ERAS for Radical cystectomy

1. Enhanced Recovery After
Surgery (ERAS)
Presented by Dr. Sanjay Dange
Guide & Mentor – Dr. Ajit Sawant (Professor & HOD)
Mentor – Dr. Prakash Pawar(Professor)
Mentor – Dr. Sunil Patil (Associate Professor)
03/07/2021

2. What is ERAS?
• Enhanced recovery / fast track protocol
• Improves post-op outcome – decreased Length of stay(LOS),
accelerated recovery, without increase in re-admission or
complication rate

3. AIMS
• ↓ post op stress
• Maintain perioperative physiological functions
• Enable early mobilization
• ↓morbidity, recovery time and LOS

4. PHASES OF ERAS
• Pre-operative
• Intra-operative
• Post-operative

5. PRE-OPERATIVE- COMPONENTS
• Patient counseling and education
• Pre-operative optimization
• Bowel preparation
• Thromboembolic prophylaxis
• Pre-operative fasting and carbohydrate loading
• Anti-microbial prophylaxis and skin preparation

6. Patient counseling and education
• Decrease fear , anxiety, fatigue
• Stoma education (decreased LOS: 6 days vs 9 days)

7. Pre-operative optimization
• Assessment & improvement of medical conditions
• Pre-op smoking cessation for minimum 4 weeks 
• ↓ risk of pneumonia
• mechanical ventilation > 48 hrs
• unplanned tracheal intubation
• Alcohol cessation for minimum 4 weeks
• Correct anemia, hypoproteinemia

8. Bowel Preparation
• No added advantage in recovery or complication
occurrence
• Safely omitted as per ERAS protocol

9. Thromboembolic prophylaxis
• DVT incidence – 5%
• Pharmacotherapy- LMWH/ Heparin
• Non pharmacological –
• compression stockings
• intermittent pneumatic compression device
• Thromboprophylaxisextended 4 weeks post-op↓ incidence of
DVT
• LMWH 40mg s/c OD or Heparin 5000 U s/c TID

10. Pre-operative fasting and
carbohydrate loading
• ↓pre-op fasting enhances patient comfort , ↓thirst and anxiety
• Clear liquids  2 hrs
• Solid foods  6 hrs
• Carbohydrate loading  ↓ peri-op insulin resistance (role in diabetics
not studied)
• Insulin resistance proportional to blood loss and magnitude of
surgery

11. Anti- microbial prophylaxis and
skin preparation
• 2nd/3rd gen cephalosporins + metronidazole/clindamycin
• 1 hour prior to skin incision
• Repeat dose 3-4 hrly
• Skin preparation with chlorhexidine-alcohol ↓ surgical site infection

12. INTRAOPERATIVE COMPONENTS
• Anesthesia protocol
• Surgical approach
• Fluid management
• Preventive intra-op hypothermia
• Pelvic drainage

13. Anesthesia protocol
• Management of stress response, fluids and analgesia
• ERAS protocol suggests
• thoracic epidural analgesia (T9-T11)
• Minimal opioid usage , inhalational anesthesia
• Low dose remifentanil or morphine + bupivacaine
• Duration : 48 to 72 hrs
• ↓ Post operative Nausea & Vomiting (PONV)
• Decreased LOS and narcotic use; early feeding

14. Surgical approach
• Morbidity with open surgery – 65%
• Minimally Invasive surgery (MIS)
• Complication rate similar to open surgery
• No conclusive data

15. Fluid management
• Hyper /hypovolemia splanchnic hypoperfusion ileusincreased
morbidity increased LOS
• Goal directed fluid therapy (GDFT): intra- op doppler to maintain
intravascular volume, cardiac output and tissue perfusion while
avoiding fluid overload.
• Monitoring urine output is difficult.

16. • Alternative: CVP , heart rate and arterial pressure
• GDFT decreases post-op ileus(POI) and PONV at 24 and 48 hrs
• Decreased blood loss, LOS and complications

17. Prevent Intra-op Hypothermia
• Prolonged exposure temp <36 degrees  increased wound
infections, blood loss and complications.
• Maintain normothermia using external heaters and warm iv
fluids.

18. Pelvic drainage
• Traditional standard of care
• No study specific to cystectomy

19. Post operative components
• NG intubation
• PONV
• POI
• Urinary drainage
• Post op analgesia
• Early mobilization
• Early oral diet
• Discharge & follow up

20. Nasogastric intubation (NGI)
• Prophylactic NGI post surgery ↑ post-op complications, no added
advantage
• Delayed GI recovery
• Routine prolonged NGI not recommended
• NG decompression recommended in prolonged Post op Ileus (POI)

21. Post operative Nausea
Vomiting(PONV)
• 25- 35% of patients
• PONV leads to mobilization difficulty, delayed oral intake, ↓ LOS,
↑ pulmonary aspiration risk
• High risk patients: females, non-smokers, motion sickness

22. • Non pharmac measures-
• ↓ pre-op anxiety
• adequate pre-op hydration
• decreased pre-op fasting
• avoid inhalational anesthetics
• Pharmacological:
• epidural analgesia, propofol
• NSAIDS
• anti-emetics (dexamethasone, ondansetron)

23. Prevent Post Op Ileus (POI)
• 4- 31% -incidence
• Inability to tolerate solids by POD 5 , need to place NGT and need to
stop oral intake due to abdominal distension , nausea and vomiting
• Epidural analgesia vs opioids
• Avoid intra-op and post-op fluid overload

24. • Alvimopan
• Oral Magnesium
• Chewing gum
• MIS

25. Urinary drainage
• No study for the need or duration of catheterization
• Uretero-ileal stenting : improved drainage of upper tract, bowel
recovery and lesser metabolic acidosis, decreased PONV
• Duration: 5 – 14 days ( not investigated)

26. Post-op analgesia
• Multimodal opioid sparing suggested
• Decreased POI, PONV, LOS
• Improved bowel recovery , early mobilization
• Decreased stress response and cardio-pulmonary complications

27. • Loco-regional blocks- eg: TAP
• Paracetamol / NSAIDS
• No data for cystectomy

28. Early mobilisation
• reduce thromboembolism, muscle breakdown, pulmonary
complication, LOS, neuropsychological changes and insulin resistance
• Ambulate POD 1 increase to three times per day

29. Early oral diet
• Start < 24 hrs with high carbohydrate , high protein fluids: positive
effect on wound healing, insulin resistance and muscle function
• Oral liquids within few hours post op soft to regular diet POD 2
• If oral intolerance >7 days TPN
• Early TPN avoided

30. Discharge and follow up
• Discharge criteria
• Pain control with oral analgesics
• Adequate mobilization
• Return of GI function
• LMWH and stoma care teaching complete
• Normal blood chemistry
• Follow-up: once weekly visit and stent removal after 10-14 days