Table 2.

Example of a RECOvER Checklist

	Item	Recommendation	Page
Title
Title	1	Gum chewing improves recovery of gut function within an enhanced recovery protocol for hepatic resection	1
Introduction
Background	2	Whether gum chewing offers additional benefit for functional gut recovery after liver resection beyond other enhanced recovery elements is uncertain	3
Guidelines	3	Melloul E, et al. World J Surg 2016 Oct;40(10):2425–2440	3
Outcomes	4	Primary outcome Time to first bowel movement after surgery Secondary outcomes Incidence of postoperative ileus, length of stay, incidence of postoperative emesis	3
Methods
IRB approval	5	General Hospital IRB #123456	4
Study design	6	Retrospective cohort study	4
Setting	7	Single institution, community-based academic hospital with stable group of surgeons during the study period	5
Timing	8	Patients included from March 2013–May 2015, events assessed daily from surgery to discharge, all patients followed until 2-week postoperative visit	5
Participants	9	Inclusion criteria 18+ years old, participating in the enhanced recovery protocol, undergoing hepatic resection, not admitted to ICU postoperatively Exclusion criteria Age <18, unable or unwilling to participate in enhanced recovery protocol, other surgical procedures, ICU admission	5
Enhanced recovery protocol	10	enhanced recovery protocol was initiated in March 2012	6
	11	Provide a flow diagram or table through the continuum of care detailing the enhanced recovery protocol including the following elements:	7
		(a) Preadmission patient education regarding the protocol  All patients receive an informational packet, watch a 10-minute video, and attend a 1-h preoperative educational class
		(b) Preadmission screening and optimization for nutritional deficiency, frailty, tobacco cessation, and ethanol use  Patients are screened for nutritional deficiency using the NRS scoring system, frailty using the scoring model published by Kim et al. and referred preoperatively for tobacco and ethanol counseling
		(c) Fasting and carbohydrate loading guidelines  Normal diet until midnight, clear liquids until 2 h before surgery, 300-ml isotonic beverage containing a total of 50 grams of maltodextrin finished 2 h before surgery
		(d) Preemptive analgesia (dose, route, timing)  300 mg celecoxib, 500 mg acetaminophen both oral given in pre-op
		(e) Anti-emetic prophylaxis (dose, route, timing)  4 mg ondansetron and 8 mg dexamethasone given intravenously prior to emergence
		(f) Intraoperative fluid management strategy  Esophageal Doppler monitoring of stroke volume variation
		(g) Types, doses, and routes of anesthetics administered  Continuous propofol, intravenous lidocaine, and low-dose ketamine infusion, no volatile anesthesia
		(h) Patient warming strategy  Forced warm air and intravenous fluid warmer
		(i) Management of postoperative fluids  0.5 ml/kg/h × 6 h
		(j) Postoperative analgesia and anti-emetic plans  0.25% liposomal bupivacaine wound infiltration, 500 mg acetaminophen and 600 mg ibuprofen every 6 h orally, 4 mg ondansetron every 6 h intravenously as needed
		(k) Plan for opioid minimization  First-line analgesic 25 mg tramadol every 6 h orally as needed, increased to 50 mg tramadol if needed, followed by addition of IV lidocaine infusion if needed, followed by pregabalin 100–300 mg every 8 h if needed, followed by 5–10 mg oral oxycodone for breakthrough pain
		(l) Drain and line management  No routine wound drains, Foley catheter removed in OR
		(m) Early mobilization strategy  Patients ambulate to chair in PACU, ambulate × 3 starting postoperative day 0, out of bed all meals, out of bed 8 h per day starting postoperative day 1
		(n) Postoperative diet and bowel regimen management  Clear liquids post-op day 0, regular diet beginning post-op day 1, standing MiraLax daily beginning post-op day 0
		(o) Criteria for discharge  Tolerating at least 2000 ml po daily, voiding independently, pain well controlled on oral medication, ambulating in hallways
		(p) Tracking of post-discharge outcomes  Patients contacted by office through daily email survey
Enhanced recovery auditing	12	All enhanced recovery elements charted by physician assistant into Enhanced Recovery Interactive Audit System (EIAS)	8
Outcomes	13	(a) Primary outcome Bowel movement as documented by RN Secondary outcomes Per patient report as collected by physician assistant interview	9
		(b) Clinical outcomes
PROs	14	European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (J Clin Epidemiol 2014)	9
Results
Patient population	15	See Figure 1 (or similar)	10
		(a) See Table 1 (or similar)	11
		(b) Participants with missing data indicated in Table 1 footnotes	11
Enhanced recovery compliance	16	Table II provides enhanced recovery compliance for the gum-chewing versus non-gum-chewing groups for 15 metrics from the enhanced recovery pathway	12
Correlations	17	Table III provides logistic regression examining gum chewing with respect to primary and secondary outcomes	13
Discussion
Context	18	Study suggests that gum chewing has additional benefits to standard bowel regimen, early feeding, and laxative guidelines for promoting early return of gut function	15
Limitations	19	Not a prospective study, did not have sufficient power to subdivide patients by indication for hepatic resection, poor compliance among the cohort with respect to early mobilization and termination of intravenous fluids	16
Other information
Funding	20	Support from departmental grant	2

RECOvER Reporting on ERAS Compliance, Outcomes, and Elements Research, IRB Institutional Review Board, ICU intensive care unit, NRS nutrition risk screening, PACU post-anesthesia care unit