Fast-track surgery and enhanced recovery after surgery are programmes that aim to reduce the physical trauma of surgery and achieve a complication-free recovery, thereby shortening hospital stays for patients.
- 17 recognised multimodal elements contribute to ERAS.
- Hospital stay and morbidity are significantly lowered in RCTs of ERAS.
- Readmission rates are similar to conventional regimes.
- There is no increase in mortality in ERAS.
- Anaesthetic monitors to guide fluid therapy, further reduce hospital stay, morbidity and stress response.
Enhanced recovery after surgery (ERAS) is a relatively new method of patient management. It is a collection of strategies that combine in a structured pathway allowing the surgical and anaesthetic teams to decrease the physical insult and aid recovery enabling earlier discharge. This is achieved with fewer complications. Fast-track (FT) programmes originated in Denmark.
Colorectal surgical dogma has insisted that elective surgery should be performed on a fully cleansed bowel in a fasted patient, with a stepwise re-introduction of fluids prior to diet. This traditional teaching has finally been challenged; the evidence suggests that this slow approach actually prolongs the length of stay!
Key elements of ERAS
Preoperative feeding (up to two hours prior to surgery)
No bowel preparation
Fluid restriction (or at least optimisation)
Perioperative high oxygen concentration
Active prevention of hypothermia
Laparoscopic or minimally-invasive incisions
No routine use of NG tubes
No routine use of drains
Enforced postoperative mobilisation
No systemic morphine use
Early removal of urinary catheters
Enhanced preoperative and postoperative nutrition via supplements
Changing expectations and practice
The effectiveness of any ERAS programme is dependant on changing patients’ expectations. Encouraging them to expect a reduced stay, with a shorter, complication-free recovery is the aim. A full explanation of each part of the process, backed up with clear, easy-to-understand written material, helps manage expectations.
The first break from traditional care is the omission of preoperative bowel preparation. A dehydrated patient results in a dehydrated bowel. To decrease dehydration and maintain normal gut function, preoperative feeding with glucose-containing fluids is allowed up to two hours before surgery.
Premedication is s "no-no"; benzodiazepines easily render a patient sleepy and unable to sit up, breathe deeply or drink normaly.
An important element of ERAS is thoracic epidural anaesthesia. This will provide analgesia for the operation itself and for the first 48 hours following theatre. Minimising the need for systemic morphine (and its many debilitating side effects) maintains gut peristalsis throughout surgery because of the sympathetic blockade from the epidural, thereby also helping gut homeostasis.
Fast track in the theatre
A high concentration of oxygen given has the effect of minimising small vessel hypoxia. This results not only in lower infection and anastomotic leak rates but also in the faster resumption of a full diet and function. At the same time, active warming maintains the patient’s core temperature as close as possible to normal. This maintainins immune function, coagulation and myocardial perfusion.
Judicious fluid administration can minimise renal impairment and cognitive dysfunction, as well as surgical complications. The use of oesophageal Doppler and LiDCO cardiac monitors has shown a reduction in morbidity and length of stay after major surgery. The concept of fluid-restrictive regimens in preventing gut oedema from fluid overload may be counter-productive, and there is evidence that more fluid (especially synthetic colloids) given appropriately under Doppler control can further reduce the length of stay by two days. Some studies cite evidence that restrictive fluid regimens are advantageous, but closer examination shows these ‘restricted’ regimens used different fluids (usually colloids) to suggest the appearance of less fluid.
Transverse incisions or laparoscopy decreases surgical trauma and insult. NICE recognises that such techniques are beneficial to patients’ recovery, with a recommendation that all primary cancers be considered for laparoscopic excision. Dissection is within anatomical planes using a power source to avoid blood loss. Drains are avoided wherever possible, as are nasogastric tubes. Urinary catheters are removed as soon as possible, thus enabling early mobilisation. This is aided in the immediate postoperative period, as the anaesthetist has rendered the patient comfortable, nausea-free, alert and awake, and as a result able to take diet and mobilise on the night of operation.