Enhanced Recovery After Surgery in Colorectal Surgery
Introduction
Enhanced Recovery After Surgery (ERAS) pathways encompass an integrated approach to comprehensive surgical care throughout the preoperative, intraoperative, and postoperative phases to optimize patients for surgery, their care, and outcomes to achieve early postoperative recovery [1–3].
Overall, ERAS protocols aim to minimize the physiologic stress caused by surgery and aid in a faster return to baseline functional status and to work for patients, as well as shorter length of hospital stay and decreased morbidity rates without increases in readmission rates [1,4,5].
ERAS pathways now exist in a multitude of surgical specialties but were early and widely adopted and studied within the field of colorectal surgery [1,5]. Cornerstones of treatment that lead to the success of ERAS pathways in colorectal surgery include setting expectations with patients and providers, optimization of nutritional status and fluid balance, minimally invasive surgical techniques, multimodal pain treatment, prevention of postoperative nausea and vomiting, early enteral nutrition, and early mobilization that occur throughout the three phases of care [1,5–7].
Implementing ERAS protocols for colorectal surgery is a vital first step; however, the better the adherence to the various elements of ERAS protocols, the better the program’s long-term success with more profound and consistent improvements in patient outcomes [2,3,6].
Multidisciplinary, institutional support and dedication to the implementation, adherence, and adaptation of ERAS programs are essential for their success over time [6,8].
Preoperative Care
The steps of the ERAS pathway begin even before surgery is scheduled, in the planning stages. Every patient being considered for colorectal surgery should be evaluated by the surgeon and anesthesiologist to assess and optimize the patient in terms of risk stratification, nutrition screening and treatment, exercise/prehabilitation, smoking cessation, avoiding alcohol abuse, comorbidity optimization, anemia screening and treatment, among others [1,9].
Once decided to proceed with surgery, preoperative education and setting expectations with patients are of the utmost importance. This education should include information about the surgery, the patient’s active role in preoperative planning and care, expected postoperative and discharge course, and education about stoma care. This education and clear communication is critical to empower patients to participate in their recovery actively, and allow them to anticipate, prepare for, and better understand their treatment course and plan [1,2,8,9].
Formal preoperative stoma education by stoma nurse specialists as part of the ERAS pathway has been associated with shorter lengths of stay [10].
In the more immediate perioperative period, there are measures that need to be taken by patients in preparation for their surgery. To help protect against development of surgical site infections by limiting the skin’s microbial content, patients can prepare with bathing and skin preparation [1,2,8]. While there is no standard recommendation for the type of regimen, mechanical and oral antibiotic bowel preparation are also a critical component of the ERAS protocol for infection prevention [2,8].
Mechanical bowel preparation can result in significant preoperative dehydration, so in order to combat this, patients should be allowed to consume clear liquids up to 2 hours before surgery [5,9]. This leads to less need for intraoperative fluid administration, which helps to limit edema and third spacing, thus enhancing postoperative recovery [5].
Additional measures aimed at limited hypotension and the need for excess intraoperative fluids include patients not taking certain medications on the morning of surgery (e.g., ACE inhibitors, diuretics) [5]. The success of these portions of the ERAS pathway depends on thorough patient-provider preoperative communication and education.
The preoperative phase continues on the day of surgery once the patient arrives at the surgical facility. In the preoperative unit, patients are given preemptive analgesia and antiemetics. The exact analgesia regimen can be adjusted for individual patient factors (e.g., age, renal function) as needed but often includes acetaminophen, celecoxib, and gabapentin [5,8,9,11].
Patients should also begin venous thromboembolism (VTE) prophylaxis in the preoperative unit, including strongly endorsing low dose unfractionated heparin, low molecular weight heparin, or fondaparinux [2].
Two hours before surgery, patients should receive a carbohydrate load. This load is thought to decrease insulin resistance and increase postoperative insulin sensitivity by limiting the catabolic effects of starvation and fasting around surgery [2,4,5,9].
Carbohydrate loading does not increase aspiration in healthy adults undergoing elective surgery [1,2] and has been associated with decreased postoperative nausea and length of stay compared to prolonged fasting [1,2,8]. Also, antibiotic prophylaxis should be administered for 60 minutes before the incision [1]. The steps integral to the preoperative ERAS pathway set the stage for patients’ postoperative recovery.
| Preoperative ERAS Elements for Colorectal Surgery | ERAS Society Graded Recommendations [9] |
|---|---|
| Patient education/communication/counseling | Strong |
| Patient optimization/risk assessment Smoking cessation Avoiding alcohol abuse Prehabilitation Nutrition screening and treatment Anemia screening and treatment | Strong Strong Strong Weak Strong Strong |
| Mechanical bowel preparation alone | Strong |
| Mechanical and oral antibiotic bowel preparation | Weak |
| Skin preparation with chlorhexidine | Strong |
| Consumption of clear liquids up to 2 hours preoperatively for goal of euvolemia | Strong |
| Prophylactic antiemetics | Strong |
| Preemptive multimodal pain regimen initiation | Strong |
| Carbohydrate loading | Strong |
| Prophylaxis for venous thromboembolism | Strong |
Intraoperative Care
Intraoperative considerations for colorectal surgery ERAS pathways stem from physiologic optimization of the patient and surgical decisions. Goal-directed fluid administration should aim for euvolemia for patients utilizing a goal urine output of 0.25cc/kg/hr [1,2,4,5,8,9]. This will aid in preventing excess fluid administration, which can cause bowel edema and subsequent ileus, and thus, delayed postoperative recovery [1,4].
Using this approach to fluid administration is associated with shorter length of stay and decreased rates of postoperative complications [4]. Further measures that should be taken intraoperatively include avoiding hypothermia and maintaining strict glycemic control [1,2,8,9].
Another crucial component of the ERAS pathway is the minimization of intraoperative narcotics as this helps to avoid known side effects of drugs that can delay patient recovery (e.g., postoperative ileus, respiratory depression, nausea/vomiting) and lessen the need for postoperative narcotics [2,5,8,11].
Intraoperative opioid avoidance can be aided with the use of epidurals and transversus abdominus plane (TAP) blocks along with continued, scheduled administration of the multimodal preemptive pain regimen started in the preoperative phase [2,5,8,11]. Prophylactic antiemetics should also be continued during this phase of care [8].
Intraoperative surgical decisions included in the ERAS pathway involve using minimally invasive surgical techniques as appropriate, limited use of surgical drains, and removing nasogastric tubes and urinary catheters at the end of the case [2,8,9]. The intraoperative elements of the ERAS pathway pave the way for enhanced recovery in the postoperative period.
| Intraoperative ERAS Elements for Colorectal Surgery | ERAS Society Graded Recommendations [9] |
|---|---|
| Epidural or TAP block | Strong |
| Goal directed fluid administration | Strong |
| Prevention of hypothermia | Strong |
| Strict glycemic control | Strong |
| Minimally invasive surgical techniques | Strong |
| Avoidance of/early discontinuation of drains/nasogastric tubes/urinary catheters | Strong |
Postoperative Care
There are many components to postoperative care in the ERAS pathway for colorectal surgery that span from the immediate postoperative period to discharge. Some of the first steps to take for patients postoperatively are to stop the administration of intravenous fluids within six hours after the operation, remove nasogastric tubes, and initiate a clear liquid diet [4,5,9]. Early postoperative discontinuation of intravenous fluids aids in maintaining euvolemia and is associated with shorter length of stay and lower rates of complications [4].
Additionally, additional antibiotic therapy after planned surgical procedures is not recommended. Avoiding nasogastric tubes is also important because their presence is associated with delays in the return of gastrointestinal activity [1].
Patients can also be offered chewing gum, which is thought to reduce postoperative ileus by stimulating the cephalovagal reflux, thus aiding in earlier return of bowel function [1].
Regarding diet, early initiation of oral nutrition and continued advancement to a regular diet within 24 hours postoperatively should be done as long as the patient tolerates this progressive advancement [1,4,5].
Early oral nutrition is associated with shorter length of stay, earlier return of bowel function, and lower morbidity rates without increased rates of anastomotic complication, pneumonia, vomiting, and nasogastric tube reinsertion [4,8].
Early initiation of oral nutrition also allows for earlier use and gastrointestinal absorption of oral pain medications, which aids in allowing for multimodal pain control and opioid avoidance [5]. Multimodal pain control regimens include acetaminophen, celecoxib, or other nonsteroidal anti-inflammatory drugs, and gabapentin Field [5,8,9,11] and help to limit, but not eliminate, postoperative opioid use [1,11].
Colorectal surgery ERAS protocols recognize the use of opioid analgesia within multimodal pain regimens but emphasize not relying on opioids for the treatment of pain due to their side effects, such as postoperative ileus, nausea, vomiting, respiratory depression, and altered mental status [11]. Avoiding these side effects of opioids along with effective multimodal pain control helps to promote early tolerance of oral nutrition and early mobilization [11].
Mu opioid receptor antagonists can also be used during the inpatient, postoperative period to help reduce rates of ileus due to opioid use [1]. An additional pharmacologic measure that can aid in patient tolerance of early diet advancement and early mobilization is the prophylactic use of antiemetics to prevent nausea and vomiting symptoms [1,2].
Early mobilization is essential to the postoperative recovery process. It helps increase muscle strength, reducing the risk of VTE complications and returning patients to baseline functional status [1,8]. Early mobilization is also associated with earlier return of bowel function and decreased pulmonary complications [8].
Other steps in the ERAS pathway help to encourage and achieve early mobilization. These include the early removal of nasogastric tubes, urinary catheters, and surgical drains, as patients may perceive difficulty with ambulation with these in place [1]. Adequate pain control with multimodal regimens, opioid avoidance, and prophylactic antiemetics also help achieve early mobilization because patients will feel better overall [2,8]
Clear communication and education are crucial and ongoing parts of postoperative care that can help shorten the length of stay. Patients who received a stoma during surgery should undergo stoma education by stoma nurse specialists [10] to help them learn to and feel comfortable with managing their new stoma. This dedicated stoma education from a specialist is associated with decreased length of stay [10].
As it was influential in the preoperative phase, setting expectations with patients remains critical to their understanding of and active participation in their postoperative recovery and discharge planning [1,2,8].
| Postoperative ERAS Elements for Colorectal Surgery | ERAS Society Graded Recommendations [9] |
|---|---|
| Early discontinuation of intravenous fluids | Strong |
| Early diet initiation and advancement | Strong |
| Strict glycemic control | Strong |
| Opioid avoidance | Strong |
| Multimodal analgesia | Strong |
| Early mobilization | Strong |
Outcomes
Implementing, utilizing, and adhering to ERAS pathways in colorectal surgery has been shown to improve patient outcomes for either laparoscopic or open surgeries [1-3]. The most well-documented benefit of ERAS in colorectal surgery is decreased length of stay [1-6,9,12], which has been demonstrated in a variety of settings, including teaching and non-teaching hospitals, resource-poor settings, and hospitals inside and outside of the United States [4].
Numerous studies have also cited fewer postoperative complications, which include ileus, wound infections, urinary tract infections, cardiopulmonary complications, and overall occurrence of any complication [1,2,5,6,9,12] with one noting as high as a 50% reduction in non-surgical complication rates [6].
Patients on an ERAS pathway further benefit from faster return of bowel function, earlier diet tolerance, and less opioid use [1,12]. This all occurred with decreased to no change in readmission rates as well [1,3,6,12]. Some of these outcomes are proposed to be achieved through decreased hormonal stress responses and postoperative inflammation as there is evidence of lower IL-6 and CRP levels in ERAS patients following colorectal surgery [1,12].
Limitations
The success of ERAS pathways in achieving these improved patient outcomes depends on adherence to the pathway elements throughout each phase of the care [2,3]. Establishing and maintaining adherence necessitates ongoing multidisciplinary education and program evaluation [3,9] and can be enhanced through prepared, standardized order sets and checklists for all care team members who will care for ERAS patients [8].
Higher adherence to ERAS protocols and pathway elements is associated with shorter length of stay, lower rates of complications, and readmissions [2-4]. When ERAS adherence is greater than 90% compared to only 50%, patients had a 25% shorter length of stay [2].
There is an increased odds of patients having longer lengths of stay when there is adherence with five or fewer components of the ERAS pathway, and the average length of stay increases as ERAS adherence decreases [4]. Therefore, implementing only a few elements of ERAS protocols is insufficient to reap the full benefits of an ERAS program [4].
It is important to remember that not all patients and surgeries are equivalent, and some patients may necessitate deviation from the ERAS pathway for various reasons [7]. Risk factors for deviation from the ERAS pathway and longer length of stay on the pathway include older age (>75-80 years), having more comorbidities, being American Society of Anesthesiology grade 3 or 4, having prior abdominal surgery or preoperative gastrointestinal obstruction, undergoing longer surgeries, having high blood loss during surgery, or the creation of a stoma/ileostomy [1,4,7].
Patients with these risk factors are likelier to experience complications or symptoms necessitating deviation from the standard ERAS protocols [1,7].
Summary
ERAS pathways in colorectal surgery improved patient outcomes, including decreased length of stay, faster return of bowel function, reduced morbidity, and fewer postoperative narcotic requirements.
The success of ERAS for colorectal surgery depends on adherence to the various elements during the preoperative, intraoperative, and postoperative phases of care.
References
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