The basic premise of Enhanced Recovery After Surgery (ERAS) is that the impact of surgery on the metabolic and endocrine response is reduced leading to earlier recovery. Implementation leads to reduced length of hospital stay and earlier return to productivity. It has also been shown to actually reduce complications without a rise in re-admissions. Beginning with colorectal surgery, the scope of ERAS has gradually been expanded to other surgical sub-specialties. Implementation at an institutional level needs the constitution of a multi-disciplinary team with representatives from all specialties involved in patient care. Nutrition plays a central role in ERAS, with almost all interventions related to it either directly or indirectly.

Multimodal interventions, under the umbrella of a single program applied to the care of the surgical patient in the peri-operative period, have come to be known as Enhanced Recovery After Surgery (ERAS). The basic premise is that the impact of surgery on the metabolic and endocrine response is reduced leading to earlier recovery. Implementation leads to reduced length of hospital stay and earlier return to productivity. It has also been shown to actually reduce complications without a rise in re-admissions. Beginning with colorectal surgery, the scope of ERAS has gradually been expanded to other surgical sub-specialties. With focused research in the area, both contraindications and limitations seem to be diminishing. Implementation at an institutional level needs the constitution of a multi-disciplinary team with representatives from all specialties involved in patient care. Nutrition plays a central role in ERAS, with almost all interventions related to it either directly or indirectly.

Aditya J. Nanavati¹ Subramaniam Prabhakar² 1Surgical Registrar, Department of Surgery, Sir JJ Group of Hospitals, Mumbai, India ²Professor, Department of Surgery, Lokmanya Tilak Municipal Medical College, Mumbai, India

INTRODUCTION
What is Enhanced Recovery After Surgery (ERAS)?

Surgical intervention leads to an endocrine and metabolic stress reaction, which slows down recovery.¹ Effectively modulating these responses to attenuate the impact of surgery may help promote an early recovery and has been associated with reduced²::

• length of stay
• complication rates
• use of analgesia
• costs for patients
• increased patient comfort and satisfaction

A single program incorporating multimodal interventions in the peri-operative period to expedite recovery has come to be known as Enhanced Recovery after Surgery (ERAS), or Fast-track surgery (FTS). The interventions included in ERAS are shown in (but are not limited to) Table 1.The program was initially developed and promulgated for use in colorectal surgery.^3,4 However, recently it has been effectively expanded to various surgical sub-specialties.^5,6

How Does it Work?

The basic principle behind ERAS is successfully delivering surgical care with minimum deviation from normal physiology/functioning. It may be better understood by plotting the physiologic or functional state versus time in the peri-operative period (Figure 1(a). When undergoing surgery, the fall from normal physiologic state actually exceeds a level caused by illness alone. This is due to the endocrine and metabolic impact of the surgical stress.⁷ This is followed by a slow recovery back to a pre-existing level of functioning. When ERAS is implemented a graph is likely to show an earlier recovery (Figure 1 (b). Three distinct phases shown in the graph are pre-, intra-, and post-operative phases. In the pre-operative phase, the upswing in the graph is a reflection of the attempt to optimize the patient. This has also been called ‘prehabilitation’. In the intra-operative phase surgical and anesthetic maneuvers are used to minimize the downswing i.e. the surgical stress response. The small vertical arrow demonstrates a reduced impact observed as a smaller fall in functional status. The post-operative rehabilitation seeks to hasten recovery demonstrated by shortening of the recovery to pre-existing functioning (long horizontal arrow). It may be ideal to rehabilitate the patient to a level as close to optimum as possible (dotted line). A sample institutional protocol and how it differs from conventional care is shown in Table 2.

Why Implement ERAS?

ERAS programs, when implemented successfully, have been associated with a 35-40% reduction in length of hospital stay.⁸ This benefit has been observed without a concurrent rise in complications or re-admissions. Some studies have noted a fall in surgical (anastomotic leaks, etc.), as well as non-surgical complications (nosocomial infections, etc.) in the post-operative period.⁹ ERAS has also been associated with an earlier return to work and productivity.¹⁰ Compared to conventional care, ERAS is associated with better quality of life outcomes.^8,11 Institutes benefit from ERAS as implementation of a structured peri-operative program streamlines patient care. Written protocols are available to staff members minimizing errors in care delivery. Early discharge means patient turnover times are reduced and institutes may be able to serve more patients within the available infrastructure. Another favorable impact of ERAS has

been cost-control. Studies from both developed, as well as developing countries, have noted a 28-32% fall in healthcare costs incurred.^12,13

When Should ERAS be Used?
Are There any Limitations?

ERAS has traditionally been used in elective colorectal surgery. Programs tailored to upper gastrointestinal, hepatobiliary and pancreatic surgeries have been described in recent years.^14,15 Scope of ERAS has been expanded to other surgical sub-specialties like cardiovascular, orthopaedic and gynecologic surgery.^5,6,16 The patient populations in early studies have belonged to the young and middle-aged populations with a few, or no, co-morbidities. There had been some controversy regarding safety and applicability of ERAS in the elderly, but recent evidence suggests that they can achieve success on the program also.¹⁷ Patients needing complex abdominal or pelvic surgery have also been observed to benefit from the program in spite of initial fears of failure. Success with multicavity surgeries like Ivor-Lewis esophagectomy in the elderly on the other hand has been limited.¹⁸ While the horizons of ERAS expand gradually, the limitations and contraindications for it seem to diminish. Tailored programs to various sub-specialties as well as individual surgical procedures help overcome most limitations. However, an important issue is that of compliance. Even in large multi-centric trials, adherence of approximately 65% has been observed.¹⁹ It has been widely acknowledged that full compliance may be difficult to achieve.²⁰

How is it Implemented?

Implementing ERAS at an institutional level requires the formation of a multi-disciplinary team. According to this author, the core team should consist of a representative from each the following branches: surgical, anesthesia, and nursing. Other important members include nutritionists, physicians (belonging to various specialties), physical & occupational therapists and social workers. Membership may be extended to any other staff from specialties/branches who are involved with patient care. This team is given the responsibility of reviewing available literature and formulating the ERAS program to be implemented at their institute. This assumes that the components of the program will be tailored to match locally available expertise and facilities. Each member is expected to communicate the role of his/her specialty in the program. Understanding where the needs of two or more specialties may converge is imperative for the smooth delivery of peri-operative care. Once formulated, written protocols must be made available to all those involved. An important component of implementation is receiving feedback, provisions for which should be provided for within the program.

Feedback is taken in the form of ease of delivering care and problems encountered by each worker within their specialty in carrying out work designated under ERAS programs. Feedback from individual staff members must be made available to the multidisciplinary team at subsequent team meetings. Along with regular audits, feedback provides a sound basis for process improvement to advocate and implement changes to the program. Apart from these internal quality check mechanisms, an external review or audit may be asked for if needed. Once changes are made the entire cycle must be re-initiated.

Nutrition in ERAS

Almost all the interventions in ERAS are either directly or indirectly related to the nutrition of the patient. In the pre-operative period the patient’s nutritional status should be evaluated. Ensuring a good nutritional status is crucial to the success of the program.²¹ Consultation and evaluation by a nutritionist is preferable and should be followed by advice to meet objective dietary goals to achieve designated end-points (like optimum body weight, etc.). ERAS protocols do not recommend specific tools for nutrition screening or assessment. However, a nutritional assessment might include:

• Insufficient oral intake
• Percent unintentional loss of usual body weight over time
• Low BMI

In the immediate pre-operative period under ERAS it is advised to keep starvation time to a minimum. A 2-hour fast for liquids and a 6-hour fast for solids are considered safe and adequate.²² Along with minimal starvation an oral carbohydrate drink 2 hours before surgery is administered (See Table 3 for available options). Oral carbohydrate loading is known to attenuate insulin resistance, minimize protein and muscle loss, and improve patient comfort.^7,23 There is a possibility that scheduling cases in the morning may interfere with the ability to adequately maintain this interval. This must be accounted and planned for in advance. This author prefers to advise patients to consume what they normally would for dinner and administers 100g of an oral carbohydrate drink (complex carbohydrate maltodextrin based formula with water) early in the morning up to 2 hours before surgery; however, even 50gm has been shown to be adequate.²⁴ As an added safety measure, the author’s institution prefers to use a prokinetic agent early in the pre-operative period. The safety and efficacy of avoiding mechanical bowel preparation has been adequately demonstrated with only some controversy remaining around its use in rectal surgery;²⁵ there are surgeons who may still suggest its use in cases of low anterior resections.

Although operative interventions are not directly related to nutrition, it is important to note that any untoward incident in the operating room can impact the nutrition of the patient and, by extension, his/her hospital stay. Principles of minimal tissue handling, selective use of drains and catheters are crucial to be able to promote ambulation, as well as to initiating oral/ enteral nutrition early in the post-operative period and epidural catheter insertion for analgesia in the post- operative period. This has been shown to reduce the incidence of ileus, improve post-operative insulin resistance, improve quality of life scores, facilitate earlier discharge and reduce overall morbidity and mortality after surgery.^26-28 Intra-operative goal-directed fluid therapy²⁹ and minimizing use of opioids/ using opioid antagonists like alvimopam contribute to the early return of bowel function in the post-operative period.³⁰

In the post-operative period nutritional management is carried out in the form of early oral (see Table 4 for one institution’s diet progression post-op) or enteral nutrition (EEN). Within ERAS programs EEN is facilitated by prophylaxis against post-operative nausea and vomiting, epidural analgesia, minimizing use of nasogastric tubes (Salem sump type decompression tubes) and other drains, catheters and tubes. Oral or Enteral nutrition can be started as early as 6-8 hours after surgery.³¹ Even though early post-operative feeding is recommended the evidence base for these recommendations is weak at best³² and there have been varying opinions regarding to the best time to initiate oral feeding. In the experience of this author, an overwhelming majority of the surgeons are more comfortable starting oral feeds on the morning after the surgery. Oral feeding is usually started with liquids. Once tolerated transition to regular diet is immediate while some may prefer to advise eating ad libitum (Food items allowed/excluded in a typical transition diet and a sample menu is shown in Table 5 and Table 6 respectively). Early oral or enteral nutrition has been demonstrated to be safe, promotes sense of well-being, preserves post-operative nutritional profile, reduces incidence of ileus and does not lead to an increase in anastomotic dehiscence.^31,33

CONCLUSION

Developments in ERAS have highlighted the importance of peri-operative care. The ability to achieve a reduced hospital stay, patient satisfaction, and reduced rate of complications without an increase in re-admissions has demonstrated how powerful a tool ERAS can be. ERAS has resulted in a significantly increased understanding of peri-operative physiology and how to modulate it to improve outcomes. This has led to the belief among some that the role peri-operative care plays may be so crucial that it warrants recognition as a separate sub-specialty since it does not exclusively fall into the domain of any of the existing specialties.³⁴ Until ERAS becomes a routine reality, it may be in the best interest of all those involved in the peri-operative care of the surgical patient to be familiar with ERAS and its principles.

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