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 hospitalization, and reduce medical costs by reducing postoperative stress, managing pain, and resuming diet and activity early. Costs.
Evidence and recommendation level
The quality of evidence and strength of recommendation based on this consensus are graded according to the GRADE system, with four levels of evidence: high, medium, low, and very low, and two levels of recommendation: strong and general.
Preoperative recommendations.
1. Patients should receive routine preoperative education and consultation, and the education should be carried out 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 (level of evidence: low; level of recommendation: strongly recommended).
3. Fasting for 6 h, water and clear liquid food for 2 h should be performed before surgery (level of evidence: high; level of recommendation: strongly recommended).
4. A comprehensive nutritional risk screening should be performed for all patients before surgery, and nutritional support therapy is feasible for patients with a nutritional risk score ≥ 3, with enteral nutrition support therapy 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; level of recommendation: strongly recommended).
Intraoperative recommendations.
1.Intraoperative hypothermia should be actively prevented: monitor and record body temperature every 30 min; take necessary measures to maintain body temperature ≥ 36℃ (level of evidence: high; level of recommendation: strongly recommended).
2. The choice of surgical access and incision should be based on good exposure of the surgical field and facilitate precise completion of surgical operations (level of evidence: very low; level of recommendation: highly recommended).
3. Hepatobiliary surgery requires the placement of surgical area drains as appropriate, and pancreatic surgery often requires the placement of drains? (Level of evidence: high; Level of recommendation: strongly recommended).
Postoperative recommendations.
1. postoperative use of preventive, scheduled, multimodal analgesia? (Level of evidence: medium; Level of recommendation: strongly recommended).
2. postoperative use of medications to modulate the inflammatory response as appropriate? (Evidence level: moderate; recommendation level: strongly recommended).
3.Prophylactic application of medication and/or mechanical antithrombotic therapy based on risk assessment? (Level of evidence: high; Grade of recommendation: strongly recommended).
4. Can metoclopramide or combined 5-hydroxytryptamine body antagonists be applied postoperatively to prevent nausea and vomiting? (Evidence level: low; recommendation level: highly recommended).
5.Postoperative individualized GDFT to maintain appropriate blood volume (Level of Evidence: High; Grade of Recommendation: Strongly Recommended).
6.Early removal of all drains? (Evidence level: high; recommendation level: highly recommended).
7.Eat liquid food on the day of gastric tube removal and gradually transition to normal diet (Level of evidence: high; Grade of recommendation: highly recommended).
8.Postoperative use of lactulose and other laxatives to promote recovery of gastrointestinal function (level of evidence: low; level of recommendation: generally recommended).
9. Carry out reasonably planned early activities and actively encourage patients to reach their goals (level of evidence: moderate; grade of recommendation: strongly recommended).
The purpose of ERAS programs is to accelerate safe postoperative recovery for the benefit of patients, not to pursue only a reduction in 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 involves not only 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.