Enhanced Recovery After Surgery (ERAS) uses a series of optimal measures of perioperative management with evidence-based medical evidence to reduce the physiological and psychological traumatic stress of surgical patients and achieve rapid recovery, which is a new concept and treatment and rehabilitation model of medicine in the 21st century.
1.Improve the therapeutic effect of
2.Reducing postoperative complications.
3. Accelerate patient recovery.
4.Shorten hospitalization time
5.Reducing medical costs
6.Reduce the burden of society and family. In clinical practice, ERAS is most successfully used in colorectal surgery. Based on our clinical research and experience, we have formed the following expert consensus on the rapid rehabilitation treatment plan for colorectal surgery in the literature.
1. Preoperative assessment and education
Pre-operative assessment of the patient’s risk and tolerance of surgery, and enhanced education will be beneficial to post-operative recovery. The patient should be informed of the important role he/she plays in this plan, including early postoperative feeding and early bedtime activities, etc. The patient should also be informed of the importance of postoperative rehabilitation and early discharge.
2.Pre-operative intestinal preparation
Preoperative routine bowel preparation (enemas, laxatives, antibiotics, fluids) is a stressful stimulus for patients, which may lead to dehydration and electrolyte imbalance, especially in elderly patients. The results of the meta-analysis suggest that bowel preparation is not beneficial for patients undergoing colorectal surgery, and that bowel preparation may also increase the risk of postoperative intestinal anastomotic fistula. Therefore, routine bowel preparation is not recommended for patients undergoing colorectal surgery, and preoperative bowel preparation is suitable for patients who require intraoperative colonoscopy.
3. Preoperative fasting and abstinence from food and drink
There is no evidence to support that prolonged fasting before conventional colorectal surgery can avoid reflux aspiration. Many national anesthesia societies now recommend that people without gastrointestinal motility disorders be allowed to eat a solid diet before 6h of anesthesia and a clear liquid diet before 2h. Some studies have shown that drinking 800mL of clear, bright water-carbon (12.5%) beverage 12h before surgery and 400mL 2~3h before surgery can reduce preoperative thirst, hunger and irritability, and significantly reduce the incidence of postoperative insulin resistance. Patients will be in a more suitable metabolic state, reducing postoperative hyperglycemia and the occurrence of complications.
4.Pre-operative anesthesia medication
Except for special patients, routine preoperative anesthetic drugs (sedative and anticholinergic) are not recommended. For nervous patients, short-acting anxiolytics may be helpful when placing the epidural catheter.
5. Use of prophylactic antibiotics
The prophylactic use of antibiotics during colon surgery is beneficial in reducing infections, but attention should be paid to:
(1) Prophylactic medication should include both aerobic and anaerobic bacteria.
(2) They should be administered half an hour before skin incision.
(3) A single dose of prophylaxis is as effective as a multi-dose regimen, and a single dose can be repeated intraoperatively if the duration of surgery is >3h. The best combination regimen is still unclear, but from an economic point of view, a single dose of metronidazole (metronidazole) in combination with cephalosporin II is recommended as a reasonable choice, and higher level antibiotics are recommended only when there is secondary infection.
6.Anesthesia plan
The use of general anesthesia combined with mid-thoracic epidural block is conducive to rapid postoperative awakening, good analgesia, reduction of stress reactions and promotion of recovery of intestinal function. Short-acting general anesthetic drugs, such as isoproterenol, remifentanil, sevoflurane and cis-atracurium, are recommended to facilitate rapid recovery from anesthesia; epidural block can reduce the use of general anesthetic drugs, inhibit stress reactions, reduce the occurrence of intestinal paralysis, and facilitate postoperative analgesia.
7.Surgical methods
Encourage the use of lumpectomy. Small incisions should be used as much as possible for caesarean colon resection.
8.Placement of nasogastric tube
Meta-analysis shows that nasogastric tubes should not be routinely placed for decompression during colorectal surgery, which can reduce the incidence of postoperative fever, pulmonary atelectasis and pneumonia. A gastric tube should be inserted to expel gas, except when gas enters the stomach during tracheal intubation, but should be removed before the patient is awake from anesthesia. Therefore, nasogastric tube should not be routinely used for postoperative decompression.
9.Avoid intraoperative hypothermia
Avoiding intraoperative hypothermia can reduce the effects on neuroendocrine metabolism and coagulation mechanism. It is recommended that intraoperative body temperature should be routinely monitored and necessary insulation measures should be used, such as covering insulation blankets, liquid and gas warming, etc.
10.Perioperative fluid therapy
Recent evidence suggests that reducing intraoperative and postoperative fluid and sodium input will help reduce postoperative complications and shorten postoperative hospital stay and speed up the recovery of gastrointestinal function. A preoperative and postoperative oral-on-demand, goal-directed, volume-restricted treatment strategy is the best way to reduce perioperative fluid overload and cardiopulmonary load.
The use of epidural anesthesia may cause vasodilation, resulting in a relative lack of intravascular volume and hypotension. Therefore, a more reasonable way to manage hypotension due to vasodilatation is to use vasoconstrictors rather than massive infusions. Intraoperative transesophageal ultrasound Doppler monitoring has been shown to be useful in titrating fluid requirements in high-risk patients.
11. Abdominal drainage
Placement of abdominal drains will affect the patient’s early bedtime activity because of the pain factor. The results of the meta-analysis showed that the use of abdominal drainage after colonic anastomosis did not reduce the incidence and severity of anastomotic fistula and other complications. Therefore, the routine placement of abdominal drains is not recommended for colectomy.
12. Urethral drainage
The placement of a urinary catheter will also affect the patient’s early postoperative activities. In patients undergoing colectomy with epidural pain relief, the risk of urinary retention will be low after 24 h of catheterization. Therefore, it is recommended that catheter removal should be considered after 1 d of catheter use for epidural pain relief in the thoracic segment. In the case of transabdominal low anterior resection of the rectum, it should be placed for about 2 d.
13.Treatment of postoperative nausea and vomiting
In order to be able to eat orally early, the problem of postoperative nausea and vomiting needs to be dealt with effectively. Drugs that may cause vomiting, such as neostigmine and opioids, should be avoided in favor of other drugs with fewer side effects. Antiemetics such as ondansetron and dexamethasone should be used prophylactically in patients at risk for vomiting. If the patient has nausea and vomiting, these drugs can be used in combination.
14. Prevention of intestinal paralysis and promotion of gastrointestinal motility
The prevention and treatment of postoperative bowel dysfunction should be emphasized, including the use of epidural pain relief, avoiding or reducing the use of opioids, avoiding excessive fluid input, and early resumption of oral feeding. Oral laxatives such as lactulose should be taken from the night before surgery until discharge.
15.Postoperative pain relief
For postoperative pain relief after colectomy, a low-dose local anesthetic or a small amount of opioid should be used for 2 d after surgery, and NSAIDs such as 4 g acetaminophen or bid100 mg flurbiprofen should be given daily as the basic pain relief drug. NSAIDs should be used for postoperative “flare-ups” when epidural bupivacaine is used, and NSIADs such as ketorolac and flurbiprofen should be used before epidural pain relief is removed and continued until discharge or beyond. Application of opioid analgesics via an intravenous analgesic self-administered pump (PCA) may not achieve the same analgesic effect and may have a less suppressive effect on surgical stress. Some studies have shown that continuous postoperative epidural analgesia reduces pulmonary complications but has little effect on other complications and hospital days. However, some studies do not fully agree with this view and consider PCA to be equivalent to epidural analgesia. The important principle of analgesia is that NSAIDs anti-inflammatory drugs should be used as the basis of postoperative analgesia, and the application of opioids should be minimized to reduce opioid-induced complications such as intestinal paralysis and to promote the early recovery of patients.
16. Postoperative nutritional therapy
The results of meta-analysis showed that early enteral nutrition or transoral diet after gastrointestinal surgery compared with postoperative fasting, there was no evidence that postoperative fasting was beneficial, early enteral irrigation could reduce the incidence of postoperative infection and shorten the postoperative hospital stay, and irrigation at the proximal end of the anastomosis did not increase the risk of enteroanastomotic fistula. However, early enteral enucleation may increase the incidence of vomiting and, in the absence of multimodal anti-intestinal paralysis therapy, may increase intestinal distention and affect the patient’s early activity and impair pulmonary function. Therefore, it is necessary to enhance the comprehensive treatment of postoperative intestinal paralysis, which facilitates the implementation of early postoperative feeding. In conventional treatment, oral adjuvant nutrition is often started 4-5 d after surgery; in ERAS programs, oral nutrition is started before the day of surgery and 4 h after surgery. It has been shown that when combined with preoperative oral carbohydrates, epidural analgesia and early enteral nutrition, nitrogen balance is promoted while postoperative hyperglycemia is reduced. The importance of multimodal therapy to maintain surgical nutritional status needs to be emphasized. Patients should be encouraged to eat orally as early as 4 h postoperatively, and approximately 400 mL of energy-assisted fluid should be given orally on the day of surgery until they have eaten a normal amount. For malnourished patients should continue to take oral adjuvant nutrients after going home.
17. Get out of bed early after surgery
Prolonged bed rest not only increases insulin resistance and muscle loss, but also reduces muscle strength, impairs pulmonary function and tissue oxygenation, and increases the risk of venous thrombosis. Postoperative pain relief can be well achieved with a portable thoracic epidural pain pump or with routine use of NSAIDs, which are important to promote early movement of the patient. Daily activity levels should be well planned and implemented, and a patient activity diary should be established. The goal is to get out of bed for 2 h on the day of surgery and 6 h daily until discharge.
18. Discharge criteria
The patient can take oral painkillers to relieve pain well; resume eating solid food without intravenous rehydration; and can move freely to the bathroom. If the patient meets all the above requirements and is willing to be discharged, the patient should be discharged. The discharge indications should be strictly observed.
19.Follow-up and outcome assessment
All good surgical practice relies on good monitoring and summary of clinical outcomes, not only to control complications and mortality, but also to provide feedback on the research program and to summarize information for improvement and education. It has been found that the readmission rate for patients undergoing ERAS programs is about 10%-20% when the length of stay is reduced to 2-3d, and a very small number of patients may have anastomotic fistula after going home. Therefore, we should strengthen the follow-up of patients after they go home and establish a clear “green channel” for readmission. Patients should be followed up by telephone within 24-48 hours of going home, and returned to the clinic 7-10 days after surgery for wound removal, discussion of pathology, and planning of further anti-cancer treatment. In general, the clinical follow-up of ERAS should be continued until 30d after surgery.