Perioperative care and surgical equipment, day surgery, ERAS, thromboembolism, stomas, diathermy, sutures, drains

Background and Context

• ERAS (Enhanced Recovery After Surgery) pathways were introduced more than 25 years ago, initially in open colorectal surgery in the 1990s
• Represent a paradigm shift in perioperative care, moving away from fragmented, discipline-siloed management
• Based on the best available evidence in medical literature, with the first ERAS Society guideline addressing colonic resection
• Core aim: integration of evidence-based, multimodal, multidisciplinary interventions that mitigate the undesirable effects of the surgical stress response
• Goals include: speeding patient recovery, improving patient outcomes and satisfaction, shortening hospitalisation, and reducing healthcare costs
• ERAS protocols span the entire perioperative period (preoperative, intraoperative, and postoperative phases)
• Early experience showed that before ERAS implementation, clinical teams had length of stay at the upper end of average, far from the 2-day targets Kehlet's group had demonstrated
• A key early finding was that different units were missing different elements of evidence-based care, leading to highly variable perioperative practice
• Increased ERAS compliance has been shown to improve outcomes in colorectal cancer surgery

Scope of Application

ERAS protocols have been developed and validated across a wide range of surgical specialties:

The Surgical Stress Response

• Surgery triggers a metabolic stress response characterised by neuroendocrine activation, catabolism, immunosuppression, and inflammation
• Traditional perioperative care was fragmented between surgeons, anaesthetists, and nursing staff, without a unified strategy to attenuate this response
• ERAS interventions work in concert to minimise surgical stress at every phase of care

Preoperative Phase

Preoperative Optimisation and Patient Education

• Patients should be seen by the surgeon prior to surgery: this is important for establishing rapport and setting recovery expectations
• Patients who may require a stoma should be seen preoperatively by an enterostomal therapist
• Adequate preoperative stoma site marking improves outcomes
• Preoperative stoma teaching shortens the time required for patients to become proficient in stoma management and reduces hospital stay
• Preoperative assessment allows identification of modifiable risk factors

Prehabilitation

• Prehabilitation (preoperative physical conditioning) has been evaluated in randomised trials for patients undergoing colorectal resection for cancer
• The principle is to build functional reserve before surgery so that postoperative recovery is faster compared to starting rehabilitation only after surgery

Preoperative Fasting and Carbohydrate Loading

• Traditional prolonged fasting (nil by mouth from midnight) is not supported by ERAS evidence
• Preoperative carbohydrate loading is a key ERAS element:
  • A carbohydrate-rich drink given preoperatively reduces preoperative discomfort in elective surgery patients
  • Shown to have beneficial effects on glucose metabolism and gastric contents in patients undergoing moderate surgery
  • Cochrane-level evidence supports preoperative carbohydrate treatment for enhancing recovery after elective surgery
• Carbohydrate loading attenuates the postoperative insulin resistance that is part of the metabolic stress response

Antibiotic Prophylaxis

• Perioperative systemic antibiotics should be given prior to incision
• For colorectal surgery, a typical regimen covers both aerobic and anaerobic intestinal bacteria:
  • A second- or third-generation cephalosporin in combination with metronidazole
• Oral antibiotics (mechanical bowel preparation with oral antibiotic preparation) are also used in colorectal ERAS protocols
• Postoperative antibiotic prophylaxis is not indicated for routine prophylaxis
• Antibiotic coverage is broadened in patients with high-risk cardiac lesions (prosthetic heart valves, previous endocarditis, surgically constructed systemic-pulmonary shunts) and intermediate-risk lesions (mitral valve prolapse, valvular heart disease, idiopathic hypertrophic conditions)

Intraoperative Phase

Anaesthetic Approach

• The choice of anaesthetic technique is integral to ERAS and influences postoperative outcomes
• Strategies that minimise opioid use intraoperatively are preferred, as they reduce postoperative ileus, nausea/vomiting, and sedation

Minimally Invasive Surgery

• Minimally invasive approaches (laparoscopic, robotic) are preferred where possible
• ERAS recommendations for gastrectomy specifically include using minimally invasive approaches when possible
• Minimally invasive surgery reduces the surgical stress response, blood loss, and facilitates early mobilisation and feeding

Fluid Management

• Goal-directed fluid therapy is a cornerstone of intraoperative ERAS
• Avoid both hypovolaemia and fluid overload
• Large-volume resuscitation, when required, should use isotonic crystalloids (normal saline or Hartmann's/lactated Ringer's) with cautious monitoring of clinical endpoints
• Normal saline can cause hyperchloraemic metabolic acidosis in high-volume resuscitation settings
• Colloid solutions (albumin, hydroxyethyl starch, FFP) have not demonstrated a clearly proven benefit over crystalloids in prospective randomised trials
• Careful monitoring of desired clinical endpoints guides ongoing fluid administration

Avoidance of Routine Drains and Tubes

• Nasogastric tube (NGT) decompression: routine use after GI tract surgery is not supported and should be avoided
• For gastrectomy specifically, ERAS society recommendations include no routine use of nasogastric or nasojejunal decompression
• Perianastomotic drains: avoiding these is also specifically recommended after gastrectomy; evidence in colorectal surgery similarly does not support routine drain placement

Temperature Management

• Maintenance of normothermia is an important intraoperative principle
• Perioperative hypothermia is associated with increased surgical site infection, coagulopathy, and impaired recovery

Perioperative Pain Management

Multimodal Analgesia

• Multimodal analgesia is fundamental to ERAS: combining different analgesic classes and routes to achieve adequate pain control while minimising opioid use
• Opioid reduction is critical because opioids cause:
  • Postoperative ileus
  • Nausea and vomiting
  • Sedation impairing early mobilisation
  • Respiratory depression

Thoracic Epidural Analgesia

• Thoracic epidural analgesia is a key component of ERAS for major open abdominal surgery
• Benefits include:
  • Effective analgesia with minimal narcotics
  • Promotion of parasympathetic activity by blunting sympathetic inhibition of the gut, thereby promoting gut motility
  • Improved mental acuity compared to traditional narcotic-based regimens
  • Better overall pain control promoting early mobility, particularly in elderly patients
• The greatest benefit is seen with epidural infusions of local anaesthetic (lidocaine or bupivacaine), compared to epidural narcotics alone

Regional and Abdominal Wall Blocks

• For minimally invasive or laparoscopic intraabdominal procedures, abdominal wall blocks provide analgesic benefit in both adult and paediatric patients
• Examples include:
  • Ilioinguinal-iliohypogastric blocks
  • Quadratus lumborum blocks
• Prospective trials and meta-analyses generally support analgesic benefit, though variability in results exists due to differing approaches
• Abdominal wall blocks are particularly useful in patients with contraindications to epidural analgesia undergoing open intraabdominal surgery

Other Analgesic Agents

• Non-opioid agents (paracetamol, NSAIDs, ketamine, dexamethasone, gabapentinoids) are incorporated into multimodal regimens
• The goal is to reduce or eliminate systemic opioids, especially in the early postoperative period

Postoperative Nausea and Vomiting (PONV) Prevention

• PONV prevention is a discrete and important component of ERAS protocols
• Uncontrolled PONV delays oral intake, prolongs hospital stay, and causes significant patient distress
• Multimodal antiemetic prophylaxis is used, especially in high-risk patients
• Strategies to reduce PONV align with strategies to reduce opioid use

Postoperative Phase

Early Nutrition and Oral Feeding

• Early postoperative oral nutrition is strongly supported by ERAS evidence and is one of its most impactful elements
• For gastrectomy: a weak recommendation exists for offering oral diet starting on postoperative day 1 even after total gastrectomy
• Early feeding attenuates catabolism, supports gut mucosal integrity, and reduces infection risk
• Routine NGT decompression or delay in feeding based on "bowel sounds" is not supported

Postoperative Ileus Management

• Alvimopan is an oral peripherally acting mu-opioid receptor antagonist used to prevent and treat postoperative ileus
• It has been evaluated particularly in colorectal surgery (including minimally invasive colorectal surgery)
• Thoracic epidurals with local anaesthetic also promote gut motility postoperatively (see above)

Early Mobilisation

• Early mobilisation is a key postoperative ERAS element
• Facilitated by adequate pain control (particularly with epidurals and multimodal analgesia), early removal of urinary catheters and IV lines, and early oral nutrition
• Reduces complications including venous thromboembolism, respiratory complications, muscle deconditioning, and hospital-acquired delirium
• Elderly patients particularly benefit from improved pain control strategies that promote early ambulation

Avoidance of Routine Postoperative Drains and Tubes

• Routine perianastomotic drains and NGTs are not indicated postoperatively in the absence of specific clinical concerns
• The evidence base specifically recommends against routine drain use after gastrectomy and in colorectal ERAS protocols

Multidisciplinary and Systems-Level Implementation

• A qualitative understanding of barriers to implementation is essential for successful adoption
• Units that audited their own practice found they were missing different elements, explaining variable outcomes before standardisation
• Compliance with the ERAS protocol (not just its introduction) drives outcome improvement

Outcomes and Benefits of ERAS

• Shortened hospital length of stay
• Reduced postoperative complications (surgical and medical)
• Improved patient satisfaction
• Reduced healthcare costs
• Faster return to baseline functional status and quality of life
• An enhanced-recovery protocol improves outcomes already during the first year of implementation, as demonstrated in consecutive patient series
• Benefits extend beyond colorectal surgery to bariatric, urological, thoracic, and emergency settings
• ERAS has been described as a framework for value-based surgery: optimising outcomes relative to costs

Key Principles Summary

• The power of ERAS lies not in any single intervention but in the cumulative effect of all evidence-based elements applied together across the perioperative continuum
• Audit and feedback on compliance with individual protocol elements is essential to sustain benefit at unit and health-system levels