Enhanced recovery after surgery (ERAS) is a series of evidence-based measures to optimize perioperative management for rapid recovery, and to reduce postoperative complications, shorten postoperative hospital stays, and reduce medical costs by reducing postoperative stress, managing pain, and resuming diet and activity early. The purpose of ERAS is to reduce postoperative complications, shorten postoperative hospital stay, and reduce medical costs by reducing postoperative stress, managing pain, and resuming diet and activity early.
The Chinese Journal of Gastrointestinal Surgery, Vol. 15, No. 1, January 2016, published an expert consensus on accelerated recovery after hepatobiliary and pancreatic surgery, and the main points of the article are as follows.
Levels of evidence and recommendations
The quality level of evidence-based medical evidence and the strength level of recommendation based on this consensus were graded according to the GRADE system, with four levels of evidence: high, medium, low, and very low, and two levels of recommendation: strongly recommended and generally recommended.
Preoperative recommendations.
1. Patients should receive routine preoperative education and counseling, and the education should continue throughout the perioperative period until the patient is discharged from the hospital (Evidence level: Low; Recommendation level: Strongly recommended).
2. Preoperative routine bowel preparation is not necessary (Evidence level: low; Grade: strongly recommended).
Fasting for 6 h, water and clear liquids for 2 h before surgery (Evidence level: high; Grade of recommendation: strongly recommended). 4.
Preoperatively, all patients should be screened for nutritional risk, and nutritional support therapy is feasible for patients with a nutritional risk score ≥ 3, with enteral nutrition support therapy being preferred (level of evidence: low; level of recommendation: general recommendation).
5. Preoperative routine application of anxiolytic drugs is not necessary (level of evidence: moderate; level of recommendation: general recommendation).
6. Preoperative routine prophylactic application of broad-spectrum antimicrobial drugs (level of evidence: high; grade of recommendation: strongly recommended).
Intraoperative recommendations.
1. Intraoperative hypothermia should be actively prevented: monitor and record temperature every 30 min; take necessary measures to maintain a temperature ≥ 36°C (Level of evidence: high; Grade of recommendation: strongly recommended). 2.
The choice of surgical approach and incision should be based on good visualization of the surgical field and precise completion of the operation (Level of Evidence: Very Low; Level of Recommendation: Strongly Recommended).
3. Placement of surgical area drains as appropriate for hepatobiliary surgery and often for pancreatic surgery (Level of Evidence: High; Grade of Recommendation: Highly Recommended).
Postoperative recommendations.
1. postoperative prophylactic, scheduled, multimodal analgesia (Level of Evidence: Moderate; Level of Recommendation: Strongly Recommended).
2. postoperative use of medications to modulate the inflammatory response as appropriate (Level of Evidence: Moderate; Grade of Recommendation: Strongly Recommended).
3. prophylactic pharmacologic and/or mechanical antithrombotic therapy based on risk assessment (Level of Evidence: High; Grade of Recommendation: Strongly Recommended).
4. Postoperative metoclopramide or combined 5-hydroxytryptamine antagonists may be used to prevent nausea and vomiting (Level of evidence: low; Grade of recommendation: strongly recommended).
Postoperative individualized GDFT to maintain appropriate blood volume (Level of Evidence: High; Grade of Recommendation: Strongly Recommended).
6. early removal of all drains (Level of Evidence: High; Grade of Recommendation: Strongly Recommended).
7. fluid food on the day of removal of the gastric tube and gradual transition to a normal diet (Level of Evidence: High; Grade of Recommendation: Highly Recommended).
8. postoperative use of laxatives such as lactulose to promote recovery of gastrointestinal function (Level of Evidence: Low; Grade of Recommendation: Generally Recommended)
9. conduct reasonably planned early activities and actively encourage patients to reach their goals (Level of Evidence: Medium; Grade of Recommendation: Strongly Recommended).
The goal of ERAS programs is to accelerate safe postoperative recovery for the benefit of the patient, not just to pursue a shorter postoperative hospital stay. The key to the ERAS protocol is to reduce the complication rate and severity level of patients after reasonable management measures, based on which the postoperative hospital stay can be safely reduced.
Hepatobiliary and pancreatic surgery not only involves 3 major organs, namely liver, biliary tract and pancreas, but also often involves gastrointestinal, spleen and vascular, and affects the functions of important systems such as digestion, circulation and immunity. The specific plan for ERAS cannot be generalized to different regions, different diseases, different procedures and patients. This article provides reference recommendations for general hepatobiliary and pancreatic surgery, which can be implemented in clinical practice on a case-by-case basis.