The research team screened nearly 3,700 records and identified 45 studies encompassing 5,283 patients who underwent a broad spectrum of major abdominal procedures, including hepatopancreatobiliary, upper gastrointestinal, colorectal and urological surgery. Of these, 17 studies involving 2,213 patients provided data suitable for quantitative pooling. Using random-effects meta-analysis with Hedges’ small-sample correction and sensitivity analyses across a wide range of plausible correlation values, the researchers calculated standardised mean changes in muscle mass, size and strength at two key intervals: within two weeks of surgery, and between three and six weeks after the operation.

The results were unambiguous. Within two weeks of surgery, skeletal muscle mass or dimensions had declined significantly, with a pooled standardised mean change of 0.34, rising to 0.39 at around one month. By conventional benchmarks these are small-to-moderate effects, but the authors translate them into more tangible terms: a downward shift of roughly 13 percentile points in muscle mass within two weeks, and 15 points by one month. Crucially, the decline appeared regardless of how muscle was measured, whether by computed tomography, ultrasound, bioelectrical impedance analysis or dual-energy X-ray absorptiometry, and it persisted across every surgical specialty examined.

Perhaps the most striking finding is the sheer speed of the process. Of 23 studies that assessed muscle within ten days of surgery, 21 reported measurable declines, and some documented losses within just five days. One study reported a 4.4% drop in total psoas muscle index merely three days after oesophagectomy, while another recorded a 9.16% reduction in the cross-sectional area of the vastus lateralis within five days of open colorectal resection. In critical care medicine, muscle loss of up to 2% per day during the first week of intensive care admission is well documented; the new analysis suggests that major surgery, even in patients who never require intensive care, can trigger a similar accelerated catabolic state.

Muscle function suffers alongside muscle size. Across six studies including 417 patients, handgrip strength fell significantly after surgery, with a pooled standardised mean change of 0.79, an effect the authors describe as indicating clinically relevant perioperative weakness, though they caution that heterogeneity between studies was substantial and the estimate imprecise. Five studies tracked both muscle mass and function simultaneously, and nearly all found parallel declines, suggesting that the loss of tissue seen on scans translates directly into lost strength. Notably, one study of liver transplant recipients found that grip strength returned to baseline within six months, whereas muscle mass took a full year to recover, hinting that function rebounds before structure does.

The clinical consequences of this muscle loss extend far beyond the immediate recovery period. Studies included in the review linked significant perioperative muscle wasting, defined in some analyses as more than a 10% reduction from baseline, with markedly higher rates of postoperative complications, prolonged hospitalisation, anastomotic leakage after oesophagectomy, poorer quality of life and reduced long-term survival. In one pancreatic surgery cohort, restoration of preoperative muscle size within 24 weeks emerged as an independent prognostic factor for survival. Muscle wasting following gastrectomy has likewise been associated with poorer overall survival, indicating that the shadows cast by the surgical catabolic response can stretch for years.

One particularly revealing study examined 457 healthy adult living liver donors, a population with no underlying disease, and found significant muscle wasting within the first postoperative week, with recovery by three months. Because these donors were otherwise well, the finding isolates the effect of surgery itself, though the authors note that hepatic resection and the metabolic demands of liver regeneration may have amplified the loss. All of the studies included in the review were conducted in elective populations, which raises a further concern: patients who undergo emergency abdominal surgery receive no preoperative optimisation and often present with marked inflammation, factors that could predispose them to even greater muscle loss.

Encouragingly, the review identified early signals that the process may be modifiable. Twelve studies tested interventions, seven of them nutritional, including carbohydrate loading, immunonutrition, amino acid supplementation and formulas enriched with the leucine metabolite HMB. Results were mixed but generally modestly positive: perioperative immunonutrition cut muscle wasting at two weeks from 16.9% to 7.04% in one trial, and HMB-enriched supplementation improved both muscle preservation and grip strength one month after liver transplantation. Beyond nutrition, two studies of neuromuscular electrical stimulation showed that stimulating the quadriceps significantly reduced muscle wasting, in one case even implying systemic benefits, while postoperative ghrelin administration reduced loss of erector spinae muscle after oesophagectomy. The evidence base remains limited by small samples and short follow-up, but the direction of effect is promising.

To give the field a common framework, the authors propose a formal concept they call perioperative muscle wasting, or POMW, defined as acute skeletal muscle loss occurring within six weeks of surgery. The threshold is deliberately pragmatic: it aligns with the late postoperative phase, during which patients remain catabolic and functionally impaired, and it coincides with the routine outpatient review that most major surgery patients attend. The authors argue that existing consensus definitions of sarcopenia, developed primarily for older adults by the European and Asian working groups and more recently by the Global Leadership Initiative in Sarcopenia, do not adequately capture the distinctive, rapid, surgery-driven process seen in often younger and fitter patients. A dedicated definition, they contend, would enable standardised measurement, earlier identification and properly powered intervention trials.

The broader message is that muscle health has been a blind spot in perioperative medicine. Enhanced Recovery After Surgery protocols, now standard for most elective major abdominal operations, emphasise early mobilisation and nutrition, yet significant wasting persists even under these regimes. The authors call for routine objective assessment of muscle, whether through CT-derived skeletal muscle index or simple grip strength testing, to be woven into perioperative pathways, alongside targeted multimodal interventions including prehabilitation, even in patients without pre-existing sarcopenia. As surgical and anaesthetic advances allow ever greater numbers of older adults to undergo major operations, the scale of the problem is set to grow. What this analysis makes clear is that the muscle lost in the days after surgery is not an inevitable footnote of recovery but a modifiable, and until now under-recognised, determinant of how well, and how long, patients live afterward.

Subject of Research: Perioperative muscle wasting following major abdominal surgery

Article Title: A Systematic Review and Meta‐Analysis of Perioperative Muscle Wasting Following Major Abdominal Surgery

Article References: Reynolds, A., George, N. M., Papadopoulou, A., & Creagh‐Brown, B. (2026). A Systematic Review and Meta‐Analysis of Perioperative Muscle Wasting Following Major Abdominal Surgery. Journal of Cachexia, Sarcopenia and Muscle, 17(5), Article e70379. https://doi.org/10.1002/jcsm.70379

Image Credits: AI Generated

DOI: 10.1002/jcsm.70379

Keywords: perioperative muscle wasting, sarcopenia, meta-analysis, abdominal surgery, muscle catabolism, handgrip strength, CT imaging, immunonutrition, enhanced recovery, surgical outcomes, Systematic, Review

The clinical context explains why timing matters so much. Large tumours of the oral cavity often leave what surgeons call volume defects, gaps in tissue that must be reconstructed with flap transfers, in which a segment of tissue, sometimes with its own blood supply, is moved to rebuild the affected area. After such operations, patients cannot eat normally while the wounds and swallowing musculature heal. Roughly 60 percent of head and neck cancer patients are already malnourished at presentation, and poor nutrition is an independent risk factor for surgical complications, morbidity and mortality. Every additional day of fasting therefore compounds an existing problem, deepening the metabolic stress that major surgery already imposes on the body.

Enhanced recovery after surgery, or ERAS, is the modern framework designed to counter that stress. These multimodal perioperative pathways combine early mobilisation, standardised anaesthetic and analgesic regimens, and careful nutritional optimisation, and they have been shown to shorten hospital stays and reduce costs. A central ERAS principle is avoiding prolonged fasting: solids are permitted up to six hours before anaesthesia, and fluids, including carbohydrate-loading drinks, up to two hours before. The ERAS Society consensus guidelines for head and neck surgery recommend that postoperative tube feeding should begin within 24 hours of surgery in patients who cannot yet tolerate oral intake. The most recent guidance from ESPEN, the European Society of Parenteral and Enteral Nutrition, goes further, stating that oral or tube feeding should start as soon as possible within the first few hours after surgery in conscious and haemodynamically stable patients.

The physiological rationale is well established. Prolonged preoperative fasting raises the risk of hyperglycaemia, metabolic stress and insulin resistance, the hallmark of the catabolic response to injury. Carbohydrate loading before surgery has been shown to blunt postoperative insulin resistance, reduce protein and nitrogen losses, improve muscle function and shorten length of stay. Early postoperative nutrition works in the same direction, limiting nitrogen and muscle loss during the critical healing window. Evidence from gastrointestinal surgery, where most of this research has been conducted, has found no benefit to keeping patients nil-by-mouth, and a Cochrane review concluded that early enteral nutrition reduced hospital stay by almost two days, with no differences in complications, including pneumonia, and only weak evidence of increased vomiting.

What remained unclear was whether these findings translate to head and neck flap surgery, where the airway, the swallow and a freshly transplanted flap all sit in close proximity. Few studies have examined the timing of tube feeding in this population, and a gap existed specifically around feeding earlier within the 24-hour window, including on the same day as surgery. The UCLH team, led by head and neck dietitian Florence Cook together with oral and maxillofacial surgeons and perioperative medicine consultants, set out to close that gap using the Plan-Do-Study-Act cycle, the four-stage improvement model, borrowed from industrial engineering, in which a change is planned, tested, studied and then adapted or adopted.

The planning stage revealed both an opportunity and a hidden inefficiency. Although the unit’s existing ERAS protocol already required feeding within 24 hours, the usual practice was to wait until the morning surgical review before commencing feeds. Discussions among stakeholders noted that operating finish times had improved, with midnight finishes now uncommon, making same-day feeding more feasible. Patient and public involvement feedback added that earlier feeding might support the energy levels patients need to mobilise the next day. The team also spotted that many patients were being sent for a chest x-ray to confirm nasogastric tube position before anyone attempted a pH aspirate test, contrary to national guidance that specifies pH testing first. Five of seven consultants agreed to trial early enteral nutrition; two declined, citing concerns about the risk-benefit ratio and nausea or vomiting. High-risk patients, such as those at risk of vomiting or delayed gastric emptying, were excluded at the operating surgeon’s discretion.

The protocol that emerged after three rounds of revision was deliberately conservative in one respect: the feed itself did not change. Patients received the established starter regimen, a 1.5 kcal/ml standard polymeric formula beginning at 20 ml per hour and increasing in 30 ml per hour steps as long as gastric aspirates stayed below 200 ml, with target rates scaled to body weight. A pre-written electronic record template ensured feeding instructions were consistent. The protocol was approved through clinical governance and rolled out on 27 May 2025, with prospective data collected over six months on fasting times, nutritional intake, complications graded by the Clavien-Dindo system, length of stay and weight change.

The results were striking. Of 45 included patients, 23 received early enteral nutrition and 22 received usual care. The early group’s median perioperative fasting time was 0.7 days compared with 1.3 days in the usual group, and feeding began a median of 4.3 hours after surgery versus 18.5 hours, differences that were highly statistically significant. Within the first 24 hours, the early group received a median of 215 ml of feed, delivering 322.5 kcal and 13.5 g of protein, while the usual-care group received nothing. Weight loss at discharge was also markedly lower in the early group, a median of 1 percent versus 5.6 percent. Crucially, safety signals were reassuring: there were no significant differences in Clavien-Dindo complications of grade three or above, in vomiting during the first 24 or 72 hours, or in gastric aspirates. Length of stay was similar between groups, and 96 percent of all patients met the ERAS target of feeding within 24 hours, an adherence rate higher than reported in previous studies.

The authors are careful about what these numbers can and cannot show. The project was a non-randomised, single-centre quality improvement exercise with a small sample and a short timeframe, so causation cannot be established and the findings may not generalise to every unit. Six patients recommended for early feeding did not receive it, for reasons including an immediate return to theatre and displaced feeding tubes, and the usual-care group contained more sarcoma cases. Even so, the pattern aligns with a growing international literature: a Japanese before-and-after study found early feeding on postoperative day one was safe and feasible without increased complications, and a randomised trial of feeding started during the operation itself reported no excess adverse events or flap failure, with some indication of enhanced wound regeneration.

The practical consequences of the project extend beyond the feeding schedule. In the Act phase of the cycle, the findings were presented to the wider surgical team, who agreed to establish early enteral nutrition as an option in the local ERAS protocol. The audit also exposed the overuse of chest x-rays for tube position checking: only 16 percent of patients had a pH aspirate attempted first, and the early-feeding group needed fewer x-rays overall, 53 versus 73, prompting further improvement cycles. The team now calls for high-quality randomised trials to confirm the safety and potential metabolic benefits of very early feeding in head and neck surgery, and for a mapping exercise of current practice, noting that as fast-track protocols become usual care, such trials may become difficult to run. For now, the message for patients facing flap reconstruction is a simple one: the era of waiting until the morning after surgery for the first calories may be coming to an end.

Subject of Research: Timing of early enteral nutrition after reconstructive head and neck flap surgery

Article Title: Early enteral feeding following flap surgery for head and neck defects: a quality improvement project using the Plan-Do-Study-Act cycle

Article References: Cook, F., Niemann, A., Ambler, G., Sahovaler, A., & Ward, P. (2026). Early enteral feeding following flap surgery for head and neck defects: a quality improvement project using the Plan-Do-Study-Act cycle. Supportive Care in Cancer, 34(10), Article 1008. https://doi.org/10.1007/s00520-026-11231-7

Image Credits: AI Generated

DOI: 10.1007/s00520-026-11231-7

Keywords: head and neck cancer, flap reconstruction, enteral nutrition, ERAS, enhanced recovery, quality improvement, Plan-Do-Study-Act, nasogastric feeding, perioperative nutrition, fasting, Clavien-Dindo complications, Supportive Care in Cancer

The retrospective analysis covered 263 consecutive patients operated on between November 2022 and December 2023. Of these, 146 patients — 55.5 percent — were discharged on post-operative day one, or POD1 in the shorthand of surgical teams. The number is striking because early discharge after craniotomy remains rare in routine neurosurgical practice globally, even though evidence has been accumulating for years that many post-operative complications reveal themselves within hours rather than days of surgery. Southampton has been quietly refining its early discharge strategy since 2006, and the pathway evaluated in this study is the product of nearly two decades of institutional experience.

The safety signal is the core of the story. Across the entire cohort, 8.0 percent of patients were readmitted to hospital unplanned within 30 days of discharge. Among those sent home on day one, the figure was almost identical at 7.5 percent. Statistically, the team found no significant association between early discharge and readmission, with an odds ratio of 0.87 and a confidence interval that comfortably spans unity. In other words, going home quickly did not make patients more likely to bounce back through the emergency department door. Mean time to readmission was 9.9 days in the early discharge group, suggesting problems, when they emerged, did so on a timeline largely independent of when patients left hospital.

The study also measured something more revealing than readmission alone: cumulative hospital days within 30 days of surgery. Patients discharged on POD1 accumulated a mean of just 1.0 hospital day, compared with 7.0 days among those requiring prolonged admission. This metric matters because it captures whether savings from early discharge are simply eaten up by later readmissions. In Southampton’s data, they were not. The one-day cohort occasionally did return — a small number needed stays averaging 5.4 days when they did — but the arithmetic still came out overwhelmingly in favour of getting patients home.

The pathway itself is a structured blend of pre-operative selection and same-day logistics. Candidates for early discharge needed good baseline functional status, no major medical frailty, an anticipated uncomplicated recovery, and the ability to mobilise safely. Final eligibility demanded four checkpoints: completion of a post-operative MRI, clearance from physiotherapy and occupational therapy, a stable neurological examination, and overall medical fitness. Patients left with a printed discharge summary, written instructions on warning signs after craniotomy, verbal briefing from ward nurses, and a direct phone line to the neuro-oncology clinical nurse specialist. Follow-up happened through a telephone clinic once histopathology results were available, and the team cross-checked regional referral systems and contacted peripheral hospitals by phone to catch readmissions anywhere in the network.

What stopped the other patients from going home early? The answer, overwhelmingly, was what happened in the immediate hours after surgery. Post-operative adverse events reduced the odds of POD1 discharge by 82 percent, and new or worsened neurological deficits — affecting movement, speech, sensation, vision or cognition — reduced them by 95 percent. Dysphasia was the most common deficit among those with prolonged admissions. Diabetes mellitus was the only pre-operative factor that significantly predicted a longer stay, cutting the odds of early discharge by more than half, though interestingly, peri-operative corticosteroid use in diabetic patients showed no link to discharge timing, and none of the readmitted patients came back with diabetes-related complications. The authors suggest the diabetes finding reflects clinical caution rather than genuine metabolic risk.

On the readmission side, one anatomical factor stood out: tumours in eloquent brain regions — areas controlling speech, movement or other critical functions — tripled the odds of an unplanned return to hospital, with an odds ratio of 3.35. The pattern extended to the reasons for those returns. Patients with eloquent-region tumours were most often readmitted with seizures, while those with tumours elsewhere mostly came back with weakness. The implication is sobering: even when surgery near functional brain areas goes smoothly and patients pass all discharge criteria, they carry a heightened risk of delayed neurological deterioration that only shows up after they are home. Targeted monitoring for this subgroup could be the next logical refinement of the pathway.

Some associations in the data resist easy explanation and the authors urge caution. Higher World Health Organization tumour grade and IDH wildtype status were both linked to a greater likelihood of early discharge, a counterintuitive result the team attributes to unmeasured confounding or selection effects rather than any biological mechanism. Posterior fossa tumours, located at the base of the skull near brainstem structures, also proved difficult: only nine of 25 such patients achieved POD1 discharge, and the rest averaged eight days in hospital. Meanwhile, the absence of a significant link between WHO Performance Status and discharge timing likely reflects the fact that patients with poor functional status were screened out of the pathway before the analysis even began.

Not every barrier to early discharge was medical. Among patients with no adverse events, no deficits and no imaging delays, prolonged admission was mostly attributable to waiting for physiotherapy and occupational therapy clearance — an operational bottleneck rather than a clinical one. Delayed post-operative MRI, which in principle should gate same-day discharge, affected only five patients in the entire cohort, with 98.1 percent of scans completed within 24 hours. The lesson for hospitals hoping to copy the model is that early discharge is as much a systems-engineering problem as a surgical one: it requires allied health assessment, imaging capacity and telephone follow-up infrastructure to move in lockstep with the operating theatre.

The limitations of the study are real. It is retrospective, so patients were never randomly assigned to early or prolonged discharge, and the 55.5 percent who went home on day one were by definition a selected, healthier subgroup. Only 21 readmission events occurred, yielding wide confidence intervals, and the analyses were univariable, leaving open the possibility of residual confounding. The authors do not claim equivalence between discharge strategies; they claim something narrower and more defensible — that in carefully chosen patients, structured day-one discharge is achievable without an observed rise in short-term readmission, and that the barriers to it are identifiable and, in many cases, modifiable. As neuro-oncology caseloads grow and hospital beds become scarcer, the ability to safely compress recovery into 24 hours offers a rare win on three fronts at once: better patient flow, lower cost, and the chance for people facing a life-limiting diagnosis to heal where most of them would prefer to be — at home.

Subject of Research: Feasibility and safety of post-operative day one discharge after craniotomy for brain tumour resection

Article Title: Post-operative day one discharge following craniotomy for tumour resection

Article References: Yogeswaran, K., Ewbank, F., Khoo, R., O’flaherty, D., Islam, M., Kaldas, A., Zafar, A., Durnford, A., Grundy, P., & Roach, J. (2026). Post-operative day one discharge following craniotomy for tumour resection. Journal of Neuro-Oncology, 179(3), Article 99. https://doi.org/10.1007/s11060-026-05790-2

Image Credits: AI Generated

DOI: 10.1007/s11060-026-05790-2

Keywords: craniotomy, brain tumour, neuro-oncology, early discharge, readmission, enhanced recovery, length of stay, neurosurgery, eloquent cortex, POD1 discharge, Post-operative, discharge