Enhanced Recovery After Surgery

Enhanced Recovery After Surgery (ERAS) is a modern approach to help people recover more quickly following surgery. Guidelines consist of a combination of evidence-based perioperative care elements that are thought to reduce post-surgical complications, length of hospital stay, and overall costs.

The elements that form ERAS consist of strategies that focus on patient engagement, pre-surgical medical optimisation, optimal anesthetic protocols, and postoperative nausea and emesis prophylaxis.

From the surgical side, key elements in ERAS include minimally invasive surgery, avoiding dehydrating bowel preparations if possible, early removal of drains and catheters, and early postoperative mobilisation.


The ERAS Protocol

The ERAS protocol can be divided into the 3 stages of the patient journey, each comprising several elements

Pre-Operative

  • Patient education regarding the surgery and the expected post-operative course and milestones
    • Most units will have developed a handbook for the patient so they know what to expect every day
  • Ensuring the patient is as healthy as possible prior to surgery, through exercise and weight loss
  • Optimising medical management, including smoking and alcohol cessation
  • Optimal pre-operative fasting guidelines
    • Altered diet prior to surgery to enhance bowel recovery and avoid bowel prep if appropriate
    • Solids allowed until 6 hours pre-operatively (unless contra-indicated)
    • Intake of clear fluids until 2 hours prior to surgery
    • Loading with 12.5% carbohydrate beverage within 2 hours of surgery

Intra-Operative

  • Use of multimodal and opioid-sparing analgesia, including regional anaesthesia and continuous wound infusion where possible
    • Including avoidance of short-acting benzodiazepines in the elderly
  • Use of multimodal postoperative nausea and vomiting prophylaxis
  • Use of minimally invasive surgery
  • Targeting a goal-directed fluid therapy regime, including goal-directed haemostasis management
    • Use of balanced salt-solutions where warranted

Post-Operative

  • Ensure adequate pain control is achieved to allow for early ambulation
  • Early oral intake
  • Multi-disciplinary post-operative patient follow-up, including in the post-acute care phase

Key Points

  • Enhanced recovery schemes aim to help people recover more quickly following surgery
  • It has been shown to reduce post-surgical complications, length of hospital stay, and overall costs
  • Each stage of the surgical journey can be influenced by enhanced recovery

Further Reading

Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials
Greco M et al., World Journal of Surgery

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