Background: This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low–middle‐income countries (LMIC's) for elective abdominal and gynecologic care.Methods: The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC's. The group consisted of seven members from the ERAS® Society and eight members from LMIC's. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592–695, Nelson et al in Int J Gynecol Cancer 29(4):651–668). Meta‐analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC's and LMIC's were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC's. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC's and determined through discussions and consensus.Results: In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno‐nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline.Conclusions: These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data‐driven, evidence‐based care in LMIC's.

The patient's experience of their postoperative recovery is an important perioperative outcome, with the 15-item quality of recovery scale (QoR-15) recommended as a standardised outcomes measure. Desflurane has a faster emergence from anaesthesia compared with other volatile anaesthetics, but it is uncertain whether this translates to better subjective quality of recovery. The hypothesis for this study is that patients receiving desflurane for maintenance of anaesthesia would have better postoperative quality of recovery than patients receiving isoflurane. Male and female adult patients undergoing ophthalmological surgery under general anaesthesia were randomly allocated to receive desflurane or isoflurane for maintenance of anaesthesia. The primary outcome was to compare postoperative QoR-15 scores. Secondary outcomes included comparing preoperative QoR-15 scores, volatile agent consumption, and time spent in the recovery room. Data from 164 patients were analysed (80 desflurane, 84 isoflurane). Median (Q1, Q3) postoperative QoR-15 scores were not significantly different (desflurane: 145 [141, 148], isoflurane: 144 [139, 147], 95% confidence interval 0-3, P=0.176, minimal clinically important difference=8). Median (Q1, Q3) volatile agent consumption was 15.4 (12.5, 19.3) ml hr^-1 in the desflurane group, and 7.4 (5.9, 9.7) ml hr^-1 in the isoflurane group. Median (Q1, Q3) time spent in the recovery room was significantly shorter in the desflurane group (desflurane: 18 [13, 23]; isoflurane: 25 [19, 32], 95% confidence interval -10 to 5, P<0.001). This study found no difference in quality of recovery between patients who received desflurane or isoflurane for maintenance of general anaesthesia during ophthalmological surgery. A shorter time in the recovery room was not associated with improved QoR-15 scores. NCT04188314.

Background: Perioperative patient-reported outcomes (PROs) allow patients to share their experiences of surgical procedures with their health care teams using standardized measures. Despite increasing recognition of their value, PROs are not routinely used in clinical practice, partly due to limited evidence of their impact on traditional clinical outcomes and uncertainty among clinicians about their use. Digital health tools offer a promising way to integrate PROs into clinical workflows and enhance patient-clinician interaction, but their success depends on person-centered design to ensure usability and relevance. Safe Surgery South Africa, a nonprofit organization, developed the Perioperative Shared Health Record (PSHR), a secure web-based tool that enables patients to share personal health information and PROs with their anesthetist and surgeon before and after surgery. Initial implementation revealed significant user experience challenges, which contributed to poor uptake. Objective: This study aimed to explore factors influencing the PSHR user experience in a low- and middle-income country (LMIC) using human-centered design principles. Methods: This observational qualitative user experience study followed the 5 design thinking stages: empathize, define, ideate, prototype, and test. Semistructured interviews were conducted with postoperative patients from both the public and private health care sectors, including those with and with no prior experience using the PSHR. Thematic analysis followed the 6-phase framework described by Braun and Clarke and was structured using Karagianni’s Optimized Honeycomb user experience model. A problem statement was developed, followed by ideation to explore solutions. Paper prototypes were created, refined, and tested through observation, interviews, and validated usability questionnaires. Results: In the empathize stage, 22 interviews were conducted in the private and public health care sectors in South Africa; 7 participants had previous experience using the PSHR. In the define stage, participants emphasized the need for connection, feedback, information, and support through their surgical journey. Contrary to expectations, patients were not discouraged by the length of questionnaires if they perceived them as purposeful. In the ideate stage, the team considered user expectations and PSHR integration into care processes. In the prototype stage, low-fidelity mock-ups were created and refined into paper prototypes. In the test stage, testing with 5 participants highlighted the importance of trust, communication, and user-friendly interfaces. Feedback loops and clinician engagement were identified as key motivators for sustained use. The mean usability questionnaire scores indicated excellent usability and high levels of user satisfaction across most domains. Conclusions: This study is one of the first to apply human-centered design principles to a perioperative digital health tool in an LMIC setting, addressing usability challenges and patient engagement. Key user experience factors influencing patient engagement included communication, feedback, and access to information throughout the surgical journey. Digital health tools such as the PSHR can strengthen communication and support person-centered perioperative care by integrating PROs into clinical workflows and care processes.