Summary: Introduction: Evidence suggests that existing pre‐operative fasting guidelines are associated with prolonged fasting times. Prolonged fasting, particularly from clear liquids, has the potential to harm patients through reduced peri‐operative wellbeing; impaired glucose metabolism and peri‐operative inflammatory response; delayed return of bowel function; and reduced muscle strength. Liberalisation of fasting practices has, therefore, become increasingly common. Such a change in practice dictates the need for updated practice guidance. We aimed to develop recommendations on peri‐operative fasting that reflect increasing global awareness of the adverse effects of prolonged fasting. Methods: Following a systematic literature review, 13 draft recommendations related to peri‐operative fasting were developed iteratively. These were modified during a three‐round Delphi process by an international, multidisciplinary stakeholder panel, which included: patients; anaesthetists; surgeons; physicians; nurses; and members of relevant international organisations from five continents. Results: Sixty‐eight stakeholders participated in the Delphi consensus process. The panel subsequently agreed on eight recommendations. We recommend continuing current practices on pre‐operative fasting for solid food and non‐clear liquids. We recommend encouraging clear liquids until 2 h before the start of anaesthesia or sedation, unless institutional protocols allow for more liberal liquid intake. We further recommend implementation of institutional protocols that allow more liberal clear liquid intake < 2 h before the start of anaesthesia or sedation. Salivation stimulants can be used until transfer for the procedure. Oral intake should be resumed as soon as clinically feasible. Preprocedural gastric ultrasound performed by a trained provider may be used to guide clinical decisions when additional information is required. Discussion: This international, multidisciplinary consensus statement aims to improve the quality of patient care by minimising periprocedural fasting times, within safe margins. To achieve this, liberalised pre‐operative clear liquid intake regimens may be implemented with institutional protocols.

BACKGROUND: International guidelines recommend preoperative clear liquid fasting for 2 h before anaesthesia. However, excessive fasting times remain widespread, potentially contributing to patient discomfort and adverse clinical outcomes. OBJECTIVE: To evaluate current preoperative liquid fasting practices among adults undergoing elective procedures across multiple European centres. DESIGN: Prospective, observational, multicentre study. SETTING: Forty-six centres in 12 European countries, conducted between November and December 2024. PATIENTS: A total of 5100 adults undergoing elective surgery or interventional procedures under general anaesthesia, regional anaesthesia or sedation. MAIN OUTCOME MEASURES: Self-reported duration of preoperative liquid fasting; incidence of prolonged fasting duration (defined as liquid fasting times of more than 4 h). Median [IQR] fasting time was calculated, with subgroup analyses by country and procedure type. RESULTS: The median [IQR] preoperative liquid fasting time was 12 [10 to 14.6] h. Only 4% of patients consumed clear liquids within 2 to 4 h, and 0.8% within 2 h. Fasting durations were consistently prolonged across most countries and procedures, except for notably shorter times in Albania. Overall, 95% of patients fasted beyond 4 h. CONCLUSIONS: Excessive preoperative liquid fasting remains highly prevalent across Europe, with poor implementation of established guidelines. These findings underscore the need for educational, institutional, and quality improvement interventions to align clinical practice with evidence-based recommendations and enhance patient-centred care. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT06527703.

Background: Off-pump coronary artery bypass grafting (OPCAB) avoids cardiopulmonary bypass (CPB) and may reduce selected perioperative complications, but its technical and hemodynamic demands remain important limitations. Methods: We narratively reviewed the literature indexed in PubMed/MEDLINE and Scopus, supplemented by Google Scholar and reference-list screening, covering January 2000 to August 2026. Priority was given to systematic reviews, meta-analyses, randomized trials, prospective studies, guidelines, and relevant landmark reports. Results: OPCAB may be particularly useful in selected patients at increased risk from CPB or aortic manipulation. Cardiac displacement and coronary stabilization can cause rapid changes in preload, ventricular function, myocardial perfusion, and cardiac output, making invasive monitoring, transesophageal echocardiography, and coordinated hemodynamic management central to anesthetic care. Current evidence does not establish the superiority of volatile anesthesia or total intravenous anesthesia. Comparative studies suggest potential reductions in perioperative stroke, transfusion, renal complications, and hospital stay, although potential stroke benefits depend on the aortic-handling strategy and should not be attributed to avoidance of CPB alone. Concerns remain regarding completeness of revascularization, graft durability, repeat revascularization, and long-term survival. Conclusions: OPCAB should be considered an individualized strategy rather than a universal alternative to on-pump CABG. Optimal outcomes depend on patient selection, surgical expertise, vigilant monitoring, and timely correction of hemodynamic compromise. Potential neurological benefits should be interpreted in relation to the aortic-handling strategy, particularly when an anaortic/no-touch technique is used.