Update of the American Guidelines for Enhanced Recovery After Surgery (ERAS) in Colorectal Surgery

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The American Society of Colon and Rectal Surgery and the American Society of Gastrointestinal and Endoscopic Surgery published in the first edition of the journal Diseases of Colon and Rectum in 2023 the updates (the last version was from 2017) of the guidelines for accelerated recovery in the postoperative period of colorectal surgery.

Advanced recovery protocols are a set of standardized perioperative processes, whose content can vary significantly, that are applied to patients undergoing elective surgeries. They are designed to improve patient outcomes, such as relieving nausea and pain, early return of intestinal function, and reducing wound infection rates and length of stay. Here, we will talk about the main measures mentioned to improve patient outcomes after elective colon and rectal resections.

As is known, colorectal surgery has always been associated with longer hospital stays, higher costs, and higher surgical site infection rates (about 20%) compared to procedures from other specialties. In addition, high rates of nausea and vomiting (80%), which also delay hospital discharge, and readmission (35%). It has been shown that the implementation of ERAS in colorectal surgery reduces morbidity rates and decreases the length of stay without increasing readmission rates.

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PREOPERATIVE INTERVENTIONS

Pre-admission counseling

• Preoperative discussion about clinical objectives and discharge criteria should be conducted before surgery. Adherence to an advanced recovery protocol that includes preoperative patient education is associated with decreased length of stay and decreased complication rates.
• Patients who will undergo ileostomy creation should receive guidance on stoma management and advice on how to avoid dehydration, which reduces the length of stay and readmission rates.

Pre-Admission Nutrition and Colon Preparation

• Clear liquids can be continued up to 2 hours before general anesthesia. This intervention, according to several randomized clinical trials, is safe and improves patients’ sense of well-being.
• Intake of carbohydrate-rich beverages should be encouraged before surgery in non-diabetic patients to attenuate surgery and fasting-induced insulin resistance. The studies that evaluated this measure showed a reduction in the length of stay, but there were no differences in complication rates or other outcomes.
• Oral nutritional supplementation is recommended in malnourished patients before elective colorectal surgery, aiming for a protein intake of 1.2 to 1.5g/kg/d for a period of 1 to 2 weeks, which decreased postoperative complications. On the other hand, the efficacy of immunonutrition, supplementation containing immunomodulatory nutrients such as arginine, fish oil (omega-3 fatty acids), nucleotides, and glutamine, over standard high-protein oral nutritional supplements remains controversial.
• Mechanical colon preparation combined with preoperative oral antibiotics is usually recommended before elective colorectal surgery. A meta-analysis of seven randomized clinical trials including 1,769 patients comparing colon preparation with and without oral antibiotics, showed a reduction in surgical site and operative wound infection. In a retrospective analysis of a national database from the United States, colon preparation with oral antibiotics was associated with decreased overall morbidity, wound infection, anastomotic dehiscence, and intra-abdominal infections.

Pre-admission optimization

• Multimodal prehabilitation, which is the improvement of the patient’s general clinical conditions, before elective colorectal surgery, may be considered for patients with multiple comorbidities or with significant performance loss, especially in patients who will undergo open surgery.

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PERIOPERATIVE INTERVENTIONS

Surgical Site Infection

• There should be a set of measures to reduce surgical site infection. There are several items described in the literature, but there is no universal standardization. The measures include chlorhexidine bath, colon preparation with oral antibiotic administration, intravenous antibiotics within one hour after incision, and standardization of surgical field preparation with chlorhexidine/alcohol. Surgical measures include the use of a wound protector, changing gowns and gloves before closing the aponeurosis, using an exclusive instrument box for closure, antimicrobial sutures, limiting traffic in the operating room, and maintaining controlled blood glucose and normothermia.

Pain Control

• A multimodal pain control plan, avoiding opioids, should be implemented before the induction of anesthesia. Several studies have shown that minimizing opioids after colorectal surgery is associated with an earlier return of intestinal function and a shorter length of stay. Measures include the use of simple analgesics (dipyrone, paracetamol) and non-hormonal anti-inflammatory drugs, especially selective ones (such as cyclooxygenase inhibitors) and ketorolac, analgesic blocks, such as lumbar square and transverse abdomen, and wound infiltration and spinal analgesia with intrathecal administration of morphine.
• Thoracic epidural analgesia, although not recommended for routine use in laparoscopic colorectal surgery, is an option for open colorectal surgery if a dedicated pain team is available for postoperative treatment.

Perioperative Nausea and Vomiting

• The use of prophylactic and multimodal antiemetics reduces perioperative nausea and vomiting. Risk factors for the development of postoperative vomiting include female sex, previous history of postoperative vomiting or nausea, non-smoker, young age, laparoscopic surgery, use of respiratory anesthesia, prolonged operative time, and opioid analgesia. Several prospective and observational studies show that combined therapy using two or more antiemetics to prevent nausea and vomiting is superior to a single agent. A meta-analysis of nine randomized clinical trials including 1,089 patients, showed that dexamethasone combined with other antiemetics provided significantly better prophylaxis than a single antiemetic, decreased the need for rescue therapy, and did not increase postoperative infections or significantly affect glycemic control.

Fluid Management

• Fluid administration should be adapted to avoid excessive fluid administration and volume overload or undue fluid restriction and hypovolemia. Both intravenous fluid overload and hypovolemia can significantly impair organ function, increase postoperative morbidity, and prolong hospital stay.
• Crystalloid solutions balanced with chloride restriction should be used for maintenance infusions and fluid boluses in patients undergoing colorectal surgery. There is no benefit in the routine use of colloid solutions for bolus fluids.
• Intraoperative hypotension should be avoided, as even short periods of mean arterial pressure <65 mmHg are associated with adverse outcomes, particularly myocardial injury and acute kidney injury.
• In high-risk patients and in patients undergoing colorectal surgery with anticipated significant intravascular losses, goal-directed hemodynamic therapy is recommended. Objective measures of hypovolemia, such as cardiac output, stroke volume, oxygen supply, oxygen extraction, and mixed venous oxygen saturation and dynamic indices of fluid responsiveness (for example, pulse pressure variation or stroke volume variation) can help decide whether intravenous fluids should be administered for resuscitation purposes.
• In the absence of surgical complications or hemodynamic instability, intravenous fluids should routinely be discontinued in the immediate postoperative period.

Surgical Approach

• A minimally invasive surgical approach should be used when available experience and when appropriate.
• The routine use of nasogastric tubes and intra-abdominal drains for colorectal surgery should be avoided.

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POSTOPERATIVE INTERVENTIONS

Patient mobilization

• Early and progressive patient mobilization is associated with a shorter length of stay.

Prevention of Paralytic Ileus

• Patients should be offered a regular diet within 24 hours after elective colorectal surgery. Early feeding is associated with a decrease in hospital stay, a faster return of gastrointestinal tract function, and a shorter time to flatus and first bowel movement.
• Simulated feeding (i.e., chewing gum for ?10min 3–4× a day) after colorectal surgery is safe, results in small improvements in gastrointestinal recovery, and may be associated with a reduction in length of stay.

Urinary Catheters

• Urinary catheters should normally be removed within 24 hours after elective high colon or rectal resection, regardless of the use of thoracic epidural analgesia.
• Generally, urinary catheters should be removed within 24 to 48 hours after mid/lower rectal resection. Manipulation and dissection near the bladder and lateral pelvic nerves during proctectomy can increase the risk of postoperative urinary retention.

Discharge criteria

• Hospital discharge before bowel movement may be offered to selected patients. Traditional discharge criteria after colorectal surgery include the presence of bowel movement along with tolerance to oral intake, adequate pain control with oral analgesia, and the ability to mobilize in the absence of complications. Many patients meet these criteria on the first or second day after surgery. However, there are increasing reports of same-day discharge, which depends on the feasibility of discharging patients before the return of intestinal function for very selected patients, with the possibility of close follow-up and adequate home support. This is an area with limited but evolving evidence. Recommendations may change as more evidence becomes available.

References

1. Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum. 2023 Jan 1;66(1):15-40.
2. Chen M, Song X, Chen LZ, Lin ZD, Zhang XL. Comparing mechanical bowel preparation with both oral and systemic antibiotics versus mechanical bowel preparation and systemic antibiotics alone for the prevention of surgical site infection after elective colorectal surgery: a meta-analysis of randomized controlled clinical trials. Dis Colon Rectum. 2016; 59:70–78.
3. Herbert G, Perry R, Andersen HK, et al. Early enteral nutrition within 24 hours of lower gastrointestinal surgery versus later commencement for length of hospital stay and postoperative complications. Cochrane Database Syst Rev. 2019;7:CD004080.
4. Hogan S, Steffens D, Rangan A, Solomon M, Carey S. The effect of diets delivered into the gastrointestinal tract on gut motility after colorectal surgery—a systematic review and meta-analysis of randomised controlled trials. Eur J Clin Nutr. 2019; 73:1331–1342.
5. Liu Q, Jiang H, Xu D, Jin J. Effect of gum chewing on amelio- rating ileus following colorectal surgery: a meta-analysis of 18 randomized controlled trials. Int J Surg. 2017; 47:107–115.

How to cite this file

Camargo, MGM. Update of the American Guidelines for Enhanced Recovery After Surgery (ERAS) in Colorectal Surgery. Gastropedia; 2022. Available at: strongupdate-of-the-american-guidelines-for-emenhanced-recovery-after-surgery-em-eras-in-colorectal-surgery-strong