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Enhanced recovery after emergency surgery: Utopia or reality?
Rehabilitación multimodal en cirugía de urgencias: ¿utopía o realidad?
Bakarne Ugarte-Sierraa,
Corresponding author
bakarne.ugartesierra@gmail.com

Corresponding author.
, Aitor Landaluce-Olavarriab, Isaac Cabrera-Sernac, Xavier Viñas-Trullend, Carlo Brugiottie, José Manuel Ramírez-Rodríguezf, Antonio Arroyog
a Servicio de Cirugía general y del Aparato Digestivo, Grupo de Investigación de Cirugía Computacional, BioCruces Bizkaia Health Research Institute, Hospital Universitario de Galdakao, Galdakao, Vizcaya, Spain
b Servicio de Cirugía general y del Aparato Digestivo, Hospital Alfredo Espinosa, Urduliz, Vizcaya, Spain
c Servicio de Cirugía general y del Aparato Digestivo, Hospital Universitario Regional de Málaga, Málaga, Spain
d Servicio de Cirugía general y del Aparato Digestivo, Hospital General de Igualada, Igualada, Barcelona, Spain
e Servicio de Cirugía general y del Aparato Digestivo, Hospital Comarcal de Inca, Inca, Balearic Islands, Spain
f Servicio de Cirugía general y del Aparato Digestivo, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
g Servicio de Cirugía general y del Aparato Digestivo, Hospital General Universitario de Elche, Elche, Alicante, Spain
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with decreased morbidity and improved efficiency&#46; Subsequently&#44; these programs have been adopted in other areas&#44; both in our specialty and in other surgical specialties&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This article is a narrative review of the main publications in the currently available literature regarding multimodal rehabilitation in emergency surgery&#44; based on a bibliographic search of the Cochrane Plus &#40;Cochrane Library&#41;&#44; Medline&#44; EMBASE and Scopus databases from 1995 to 2019&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Below&#44; we describe a series of common pre-&#44; intra- and postoperative ERAS measures in urgent surgery as well as a series of factors particular to the management of the selected pathologies&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Common measures</span><p id="par0025" class="elsevierStylePara elsevierViewall">Although there are probably certain things that can be extrapolated from elective surgery&#44; the protocolization of multimodal rehabilitation measures for urgent surgery has a series of peculiarities of its own&#46; Therefore&#44; modified ERAS programs are used&#44; with a preoperative phase that has little margin for optimization&#46; This makes it necessary to have a greater impact on the intra- and postoperative phases&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Preoperative measures</span><p id="par0030" class="elsevierStylePara elsevierViewall">A high preoperative HbA1c level or preoperative hyperglycemia is clearly associated with increased morbidity&#46; Since the determination of HbA1c in emergency departments is quite difficult&#44; glycemic control is recommended throughout the perioperative period&#44; with a target of 140&#8211;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Given the urgent nature of the pathology&#44; patient acceptance and satisfaction are other concerns to be studied&#46; These issues are combated with proper protocolization&#44; extensive preoperative counseling&#44; and information on the benefits of this type of treatment and early discharge&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Intraoperative measures</span><p id="par0040" class="elsevierStylePara elsevierViewall">There are different factors over which strict control must be maintained&#44; such as intraoperative fluid therapy&#44; hypothermia prevention&#44; analgesia&#44; hemodynamic changes&#44; antiemetic prophylaxis&#44; etc&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is a real challenge to establish restrictive fluid therapy&#47;goal-directed fluid therapy in the emergency setting because it is a break from the traditional teaching applied in critically ill patients&#44; which almost requires large volumes of fluid without restrictions to combat hypotension&#44; vasodilation and the consequent capillary leakage of fluid&#46; The consistency of the results obtained in elective surgery in terms of restrictive fluid therapy makes it necessary to consider whether excess fluid can&#44; in fact&#44; create or perpetuate something that we want to avoid&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The use of balanced electrolyte solutions &#40;lactated Ringer&#39;s&#44; plasma-lyte&#41; is recommended over saline or colloids &#40;grade of recommendation&#58; GR-IIC&#41;&#44; which is especially important in the management of unstable patients&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">6</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">It is essential to keep the room warm and avoid patient heat loss as much as possible&#46; More than 50&#37; of patients in the emergency room have hypothermia&#46; The most important consequences of hypothermia are increased perioperative blood loss&#47;coagulopathy&#44; heart problems &#40;myocardial ischemia&#44; arrhythmias&#41; and increased wall infections&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">7</span></a> Preoperative active warming is indicated in high-risk patients &#40;over 60 years&#41; &#40;GR-IC&#41;&#44; and it is recommended in all emergency surgery patients&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Regarding pain management&#44; the best therapeutic option is balanced or multimodal analgesia&#46; This involves combining different drugs or anesthetic techniques with different mechanisms of action &#40;regional TAP block &#91;transversus abdominis plane&#93; in cases of laparotomy&#44; etc&#46;&#41; and in doses lower than those used in monotherapy&#46; The aim is to achieve greater analgesic potency with fewer adverse effects&#46; There are many papers that support this concept of analgesia&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Likewise&#44; the risk of postoperative nausea and vomiting in all patients should be stratified using the Apfel scale&#44; and prophylactic measures should be based on this&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Postoperative measures</span><p id="par0070" class="elsevierStylePara elsevierViewall">As in any ERAS protocol&#44; early introduction of the oral diet and ambulation is recommended &#40;as well as the early removal of catheters and drains&#44; if any&#41;&#44; while taking into account that the urgent nature of the pathology will require a cadence that is different from elective surgeries&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A novel trend in postoperative patient care is the idea of the &#8216;handoff&#8217;&#44; or transfer&#44; of patients to the reanimation area&#44; avoiding noise or stress in order to achieve a more placid post-anesthetic recovery and avoid problems associated with an inadequate transfer &#40;greater initial postoperative pain&#44; anxiety&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">10</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Specific measures by pathologies</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Acute appendicitis</span><p id="par0080" class="elsevierStylePara elsevierViewall">The literature shows that the mean postoperative stay for acute appendicitis is 1&#46;8&#8211;2&#46;2 days&#44; which is similar for open or laparoscopic surgery&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">An ERAS protocol would allow for earlier return to home&#44; school or work and would reduce postoperative discomfort&#44; costs&#44; and even the possibility of day surgery&#44; which would provide individual&#44; family&#44; health and social benefits&#44; reducing hospital costs and loss of productivity&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Preoperative measures</span><p id="par0090" class="elsevierStylePara elsevierViewall">Antibiotic prophylaxis has been shown to be effective in preventing superficial surgical site infections and intra-abdominal abscesses in patients with uncomplicated appendicitis&#46; However&#44; there is no evidence to support the routine administration of postoperative antibiotics&#46; Therefore&#44; in uncomplicated acute appendicitis &#40;in the absence of gangrene or perforation&#41;&#44; only one preoperative dose is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">11</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Likewise&#44; preoperative voluntary urination is recommended to avoid catheterization&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Intraoperative measures</span><p id="par0100" class="elsevierStylePara elsevierViewall">Regarding the access route&#44; laparoscopic appendectomy should be the first option if the surgical team has been trained&#46; The laparoscopic procedure offers clear advantages in terms of less pain&#44; lower incidence of surgical site infection&#44; shorter hospital stay&#44; earlier return to work and decrease in general costs &#40;GR-IA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">12</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Nasogastric and drain tubes should be avoided in uncomplicated acute appendicitis&#46; The routine use of surgical drains does not reduce the incidence of intra-abdominal abscess&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">13</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Although minimally invasive&#44; laparoscopic appendectomy in uncomplicated acute appendicitis continues to produce considerable postoperative pain&#44; hospitalizations of 1&#8211;2 days&#44; and 1&#8211;3 weeks missed work or school&#46; Recommendations include pre-incisional port infiltration &#40;local anesthetic and epinephrine&#41;&#44; opioid-sparing pre- and postoperative multimodal analgesia&#44; along with single-dose parenteral NSAIDs at the end of the procedure&#46; In 2017&#44; Hamill et al&#46; conducted a non-systematic review of evidence-based measures to optimize recovery after laparoscopic appendectomy&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">13</span></a> Some of their notable conclusions were&#58; the protocolized approach has not yet been studied in randomized clinical trials&#59; neither minilaparoscopy nor SILS &#40;Single-incision Laparoscopic Surgery&#41; improved recovery&#59; TAP block did not reduce postoperative pain<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">14&#44;15</span></a>&#59; on the other hand&#44; local intraperitoneal anesthesia showed benefits in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">16&#44;17</span></a> No trials were found about NOTES &#40;natural orifice transluminal endoscopic surgery&#41; appendectomy or about the use of drain tubes&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Intraoperative fluid therapy&#44; prevention of hypothermia&#44; analgesia and hemodynamic changes should be strictly monitored to reduce metabolic stress&#44; along with antiemetic prophylaxis &#40;with dexamethasone and ondansetron&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Postoperative measures</span><p id="par0120" class="elsevierStylePara elsevierViewall">It is mandatory to underline the importance of insisting on the early initiation of oral diet and ambulation&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Lefrancois et al&#46; described the Saint-Antoine Score&#44; which is a predictive score based on 5 factors independently associated with early hospital discharge &#40;BMI &#60;28<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; leukocyte count &#60;15<span class="elsevierStyleHsp" style=""></span>000&#47;&#956;l&#44; CRP &#60;30<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#44; absence of radiological signs of perforation&#44; and appendix diameter &#40;&#8804;10<span class="elsevierStyleHsp" style=""></span>mm on imaging&#41; when observing that 71&#37; of the patients with 4 criteria and 92&#37; with 5 criteria were day surgery patients&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">18</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In hospitals and selected cases &#40;without protocolization&#41;&#44; uncomplicated acute appendicitis has been successfully managed as day surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">19</span></a> with outpatient surgery rates of 35&#37;&#46; Several groups have developed day surgery protocols for laparoscopic appendicitis&#44; increasing the outpatient rate without an increase in morbidity and mortality&#44;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">20&#44;21</span></a> achieving outpatient treatment rates of 85&#37;&#44; without a greater number of readmissions&#44; and estimated cost savings&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">22</span></a> Several subsequent studies confirm the safety of this approach in adults&#44; without higher rates of complications or readmissions&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">23&#44;24</span></a> The absence of mortality and low morbidity &#40;5&#37;&#41; observed in recent studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">20&#44;23&#44;25</span></a> demonstrate the safety and efficacy of this strategy&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Acute cholecystitis</span><p id="par0135" class="elsevierStylePara elsevierViewall">Acute lithiasic cholecystitis is diagnosed in 3&#37;&#8211;10&#37; of patients with acute abdominal pain and represents 1&#47;3 of emergency admissions&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">26</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Most of the measures do not differ from the usual ERAS recommendations listed above&#46; Below&#44; we show some specific features in the case at hand&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Preoperative measures</span><p id="par0145" class="elsevierStylePara elsevierViewall">There is some controversy regarding the timing of cholecystectomy in acute cholecystitis&#46; A meta-analysis<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">27</span></a> showed that morbidity and conversion to an open procedure is the same for early cholecystectomy &#40;within 7 days of onset of symptoms&#41; and that performed in a second stage&#46; Early cholecystectomy is associated with a significantly shorter total hospital stay and is the treatment of choice according to the recommendations of the latest guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">26&#8211;28</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">According to the World Society of Emergency Surgery &#40;WSES&#41; guidelines&#44; early laparoscopic cholecystectomy should be performed as soon as possible&#44; but can be performed up to 10 days after the onset of symptoms &#40;GR-IA&#41;&#46; However&#44; we should realize that surgery prior to this time period is associated with a shorter hospital stay and fewer complications &#40;GR-IIB&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">With regard to antibiotic prophylaxis&#44; uncomplicated acute cholecystitis can be treated without routine postoperative antibiotics as long as the focus of the infection is controlled by cholecystectomy &#40;GR-IB&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Intraoperative measures</span><p id="par0160" class="elsevierStylePara elsevierViewall">The laparoscopic approach for acute cholecystitis is considered safe&#44; feasible&#44; with a low complication rate and associated with a shorter hospital stay &#40;GR-IA&#41;&#46; Initially&#44; a laparoscopic approach should be attempted in all patients&#44; except in the case of absolute contraindication due to anesthesia or septic shock &#40;GR-IIB&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">29</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">There is no consensus &#40;with retrospective and uncontrolled studies&#41; regarding the value of abdominal drainage after early laparoscopic cholecystectomy for mild or moderate acute cholecystitis &#40;I or II of the Tokyo classification&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">30</span></a> Its use and characteristics depend on the surgeon&#46; It is often used in high-risk populations&#44; although there is no measurable benefit in the postoperative period&#44; and it may even compromise patient recovery in the context of early laparoscopic cholecystectomy for grades I or II acute cholecystitis&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">31</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">A Cochrane meta-analysis included a series of randomized studies that compared &#8216;no drain&#8217; and &#8216;drain&#8217; strategies after open cholecystectomy&#44; demonstrating that routine use of surgical drains after open cholecystectomy does not provide any patient benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">30</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">In contrast&#44; drainage increased the incidence of wound infections&#44; chest infections&#44; and atelectasis&#44; and yet did not affect the incidence of postoperative abdominal collections&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">32</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Postoperative measures</span><p id="par0180" class="elsevierStylePara elsevierViewall">In complicated cholecystitis&#44; antimicrobial regimens will depend on the suspected pathogens involved and the risk factors for the main resistance patterns &#40;GR-IIIB&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">29</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the multimodal rehabilitation protocol in acute cholecystitis of the Spanish Multimodal Rehabilitation Group &#40;Zaragoza&#44; 2016&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Perforated peptic ulcer</span><p id="par0185" class="elsevierStylePara elsevierViewall">The presence of a perforated peptic ulcer is a surgical emergency in which a delay of more than 12<span class="elsevierStyleHsp" style=""></span>h significantly increases mortality&#46; Associated comorbidity increases postoperative complications by nine-fold&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">33</span></a> Diabetic patients have a higher risk of 30-day mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">34</span></a> Advanced age is an independent risk factor for higher mortality in ulcer perforations&#44;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">35</span></a> and the onset of patients with hypotension&#44; metabolic acidosis&#44; kidney damage or hypoalbuminemia is associated with a worse prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0500"><span class="elsevierStyleSup">36&#44;37</span></a> All of this means that there are very few preparatory measures that can be performed before urgent surgery&#44; with 30-day mortality estimated to be around 24&#37;&#46;</p><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Preoperative measures</span><p id="par0190" class="elsevierStylePara elsevierViewall">The use of a nasogastric tube is indicated to avoid the leakage of irritants&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The infusion of high doses of inhibitors is recommended in digestive bleeding&#44; where the cessation of bleeding and the healing of ulcers have been seen&#46; Although its impact on perforations secondary to ulcers has not been documented&#44; it is recommended to start high doses of proton pump inhibitors as soon as possible with a loading dose of 80<span class="elsevierStyleHsp" style=""></span>mg and 8<span class="elsevierStyleHsp" style=""></span>mg&#47;h of the inhibitor as it is believed to favor fibrin formation and promote rapid sealing of perforations&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">38</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Antibiotic therapy should cover a spectrum that includes enteric gram-negative colonies&#44; anaerobes&#44; and oral mucosal flora&#46; Given the recent resistance of enterobacteria&#44; mainly <span class="elsevierStyleItalic">Escherichia coli</span>&#44; empirical antibiotic therapy should be based on local&#47;regional sensitivity and will have to detect patients at risk of having extended-spectrum beta-lactamases&#44; where antibiotic therapy should be based on ertapenem-type drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">39</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">The importance of adequate empirical treatment was made apparent in a study of 425 patients with secondary peritonitis &#40;including patients with perforated ulcer&#41;&#46; In this study&#44; 13&#37; of the treatment was inappropriate&#44; and in these patients the resolution of the condition occurred only in 53&#37;&#44; compared to 70&#37; of those treated appropriately&#46; This failure to resolve the symptoms was associated with a 6-day increase in patient hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">40</span></a> The efficacy of intravenous treatment for <span class="elsevierStyleItalic">Helicobacter pylori</span> during the postoperative period has not been established&#44; and it is recommended to start treatment after discharge once oral tolerance has been correctly established to avoid resistance if it is interrupted due to lack of tolerance&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">41</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Both intra- and postoperative measures do not differ greatly from the usual ERAS recommendations&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Intraoperative measures</span><p id="par0215" class="elsevierStylePara elsevierViewall">There is currently no evidence that laparoscopy is superior to open surgery&#44; but there is also no evidence that laparoscopy is harmful in patients with sepsis or generalized peritonitis&#46; As no difference in mortality has been demonstrated by the open versus the laparoscopic technique&#44; the choice of one or the other will be determined by the surgeon&#39;s experience and the characteristics of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">42</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">Drain tube placement is recommended in peritonitis&#44; as it has shown fewer postoperative complications&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">43</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Postoperative measures</span><p id="par0225" class="elsevierStylePara elsevierViewall">The nasogastric tube should not remain in place for more than 2 days&#44; and early onset of tolerance is preferred&#44; although there are few related studies&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">44</span></a></p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Mechanical obstruction due to colon cancer</span><p id="par0230" class="elsevierStylePara elsevierViewall">ERAS programs in elective colon surgery have been used with favorable results&#44;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">45&#8211;49</span></a> and the implementation in Spain of the IMPRICA program for adherence to the RICA guidelines &#40;<span class="elsevierStyleItalic">Recuperaci&#243;n Intensificada en Cirug&#237;a Abdominal</span> or Intensified Recovery in Abdominal Surgery&#41;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">1</span></a> is also relevant&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">Their application in urgent colon surgery is rather scarce&#44; and they focus on the obstruction&#46; Shida et al&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">50</span></a> evaluated 122 urgent colectomies for colorectal obstructive neoplasm&#44; 48 treated traditionally and 80 with a modified ERAS program&#44; concluding that these programs reduce hospital stay without increasing morbidity&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">Within the management of complete mechanical obstruction due to colon cancer&#44; one of the most debated concepts is the role of stents&#46; It is accepted that in patients with potentially curable colon cancer on the left side of the colon&#44; with high surgical risk&#44; ASA III or &#62;70 years of age&#44; stents could be considered a good alternative as a bridge to subsequently perform scheduled ERAS surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">51</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">In urgent surgery for colon cancer with complete mechanical obstruction&#44; various measures have been studied based on the recommendations of the ERAS group and their impact on morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">4</span></a></p><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Preoperative measures</span><p id="par0250" class="elsevierStylePara elsevierViewall">It is recommended to estimate the surgical risk &#40;ASA&#44; CR-POSSUM&#41;&#46; A risk greater than 10&#37; implies a need for admission to the intensive care unit&#44; postoperatively and even preoperatively for optimization prior to surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">52</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">A central venous catheter is necessary for goal-directed fluid therapy &#40;central venous pressure between 8 and 12<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#44; measured arterial pressure of 65 or less&#44; and urinary volume of at least 0&#46;5<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;h&#41;&#46; Volume replacement is indicated with isotopic saline solutions or lactated Ringer&#39;s&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">53</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">In patients with severe colon distention and vomiting&#44; a nasogastric tube is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">54</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Early initiation of broad-spectrum antibiotic therapy is also recommended&#44; and the empirical choice of antibiotics is determined according to the sensitivities in the area&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Intraoperative measures</span><p id="par0270" class="elsevierStylePara elsevierViewall">In patients who are scheduled to undergo open surgery&#44; an epidural catheter should be considered together with general anesthesia for better control of postoperative pain&#46; Its use should not be indicated in patients with coagulopathy&#44; bleeding tendencies or hemodynamic instability&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">55</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">Goal-directed fluid therapy is recommended&#44; although there are not many studies in emergency surgery&#44; and the results do not seem to influence morbidity&#44; mortality&#44; or renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">53</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">Perioperative hypothermia is associated with increased surgical site infection&#44; more cardiac complications&#44; and increased blood loss&#46; Hypothermia prevention is recommended from the preoperative period&#44; using active heating systems&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Laparoscopic surgery in urgent colectomy is difficult to perform&#46; Rea et al&#46; analyzed 67<span class="elsevierStyleHsp" style=""></span>645 patients &#40;multicenter data&#41;&#44; and only 3&#46;9&#37; were treated laparoscopically&#44; with a conversion rate of 55&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">56</span></a> The laparoscopic approach is associated with a shorter hospital stay and a lower rate of postoperative complications&#44; although the extreme technical difficulty of laparoscopic surgery in patients with complete mechanical obstruction due to colon cancer must be taken into account&#44; which requires super-specialization that is not always available at the time of surgery&#44; so the laparoscopic approach is only recommended in specialized units&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">57</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">The latest WSES 2017 guidelines do not recommend intraoperative colon lavage &#40;GR-IB&#41; as it does not influence anastomotic dehiscence or morbidity&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Surgical drains are not generally recommended&#44; except in cases associated with significant bleeding&#44; purulent or fecal peritonitis&#44; and high-risk anastomosis&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">58</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Postoperative measures</span><p id="par0300" class="elsevierStylePara elsevierViewall">Multimodal analgesia adapted to the emergency is recommended&#44; where prior standardization is not possible&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">54</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">Several studies recommend early removal of the nasogastric tube&#44; even after surgery&#44; since its early removal is not related to a worse outcome&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">54</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">No obvious improvement in the recovery of lung function or in the decrease in respiratory complications<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">59</span></a> has been demonstrated with the use of an incentive spirometer&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Early initiation of oral tolerance is different from scheduled surgery&#44; and the presence of ileus should make us consider slower initiation&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">58</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">And lastly&#44; although there is no evidence on the benefits&#44; early mobilization is recommended because chronic bedrest is associated with a higher risk of thromboembolism&#44; muscle weakness&#44; pneumonia&#44; and insulin resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">60</span></a><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes the current recommendations for the different pathologies set out in the text&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0325" class="elsevierStylePara elsevierViewall">Although some groups have suggested global inclusion of patients and pathologies in ERAS programs&#44; they often define exceptions and exclude patients with multiple comorbidities&#44; significant chronic disease &#40;including mental illness&#41;&#44; high anesthetic risks &#40;ASA&#62;III&#41;&#44; alcohol abuse&#44; diseases that make epidural analgesia impossible&#44; and language difficulties&#44; while the exclusion factor <span class="elsevierStyleItalic">par excellence</span> was urgent clinical presentation&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Despite the large volume of existing literature on ERAS in elective surgery&#44; there are few studies that have investigated the effectiveness of ERAS programs in urgent surgery patients&#44; although some guidelines indicate that their use may be appropriate&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">5</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">Gonenc et al&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">44</span></a> demonstrated safety and viability in selected upper gastrointestinal tract emergencies and Lohsiriwat<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">61</span></a> in colorectal emergencies&#46; Wiseley and Barclay<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">5</span></a> retrospectively studied all types of urgent surgery in 370 patients&#46; The most frequent etiology was obstruction&#44; but the etiology was not recorded by subgroup of surgical pathology&#44; 169 patients in the study were pre-ERAS compared to 201 ERAS&#44; showing a significant decrease in morbidity for this group and concluding that the application of ERAS programs in urgent patients is not harmful to them&#46; Likewise&#44; Le Guen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">62</span></a> support many ERAS measures&#44; although they acknowledge a limited level of evidence&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">In 2009&#44; within the English guidelines for the implementation of enhanced recovery protocols<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">63</span></a> it was recommended that &#8220;everything should be done to implement as many measures as possible&#8221; in the context of enhanced recovery protocols in the emergency setting&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">The current situation of our healthcare system forces us to identify areas for improvement where we can be more efficient without affecting the quality of care&#46; Recent publications in the urgent field look for methods to reduce hospital costs and stays&#44; maintaining a high quality of care and patient satisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">64</span></a></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusion</span><p id="par0350" class="elsevierStylePara elsevierViewall">It is necessary to establish multidisciplinary working groups interested in developing ERAS protocols for patients with urgent pathology and implementing multicenter projects that guarantee their viability&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interests</span><p id="par0355" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Common measures"
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              "titulo" => "Preoperative measures"
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            1 => array:2 [
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              "titulo" => "Intraoperative measures"
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              "titulo" => "Postoperative measures"
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          "identificador" => "sec0030"
          "titulo" => "Specific measures by pathologies"
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              "identificador" => "sec0035"
              "titulo" => "Acute appendicitis"
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                  "identificador" => "sec0040"
                  "titulo" => "Preoperative measures"
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                1 => array:2 [
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                  "titulo" => "Intraoperative measures"
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                  "identificador" => "sec0050"
                  "titulo" => "Postoperative measures"
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              "titulo" => "Acute cholecystitis"
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                  "titulo" => "Preoperative measures"
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                  "titulo" => "Intraoperative measures"
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                  "identificador" => "sec0070"
                  "titulo" => "Postoperative measures"
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              "identificador" => "sec0075"
              "titulo" => "Perforated peptic ulcer"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0080"
                  "titulo" => "Preoperative measures"
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                1 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Intraoperative measures"
                ]
                2 => array:2 [
                  "identificador" => "sec0090"
                  "titulo" => "Postoperative measures"
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              "identificador" => "sec0095"
              "titulo" => "Mechanical obstruction due to colon cancer"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "Preoperative measures"
                ]
                1 => array:2 [
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                  "titulo" => "Intraoperative measures"
                ]
                2 => array:2 [
                  "identificador" => "sec0110"
                  "titulo" => "Postoperative measures"
                ]
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            ]
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          "titulo" => "Discussion"
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          "titulo" => "Conclusion"
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          "titulo" => "Conflict of interests"
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          "identificador" => "xack524665"
          "titulo" => "Acknowledgements"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
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    "fechaRecibido" => "2019-11-03"
    "fechaAceptado" => "2020-04-26"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1359765"
          "palabras" => array:6 [
            0 => "Enhanced recovery after surgery"
            1 => "Emergency surgery"
            2 => "Acute appendicitis"
            3 => "Acute cholecystitis"
            4 => "Perforated peptic ulcer"
            5 => "Emergency colectomy"
          ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1359766"
          "palabras" => array:6 [
            0 => "Rehabilitaci&#243;n multimodal"
            1 => "Cirug&#237;a urgente"
            2 => "Apendicitis aguda"
            3 => "Colecistitis aguda"
            4 => "&#218;lcera p&#233;ptica perforada"
            5 => "Colectom&#237;a urgente"
          ]
        ]
      ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Enhanced recovery after surgery &#40;ERAS&#41; constitutes the application of a series of perioperative measures based on the evidence&#44; in order to achieve a better recovery of the patient and a decrease of the complications and the mortality&#46; These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties&#46; The main excluding factor for the application of such programs has been the urgent clinical presentation&#44; which has caused that despite the large volume of existing literature on ERAS in elective surgery&#44; there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies&#46; The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0015" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La rehabilitaci&#243;n multimodal quir&#250;rgica &#40;ERAS&#41; constituye la aplicaci&#243;n de una serie de medidas perioperatorias basadas en la evidencia&#44; con el fin de lograr una mejor recuperaci&#243;n del paciente y una disminuci&#243;n de las complicaciones y la mortalidad&#46; Estos programas de rehabilitaci&#243;n multimodal inicialmente demostraron sus ventajas en el &#225;mbito de la cirug&#237;a colorrectal siendo adoptados progresivamente por otras &#225;reas quir&#250;rgicas dentro de la cirug&#237;a general y por otras especialidades quir&#250;rgicas&#46; El factor excluyente principal para la aplicaci&#243;n de este tipo de programas ha sido la presentaci&#243;n cl&#237;nica urgente&#44; lo que ha provocado que a pesar del gran volumen de literatura existente sobre ERAS en cirug&#237;a electiva&#44; existan pocos estudios que hayan investigado la efectividad de estos programas en pacientes quir&#250;rgicos en urgencias&#46; El objetivo de este art&#237;culo es mostrar las medidas de recuperaci&#243;n intensificada de que disponemos en la actualidad seg&#250;n la evidencia existente para cirug&#237;a urgente&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ugarte-Sierra B&#44; Landaluce-Olavarria A&#44; Cabrera-Serna I&#44; Vi&#241;as-Trullen X&#44; Brugiotti C&#44; Ram&#237;rez-Rodr&#237;guez JM&#44; et al&#46; Rehabilitaci&#243;n multimodal en cirug&#237;a de urgencias&#58; &#191;utop&#237;a o realidad&#63; Cir Esp&#46; 2021&#59;99&#58;258&#8211;266&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Inclusion criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Exclusion criteria&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Patients who underwent urgent surgery for acute cholecystitis&#44; who met the criteria&#58;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- All patients with acute cholecystitis &#40;Tokyo classification&#41; ASA I and II with onset of symptoms &#60;5 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">- Patient with acute cholecystitis&#44; Tokyo III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- ASA I and II<span class="elsevierStyleSmallCaps">&#44;</span> and assessment of patients with ASA III&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">- Remainder of ASA III patients and ASA IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Patient treated with oral anticoagulants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">- Patients with severe cholecystitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">- Patients with biliary peritonitis&#44; perivesicular&#47;hepatic abscess&#44; gangrenous&#47;emphysematous cholecystitis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Onset of symptoms &#62;5 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">- Chronic liver disease&#44; child B and C&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Responsibility&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Preoperative&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Preoperative assessment and ER workup&#44; including PCR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Surgeon<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Anesthesiologist<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Nurse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antibiotic prophylaxis according to the hospital protocol &#40;maintain until surgery and withdraw post-op&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">All patients who meet the criterion to join the protocol with be well informed and give their written consent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perioperative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Intraoperative</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SurgeonNurse<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Anesthesiologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Induction of anesthesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oxygenation FiO<span class="elsevierStyleInf">2</span> 0&#46;6&#8211;0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemodynamic optimization with goal-directed fluid therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fluid therapy in continuous balanced perfusion &#40;3&#46;5<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;h for laparoscopy&#59; 7<span class="elsevierStyleHsp" style=""></span>mL&#47;kg&#47;h for laparotomy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Urinary catheter&#44; if necessary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Minimally invasive surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active heating with a thermal blanket and fluid warmer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prophylaxis for postoperative nausea and vomiting&#44; according to the Apfel scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No drain tubes&#44; when possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Infiltration of laparoscopy ports or TAP block&#44; according to procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postoperative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Immediately after surgery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nurse<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Anesthesiologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active temperature maintenance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Maintenance of FiO<span class="elsevierStyleInf">2</span> 0&#46;5 2<span class="elsevierStyleHsp" style=""></span>h after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Analgesia administered according to procedure&#59; minimal administration of morphine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Restrictive fluid therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Initiation of oral tolerance 6<span class="elsevierStyleHsp" style=""></span>h after surgery &#40;or the following morning if the surgery is evening&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ambulation 8<span class="elsevierStyleHsp" style=""></span>h after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prophylaxis for thromboembolism starting 12<span class="elsevierStyleHsp" style=""></span>h after surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1st postoperative day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Progressive diet&#59; if correct oral tolerance&#44; withdrawal of iv fluids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nurse<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Surgeon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assess withdrawal of any surgical drains&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active movement &#40;bed&#47;chair&#47;initiate walking&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assess withdrawal of bladder catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Withdrawal epidural catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Follow-up lab work with CRP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prophylaxis for thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assess discharge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2nd postoperative day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal diet&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nurse<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Surgeon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Active movement &#40;walking&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prophylaxis for thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Assess discharge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Discharge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Telephone follow-up after discharge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nurse<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Surgeon<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>MAP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">General criteria after discharge&#58; No surgical complications&#44; no fever&#44; pain under control with oral analgesia&#44; normal walking&#44; patient willingness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Follow-up after discharge&#47;continued care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Home support-Coordination with Primary Care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2573233.png"
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Multimodal rehabilitation protocol in acute cholecystitis of the Spanish Multimodal Rehabilitation Group&#46;</p>"
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      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Multimodal rehabilitation in urgent surgery</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Acute Appendicitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Acute cholecystitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Perforated peptic ulcer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Colon obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preoperative measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antibiotic prophylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perioperative glycemia measurement 140&#8211;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASA&#47;CR-POSSUM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Voluntary urination&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Information to patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NG tube &#40;if distension&#47;vomiting&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Broad-spectrum antibiotic therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NG tube&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PPI 80<span class="elsevierStyleHsp" style=""></span>mg bolus<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mg&#47;h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intraoperative measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perioperative glycemia measurement 140&#8211;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Laparoscopic approach depending on team experience&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Central catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Restrictive fluid therapy&#47;goal-directed fluid therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NG tube&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Epidural catheter &#40;open surgery&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normothermia &#8211; active warming systems&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Drain in peritonitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NG tube &#40;if distension&#47;vomiting&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Multimodal analgesia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid intraoperative colonic lavage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prevention of nausea and vomiting &#8211; Apfel scale&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Drain in peritonitis&#44; bleeding&#44; or high-risk anastomosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Prioritize laparoscopic approach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid urinary catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid NG tube&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Avoid use of surgical drains &#40;uncomplicated&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Postoperative measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Perioperative glycemia measurement 140&#8211;180<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antibiotic therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Early removal of NG tube&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Restrictive fluid therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NG tube &#60;48<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Antibiotic therapy &#40;except uncomplicated&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HP eradication therapy after tolerance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initiate oral intake and early ambulation&#44; if possible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2573232.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Summary of current recommendations for different pathologies discussed in the text&#46;</p>"
        ]
      ]
      2 => array:5 [
        "identificador" => "fig0005"
        "tipo" => "MULTIMEDIAFIGURA"
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        "mostrarDisplay" => true
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "fx1.jpeg"
            "Alto" => 748
            "Ancho" => 1333
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:64 [
            0 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Via cl&#237;nica de recuperaci&#243;n intensificada &#40;RICA&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; Calvo"
                            1 => "E&#46; del Valle"
                            2 => "J&#46;M&#46; Ram&#237;rez"
                            3 => "C&#46; Loinaz"
                            4 => "C&#46; Martin Trapero"
                            5 => "C&#46; Nogueiras"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2015"
                        "editorial" => "Ministerio de Sanidad&#44; Servicios Sociales e Igualdad e Instituto Aragon&#233;s de Ciencias de la Salud"
                        "editorialLocalizacion" => "Madrid"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multilodal estrategies to improve surgical outcome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46; Kehlet"
                            1 => "D&#46;W&#46; Wilmore"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0002-9610(02)00866-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Surg"
                        "fecha" => "2002"
                        "volumen" => "183"
                        "paginaInicial" => "630"
                        "paginaFinal" => "641"
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0360" class="elsevierStylePara elsevierViewall">The authors would like to acknowledge Carlo Brugiotti&#44; Xavier Vi&#241;as&#44; Mar&#237;a Jos&#233; Fas&#44; Alberto Felipe Bravo&#44; Antonio P&#233;rez&#44; Jos&#233; Antonio L&#243;pez&#44; Irene Ortega&#44; Gianchandani Moorjani&#44; Rajesh Haresh&#44; Luis Tall&#243;n&#44; Carlos David Albendea&#44; Maria Infantes&#44; Ruben Gonzalez&#44; Ricardo Ortega&#44; Ana Palomares&#44; Antonio D&#225;maso&#44; Luis Vega&#44; Marina Molinete&#44; Aitor Landaluce&#44; Enric Macarulla y Bakarne Ugarte&#44; who participated in the 2016 Zaragoza Conference for the development of the initial protocols for multimodal rehabilitation in urgent surgery of the Spanish Multimodal Rehabilitation Group &#40;currently being revised by the workgroup&#42;&#41;&#44; from which we showed an example in this article&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">&#42;Emergency Surgery Workgroup of the Spanish Multimodal Workgroup&#58; Bakarne Ugarte&#44; Aitor Landaluce&#44; Isaac Cabrera&#44; Jos&#233; Antonio L&#243;pez&#44; Susana Postigo&#44; Manuel Artiles&#44; Jaume Tur&#44; Mar&#237;a Dolores P&#233;rez&#44; Fernando Tur&#233;gano&#44; Alexander Forero&#44; Andrea Craus&#44; Francisca Garc&#237;a-Moreno&#44; Luis Tall&#243;n&#44; Ricardo Gonz&#225;lez&#44; Pablo Muriel&#44; Providencia Garc&#237;a&#44; Nicol&#225;s Mac&#237;as&#44; Jennifer Garc&#237;a&#44; Isidro Mart&#237;nez&#44; Luis Alberto Mart&#237;nez&#44; Di&#233;ter Morales&#44; Andrea Campos&#44; David Costa&#44; Ignacio Rey&#44; Francisco Blanco&#44; Francisco Jim&#233;nez&#44; Marta Gonz&#225;lez&#44; Rula Nasimi&#44; Marta Guti&#233;rrez&#46;</p>"
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Article information
ISSN: 21735077
Original language: English
DOI:10.1016/j.cireng.2021.03.013
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