Enhanced recovery in intestinal surgery

Enhanced recovery after surgery (ERAS) programmes utilize a multi-modal and multidisciplinary approach to surgical care. The aim of ERAS is to reduce the surgical stress response, to maintain physiological function and metabolic homeostasis and to expedite patients’ recovery to their baseline status. Following its success in colorectal surgery, ERAS is increasingly adopted by other surgical specialities. A good ERAS programme involves integrated preoperative, intra-operative and postoperative evidence-based practice. Successful ERAS programmes translate to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which will help facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are not only transferable to other surgical specialities, but may also allow medical specialities to improve patient care and recovery. ERAS is therefore expected to become the standard of care for the majority of hospital inpatients.     

Enhanced recovery in intestinal surgery

Enhanced recovery after surgery (ERAS) programmes utilize a multi-modal and multidisciplinary approach to surgical care. The aim of ERAS is to reduce the surgical stress response, to maintain physiological function and metabolic homeostasis and to expedite patients' recovery to their baseline status. Following its success in colorectal surgery, ERAS is increasingly adopted by other surgical specialities. A good ERAS programme involves integrated preoperative, intra-operative and postoperative evidence-based practice. Successful ERAS programmes translate to a standardized patient care pathway, improved clinical outcomes and shorter hospital stay, all of which will help facilitate the increasing demand on healthcare and bed pressure. Its principles and many components are not only transferable to other surgical specialities, but may also allow medical specialities to improve patient care and recovery. ERAS is therefore expected to become the standard of care for the majority of hospital inpatients.     

Enhanced recovery after surgery (ERAS) protocol in spine surgery

Enhanced recovery after surgery (ERAS) protocols are a set of interventions which are carried out in the preoperative and perioperative period. They are aimed to decrease the harmful effects of surgery on the body and help the patient recover better post-surgery. The effectiveness of ERAS has been well established in various other surgical specialities. Earlier spine surgery was thought to be very complex for application of ERAS protocols. However, this has changed over the last decade with (ERAS) protocols gaining widespread popularity in spine surgery. Initial studies involving ERAS in spine surgery were limited to lumbar spine. However, over the years the horizon of ERAS has expanded to include anterior cervical surgeries, spine deformity, spinal tumors and spine surgery in the elderly. ERAS has been shown to reduce the length of hospital stay, overall hospital costs, opioid consumption in perioperative and postoperative period and to lower complication rates in spine surgery. In this narrative review, we discuss various aspects of ERAS in spine surgery including the benefits of ERAS in spine surgery, the various components of preoperative, intraoperative and postoperative measures of ERAS protocol.     

Implementation of an enhanced recovery after surgery program including a patient school: Impact on quality of life results

IntroductionEnhanced Recovery After Surgery (ERAS) protocols and educational programmes have been shown to accelerate orthopaedic surgery recovery with fewer complications, and improve patient-reported outcomes (PROs) for different types of surgery. The objective was to evaluate the impact of an ERAS programme including a patient school on health outcomes and PROs for Total Knee Replacement (TKR) surgery.Material and methodsA multidisciplinary group created the programme and the patient school (preoperative consultations where the patients’ surgical processes are explained and are also given instructions for an appropriate perioperative care management). An observational, prospective study was conducted on all patients operated for TKR from March 2021 to March 2022. Main health outcomes were: hospital stay length, surgical complications and surgery cancellations due to a wrong preoperative medication management. PROs evaluated were: patient satisfaction with pain management, the school, and quality of life before and after surgery (EQ-5D).ResultsOne hundred thirty-three patients were included. Median hospital stay length was 3 days (IQR 3-5). Rate of surgical complications was 25.6%. No surgery was cancelled. Patient satisfaction rates with pain management and with the school were 8.10/10 and 9.89/10, respectively. Concerning quality of life, mean improvement in mobility and knee pain after the surgery was 0.66 (p < 0.05) and 0.84 (p < 0.05), respectively.ConclusionsThe ERAS programme including a patient school was highly successful with a fast recovery, a short hospital stay length, no surgery cancellations, and improved PROs.     

Enhanced recovery after colorectal surgery: principles and current practice

Enhanced recovery after surgery (ERAS) programmes have become an integral part of current management of surgical patients. These have evolved over the years with the key philosophy of improving patient outcomes by combining the best possible preoperative optimization, surgical and anaesthetic techniques and postoperative care, with the specific aim of minimizing disturbance to normal physiology. This article provides an overview of the evidence to support these concepts and provides a framework for setting up an effective ERAS programme for colorectal surgery.     

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.     

Perioperative care: a survey of New Zealand and Australian colorectal surgeons

Aim Recent surveys in Europe and North America have demonstrated significant challenges in the implementation of evidence‐based surgical practice. Method A survey of New Zealand and Australian colorectal surgeons was conducted to help understand current practice and perceived barriers to interventions in this region. Questions were based around elective colorectal resection care. Results There were 152 eligible participants identified. Over a 60‐day period, 82 (54%) surgeons responded but only 76 (50%) of the questionnaires were complete; they were used for data analysis. The majority of surgeons indicated a preference for laparoscopic techniques. Barriers to laparoscopy include lack of operating time, lack of adequate training and institutional pressures. Only 28 (37%) indicated that they cared for patients in a formalized enhanced recovery programme (ERAS). Barriers to implementing ERAS included lack of support from institutions and other specialities. Routine oral ‘mechanical’ bowel preparation for colon and rectal resection was preferred by 28% and 63%, respectively. Drainage after routine colon and rectal resection was not used by 62 (83%) and 39 (53%). Prophylactic nasogastric intubation afterwards was not used by 66 (87%) responders. The preferred mode of analgesia was patient‐controlled opioid analgesia (PCA) for 52%. A ‘restrictive’ intravenous fluid therapy was preferred by 34 (49%) while 33 (48%) preferred no fluid restriction. A prolonged ‘nil by mouth’ status was preferred by 28%. Conclusion There appears to be a high rate of evidence in agreement with some interventions but not others. The systemic barriers to implementing evidence‐based perioperative care need attention.     

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.     

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 program for elective abdominal surgery at three Victorian hospitals

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgical in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A post-implementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.     

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.     

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??Enhanced recovery after surgery: current controversies and concerns YANG Yin-mo. Department of Surgery??Beijing University First Hospital??Beijing 100034??China
Abstract The enhanced recovery after surgery??ERAS?? protocol is an evidence based??perioperative care pathway??which is to reduce the physiological neuroendocrine stress response to surgery??with the ultimate goal of improving patient recovery and outcomes. In clinical practice, the multidisciplinary team??multimodal approach??and individualized program are necessary to get the ERAS protocol implemented. It is the most important approach for patient recovery to improve the quality of surgery so as to reduce the surgical stress. The goals of ERAS should be realistic and the related program should be implemented under national conditions by adhering to the principle of safety first??and efficiency second.     

加速康复外科临床实践中应重视的几个问题

加速康复外科（ERAS）基于循证医学基础,通过优化围手术期诊疗路径,达到促进术后康复的目的。ERAS的理论基础是减少围手术期应激及其导致的代谢改变。临床实践中应坚持以多学科合作为基础,针对病人的具体情况多模式、个体化地开展ERAS。提高手术质量、减少创伤应激是促进病人术后康复的重要途径。ERAS应与我国国情及临床的实际情况相结合,秉承安全第一、效率第二的基本原则。     

Enhanced recovery after surgery:Current research insights and future direction

Since the concept of enhanced recovery after surgery(ERAS)was introduced in the late 1990 s the idea of implementing specific interventions throughout the perioperative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol,leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery,rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes,described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS,e.g.,the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better,more reliable patient outcomes.     

Enhanced recovery after surgery (ERAS)—Concepts,components, and application to spine surgery

This article describes the concept of Enhanced Recovery after Surgery (ERAS) and its application to spine surgery. ERAS is a multimodal approach designed to reduce the surgical stress response and accelerate recovery following surgery. It is a multi-disciplinary, patient-centred approach that employs an evidenced-based pathway of standardised care. It has been proven across a range of surgical pathways but has yet to be defined and adopted in spine surgery. ERAS pathways are needed in spine surgery. Patient recovery is often long, painful, expensive, and a highly variable experience. Consequently, ERAS programs will find great utility in this subspecialty.     

Enhanced recovery after surgery (ERAS) pathways in autologous breast reconstruction: a systematic review

Enhanced recovery after surgery (ERAS) pathways aim to achieve earlier recovery and reduced hospital length-of-stay (LOS) by providing multi-modal perioperative care. The tenets of ERAS pathways include pre-operative optimisation, prevention of surgical complications, reduction of physiological stress response to surgery and rehabilitation to normal function. To date, ERAS protocols have gained broad acceptance by many surgical specialities. Contemporary literature has identified decreased LOS, improved quality of care and reduced healthcare expenditures. We aimed to systematically review the current literature and assess the current state of ERAS in autologous breast reconstruction. A systematic review of MEDLINE, EMBASE, ScienceDirect, Cochrane Libraries and Web of Science databases in October 2015 was performed according to the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement. Articles pertaining to the use of ERAS in plastic and reconstructive surgery were included for analysis. Review articles, conference proceedings and correspondence were excluded from the assessment. Five hundred fifty-seven articles were identified, of which three suitable articles were included for assessment. Of these, one series outlined the learning curve associated with ERAS pathways and two series were comparative in nature. Meta-analytical analysis was not possible do to insufficient data and heterogeneity in outcome measures. In two of these comparative series, there was no statistical difference in rates of systemic infective (OR 0.91, 95 % CI 0.29 to 2.80, p?=?0.86), total flap loss (OR 1.09, 95 % CI 0.37 to 3.19, p?=?0.87), partial flap loss (OR 1.64, 95 % CI 0.66 to 4.10, p?=?0.29) or wound infection (OR 1.38, 95 % CI 0.78 to 2.34, p?=?0.29). LOS was significantly reduced in the ERAS group in both comparative studies from 7.4 to 6.2 days (p?<?0.001) and 6.6 to 3.9 days (p?<?0.001), respectively. ERAS pathways in breast reconstruction appear to consistently reduce LOS. From the available literature there were no significant detrimental effects on patient care following the implementation of ERAS pathways. Further research is required to definitively determine safety in the assessed cohort and to determine reductions in healthcare-related expenditures.Level of evidence: Not ratable     

Enhanced recovery after surgery in children: Promising,evidence‐based multidisciplinary care

Enhanced recovery after surgery (ERAS) is a multimodal approach to the care of the surgical patient focused on reducing the stress response and associated physiologic changes that accompany surgery. Over the past 20 years, ERAS programs have been found to result in reduced LOS and complications in adult patients. Despite abundant adult literature describing implementation and outcomes of enhanced recovery programs, pediatric data in this area is sparse. This educational review describes the history and elements of ERAS protocols, reviews the available evidence in adult and pediatric populations, compares and contrasts ERAS with the PSH, and offers strategies for implementation and ideas for future directions of ERAS in children.     

Fast-Track for the Modern Colorectal Department

In recent years, fast-track or enhanced recovery after surgery (ERAS) colorectal pathways have been utilized to achieve faster recovery and discharge from hospital with swift resumption of normal activities of daily living without an increase in complications or readmissions. Despite the large body of evidence available, however, adoption of the fast-track methodology in current surgical practice has been slow and sporadic. As outlined by a recent Cochrane review, practice uptake has mostly focused on individual component uptake. Therefore, instead of repeating what already has been established in the literature pertaining to colorectal fast-track surgery, the aim of this article is to interrogate the evidence concerning the individual components of ERAS pathways as they relate to a contemporary surgical department to determine the most relevant critical components for patients undergoing colorectal surgery in modern surgical practice.     

Effects of a new perioperative enhanced recovery after surgery protocol in hepatectomy for hepatocellular carcinoma

Enhanced recovery after surgery (ERAS) protocols are becoming the standard of care in many surgical procedures, although data on their use following hepatectomy for hepatocellular carcinoma (HCC) are scarce. This study aimed to evaluate the effects of a new ERAS pathway in terms of the patient nutrition status after hepatectomy for HCC. This is a retrospective analysis of 97 consecutive patients treated with open or laparoscopic hepatectomy for HCC between January 2011 and August 2014. We compared the perioperative outcomes between patients whose treatment incorporated the ERAS pathway and control patients. The nutritional status was evaluated using the controlling nutritional status score. The length of hospital stay (LOS) after both open and laparoscopic hepatectomy was shorter for the ERAS group than the control group. The days of ambulation and cessation of intravenous infusion were earlier and the postoperative nutrition status was statistically better in the ERAS group than in the control group. A multivariate analysis showed that being in the non-ERAS group was a risk factor of delayed discharge. There were no marked differences in the rate of severe complications between the two groups. The ERAS pathway seems feasible and safe and results in a faster recovery, reduced LOS, improved nutrition status, and fewer severe complications.     

Enhanced Recovery After Surgery (ERAS) programme versus conventional perioperative care in patients undergoing major intra-abdominal surgical procedures

Aim-Background

Enhanced Recovery After Surgery (ERAS) programmes have been applied mainly in patients undergoing major lower gastrointestinal surgery, to attenuate stress response to surgery and enable rapid recovery. The aim of this study was to evaluate whether the implementation of ERAS care, as compared to traditional care, is associated with less morbidity (decreased incidence of major postoperative complications) and improved outcome in patients undergoing elective major upper and lower intra-abdominal surgery.

Methods

The patients of two individual surgeons following the ERAS regime were prospectively studied over 6 months and compared with the patients of the other 4 surgeons in the department who followed conventional perioperative care during the same period of time. The outcome measures included incidence of major postoperative complications, length of postoperative hospital stay, number of relaparotomies, number of readmissions, and mortality within 30 days of surgery. Data analysis was performed by the use of Fisher’s exact test and Student’s t-test.

Results

Sixteen patients treated in accordance with the ERAS programme were compared against 38 controls that received conventional postoperative care. The two groups were similar in terms of age, gender, ASA grade, types of disease and surgery. The ERAS group showed significantly lower morbidity compared to the control group (12.5% vs. 42.1% respectively; p=0.052). Length of stay was significantly shorter in the ERAS group (5 ± 1.6 days vs. 12.2 ± 5.9 days; p<0.00001). There was no difference in readmission rate, relaparotomy rate and mortality between the two groups.

Conclusion

The ERAS programme displays a trend toward a significantly lower incidence of postoperative complications and considerably reduces the length of hospital stay in patients undergoing major elective upper and lower intra-abdominal surgery.