Enhanced recovery after surgery protocols - compliance and variations in practice during routine colorectal surgery

Aim Although there are numerous studies on the efficacy of enhanced recovery after surgery (ERAS) protocols in reducing length of stay, the long‐term compliance to such protocols in routine clinical practice has not been well documented. The aim of this study was to review the published literature on compliance to ERAS in patients undergoing colorectal surgery in routine clinical practice. Method Medline, Embase and PubMed databases were searched to identify studies that focused on compliance to ERAS protocols during routine clinical practice. Fourteen studies fulfilled the inclusion criteria and a total of 19 perioperative ERAS modalities were identified across these studies. Results None of the studies used all 19 ERAS modalities within their ERAS protocols. Compliance to the various modalities varied considerably between studies and, in general, was poorest during the postoperative period. The use of epidural had the highest compliance (between 67 and 100%), whereas the use of transverse incisions (25%) had the lowest compliance. Length of stay in hospital ranged from 2 to 13 days. Higher compliance was associated with a reduced length of hospital stay. However, reduced length of hospital stay was associated with a high rate of readmission. Conclusion There is significant variation in the components of, as well as in compliance to, ERAS protocols in daily practice. This may contribute to the observed variation between the studies in length of hospital stay. A standardized and practically feasible ERAS protocol should be established in order to improve the implementation and optimal outcome.     

Enhanced recovery for colorectal surgery: Practical hints, results and future challenges

Enhanced recovery after surgery (ERAS) protocols are now achieving worldwide diffusion in both university and district hospitals with special interest in colorectal surgery. The optimization of the patient’s preoperative clinical conditions, the careful intraoperative administration of fluids and drugs and the postoperative encouragement to resume the normal physiological functions as early as possible has produced results in a large amounts of studies. These approaches successfully challenged long-standing and well-established perioperative managements and finally achieved the status of gold standard treatments for the perioperative management of uncomplicated colorectal surgery. Even more important, it seems that the clinical improvement of the patient’s clinical management through ERAS protocols is now reaching his best outcomes (length of stay of 4-6 d after the operation) and therefore any further measures add little to the results already established (i.e., the adjunct of laparoscopic surgery to ERAS). Still dedicated meetings and courses around the world are exploring new aspects including the improvement the preoperative nutrition status to provide the energy necessary to face the surgical stress, the preoperative individuation of special requirements that could be properly addressed before the date of surgery and therefore would reduce the number of unnecessary days spent in hospital once fully recovered (i.e., rehabilitation, social discharges), and finally the development of an important web of out-of-hours direct access in order to individuate alarm symptoms in those patients at risk of complications that could prompt an early readmission.     

加速康复外科在腰椎融合手术中的应用研究

目的 研究加速康复外科(enhanced recovery after surgery,ERAS)在脊柱外科腰椎融合手术中的应用效果.方法 对2015年1~8月于我科行腰椎融合手术且融合节段≤3个的236例病人进行前瞻性研究,根据病人意愿分为对照组(117例)及加速康复组(ERAS组,119例),分别对两组病人围手术期采取常规干预和ERAS干预.对比分析两组病人手术前后不同时间点的疼痛视觉模拟量表(visual ana-logue scale,VAS)评分、Oswestry功能障碍指数(Oswestry disfunction index,ODI)评分,以及阿片类药物使用情况、术后并发症、术后住院时间、术后1个月内再次住院率、病人治疗满意度等情况.结果 ERAS组在术后3 d内、出院时及术后1个月VAS评分均优于对照组(P<0.05),术后恶心呕吐的发生率显著小于对照组(P<0.05),阿片类药物在术后第1天和第2天使用量小于对照组(P<0.05),术后平均住院时间(4.9 d)与对照组(6.2 d)比较,差异有统计学意义(P<0.05).两组病例在术后1个月内再次住院率比较,差异无统计学意义(P=0.339).病人平均随访时间为(13.4±0.9)个月.两组末次随访的VAS评分(P=0.368)和ODI评分(P=0.251)比较,差异均无统计学意义.结论 实施ERAS可以在不影响腰椎融合手术病人再次住院率的情况下,缩短了病人术后住院时间、改善了病人术后疼痛、降低了术后并发症发生率及减少了阿片类药物的使用,值得在脊柱外科临床推广.     

Enhanced recovery after surgery: A clinical review of implementation across multiple surgical subspecialties

Enhanced recovery after surgery (ERAS) is a multimodal protocol applied towards perioperative patient care. ERAS programs are implemented by a multidisciplinary team centered around the patient, incorporating outpatient clinical staff, preoperative nurses, anesthesiologists, operative nurses, postoperative recovery staff, floor inpatient nurses, dieticians, physical therapists, social workers, and surgeons. Initial studies on perioperative care measures focused on cardiac surgery. Subsequently, the development of the ERAS Study Group in 2001 focused on colorectal surgery and postoperative outcome measures. Today, ERAS protocols have been implemented across many surgical subspecialties including: bariatric, breast, plastic, cardiac, colorectal, esophageal, head and neck, hepatic, gynecologic, neurosurgical, orthopedic, pancreatic, thoracic, and urologic surgery. The goal of ERAS programs is to promote rapid recovery as quantified by decreasing the length of hospital stay, complications, and cost of specific surgical interventions. In the setting of the opioid crisis in America, there is also an increasing focus on minimizing perioperative narcotic use. The purpose of this review is to compare ERAS protocols across surgical subspecialties, focusing on quantified metrics of improvement, and to provide a clear and concise summary of the literature in regards to current ERAS practices and success rates.     

快速康复外科理念在腹腔镜小肝癌治疗中的应用

目的:探讨快速康复外科(ERAS)理念应用于腹腔镜小肝癌切除术患者围手术期的临床价值。方法:分析2016年1月—2017年12月50例腹腔镜小肝癌切除术患者的临床资料,其中24例围手术期采用ERAS方案(ERAS组),26例围手术期采用传统方案(对照组)。比较两组患者相关临床指标。结果:两组患者术前临床资料具有可比性。与对照组比较,ERAS组术中出血量、手术时间均无统计学差异(均P0.05),术后肛门排气时间与住院时间明显缩短、住院总费用明显减少、并发症发生率均明显降低(均P0.05);ERAS组术后1、3、5d的Qo R-15恢复质量评分与C反应蛋白水平均明显优于对照组(均P0.05)。结论:腹腔镜小肝癌切除术患者围手术期应用ERAS理念可以有效的减轻手术创伤应激、缩短住院时间、降低住院费用、减少手术并发症,从而加快患者的康复。     

Enhanced recovery after surgery of patients undergoing radical cystectomy for bladder cancer

Radical cystectomy (RC) is the standard treatment for patients diagnosed with muscle invasive bladder cancer, but is associated with significant morbidity and long hospital stays. Enhanced recovery after surgery (ERAS) is based on a variety of interventions during the peri-treatment stage. It is designed to improve morbidity, enhance recovery, and reduce hospital stays after RC. The study provides an overview of the key elements of the ERAS protocol recommended for patients undergoing RC and directions for further research. We have analyzed the rationale for 15 key elements related to the ERAS protocol: preoperative patient counseling and education, preoperative medical optimization and nutrition, mechanical bowel preparation, preoperative fasting and carbohydrate loading, pre-anesthetic medication, thromboembolic prophylaxis, minimally invasive surgical approach, resection-site drainage, preventing intraoperative hypothermia, perioperative fluid management, perioperative analgesia, urinary drainage, prevention of postoperative ileus, nausea and vomiting, early oral feeding, and early mobilization. Several studies have shown that ERAS improves the recovery of RC patients. Evidence suggests that ERAS facilitates the recovery of RC patients. However, additional randomized controlled studies or large prospective studies are needed to demonstrate the effectiveness of ERAS in RC patients.     

Fast-track surgery - conditions and challenges in postsurgical treatment: a review of elements of translational research in enhanced recovery after surgery

Background: Enhanced recovery after surgery (ERAS) or fast-track surgery is a perioperative and postoperative care concept initiated in the early 1990s aiming to reduce the length of hospital stays following elective abdominal surgery. Twenty treatment items defined in the Consensus Guidelines established in 2009 were included in this concept. The success of ERAS depends highly on multidisciplinary teamwork and patient compliance. Several ERAS items and their impact on perioperative and postoperative care have recently been discussed. In this connection, translational research topics triggered increasing interest in ERAS and new impulses aimed at improving the ERAS concept. We thus reviewed the surgical literature to highlight the role of translational research items in ERAS. Methods: A literature search of Medline?, PubMed? and the Cochrane Database was performed. Two investigators independently reviewed the abstracts and appropriate articles were included in this review. Results: Articles have been selected. The advantages of the ERAS concept over conventional postoperative care were established by four meta-analyses and several reviews. But, due to the lack of standardization of the protocols, the level of evidence is still low. The implementation of ERAS into clinical practice is furthermore hampered by the poor compliance with ERAS protocols and remains a challenge for the future. Moreover, recent trials challenge the role of some ERAS items, e.g. epidural anesthesia. Translational research trials investigating stress, immune and inflammatory response after surgery, new analgesic concepts, goal-directed fluid therapy and new drugs and substances to improve the outcome of ERAS provide first promising data but still need to be integrated in the ERAS concept. Conclusion: The Consensus Guidelines for ERAS are subject to the constant evolution of treatment strategies and implementation of translational research findings. Improvement of the compliance with ERAS protocols in surgical clinics and updating of ERAS items taking into account recent findings in translational research may improve the outcomes of ERAS but remain a long-term challenge in surgery for the next years.     

快速康复外科在胰十二指肠切除术围术期管理中的应用价值

背景与目的：近年来,快速康复外科（ERAS）理念已在许多外科领域推广应用,并取得了显著成效。然而ERAS在胰十二指肠切除术（PD）围术期的应用仍然有限。本研究通过前瞻性临床分析,探讨ERAS在PD围术期管理中的应用价值。 方法：前瞻性连续收集2017年12月—2019年9月间中南大学湘雅医院胰腺外科收治的101例行PD患者的临床资料,其中32例采用ERAS临床路径进行围术期管理（ERAS组）,69例采用传统方法进行围术期管理（传统组）。比较两组患者的临床结局。 结果：与传统组比较,ERAS组的术中失血量明显较低（P<0.05）。此外,ERAS组术后血清白蛋白水平明显高于传统组,术后肛门排气时间、下床活动时间和术后住院时间明显短于传统组,住院费用明显低于传统组（均P<0.05）。在术后并发症方面,ERAS组的总体并发症的发生率、术后胰瘘、肺部并发症发生率以及严重并发症比例均明显低于传统组（均P<0.05）。 结论：将ERAS理念应用于PD围术期管理是安全、有效的,能明显降低术后并发症发生率,促进患者的快速康复。     

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery(ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay(LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.     

多学科合作快速康复外科理念在腹腔镜腹股沟疝修补术围手术期的应用

目的:探讨以多学科团队(MDT)合作为基础的快速康复外科(ERAS)在腹腔镜腹股沟疝修补术围手术期应用的可行性及有效性。方法:将782例行择期腹腔镜腹股沟疝修补术的患者按入院顺序随机分为ERAS组(392例)和对照组(390例)。对照组接受常规治疗护理;ERAS组接受MDT合作ERAS理念的治疗护理,主要干预措施包括住院模式选择,医护一体化健康教育,饮食要求,胃肠道准备,尿潴留预防,术后早期活动,伤口疼痛预防,麻醉前给药,防止术中低温,围手术期补液管理,术后恶心、呕吐预防及1个月患者舒适度评价等。比较两组患者术后疼痛、恢复情况、并发症与应激反应发生率、术后舒适度等。结果:与对照组比较,ERAS组术后次日清晨NRS疼痛评分降低,恢复正常饮食时间、下床活动时间、住院时间均减少,术后满意率增加,血清肿、尿潴留、伤口感染等并发症与不适感、恶心反应的发生率降低,术后1个月中位腹股沟疼痛调查表评分降低(均P0.05)。结论:在腹腔镜腹股沟疝修补术患者围手术期中采用MDT合作ERAS理念可以减轻患者不适,加速康复,缩短住院时间,提高患者满意度及舒适度。     

加速康复外科技术应用于小儿咽部手术临床分析

目的 探讨加速康复外科(enhanced recovery after surgery,ERAS)技术在小儿咽部手术中的应用效果. 方法 择期接受咽部手术的6～12岁患儿60例,按随机数字表法分为ERAS组和传统方法(conservative treatment surgery,CTS)组(每组30例).其中ERAS组在术前宣教、麻醉处理、术后镇痛等方面给予具有循证医学证据支持的优化措施,CTS组采用常规围麻醉期处理.观察术后清醒时及术后2、8、24h时两组患儿血流动力学的变化、躁动评分、镇痛效果(VAS评分)、术后24 h内是否需要补救镇痛、术后24h内恶心呕吐并发症的发生率、住院天数. 结果 两组患儿各时点的生命体征、手术时间差异无统计学意义(P＞0.05);ERAS组各时点的躁动评分[(2.41±0.50)、(2.48±0.67)、(2.39±0.81)、(2.33±0.51)分]、VAS评分[(3.3±0.5)、(3.2±0.5)、(3.0±0.6)、(2.6±0.9)分]、术后补救镇痛率(30％)和术后恶心呕吐发生率(33.3％)均低于CTS组的躁动评分[(3.54±1.01)、(3.63±0.92)、(3.42±0.32)、(3.38±0.20)分]、VAS评分[(5.3±0.4)、(4.9±0.3)、(4.8±0.4)、(3.9±0.5)分]、术后补救镇痛率(50％)和术后恶心呕吐发生率(66.7％)(P＜0.05).ERAS组住院时间[(5.5±0.8)d]也明显短于CTS组[(7.1±0.5)d](P＜0.05).结论 ERAS技术能减轻咽部手术患儿的术后躁动与疼痛,缩短住院时间,促进患儿康复.     

Enhanced recovery after surgery in emergency colorectal surgery:Review of literature and current practices

Enhanced recovery after surgery(ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows:(1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay – without increased risks of readmission,reoperation and death after emergency colorectal surgery; and(2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.     

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.     

Enhanced recovery after surgery programs hasten recovery after colorectal resections

Colorectal resection was traditionally associated with significant morbidity and prolonged stay in hospital.Laparoscopic colorectal resection was first described in 1991 as a minimally invasive form of colorectal surgery.It was later on assessed by multiple randomized controlled trials and meta-analysis and was found to be associated with a faster recovery,lower complication rates and a shorter stay in hospital compared with open resection.To assess the effect of enhanced recovery after surgery (ERAS) program on postoperative length of stay after elective colorectal resections,a literature review was conducted,supplemented by the results of 111 ERAS colorectal resections at regional NWS Hospital using a protocol based on the Fast Track approach described by Kehlet in 1999.ERAS has been shown to improve postoperative recovery,reduce length of stay and enhance early return to normal function when compared with traditional colorectal surgical protocols.The role of laparoscopic surgery in colorectal resections within a fast-track (ERAS) program is controversial.The current evidence suggests that within such a program,there is no difference between laparoscopic and open colorectal surgery in terms of postoperative recovery rates or length of hospital stay.     

胰十二指肠切除术围术期规范化开展加速康复外科的几点争议

胰十二指肠切除术(PD)是普通外科最为复杂的手术之一,手术吻合口多,出现胰瘘、胆瘘、腹腔感染等并发症的风险大,围术期管理困难。近年提倡并应用的精准、微创、损伤控制的现代外科理念为加速康复外科(ERAS)的施行奠定了基础,尽管国际上已发布纲要性的共识指南,国内对于PD围手术期管理中实施ERAS仍存在不少争议。为了在PD围术期规范化开展ERAS,笔者就术前禁食禁饮时间、术后鼻胃管和腹腔引流管拔除时机、术后生长抑素使用与否等几个关键的争议问题进行讨论和阐释。     

ERAS理念指导下围术期液体治疗的研究进展

加速康复外科(ERAS)是指围术期通过基于循证医学证据的一系列多模式策略来促进患者快速康复的新型理念。围术期液体治疗是ERAS的重要组成部分,包括术前、术中及术后3个阶段,其目的旨在维持患者术前、术中、术后的循环血容量状态,保证循环稳定和组织的有效灌注,避免组织缺血、缺氧,同时可以减轻患者手术应激,维护内环境稳定,降低术后呼吸、循环系统等重要脏器的并发症,加速患者康复。关于围术期液体治疗一直存在争议,目标导向液体治疗是目前大家公认的一种方法。本文将对ERAS理念指导下围术期液体治疗的最新进展及其对术后转归的影响作一综述。     

加速康复外科在胰十二指肠切除术中的应用

目的 本研究旨在评估加速康复外科（ERAS）在胰十二指肠切除术中应用的安全性和有效性。方法 将2014年1月至2015年12月我院54例胰十二指肠切除术患者随机为传统组（39例）和加速康复组（ERAS组,15例）两组。传统组按传统方法进行围手术期处理。ERAS组接受加速康复外科策略的围手术期处理,主要包括：术前教育、术前减黄、术前营养支持、术中保温、术后强化镇痛、术后早期肠内营养支持及早期恢复口服饮食、术后早期下床活动、术后强化血糖控制等。观察比较两组患者病死率、再手术率、术后平均住院日、治疗费用,以及胰瘘、胃排空延迟和其他腹腔并发症的发生率。结果 两组患者的平均年龄、性别、原发病构成以及术前黄疸或糖尿病构成比例差别无统计学意义（P>0.05）。传统组死亡2例,再手术1例,1周内再入院1例。ERAS组没有死亡、再手术及再入院病例。传统组共发生胰瘘12例,ERAS组2例（30.8% vs 13.3%,P=0.191）。其中传统组有B级胰瘘2例,C级胰瘘3例,A级胰瘘7例;ERAS组均为A级胰瘘。传统组胃延迟排空发生率显著高于ERAS组（35.9% vs 6.7%,P=0.031）。包括腹腔出血、腹腔积液等其他腹腔并发症的发生率两组间没有明显统计学差异（P>0.05）。ERAS组术后胃肠道功能恢复时间、平均住院日（21 d vs 17 d,P=0.046）和住院费用（97 130元 vs 80 963元,P=0.047）明显少于传统组。结论 结合胰十二指肠切除手术特点所制定的加速康复外科策略在胰十二指肠切除术中的应用是安全的,并且可以有效降低患者术后胰瘘、胃排空延迟的发生率,减少术后住院时间和住院费用,有利于患者更快更好地康复。     

Enhanced recovery after surgery care to reduce surgical site wound infection and postoperative complications for patients undergoing liver surgery

This study comprehensively assessed the effect of enhanced recovery after surgery (ERAS) on wound infection and postoperative complications in patients undergoing liver surgery. The PubMed, EMBASE, MEDLINE, Cochrane Library, China National Knowledge Infrastructure (CNKI), VIP, and Wanfang electronic databases were searched to collect published studies on the use of ERAS in liver surgery until December 2022. Literature selection was performed independently by two investigators according to the inclusion and exclusion criteria, and quality evaluation and data extraction were performed. RevMan 5.4 software was used in this study. Compared with the control group, the ERAS group showed a significantly lower incidence of postoperative wound infection (odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.41–0.84, P = .004) and overall postoperative complication rate (OR: 0.43, 95% CI: 0.33–0.57, P < .001) and significantly shorter postoperative hospital stay (mean difference: −2.30, 95% CI: −2.92 to −1.68, P < .001). Therefore, ERAS was safe and feasible when applied to liver resection, reducing the incidence of wound infection and total postoperative complications, and shortening the length of hospital stay. However, further studies are required to investigate the impact of ERAS protocols on clinical outcomes.     

加速康复外科在腹腔镜胰十二指肠切除术围手术期管理中的临床应用

目的:探讨加速康复外科(ERAS)在腹腔镜胰十二指肠切除术围手术期管理中的临床应用价值。方法:选取2016年1月至2019年1月收治的168例行腹腔镜胰十二指肠切除术的患者,采用随机数字法分为ERAS组与对照组,ERAS组围手术期采取ERAS措施,对照组采取常规围手术期处理。对比分析两组术后恢复情况、术后并发症发生情况、术后住院时间、住院费用、再次手术率及病死率。结果:ERAS组首次肛门排气时间、进食时间、胃管留置时间、腹腔引流管与尿管拔除时间、疼痛、住院费用、身体质量指数优于对照组,差异均有统计学意义(P<0.05),两组术后总体并发症发生率、胰瘘与腹腔出血情况、再手术、再入院、病死率差异无统计学意义(P>0.05)。结论:腹腔镜胰十二指肠切除术围手术期应用ERAS措施可促进患者术后快速康复,缩短住院时间,降低住院费用,安全性高。     

心脏瓣膜置换患者围手术期加速康复外科护理

目的探索加速康复外科护理应用于心脏瓣膜置换患者围手术期的效果。方法将2015年1~12月行低温体外循环下瓣膜置换术患者37例作为对照组,给予常规心外科治疗与护理;2016年1~12月行相同手术的患者39例作为观察组,应用加速康复外科护理进行围手术期管理。结果观察组术后腹胀、切口感染、肺部感染发生率显著低于对照组,术后首次下床时间、ICU观察时间及住院时间显著短于对照组,且住院费用显著少于对照组(P0.05,P0.01);观察组出院时满意度显著高于对照组(P0.05)。结论心脏瓣膜置换患者围手术期实施加速康复外科护理,可有效促进患者术后康复,减少术后并发症,缩短患者住院时间,降低住院费用,从而提升患者满意度。