Purpose: In this retrospective pilot study, we aim to evaluate the accuracy and reliability of the P-POSSUM and ACS-NSQIP surgical risk calculators in predicting postoperative complications in gynaecological–oncological (GO) robotic surgery (RS). Methods: Retrospective data collection undertaken through a dedicated GO database and patient notes at a tertiary referral cancer centre. Following data lock with the actual post-op event/complication, the risk calculators were used to measure predictive scores for each patient. Baseline analysis of 153 patients, based on statistician advice, was undertaken to evaluate P-POSSUM and ACS-NSQIP validity and relevance in GO patients undergoing RS performed. Results: P-POSSUM reports on mortality and morbidity only; ACS-NSQIP reports some individual complications as well. ACS-NSQIP risk prediction was most accurate for venous thromboembolism (VTE) (area under the curve (AUC)-0.793) and pneumonia (AUC-0.657) and it showed 90% accuracy in prediction of five major complications (Brier score 0.01). Morbidity was much better predicted by ACS-NSQIP than by P-POSSUM (AUC-0.608 vs. AUC-0.551) with the same result in mortality prediction (Brier score 0.0000). Moreover, a statistically significant overestimation of morbidity has been shown by the P-POSSUM calculator (p = 0.018). Conclusions: Despite the limitations of this pilot study, the ACS-NSQIP risk calculator appears to be a better predictor of major complications and mortality, making it suitable for use by GO surgeons as an informed consent tool. Larger data collection and analyses are ongoing to validate this further.

Background: Intraoperative hypotension is a common occurrence in patients undergoing anaesthesia, although there is no standardised definition of hypotension. International consensus statements provide some guidelines for the management of intraoperative hypotension, but general clinical practice is unknown. We aimed to survey anaesthesiologists' values and preferences regarding intraoperative blood pressure management, including whether they would support future research on this topic. Methods: We conducted an international, online survey of routine practice and opinion. The target population was anaesthesiologists who regularly anaesthetise adult patients. Results are reported descriptively and in accordance with the Consensus‐Based Checklist for Reporting of Survey Studies (CROSS) checklist. Results: A total of 1640 anaesthesiologists from 11 European countries participated in the survey. The majority of respondents were specialists (1322 of 1640, 80.6%, 95% CI 78.7–82.6). Almost all respondents worked in public hospitals (1613 of 1640, 98.4%). The overall response rate was 22.7%. Most respondents reported using absolute mean arterial pressure as their main unit of measurement to quantify hypotension (1098 of 1640, 67.0%, 95% CI 64.6–69.2). Respondents were most likely to initiate vasoactive treatment at a mean arterial pressure below 60 or 65 mmHg. Chronic arterial hypertension, traumatic brain injury and surgical procedures involving head‐up positioning of the patient were the three most common scenarios where respondents would raise their threshold for treatment. Most respondents considered the establishment of safe intraoperative blood pressure thresholds a critical research question, and almost all respondents (1509 of 1640, 92.0%) indicated a willingness to randomise patients to specific blood pressure targets. For 72.9% (1196 of 1640), the lowest acceptable mean arterial pressure for randomisation was 60 mmHg. Respondents were also interested in the comparison of efficacy and safety of vasoactive agents, and the most sought‐after comparison was phenylephrine versus noradrenaline (1252 of 1640, 76.3%). The willingness of respondents to administer these agents in peripheral venous access differed according to geography. Conclusion: In this international survey, mean arterial pressures of 60 or 65 mmHg were the most commonly reported blood pressure thresholds leading to initiation of treatment with vasoactive agents. Almost all respondents indicated patient groups for whom they would alter their treatment threshold, namely those suffering from chronic arterial hypertension, those undergoing surgery in a head‐up position, and patients with traumatic brain injury. The majority of respondents supported future trials establishing optimal mean arterial pressure threshold and choice of vasoactive agent. We noticed a geographical variation in willingness to administer vasoactive agents in peripheral venous access. Editorial Comment: This survey of anaesthesiologists from European countries queried practitioner perceptions of blood pressure management in adults during anaesthesia with focus on hypotension. Queries and responses also concerned circumstances and blood pressure levels which clinicians report being willing to treat actively, and how they might do this practically.

In recent years, the popularity and application of the ERAS approach has expanded to cover a wide variety of surgical specialties and procedures. This has partly been driven by the ERAS Society, who have published a number of consensus guidelines for surgical procedures including gastrectomy and oesophagectomy. Upper gastrointestinal (GI) surgery includes some of the highest risk elective procedures performed on a routine basis, and consequently, has a lot to gain from the perceived benefits of ERAS. Evidence derived from several recent meta-analyses demonstrates a reduction in hospital length of stay, hospital costs and stress response to surgery through the implementation of ERAS principles in patients undergoing gastrectomy. Although the body of evidence concerning ERAS in oesophagectomy is not as large, analysis of the available data suggests that the application of ERAS principles may result in a reduction of hospital length of stay, pulmonary complications and anastomotic leakage. This review examines the consensus guidelines published by the ERAS Society for both gastrectomy and oesophagectomy and investigates the rationale for some of the recommendations made therein. Both sets of guidelines are comprised of a number of generic ERAS recommendations, common to enhanced recovery programmes across all specialties, as well as specific, evidence-based recommendations applicable to the two surgical procedures concerned. Whilst the advent of these publications represents a significant step forward in the perioperative management of patients undergoing these procedures, many questions still remain. Whether the widespread adoption and implementation of these pathways produces the same magnitude of benefit we have seen elsewhere, for instance in colorectal surgery, remains to be seen, but regardless of that, further research is required to clarify these issues. As new evidence emerges, so the guidelines may be refined and the potential for improving patient’s quality of life and perhaps even overall survival will increase.

Editor—We read with interest the recent editorial Perioperative management of diabetic patients: new controversies.¹ This is indeed a topic which continues to cause confusion amongst those involved in the perioperative care of these patients.