Enhanced recovery after surgery: Progress in adapted pathways for implementation in standard and emerging surgical settings

Abstract

The concept of enhanced recovery after surgery (ERAS) has been practiced for decades and has been implemented in numerous surgical specialties. ERAS is a global surgical quality improvement initiative, and it is an element in the field of perioperative care. ERAS had shown significant clinical outcomes, patient-reported satisfaction, and improvements in medical service cost. ERAS has been developed for specific surgical procedures, but with the fast progress of newly introduced surgical procedures, the original ERAS have been developed and modified. Recently appearing Topics and future research trends encompass ERAS protocols for other types of surgery and the enhancement of perioperative status, including but not limited to pediatric surgery, laparoscopic and robotic assisted surgery, bariatric surgery, thoracic surgery, and renal transplantation. The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative, operative, and post-operative pathways. ERAS costs are higher than traditional care, but the patient’s clinical outcome and satisfaction are higher. ERAS is in progress in the fields of anesthetic tasks, pediatric surgery, and organ transplantation. Although ERAS has shown significant clinical outcomes, there are needs to modify the protocol for specific cases, hospital facilities, resources, and nurses training on elements of ERAS. Several challenges and limitations exist in the implementation of ERAS that deserve consideration, it includes: Frailty, maximizing nutrition, prehabilitation, treating preoperative anemia, and enhancing ERAS adoption globally are all included.

Key Words: Enhanced recovery after surgery; Anesthesia; Nurses; Elderly; Bowel preparation; ERAS; Perioperative nutrition; Major & ambulatory surgery

Core Tip: Enhanced recovery after surgery protocols (ERAS) is implemented in different surgical settings. The major advantage of ERAS is the early mobilization of the patient, which diminishes the possible risk of postoperative complications, including ileus and thromboembolic events. ERAS protocols include reduction of the period of hunger, acceleration of carbohydrate load, early oral feeding, and early mobilization that accelerates the recovery of normal activities, and reduces recovery time, hospital stay and hospital costs. ERAS is implemented in standard surgical settings; recently, ERAS has been successfully implemented in pediatric surgery, laparoscopy and robotic assisted surgery, and organ transplantation.

INTRODUCTION

Recently, Nag et al[1], and Sun et al[2], published an elaborated article on enhanced recovery after surgery (ERAS) for total knee arthroplasty and in elderly patient who underwent video-assisted thoracic surgery for lung cancer. Both articles presented the experience and benefits of the implementation of ERAS.

The concept ERAS has been practiced for decades and is implemented in different settings. At present, it is an element in the field of perioperative care. ERAS had shown significant clinical outcomes, patient-reported outcomes, and improvements medical service costs. Several challenges and limitations exist in the implementation of ERAS that deserve consideration.

ERAS has been developed for specific surgical procedures. With the fast progress of newly introduced surgical procedures, the original ERAS had been developed and modified to suit and be applicable for a specified procedure

ERAS has achieved significant benefits for patients and the health systems[3-6]. More than 3242 articles and reviews from 1997 to 2022 were published on ERAS in 684 journals in 78 nations, with China and the United States leading the way. The majority of these publications deal with oncology and surgery. Future research trends and recently emerging subjects include enhancing perioperative status and ERAS protocols for various surgical procedures, including pediatric surgery, laparoscopic surgery, robotic assisted surgery, bariatric surgery, thoracic surgery, renal transplantation, hand surgery, gynecologic surgery, and rehabilitation[7-11].

ERAS is an established element in standard surgical settings for oncological and non-oncological surgery. The elements and pathways of ERAS have been developed with the introduction of up-to-date methodologies in the pre-operative, operative, and post-operative pathways. The main elements are adapted for specific surgical procedures.

ADAPTED PATHWAYS FOR ERAS IN NEWLY EMERGING SURGICAL SETTINGS

Enhanced recovery after surgery in pediatric age groups and children

Implementation of ERAS in pediatric urologic surgery was successful in a few series. The safety and efficacy of ERAS protocols in pediatrics have been reported recently; the items of ERAS protocols have been well studied, and items were selected to suit the pediatric age. These selected items of ERAS were applied in specific situations, namely, pediatric augmentation cystoplasty, exstrophy and epispadias complex, and cloacal extropy. Implementation of ERAS has added significant benefits for children without increasing the risk of complications[12,13]. In pediatric age, ERAS components have been modified, targeted by the care pathway, and customized for pediatric urology patients (Table 1)[13].

Table 1 Modified enhanced recovery after surgery pathway in pediatric surgical patients[13].

Preoperative	Intraoperative	Postoperative
Counsel about ERAS, obtained from caregiver	Regional anesthesia with catheter-based block	Prevention of nausea and vomiting
Clear-liquid carbohydrate load (10 mL/kg up to 350 mL)	Avoiding excess drains, intraperitoneal or subcutaneous	Early feeding, clear fluids in post-operative day zero, regular diet on post-operative day one
Avoid prolonged fasting, eat regular diet, clears-only diet is given in the day prior to surgery	Ensure euvolaemia, parenteral fluids are crystalloid administered 4–7 mL/kg/h	Early mobilization, out-of-bed in the post-operative day one
No bowel preparation	Normothermia (36 °C–38 °C during the surgical procedure. (skin-to-skin time/ endoscopy/ laparoscopy)	Adjunctive pain medication (acetaminophen and non-steroidal anti-inflammatory drugs)
Antibiotic prophylaxis	Minimizing opioids (< 0.15 mg/kg intravenous morphine equivalents)	Early stoppage of intravenous fluids (either discontinue or lower rate to keep vein open. Post-operative day two)
Prophylaxis against deep vein thrombosis (age ≥ 14, or presence of risk factors)	Minimally invasive surgical procedures	Early removal of extra drains/catheters. Non-urinary drain is removal by post-operative day four

ERAS: Enhanced recovery after surgery.

Enhanced recovery after surgery for elderly patients

Enhanced recovery in colorectal surgery entails multiple modes and a multidisciplinary approach aiming at reducing surgical stress, early recovery, and early mobilization through optimization in the pre-, intra-, and postoperative care of the patients. ERAS was implemented safely in elderly patients with multiple comorbidities who underwent colectomy[6]. ERAS was implemented in elderly patients with a high body mass index who had undergone laparoscopic cholecystectomy[14].

The two main components that have been emphasis in the elderly are the pre- and post-rehabilitation programs and the shortening of preoperative fasting time.

However, different studies showed that the patients who had the ERAS protocol had a significantly shorter preoperative fasting time and alleviated preoperative hunger sensations compared to the non-ERAS patients. When compared to patients in the non-ERAS protocol group, elderly patients in the ERAS protocol group showed better results in terms of length of hospital stay, postoperative pain scores, postoperative hunger scores, and satisfaction levels.

Enhanced recovery after surgery recommendations for renal transplantation

The evidence foundation for ERAS in kidney transplantation is still weak when compared to other surgical specialties. The use of ERAS was found to shorten hospital stays without changing readmission rates in six trials involving a total of 1225 individuals. Applying the already available evidence has resulted in significant improvements to patient outcomes. This has demonstrated that ERAS is a safe, practical procedure for kidney transplant surgery that offers better postoperative results[15].

Enhanced recovery after surgery for laparoscopic colorectal surgery

ERAS has been widely used in colorectal laparoscopic surgery. Nonetheless, a number of studies have discovered that not all patients benefit from ERAS treatments. 1463 participants from seven studies were examined. The majority of the time, a prolonged duration of stay following surgery was linked to the criterion of ERAS failure. Identified risk factors were more intraoperative blood loss, longer operative duration. However, these elements are not directly related to ERAS rather it was related to the surgical performance. These findings will direct the doctor to take different action in a timely manner[16].

ROLE OF ANESTHESIA IN ENHANCED RECOVERY AFTER SURGERY PROTOCOLS

Protocols for Enhanced Recovery After Surgery (ERAS) and procedures for interventional loco-regional anesthesia (LRA) have been evolving continuously. In addition to introducing several novel techniques to supplement ERAS procedures, ultrasound-guided regional anesthesia has resulted in the improvement of conventional methods. LRA can be used in more and more ERAS indications because to its effectiveness and adaptability. One of the main therapies enhancing postoperative outcomes is the combination of multimodal analgesic strategies with regional anesthetic procedures[17,18] (Table 2).

Table 2 Anesthetic task in enhanced recovery after surgery.

Preoperative	Intraoperative	Postoperative
Preoperative counseling & patient evaluation with requires investigators including laboratory work	Shot acting anesthetics and analgesics. Multimodal opioid sparing and pain management plan should be used and implemented before the induction of anesthesia. Narcotic alternatives that decreases opioid needs are: acetaminophen, non-steroidal anti-inflammatory drugs, 2-agonists as clonidine and gabapentin, and IV Xylocaine infusion	Shifting of the patient to the surgical ICU. On arrival of the patient in the ICU, all laboratory tests should be done: Chest X-ray, arterial blood gases, checking hemodynamic stability, verification of the lines, body temperature, making sure that the patient is warm enough and pain-free, as well as baseline monitoring
Patient education and information in collaboration with the surgeon, and nursing staff	Restricted sodium and fluid infusion. Goal directed fluid therapy. Prevent hyponatremia, and optimization of intravascular volume avoiding hypo or hypervolemia. The use of electrical cardiometry device could be a guide to goal-directed fluid therapy, noninvasive determination of stroke volume and cardiac output	No nasogastric tube
Scheduling period of fasting or no fasting	Regional anesthesia (when indicated): (1) Epidural anesthesia (mid-thoracic, lumbar, epidural catheter should be inserted between T5 and T8 roots levels); (2) Lumbar nerve block; (3) regional nerve block; and (4) local anesthesia	Post-operative pain relief is either through an epidural catheter that should be removed 12 h before application of anticoagulant or the use of patient-controlled analgesia
Preoperative carbohydrate drinks are recommended for patients without diabetes. In adults, clear fluid is given 5–6 h before the procedure, and in pediatrics, 2 h	Prevent hypothermia: Body& limbs warming. Maintaining intraoperative normothermia with either passive (surgical draping, sheets, and blanket), or active with electric heating blanket, space heater, or the burr hugger	Encourage early and progressive patient mobilization
Nutritional status should be assessed using a systemic screening tool, and malnourished patients should be optimized with oral Supplements, or parental nutrition	Prevention of PONV. Preemptive multimodal antiemetic prophylaxis should be used in all at-risk patients to reduce PONV. An intervention for patients determined to be high-risk for PONV is the administration of dexamethasone (8 mg) at the induction of anesthesia and ondansetron (Zofran) (4 mg) at emergence from anesthesia. The combination of ondansetron with dexamethasone is superior to single-agent therapy in the prevention of PONV in moderate- to high-risk patients undergoing abdominal surgery	Non-opioid analgesia
Prophylactics for thromboembolic events	Patients at high risk, it is recommended to use low-molecular-weight heparin	Early removing of urinary catheter
Antibiotic prophylactic		Evaluation of outcome

PONV: Post-operative nausea and vomiting; ICU: Intensive care unit.

The ERAS pathway has a number of components that enhance hemodynamic and perioperative fluid treatment. Liberal fluid treatment has been replaced by more customized methods in modern perioperative fluid management. One critical component is ensuring appropriate mean arterial pressure and preventing intraoperative hypotension. Heart output monitoring is used in goal-directed hemodynamic treatment (GDHT) to direct the administration of fluid and vasopressors, reduces complications and is best suited to high-risk patients or in high-risk procedures. ERAS pathways aid in providing proper hemodynamic management regarding fluid and hemodynamic therapy approaches[19]

Economic, cost, and clinical benefits of enhanced recovery after surgery in major oncology surgery

Pancreaticoduodenectomy: ERAS accelerates recovery and improves clinical outcomes. However, the evidence on cost benefit of ERAS has not been well evaluated in terms of cost benefit, compliance, and clinical benefits. A study on pancreaticoduodenectomy comparing ERAS programs and traditional care on hospital cost, length of stay, complications, delayed gastric emptying, readmission, reoperation, mortality, and compliance. The study showed that hospital costs were significantly reduced in the ERAS group, and the length of stay was shortened by 3.15 d in the ERAS group. Fewer patients in the ERAS group had complications. Incidences of delayed gastric emptying had significantly decreased in the ERAS group. The number of deaths was fewer in the ERAS group. ERAS implementation did not change readmissions and reoperations rate compared to traditional techniques. ERAS delivers significant cost savings, better clinical outcomes, and a lower rate of complications[20].

Hepatectomy: Addressing the economics of ERAS compared to conventional treatment, multiple elements are considered: Cost-effectiveness analysis, cost-benefit analysis and cost-minimization analysis, and capital flow diagram analysis. ERAS considerably lowers the overall social cost ($5958.67 vs $6725.80) and the financial burden of disease on patients ($8935.02 vs $10470.02). The average daily cost per capita in the ERAS group increased ($669.51 vs $589.98), according to a capital flow diagram study, but the advantages were contingent on lower hospital stays and less productivity loss. ERAS reduces the average length of stay, consequently reducing the economic burden and promoting the hospital bed turnover rate[21].

The role of nurses within enhanced recovery after surgery

As the healthcare providers that interact with patients the most during the perioperative pathway, nurses are recognized for their critical role in implementing numerous ERAS components. To guarantee highly educated nurses and optimal ERAS implementation, ongoing ERAS training will be necessary.

Nurses may fulfill extended roles in the postoperative period in certain types of surgery, such as coordinating pain management, mobilization, and oral feeding, along with the collection and analysis of data. Nurses should have a significant role in the preoperative period, the early postoperative phase, and the follow-up period[22].

CONCLUSION

The concept of ERAS has been practiced for decades; it has been developed and modified for implementation in mostly all surgical specialties. Recently, ERAS has been implemented in pediatric surgery, elderly patients, laparoscopic and robotic surgery, and organ transplantation. Eras costs are higher than traditional care; on the other side, the benefit of ERAS for the patient’s clinical outcome and satisfaction is higher. ERAS is in progress in anesthetic tasks, pediatric surgery, and organ transplantation. Although ERAS has shown significant clinical outcomes, there are needs to modify the protocol to the specific case, hospital facilities, resources, and nurses training on elements of ERAS.