Enhanced Recovery After Surgery: The Future of Improving Surgical Care
Section snippets
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
References (139)
Multimodal approach to control postoperative pathophysiology and rehabilitation
Br J Anaesth
(1997)- et al.
Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials
J Gastrointest Surg
(2009) - et al.
Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection
Clin Nutr
(2005) - et al.
A comparison in five European centres of case mix, clinical management and outcomes following either conventional or fast-track perioperative care in colorectal surgery
Clin Nutr
(2005) - et al.
Enhanced recovery programs reduce complications after colorectal surgery
Clin Nutr Suppl
(2008) - et al.
In 1995 a correlation between malnutrition and poor outcome in critically ill patients still exists
Nutrition
(1996) - et al.
Prevalence of malnutrition in nonsurgical hospitalized patients and its association with disease complications
Am J Clin Nutr
(1997) - et al.
Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial
Lancet
(2002) - et al.
Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty
Lancet
(1996) - et al.
Methods for decreasing postoperative gut dysmotility
Lancet Oncol
(2003)
The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery preserves skeletal muscle mass postoperatively–a randomised clinical trial
Clin Nutr
Is urinary drainage necessary during continuous epidural analgesia after colonic resection?
Reg Anesth Pain Med
Early oral feeding after elective abdominal surgery–what are the issues?
Nutrition
Multimodal strategies to improve surgical outcome
Am J Surg
Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis
J Gastrointest Surg
To eat or not to eat: facilitating early oral intake after elective colonic surgery in the Netherlands
Clin Nutr
ESPEN Guidelines on Parenteral Nutrition: surgery
Clin Nutr
ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation
Clin Nutr
ESPEN guidelines on parenteral nutrition: surgery
Clin Nutr
Laparoscopic versus open colorectal resection for cancer: a meta-analysis of results of randomized controlled trials on recurrence
Eur J Surg Oncol
The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer
Colorectal Dis
Fast-track vs standard care in colorectal surgery: a meta-analysis update
Int J Colorectal Dis
Enhanced recovery in colorectal resections: a systematic review and meta-analysis
Colorectal Dis
Consensus review of optimal perioperative care in colorectal surgery: enhanced recovery after surgery (ERAS) Group recommendations
Arch Surg
Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme.
Br J Surg
‘Fast track’ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery
Br J Surg
Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries
BMJ
Patterns in current anaesthesiologic perioperative practice for colonic resections. A survey in 5 Northern-European countries
Acta Anaesthesiol Scand
A protocol is not enough to implement an enhanced recovery programme for colorectal resection
Br J Surg
An enhanced-recovery protocol improves outcome after colorectal resection already during the first year: a single-center experience in 168 consecutive patients
Dis Colon Rectum
Determinants of outcome after colorectal resection within an enhanced recovery programme
Br J Surg
Physiologic effects of bowel preparation
Dis Colon Rectum
Fluid, electrolytes and nutrition: physiological and clinical aspects
Proc Nutr Soc
Fluid overload and surgical outcome: another piece in the jigsaw
Ann Surg
Respiratory muscle strength and maximal voluntary ventilation in undernourished patients
Am Rev Respir Dis
A qualitative evaluation of patients' experiences of an enhanced recovery programme for colorectal cancer.
Colorectal Dis
Effect of preoperative suggestion on postoperative gastrointestinal motility
West J Med
Reduction of postoperative pain by encouragement and instruction of patients. A study of doctor-patient rapport
N Engl J Med
Mechanical bowel preparation for elective colorectal surgery
Cochrane Database Syst Rev
Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection
Br J Surg
Current understanding of patients' attitudes toward and preparation for anesthesia: a review
Anesth Analg
The importance of patient expectations in predicting functional outcomes after total joint arthroplasty
J Rheumatol
What is the role of mechanical bowel preparation in patients undergoing colorectal surgery?
Dis Colon Rectum
Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study
Arch Surg
Malnutrition in the hospital: age as a special risk factor
Pflege Z
Meta-analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation
Br J Surg
Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics
Br J Surg
Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial
JAMA
Prophylactic anastomotic drainage for colorectal surgery
Cochrane Database Syst Rev
Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group
N Engl J Med
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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.