereas GLIM-defined malnutrition appears to influence their severity. These findings support a comprehensive perioperative approach to risk stratification and highlight the potential role of targeted prehabilitation strategies aimed at improving surgical resilience and postoperative outcomes. Full article

(This article belongs to the Special Issue Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery After Surgery, Perioperative Optimization and Prehabilitation: 2nd Edition)

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17 pages, 2766 KB

Open AccessArticle

Outcomes of Selective Versus Routine Gastric Tube Decompression After Gastrectomy for Gastric Cancer with Pyloric Obstruction: A Retrospective Cohort Study

by Yonghu Xu, Yushi Liu, Pengfei Kong, Yantian Fang and Dazhi Xu

J. Clin. Med. 2026, 15(1), 276; https://doi.org/10.3390/jcm15010276 - 30 Dec 2025

Cited by 1 | Viewed by 857

Abstract

Background/Objectives: The utility of routine gastric tube (GT) placement following gastrectomy in gastric cancer (GC) patients with pyloric obstruction remains controversial. This practice conflicts with Enhanced Recovery After Surgery (ERAS) principles, and its value in this high-risk subgroup is unclear. This study aimed to compare the clinical and economic outcomes of routine versus selective gastric tube use in these patients, and to identify predictors for prolonged gastric tube retention. Methods: A single-center retrospective cohort study was conducted on 133 GC patients with pyloric obstruction who underwent gastrectomy. Patients were stratified into GT (n = 63) and non-GT (n = 70) groups. Primary outcomes included 30-day complications, 90-day mortality, hospitalization duration, and costs. Univariate and multivariable Cox regression analyses were used to identify predictors of prolonged GT retention. Results: Routine GT use provided no clinical benefit, with similar 30-day complication (22.2% vs. 22.9%, p = 0.945) and 90-day mortality (1.6% vs. 0%, p = 0.290) rates. However, it was associated with a significantly prolonged postoperative hospital stay (8.8 ± 2.5 vs. 8.0 ± 4.2 days, p = 0.034) and a mean cost increase of ¥5900 per patient (p = 0.006). A dose–response relationship was evident: each additional day of GT retention correlated with 0.57 extra hospital days (r = 0.567, p < 0.001) and ¥3600 in added costs (r = 0.360, p = 0.004). Multivariable analysis identified longer preoperative fasting time (Adjusted HR = 1.27 per hour, 95% CI: 1.10–1.45, p = 0.001) and GLIM-defined malnutrition (Adjusted HR = 2.04, 95% CI: 1.02–4.17, p = 0.045) as independent predictors for prolonged GT retention. Conclusions: Routine GT placement after gastrectomy in obstructed GC patients increases healthcare costs and prolongs hospitalization without improving clinical outcomes. Preoperative fasting duration and nutritional status are key predictors for prolonged GT need. A selective GT strategy, guided by these parameters, is recommended to optimize recovery and resource utilization, aligning with ERAS principles. Full article

(This article belongs to the Special Issue Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery After Surgery, Perioperative Optimization and Prehabilitation: 2nd Edition)

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16 pages, 3922 KB

Open AccessArticle

The Impact of Multidisciplinary Preoperative Optimization Program on Postoperative Outcomes Among Surgical Oncology Patients

by Yasmin Safi, Mohammad S. Alyahya, Nihaya A. Al-sheyab, Mohammad Suliman and Mahmoud Al-Masri

J. Clin. Med. 2025, 14(21), 7820; https://doi.org/10.3390/jcm14217820 - 4 Nov 2025

Cited by 1 | Viewed by 1671

Abstract

Background: Preoperative optimization has emerged as a critical strategy in enhancing surgical outcomes, particularly for oncological patients. By addressing modifiable risk factors before surgery, healthcare providers aim to improve postoperative outcomes. The aim of this study was to evaluate the impact of a preoperative optimization program on postoperative outcomes and improvements in modifiable risk factors (anemia, malnutrition, smoking, and endocrine management) among oncology patients undergoing elective surgery. Methods: A retrospective pretest–posttest study was conducted including all oncology patients who underwent elective general surgery at King Hussein Cancer Center between January 2020 and December 2021. The preoperative optimization program was launched in May 2020 and fully implemented by December 2020. Program elements included anemia management, nutritional support, smoking cessation, and glycemic control. Patients were divided into pre-implementation and post-implementation cohorts, and outcomes were assessed at baseline, immediately preoperatively, and 30 days postoperatively. Results: The sample included 503 individuals, 53.9% had preoperative anemia, 15.5% had malnutrition, 40.6% were smokers, and 41.6% had uncontrolled DM. The optimized group demonstrated significant improvements in hemoglobin, albumin, and smoking cessation rates. In contrast, the control group showed worsening hemoglobin and albumin levels over the same period. Serious complications (Clavien–Dindo III–IV) were significantly more frequent in the control group (p = 0.006). The likelihood of postoperative complications among the control group was significantly higher than the optimized group (OR: 2.2, 95%CI: 1.5–3.2, p < 0.001). Conclusions: Implementation of a comprehensive preoperative optimization program significantly improved modifiable risk factors and reduced serious postoperative complications, highlighting its value for adoption in oncology surgical care. Full article

(This article belongs to the Special Issue Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery After Surgery, Perioperative Optimization and Prehabilitation: 2nd Edition)

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Review

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43 pages, 1125 KB

Open AccessReview

Prehabilitation in Obese Patients with Ventral Hernia: A Narrative Review and Proposal of a Clinical Algorithm

by Monika Maćków, Grzegorz Sęk, Michaela Godyla-Jabłoński, Ewa Raczkowska, Marek Zawadzki and Katarzyna Neubauer

J. Clin. Med. 2026, 15(8), 2942; https://doi.org/10.3390/jcm15082942 - 13 Apr 2026

Viewed by 860

Abstract

Background: Overweight and obesity are major health problems of the 21st century. As a significant risk factor for numerous noncommunicable diseases, obesity is also strongly associated with the development of abdominal hernias, which significantly impair patients’ quality of life. The review focuses on the pathophysiological mechanisms linking obesity to hernias and the impact of key prehabilitation components. Available research indicates a complex interrelationship between obesity and the development of ventral hernias, driven by pathophysiological mechanisms such as increased intra-abdominal pressure and chronic inflammation, which weakens the collagen matrix of the abdominal wall. Furthermore, both smoking and alcohol consumption significantly increase the risk of abdominal obesity and surgical complications; in turn, physical activity is crucial for reducing visceral fat. Psychological support may reduce pre-operative stress and contribute to improved outcomes. Nutritional intervention and weight loss are other essential components of preoperative management for ventral hernia repair. This review aims to highlight the role of prehabilitation in ventral hernia surgery in obese patients and to propose a structured, evidence-based algorithm (DEPP) for this high-risk population. The algorithm includes: Dietary intervention (D), Elimination of smoking and alcohol consumption (E), Physical activity (P), and Psychological support (P). The algorithm was developed to systematize the clinical approach and determine the steps to be taken in the treatment of patients with obesity and abdominal hernia. Methodology: A literature search was conducted across PubMed, Scopus, and Google Scholar databases for articles published between 2002 and 2026. We included randomized controlled trials, prospective/retrospective cohort studies, systematic reviews, and meta-analyses. Conclusions: Prehabilitation is a multifaceted strategy for optimizing the health of patients with obesity prior to abdominal hernia repair. The proposed prehabilitation algorithm, known as DEPP, is a preliminary approach for managing this group of patients. Full article

(This article belongs to the Special Issue Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery After Surgery, Perioperative Optimization and Prehabilitation: 2nd Edition)

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Other

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19 pages, 1061 KB

Open AccessSystematic Review

Impact of Prehabilitation Components on Oxygen Uptake of People Undergoing Major Abdominal and Cardiothoracic Surgery: A Network Meta-Analysis of Randomized Controlled Trials

by Susana Priego-Jiménez, Pablo Priego-Jiménez, María López-González, Arturo Martinez-Rodrigo, Anais López-Requena and Celia Álvarez-Bueno

J. Clin. Med. 2026, 15(1), 175; https://doi.org/10.3390/jcm15010175 - 25 Dec 2025

Viewed by 1055

Abstract

Background/Objectives: Patient preoperative cardiorespiratory physical fitness measured by maximal oxygen consumption (VO2max) is highly relevant to postoperative outcomes, with low VO2max associated with a greater symptom burden and a greater prevalence of long-term treatment-related cardiovascular disease risk factors in patients undergoing surgery. A network meta-analysis (NMA) was conducted to determine the effects of different components of prehabilitation, including exercise, nutrition, psychological intervention, and different combinations of the aforementioned interventions, on oxygen consumption in people undergoing major abdominal or cardiothoracic surgery. Methods: A literature search was conducted from inception to December 2025. Randomized controlled trials on the effectiveness of prehabilitation programmes on pre-surgery VO2max were included. The risk of bias was assessed via the Cochrane risk of bias (RoB 2.0) tool, and the quality of evidence was assessed via the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) tool. Pairwise meta-analyses and NMAs were conducted for direct and indirect evidence. Results: Fourteen studies were included in this NMA. The highest effect (ES) for VO2max scores was for the exercise group versus the control group (ES: 0.44; 95% CI: 0.11, 0.78). When exercise was categorized according to intensity, the highest effect was for high-intensity interval training (HIIT) versus the control (ES: 0.51; 95% CI: 0.04, 0.97). Conclusions: Exercise HIIT should be considered the most effective strategy for improving exercise capacity in patients undergoing major abdominal or cardiothoracic surgery. Given the importance of VO2 as a predictor of morbidity, mortality, and the potential occurrence of adverse events after the procedure in surgical patients, it is essential to include its measurement in future studies to estimate both the risk of procedures and the effect of prehabilitation programmes. Full article

(This article belongs to the Special Issue Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery After Surgery, Perioperative Optimization and Prehabilitation: 2nd Edition)

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16 pages, 1017 KB

Open AccessPerspective

Prehabilitation: A Catalyst for Transforming Toward Value-Based, Personalized Perioperative Health and Care

by Brenda H. van Koningsveld-Couperus, Thijs de Rooij, Nico L. van Meeteren, Benedikt Preckel, Markus W. Hollmann and Gertrude J. Nieuwenhuijs-Moeke

J. Clin. Med. 2025, 14(19), 6747; https://doi.org/10.3390/jcm14196747 - 24 Sep 2025

Cited by 2 | Viewed by 1609

Abstract

The growing strain on global healthcare systems, driven by aging populations, rising prevalence of chronic diseases, and workforce shortages, has increased interest in strategies that enhance perioperative outcomes and healthcare sustainability. From this perspective, prehabilitation—a proactive, multimodal approach to enhance patients’ functional, nutritional, and psychological status prior to surgery—has gained attention as a potential contributor to value-based, personalized care. This study aims to synthesize mechanistic rationale, clinical evidence, and system-level considerations for prehabilitation, with particular focus on allostatic capacity and the body’s response to surgical stress. Current evidence shows that prehabilitation may reduce postoperative complications, shorten hospital stays, and improve functional recovery, particularly when interventions are multimodal. However, the existing literature is characterized by methodological heterogeneity and variable quality, seemingly limiting generalizability and large-scale implementation. Further research is required to standardize outcome measures, identify patient subgroups most likely to benefit, and evaluate cost-effectiveness. Integration of prehabilitation into perioperative care pathways will depend on improved mechanistic understanding, robust clinical trials, and alignment with broader health policy and system-level initiatives. Prehabilitation may represent a meaningful step toward value-based and sustainable surgical care, though its implementation must be guided by high-quality evidence and careful consideration of context-specific factors. Full article

(This article belongs to the Special Issue Advances in Perioperative Care: Challenges and Perspectives in Enhanced Recovery After Surgery, Perioperative Optimization and Prehabilitation: 2nd Edition)

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