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Enhanced Recovery After Surgery: an update

Freek Gillissen, Jos
29 July, 2013  
Enhanced Recovery After Surgery (ERAS) programmes aim at reduced morbidity, earlier recovery and reduced hospital stay in patients undergoing major abdominal surgery. Key elements are discussed
Freek Gillissen
José Maessen
Kees Dejong
Maarten von Meyenfeldt
Maastricht University Medical Centre,
Maastricht, The Netherlands
The aim of this Enhanced Recovery After Surgery (ERAS) programme is to promote early recovery from major surgical trauma by reducing the stress of the surgical procedure and the loss of functional capacity.(1,2) These benefits, in turn, should result in a shorter recovery time from colorectal surgery and, consequently, in a reduction of length of hospital stay (LOS).(3)
Recovery, LOS and morbidity after surgery have been greatly improved by the introduction of a range of perioperative interventions, proven to reduce the stress of the surgical procedure and the loss of functional capacity.(1–4) These evidence-based interventions are combined within a standardised protocol, the ERAS programme.(2)  The introduction of this programme in everyday practice results in reduced rates of morbidity, earlier recovery and shorter LOS. Several versions of ERAS programmes have been published over the years within different fields of abdominal surgery. This article provides an overview of the latest insights and knowledge about protocol care elements reducing morbidity and promoting early recovery after colorectal surgery.
ERAS programme 
In 2001, the ERAS society was established, representing five northern European centres (Maastricht University Medical Centre, Maastricht, The Netherlands; University Hospital Northern Norway, Tromsø, Norway; Karolinska Institute at Ersta Hospital, Stockholm, Sweden; The Royal Infirmary, Edinburgh, UK; Hvidovre University Hospital, Copenhagen, Denmark). The ERAS group proposed an evidence-based modification of the multimodal fast-track programme pioneered by Kehlet. A core protocol of more than 22 perioperative care elements was developed (Figure 1). This protocol has been documented in detail elsewhere and includes, amongst others, preoperative counseling, no bowel preparation, no preoperative oral fluid restriction, carbohydrate loading up to two hours before surgery, perioperative fluid restriction, early mobilisation and early oral diet and use of nutritional supplements.(1)
The single ERAS protocol care elements are based on best available scientific evidence and the combination of the different care elements leads to strong evidence-based perioperative care.
Key elements of the ERAS programme
Preoperative bowel preparation
Mechanical bowel preparation is distressing for patients, can lead to dehydration and is associated with prolonged ileus after colonic surgery.(5)  There is also a tendency towards an increase of postoperative complications after bowel cleaning. Literature has shown that open, as well as laparoscopic abdominal, surgery might be undertaken safely without preoperative mechanical bowel preparation. There is no clear evidence about the use of bowel cleansing in combination with a low anterior resection. A Cochrane review showed no increased leak rate in patients without bowel cleansing, but a more recent study showed that bowel preparation in ultralow rectal anastomoses protects against anastomotic leaks.(6,7) 
Preoperative fasting and carbohydrate loading
Fasting from midnight has been standard practice to reduce the risk of pulmonary aspiration in elective surgery. However, there is no scientific evidence to support this dogma. A Cochrane review shows that a preoperative fasting period of two hours does not increase any complication rates. Therefore, anaesthesia societies now recommend intake of clear fluids until two hours before surgery and solid food until six hours before surgery.(8) Patients with uncomplicated type 2 diabetes and obese patients are not excluded from these regimens, as they can have normal gastric emptying.(9) Providing a clear carbohydrate-rich beverage two to three hours before surgery reduces preoperative thirst, hunger and anxiety and reduces postoperative insulin resistance.(10)  Scientific evidence suggests that diabetic patients have the same gastric-emptying characteristics as non-diabetic patients and have no increased aspiration rates after preoperative carbohydrate loading.(9) The ultimate goal of these measures is that by being in an anabolic state, patients have less postoperative nitrogen and protein loss as well as better maintained lean body mass and muscle strength.   
Antimicrobial prophylaxis and skin preparation 
Infectious complications in colorectal surgery can be minimised by the use of prophylactic antibiotics against both aerobes and anaerobes, with the first dose being administered intravenously one hour prior to skin incision. A single dose is as effective as multidose regimens, but repeated doses during prolonged procedures (more than three hours) may be beneficial.(11) If hair removal is necessary before surgery, hair clipping is associated with fewer surgical-site infections than is shaving with razors.(12) 
Preventing intraoperative hypothermia   
Normal body homeostasis is maintained if normothermia is kept during surgery. A rise in complications (wound infections, morbid cardiac events and bleeding) has been shown in patients becoming hypothermic (below 36°C). There is also a higher risk of shivering in patients with hypothermia, which increases oxygen consumption at an important time in recovery.(13)  Patients report lower pain scores if they are normothermic. As it is easier to maintain the patients’ temperature rather than raising it after a drop in temperature, patients should be actively warmed during surgery using a Bair Hugger®. 
Prevention of postoperative ileus
Postoperative ileus is a major cause of delayed recovery and prolonged LOS after abdominal surgery. There is no known effective prokinetic agent to treat postoperative ileus, but there are several successful interventions to prevent postoperative ileus. The use of mid-thoracic epidural analgesia is a highly effective method to avoid postoperative ileus compared with the use of intravenous opioid analgesia.(14) Prevention of fluid overloading during and after surgery leads to an improved gastrointestinal function. 
The administration of oral laxatives such as magnesium oxide promotes the postoperative bowel function and thereby shortens the duration of a postoperative ileum.(15) The same holds true for the use of coffee and chewing gum after surgery.(16) A recent study showed that coffee consumption after colectomy is safe, and it is associated with a reduced time to first bowel action.(17) Laparoscopic surgery is also associated with a faster return of bowel function compared with open surgery.(18) 
Early nutrition
Recent evidence shows that the presence of low muscle mass and cachexia is predictive of complications and a higher LOS after colonic surgery.(19)  By administering carbohydrate-rich beverages preoperatively and promoting early postoperative nutrition, nutritional status may not be as critical as in more traditional surgical care. Normal food is the basis for nutrition before and after surgery. It has been demonstrated that early resumption of solid nutrition is feasible and safe.
Patients can drink immediately after surgery and, if tolerated, can eat solid food starting from the day of surgery onwards. Although there is an increased risk of vomiting postoperatively, early oral uptake is not associated with an increased risk of anastomotic dehiscence. In this way, patients consume 
1200–1500kcal/day, while this intake increases if oral nutritional supplements (ONS) are used from the day of surgery until at least the fourth postoperative day, thus achieving a higher intake of energy and proteins during the early postoperative phase.(20) 
Early mobilisation
Early mobilisation reduces insulin resistance and muscle loss and the risk of thromboembolism. Mobilising patients early increases muscle strength, pulmonary function and tissue oxygenation. It is essential that patients be stimulated to get out of bed on the day of surgery, and stay out of bed for a couple of hours on the first postoperative day.(18)  By avoiding abdominal drains and urine catheters, patients are mobilised more easily. Failure to mobilise on the first postoperative day may be due to inadequate control of pain, continued intravenous administration of fluids (rather than oral fluid intake) or patient motivation. 
Clinical outcomes 
Several studies have shown that there is an association between the ERAS programme and earlier recovery and discharge after colonic resection compared with traditional perioperative care. Two systematic reviews reported the positive effect of perioperative treatment with the ERAS protocol on morbidity, recovery and LOS,(3,21) while mortality and readmissions were not increased in patients undergoing surgery within the ERAS programme compared with traditional care.
Implications on health economics 
There is little publication available yet about the impact of the ERAS programme after major abdominal surgery on health economics and quality of life. A 2011 meta analysis of randomised, controlled trials shows that treating patients within the ERAS programme is more cost effective than treating patients using traditional care.(22)  One recent Dutch study, however, showed no significant differences between patients treated within fast track surgery and standard care.(18) Thus, although no significant results have been shown yet, it is reasonable to expect in the near future data supporting the cost effectiveness of the ERAS programme as it demonstrates the reduction of the number of postoperative complications and the median LOS.
The introduction of an ERAS programme results in drastic changes within major abdominal surgery. Dogmas within the perioperative care are abandoned and patients recover earlier and are discharged earlier. Although evidence in literature for some protocol elements is not as solid as for other elements, the key to a successful early recovery of patients after abdominal surgery is the multimodal aspect of the ERAS programme. Each and every element contributes to its success.
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