Enhanced Recovery after Surgery its relevance - Evidence Based

Dr. Deep Goel, FACS (USA), FRCS (England)
Director
Department of Surgical Gastro-oncology, Bariatric & Minimal
Access Surgery
Centre for Digestive and Liver Disease
BLK Super Specialty Hospital, New Delhi.
ERAS Protocols and Its Relevance
- Evidence Based

Disclosure
• Consultant and mentor- J & J
• Advisory consultant- Medtronics

Pub med Search
• Key words
– ERAS
– Enhance recovery
– Colon surgery
– Newer guidelines
– Colon cancer treatment
– Laparoscopic colonic surgery

Pub Med Search + Guidelines
+ Recommendations
• The European Society for Clinical Nutrition and
Metabolism
• The International Association for Surgical
Metabolism and Nutrition 2012
• American Society for Colon and Rectal Surgery
• World Journal of Surgery

N Engl J Med 270:825–827
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Intensive insulin therapy in the critically ill patients.
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patients undergoing colonic surgery: a randomized clinical trial (LAFA-study).
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The Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing major elective open
colorectal surgery: a meta-analysis of randomized controlled trials.

What is ERAS
• Stands for Enhanced Recovery after Surgery
• The immediate challenge to improve the quality of
surgical care by not discovering new knowledge but
by integrating what we already know
• Initiated by Professor Henrik Kehlete in 1990’s

Enhanced Recovery is ……
• Evidence-based clinical pathways
• Multidisciplinary in scope
• Outcome driven
• Better for patients
• Better for healthcare organizations
• “Complex” task to implement upto 20 elements

Recommendation's of ERAS Society
Based on quality of evidence
– High
– Moderate
– Low
– Very low
Recommendation's
– Strong recommendation- Means panel is confident that
desirable effects outweigh the undesirable effects
– Weak recommendation’s-Panel is less confident that
desirable effects outweigh undesirable effects.

Recommendations
• Pre-operative
• Intra operative
• Post operative

– Diminishes fear and anxiety
– Improve post-op recovery
– Quicken hospital discharge
– Improves wound healing and recovery after lap surgery
Evidence Low
Recommendation Strong
Pre-admission information, education
and counseling

Pre-operative Medical Optimization
• It is necessary
• Alcohol abuse
– wound and cardio pulmonary complications
• One month of abstinence improve results
Evidence Low to High

Pre-op Bowel Preparation
• Mechanical bowel preparation
– Causes dehydration
– Spillage of bowel contents
– Prolonged ileus
– Bowel preparation should be avoided
Evidence High

Pre-op Fasting & Carbohydrate
Treatment
• Clear and high carb liquid should be allowed
up to 2 hrs prior to surgery
• Solid food up to 6 hrs prior to surgery
Evidence Moderate

• Long acting sedative premedication should be avoided
within 12 hrs of surgery because it affects immediate
post-op recovery by impairing mobility and oral intake.
• Short acting anesthetic drugs combined with regional
anesthetic procedures like spinal anesthesia & field
blocks should be encouraged.
Evidence High
Pre-anesthetic Medication

Prophylaxis against Thrombo-Embolism
• The incidence of asymptomatic DVT in colorectal
surgery is 30% and fatal pulmonary embolism in 1%.
• All colorectal patients should receive mechanical
thrombo prophylaxis to reduce DVT.
• Use of LMWH reduces DVT and VTE.
Evidence High

Antimicrobial Prophylaxis
• IV antibiotics - 30-60 min before the incision
• Repeat doses during prolonged procedures
may be beneficial.
Evidence High

Standard Anesthesia Protocol
• Tri-modal approach
– A regional anesthesia block used in addition to GA
• Reduced post-op use of opiates
• Rapid awakening from anesthesia
• Early enteral intake and mobilization
• Use of epidural analgesia is superior to opioids

Post-op Nausea and Vomiting (PONV)
• Regional anesthesia technique like epidural TAP block
has reduced the opiates use and thus PONV.
• Use of NSAIDS as an alternative to opiate is well
established
Evidence Low

Laparoscopy and Modifications of
Surgical Access
• Laparoscopic surgery for colonic resection is
recommended if expertise is available

Naso-gastric Intubation
• Post operative NG should not be used routinely
• NG tube should be removed before reversal of
anesthesia.
Evidence High

Preventing Intra-op Hypothermia
• Hypothermia (<36 degree C) can cause cardiac
events, bleeding and wound infection.
• Normothermia to be maintained with
warming device and warm IV fluid.
Evidence High

Peri-operative Fluid Management
• Fluid overload can cause bowel and lung
edema.
• Fluid shift should be minimized by
– Avoid bowel preparation
– Maintain hydration upto 2 hrs before surgery
– Avoid blood loss
Evidence High

Drainage of Peritoneal Cavity after
Colonic Resection
• Routine drainage is discouraged
Evidence High

Urinary Drainage
• Routine transurethral bladder drainage for 1-2
days is recommended.
• Catheter should be removed early.
Evidence Low

Post-operative Recommendation
• Lap colonic resection leads faster return of bowel
function.
• Fluid overload to be avoided to prevent ileus
• Peri-operative chewing gum reduces ileus.
Evidence High

Post-operative Analgesia
• Optimal analgesia should give
- Good pain relief
- Allow early mobilization
- Early return of gut function and feeding
Evidence High

Post-op Analgesia
• Low dose epidural local anesthetic with short
acting opiates gives good analgesia decreases
risk of hypotension due to sympathetic block.
Evidence High

Peri-operative Nutritional Care
• Under ERAS protocol early enteral feeding
– Reduce risk of infection
– Reduce hospital stay
– No anastomotic dehiscence
Evidence High

Peri-operative Nutritional Care
• Immuno-nutrition containing arginine,
glutamine, Omega-3 fatty acids are used.
Evidence Low
Recommendation Weak

Post-operative Control of Glucose
• Hyperglycemia is a risk factor for complication.
Patients with higher pre-op HBA1C level has more
complications.
• Control of hyperglycemia showed improved results
• ERAS protocol improves insulin action.
Evidence Moderate

Early Mobilization
• Reduce chest complication
• Counteract insulin resistance
• Improves muscle strength
Evidence Low

Audit
• Periodic auditing is a key element in ERAS
programme and improves quality of
healthcare.
Evidence Moderate

Outcomes of ERAS
• ERAS versus traditional peri-operative care
– Early recovery & discharge from hospital
– Morbidity
– Re-admission
– cost

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