Enhanced recovery programs are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. These protocols include evidence-based techniques to minimize surgical trauma and postoperative pain, reduce complications, improve outcomes, and decrease hospital length of stay, while expediting recovery following elective procedures.Protocols have been developed for colorectal surgery patients to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery

1. Dr. Deep Goel, FACS (USA), FRCS (England)
Director
Department of Surgical Gastro-oncology, Bariatric & Minimal
Access Surgery
Centre for Digestive and Liver Disease
BLK Super Specialty Hospital, New Delhi.
ERAS Protocols and Its Relevance
- Evidence Based

2. Disclosure
• Consultant and mentor- J & J
• Advisory consultant- Medtronics

3. Pub med Search
• Key words
– ERAS
– Enhance recovery
– Colon surgery
– Newer guidelines
– Colon cancer treatment
– Laparoscopic colonic surgery

4. Pub Med Search + Guidelines
+ Recommendations
• The European Society for Clinical Nutrition and
Metabolism
• The International Association for Surgical
Metabolism and Nutrition 2012
• American Society for Colon and Rectal Surgery
• World Journal of Surgery

5. N Engl J Med 270:825–827
Reduction of postoperative pain by encouragement and instruction of patients. a study of doctor-patient
rapport.
Egbert LD, Battit GE, Welch CE, Bartlett MK (1964)
Surg Endosc 26(6):1730–1736
The effect of perioperative psychological intervention on fatigue after laparoscopic cholecystectomy: a
randomized controlled trial.
Kahokehr A, Broadbent E, Wheeler BR, Sammour T, Hill AG (2012)
Br J Surg 86(7):869–874
Preoperative alcoholism and postoperative morbidity.
Tonnesen H, Kehlet H (1999)
Dis Colon Rectum 47(8):1397–1402
Physiologic effects of bowel preparation.
Holte K, Nielsen KG, Madsen JL, Kehlet H (2004)
BMC Surg 7:5
Preoperative mechanical preparation of the colon: the patient’s experience.
Jung B, Lannerstad O, Pahlman L, Arodell M, Unosson M, Nilsson E (2007)
Acta Anaesthesiol Scand 40(8 Pt 2):971–974
Fasting guidelines in different countries.
Eriksson LI, Sandin R (1996)
Anesth Analg 93(5):1344–1350
A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients.
Hausel J, Nygren J, Lagerkranser M, Hellstrom PM, Hammarqvist F, Almstrom C et al (2001)
Dis Colon Rectum 53(10):1355–1360
How much do we need to worry about venous thromboembolism after hospital discharge? A study of
colorectal surgery patients using the National Surgical Quality Improvement Program database.
Fleming FJ, Kim MJ, Salloum RM, Young KC, Monson JR (2010)
Cochrane Database Syst Rev 3:CD001484
Elastic compression stockings for prevention of deep vein thrombosis.
Amaragiri SV, Lees TA (2003)
J Am Coll Surg 213(5):596–603 603 e1
Perioperative pharmacologic prophylaxis for venous thromboembolism in colorectal surgery.
Kwon S, Meissner M, Symons R, Steele S, Thirlby R, Billingham R et al (2011)
Ann Surg 250(1):10–16
Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the trial to reduce
antimicrobial prophylaxis errors.
Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ et al (2009)
Arch Surg 142(7):657–661
Randomized, multicenter trial of antibiotic prophylaxis in elective colorectal surgery: single dose vs 3 doses
of a second-generation cephalosporin without metronidazole and oral antibiotics.
Fujita S, Saito N, Yamada T, Takii Y, Kondo K, Ohue M et al (2007)
JAMA 290(18):2455–2463
Efficacy of postoperative epidural analgesia: a meta-analysis.
Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL (2003)
Cochrane Database Syst Rev 8(12):CD007705
Perioperative transversus abdominis plane (TAP) blocks for analgesia after abdominal surgery.
Charlton S, Cyna AM, Middleton P, Griffiths JD (2010)
Ann Surg 254(6):868–875
Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in
patients undergoing colonic surgery: a randomized clinical trial (LAFA-study).
Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF et al (2011)
Int J Colorectal Dis 26(4):423–429
The role of nasogastric tube in decompression after elective colon and rectum surgery: a meta-analysis.
Rao W, Zhang X, Zhang J, Yan R, Hu Z, Wang Q (2011)
N Engl J Med 334(19):1209–1215
Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten
hospitalization. Study of Wound Infection and Temperature Group.
Kurz A et al (1996)
JAMA 277(14):1127–1134
Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events.A randomized
clinical trial.
Frank SM et al (1997)
Lancet 347(8997):289–292
Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty.
Schmied H et al (1996)
Br J Surg 94(4):421–426
Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery.
Wong PF, et al (2007)
Proc Nutr Soc 69(4):488–498
A meta-analysis of randomised controlled trials of intravenous fluid therapy in major elective open
Ann Surg 240(6):1074–1084 discussion 1084-5
Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-
analyses.
Petrowsky H, Demartines N, Rousson V, Clavien PA (2004)
Reg Anesth Pain Med 34(6):542–548
Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic
epidural analgesia.
Zaouter C, Kaneva P, Carli F (2009)
Colorectal Dis 8(5):375–388
Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer.
Tjandra JJ et al(2006)
Dis Colon Rectum 50(12):2149–2157
Use of chewing gum in reducing postoperative ileus after elective colorectal resection: a systematic review.
Chan MK, Law WL (2007)
Cochrane Database Syst Rev 1:CD004088
Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-
abdominal surgery.
Werawatganon T, Charuluxanun S (2005)
Colorectal Dis 12(2):119–124
The evolution of analgesia in an ‘accelerated’ recovery programme for resectional laparoscopic colorectal
surgery with anastomosis.
Zafar N, Davies R, Greenslade GL, Dixon AR (2010)
Acta Anaesthesiol Scand 50(9):1152–1160
Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five
BMJ 323(7316):773–776
Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-
analysis of controlled trials.
Lewis SJ, Egger M, Sylvester PA, Thomas S (2001)
Br J Surg 94(5):555–561
Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery.
Han-Geurts IJ, Hop WC, Kok NF, Lim A, Brouwer KJ, Jeekel J (2007)
Ann Surg 255(6):1060–1068
A meta-analysis of the effect of combinations of immune modulating nutrients on outcome in patients
undergoing major open gastrointestinal surgery.
Marimuthu K, Varadhan KK, Ljungqvist O, Lobo DN (2012)
N Engl J Med 345(19):1359–1367
Intensive insulin therapy in the critically ill patients.
van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M et al (2001)
Ann Surg 254(6):868–875
Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in
patients undergoing colonic surgery: a randomized clinical trial (LAFA-study).
Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF et al (2011)
Arch Surg 146(5):571–577
Adherence to the Enhanced Recovery After Surgery protocol and outcomes after colorectal cancer surgery.
Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J (2011)
Clin Nutr 29(4):434–440
The Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing major elective open
colorectal surgery: a meta-analysis of randomized controlled trials.

6. What is ERAS
• Stands for Enhanced Recovery after Surgery
• The immediate challenge to improve the quality of
surgical care by not discovering new knowledge but
by integrating what we already know
• Initiated by Professor Henrik Kehlete in 1990’s

7. Enhanced Recovery is ……
• Evidence-based clinical pathways
• Multidisciplinary in scope
• Outcome driven
• Better for patients
• Better for healthcare organizations
• “Complex” task to implement upto 20 elements

8. Recommendation's of ERAS Society
Based on quality of evidence
– High
– Moderate
– Low
– Very low
Recommendation's
– Strong recommendation- Means panel is confident that
desirable effects outweigh the undesirable effects
– Weak recommendation’s-Panel is less confident that
desirable effects outweigh undesirable effects.

9. Recommendations
• Pre-operative
• Intra operative
• Post operative

10. – Diminishes fear and anxiety
– Improve post-op recovery
– Quicken hospital discharge
– Improves wound healing and recovery after lap surgery
Evidence Low
Recommendation Strong
Pre-admission information, education
and counseling

11. Pre-operative Medical Optimization
• It is necessary
• Alcohol abuse
– wound and cardio pulmonary complications
• One month of abstinence improve results
Evidence Low to High
Recommendation Strong

12. Pre-op Bowel Preparation
• Mechanical bowel preparation
– Causes dehydration
– Spillage of bowel contents
– Prolonged ileus
– Bowel preparation should be avoided
Evidence High
Recommendation Strong

13. Pre-op Fasting & Carbohydrate
Treatment
• Clear and high carb liquid should be allowed
up to 2 hrs prior to surgery
• Solid food up to 6 hrs prior to surgery
Evidence Moderate
Recommendation Strong

14. • Long acting sedative premedication should be avoided
within 12 hrs of surgery because it affects immediate
post-op recovery by impairing mobility and oral intake.
• Short acting anesthetic drugs combined with regional
anesthetic procedures like spinal anesthesia & field
blocks should be encouraged.
Evidence High
Recommendation Strong
Pre-anesthetic Medication

15. Prophylaxis against Thrombo-Embolism
• The incidence of asymptomatic DVT in colorectal
surgery is 30% and fatal pulmonary embolism in 1%.
• All colorectal patients should receive mechanical
thrombo prophylaxis to reduce DVT.
• Use of LMWH reduces DVT and VTE.
Evidence High
Recommendation Strong

16. Antimicrobial Prophylaxis
• IV antibiotics - 30-60 min before the incision
• Repeat doses during prolonged procedures
may be beneficial.
Evidence High
Recommendation Strong

17. Standard Anesthesia Protocol
• Tri-modal approach
– A regional anesthesia block used in addition to GA
• Reduced post-op use of opiates
• Rapid awakening from anesthesia
• Early enteral intake and mobilization
• Use of epidural analgesia is superior to opioids
Evidence Low to High
Recommendation Strong

18. Post-op Nausea and Vomiting (PONV)
• Regional anesthesia technique like epidural TAP block
has reduced the opiates use and thus PONV.
• Use of NSAIDS as an alternative to opiate is well
established
Evidence Low
Recommendation Strong

19. Laparoscopy and Modifications of
Surgical Access
• Laparoscopic surgery for colonic resection is
recommended if expertise is available
Evidence Low to High
Recommendation Strong

20. Naso-gastric Intubation
• Post operative NG should not be used routinely
• NG tube should be removed before reversal of
anesthesia.
Evidence High
Recommendation Strong

21. Preventing Intra-op Hypothermia
• Hypothermia (<36 degree C) can cause cardiac
events, bleeding and wound infection.
• Normothermia to be maintained with
warming device and warm IV fluid.
Evidence High
Recommendation Strong

22. Peri-operative Fluid Management
• Fluid overload can cause bowel and lung
edema.
• Fluid shift should be minimized by
– Avoid bowel preparation
– Maintain hydration upto 2 hrs before surgery
– Avoid blood loss
Evidence High
Recommendation Strong

23. Drainage of Peritoneal Cavity after
Colonic Resection
• Routine drainage is discouraged
Evidence High
Recommendation Strong

24. Urinary Drainage
• Routine transurethral bladder drainage for 1-2
days is recommended.
• Catheter should be removed early.
Evidence Low
Recommendation Strong

25. Post-operative Recommendation
• Lap colonic resection leads faster return of bowel
function.
• Fluid overload to be avoided to prevent ileus
• Peri-operative chewing gum reduces ileus.
Evidence High
Recommendation Strong

26. Post-operative Analgesia
• Optimal analgesia should give
- Good pain relief
- Allow early mobilization
- Early return of gut function and feeding
Evidence High
Recommendation Strong

27. Post-op Analgesia
• Low dose epidural local anesthetic with short
acting opiates gives good analgesia decreases
risk of hypotension due to sympathetic block.
Evidence High
Recommendation Strong

28. Peri-operative Nutritional Care
• Under ERAS protocol early enteral feeding
– Reduce risk of infection
– Reduce hospital stay
– No anastomotic dehiscence
Evidence High
Recommendation Strong

29. Peri-operative Nutritional Care
• Immuno-nutrition containing arginine,
glutamine, Omega-3 fatty acids are used.
Evidence Low
Recommendation Weak

30. Post-operative Control of Glucose
• Hyperglycemia is a risk factor for complication.
Patients with higher pre-op HBA1C level has more
complications.
• Control of hyperglycemia showed improved results
• ERAS protocol improves insulin action.
Evidence Moderate
Recommendation Strong

31. Early Mobilization
• Reduce chest complication
• Counteract insulin resistance
• Improves muscle strength
Evidence Low
Recommendation Strong

32. Audit
• Periodic auditing is a key element in ERAS
programme and improves quality of
healthcare.
Evidence Moderate
Recommendation Strong

33. Outcomes of ERAS
• ERAS versus traditional peri-operative care
– Early recovery & discharge from hospital
– Morbidity
– Re-admission
– cost
Evidence Low to High
Recommendation Strong

34. GIS Team