Fast-track or Enhanced Recovery After Surgery (ERAS) programs aim to reduce surgical stress and speed recovery through a multimodal approach. ERAS was pioneered by Henrik Kehlet in 1995 through laparoscopic colon resections with early feeding, mobilization, and discharge by postoperative day 2-3. ERAS utilizes a multidisciplinary team to implement protocols like preoperative carbohydrate drinks, short-acting anesthesia, epidurals, early feeding and mobilization, and discharge when criteria are met to reduce recovery time from major surgery. ERAS benefits even fragile elderly patients and makes more efficient use of healthcare resources without expensive infrastructure changes.

1. Fast Track Surgery :
implications for developping
countries.
Prof. Dr. Y. Van Nieuwenhove
Dpt. Of Gastrointestinal Surgery
University Hospital Ghent, Belgium

2. Fast-track??
• Enhanced Recovery After Surgery

4. ERAS
• Enhanced Recovery After Surgery
– Multimodal program of perioperative care
– Change old habits
– Apply new insights
– No need for expensive infrastructure
– Efficient use of resources

5. Henrik Kehlet from Danmark
• Lancet 1995: “stress-free” colon resection
in 8 patients >70yrs
– Laparoscopic approach
– Pain control by epidural
– Early (day 1) feeding
– Early (day 1) mobilisation
– Discharge from hospital day 2-3

6. Open-laparoscopic?
• Basse, Ann Surg 2005
– RCT: 30 pts lap / 30 open colectomy
– Age 75 (57-90)!!
– Pts blinded by abdominal dressing
– Hospital stay: L 2 (2-20) vs O 2 (2-5)
– 1/3 of patients did not feel type of surgery

7. Multimodal
• Surgeon, anaesthetist, nurse, patient,
family,…
• Elective surgery
• to be planned in a clear program

8. Which patients?
• All patients
– More fragile => better effect
• Elective surgery
• No extra problems to be expected

9. THE STEPS TO TAKE
Enhanced Recovery After Surgery

10. Bowel preparation
Slim et al, BJS 2004

11. Preoperative feeding
• Ljunqvist BJS 2002
– Fasted for solids >6hrs before surgery
– Clear liquids allowed 2-3h before surgery
– Clear carbohydrate liquid can reduce
metabolic stress

12. Anaesthesiology
• Short acting anaesthetics (propofol,
remifentanyl..)
• Epidural catheter (T7-8 / T9-10) with long
acting local anaesthetic
• PONV prevention
• Paracetamol, NSAIDS as pain control

13. Laparoscopy or open surgery?
LAFA study, Vlug et al, Ann Surg 2011

14. Drain-no drain
Petrowsky et al,

15. Gastric tube?
Verma & Nelson, Cochrane database 2007

16. PONV

17. Feeding and mobilisation
Lewis et al, BMJ 2001

18. Discharge when…
1. Oral feeding is possible
2. Oral pain control is possible
3. No signs of septic complications
4. Patient can walk around
5. Patient is willing to go

19. Take home message
• ERAS ≠ fast surgery
• Breaks with tradition
• Better for most patients
• Multimodal approach
• Cost reducing, efficient use of resources