Enhanced Recovery after Surgery

*Navin Kumar, Rohik Anjum, Dhiraj Mallik, Farhanul Huda, Bibek Karki and Somprakas Basu*

#### **Abstract**

Enhanced recovery after surgery (ERAS) protocols are specialized perioperative care guidelines. The protocol was first published in 2005. Since then, it has been associated with improved perioperative outcomes. This multimodal peri-operative protocols standardize the perioperative care to minimize the surgical stress response and post-operative pain, reduce complications, improve post-operative outcomes, expedite recovery and decrease the length of hospital stay. It initially started with colorectal surgery, but now it is used in hepatobiliary, upper gastrointestinal system, urology, gynecology, vascular surgery, bariatric, and non-gastro intestinal specialties. Its role is well established in elective surgery. Now there are enough evidence suggesting its role in emergency surgeries as well. There are 24 elements of the ERAS bundle. However, only some critical elements of the ERAS bundle are feasible to be used in emergency surgery. Postoperative pain management is one of the significant elements in the ERAS bundle. Multimodal analgesia is the optimal modality for pain control. It facilitates early ambulation and rehabilitation. Current evidence recommends the ERAS protocol. However, each item within the protocol constantly changes over time, depending upon the evidence.

**Keywords:** ERAS, length of hospital stay, postoperative pain, perioperative care, protocol, multimodal analgesia

#### **1. Introduction**

There are various challenges in the care of a patient in his surgical journey, which starts from preadmission, preoperative, and intraoperative care till postoperative recovery. Each unit has its focus, affecting the one to follow. The same surgery may have different outcomes because the surgical outcome depends on the perioperative management rather than the actual operation. Patients require hospital care after major abdominal surgery because of the need for parenteral analgesia for persistent pain and intravenous fluid because of bowel dysfunction and postoperative complications. The length of hospital stay may vary in different parts of the world because of the variation in perioperative care. Henrik Kehlet showed that a patient could be discharged in 2 days after the open sigmoid resections [1]. The length of stay after these operations was ten days in most countries; thus, he pioneered fast-track surgery [2].

In earlier days, postoperative care was different among different centers because of the lack of specific protocols for specific organ-based surgeries. It was decided to promote the change in practice in the care of surgical patients. The Enhanced

Recovery After Surgery (ERAS) study group was formed in 2001 in Europe to combat this problem. Professor Ken Fearon, University of Edinburgh, UK, and Professor Olle Ljungqvist, Karolinska Institute, Sweden, assembled in 2001 to develop ideas about ERAS with the surgical department or Universities of three other northern European Countries (Denmark, Norway, and The Netherlands) [3]. They found a discrepancy between the actual practices and evidence-based best practices. Much published evidence suggests that perioperative care differs in different parts of the world, and there is a minimum adherence to evidence-based practice [4].

The aim of the ERAS study group (http://www.erassociety.org) was to find out the ways for quality surgical recovery rather than speed. The study group met several times to reach a consensus on a protocol to improve the quality of surgical recovery. These were called ERAS protocols. These are procedure-specific guidelines. The group focused on enhancing recovery and reducing complications by modifying the metabolic response to surgical insult rather than limiting the length of stay. They found that early mobilization and enteral nutrition are beneficial in the postoperative period, leading to rapid hospital discharge [5]. The first guideline was published in 2005 for colorectal surgery [3]. In 2012 the guidelines were divided into colonic and rectal surgery, but in 2018 these two surgical specialties guidelines were combined [6–8]. The Dutch group led the implementation of the first guidelines and showed improvements in recovery time [9]. They showed that the guidelines could be implemented in a structured way. ERAS protocol, when implemented in a structured way, showed a significant reduction in postoperative morbidity (48%) and length of hospital stay (2.5 days) in colorectal surgery when compared with traditional perioperative care [10, 11]. The ERAS society was registered in Sweden in 2010 (www.erassociety. org). This is an international non-profit medical academic society whose members are from different professions involved in surgical care [5].

Current evidence recommends the ERAS protocol as a whole (all elements) and not as a single element. However, each element within the protocol constantly changes over time, depending upon the evidence. Now, these protocols have been adapted for the upper gastrointestinal system, urology, gynecology, vascular surgery, hepato-pancreatico-biliary, esophageal, bariatric, and non-gastrointestinal specialties [12, 13]. The ERAS guideline has changed over the years since its inception. The first ERAS guideline was based on expert opinion and literature review, but the recent guideline is based on evidence-based grading.
