Elsevier

Critical Care Clinics

Volume 26, Issue 3, July 2010, Pages 527-547
Critical Care Clinics

Enhanced Recovery After Surgery: The Future of Improving Surgical Care

https://doi.org/10.1016/j.ccc.2010.04.003Get rights and content

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History and philosophy of enhanced recovery after surgery

The main philosophy of the ERAS protocol is to reduce the metabolic stress caused by surgical trauma and at the same time support the return of functions that allow patients to get back to normal activities rapidly (Fig. 2).

The work by Henrik Kehlet in 19971 proposed a multimodal approach to perioperative care to achieve this goal. A couple of years later, the same group published a paper reporting median length of stay of 2 days following colonic resections using this philosophy.8 These were

Components of enhanced recovery after surgery

Fig. 3 depicts the various elements of the ERAS pathway, which are grouped according to the timing of intervention of these elements throughout the perioperative period. Although most of these elements are derived from high-quality evidence from published literature, some of the less studied elements of the ERAS pathway are based on common consensus review or derived from traditional-care settings.

The rationale7, 17, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39

Role of laparoscopy

Laparoscopic colorectal surgery has struggled to get wider acceptance in ERAS protocols because of its steep learning curve, concerns with oncological outcomes, and initial reports on port-site recurrence after curative resection. Several studies show that these reasons are unjustified and have reported individual advantages of minimally invasive surgery, such as reduced inflammatory response, insulin resistance, improved pulmonary function, early return of bowel function, mobilization, less

Evidence from other specialties

ERAS pathways have also shown positive outcomes, such as decreased length of stay and complications, in patients undergoing surgical procedures other than colorectal surgery, such as thoracic,104 vascular,105, 106 orthopedics, urology,107, 108, 109, 110 esophageal,111, 112 pancreatic,113, 114, 115 and liver116, 117 surgery. However, the evidence is limited and needs further evaluation in future prospective studies.

Costs and savings

Evidence presented for individual elements of the ERAS pathway in the perioperative period result in favorable outcomes without increasing readmission or mortality rates. Although factors, such as patients' fear or anxiety, preoperative organ dysfunction, surgical stress response, perioperative hypothermia, hypoxemia, nausea, vomiting, ileus, sleep disturbance, semi-starvation, nasogastric tubes, and drains and catheters, can delay recovery, ERAS addresses these factors by preoperative

Implementation: difficulties and solutions

The implementation of ERAS pathways, despite demonstration of advantages with regards to clinical outcomes, such as length of stay, complications, readmissions, or mortality, have been slow or have not been applied optimally in many centers.47, 126, 127 Even though individual elements of ERAS pathways are based on evidence-based principles that have been successfully implemented in dedicated centers and district general hospitals,128, 129, 130, 131, 132 critics argue that reported advantages in

Summary

In units where ERAS has been studied or implemented, the evidence shows marked improvements in patient care and outcome. ERAS results in substantially faster recovery of function and significantly fewer complications. Although there are no exact figures available, these improvements also represent economic benefits to the society. These improvements have been shown for patients undergoing elective colorectal surgery, and there are reports demonstrating similar improvements in many other types

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    Conflict of interest: D.N.L. and O.L. are members of the ERAS Group and have received research funding/honoraria/travel bursaries from Nutricia Clinical Care and Fresenius Kabi. O.L. is also the holder of a patent for a preoperative carbohydrate drink, licensed to Nutricia for manufacture. K.K.V. has no conflict of interest to declare.

    Funding: K.K.V. was supported by a research fellowship awarded by the Nottingham Digestive Diseases Centre NIHR Biomedical Research Unit.

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