Approaches for Enhanced Recovery after colorectal surgery is described here. Hope you will find this informative and hope you will enjoy.

1. Welcome
Enhanced Recovery After
Colorectal Surgery
1
Prepared by Dr. Sananda Halder
MBBS, Dhaka Medical College
& Engr. Muhammad Ridwanul Hoque

2. Enhanced Recovery
 Enhanced Recovery is an approach to the perioperative care of patients
undergoing surgery.
 It is designed to speed clinical recovery of the patient and reduce the cost &
length of stay of the patient in the hospital.
 It is achieved by optimizing the health of the patient before surgery and then
delivering evidence-based care in the peri-operational period.
2

3. ERAS & Colorectal SurgeryContemporary colorectal surgery is often associated with long length of stay, high cost and rates of
surgical site infection approaching 20%.
During the hospital stay for elective colorectal surgery, the incidence of perioperative nausea and
vomiting (PONV) may be as high as 80% in patients with certain risk factors. After discharge from
colorectal surgery, readmission rates have been noted as high as 35.4%.
Enhanced recovery after surgery (ERAS) protocols are used so and the content of these
specific protocols may vary significantly, but all are designed as a means to improve patient outcomes.
Outcomes of interest to patients and providers include freedom from nausea, freedom from pain at rest,
early return of bowel function, improved wound healing, and early hospital discharge.
3

4. There are many Pre-operative, Intra-operative and Post-operative components in a
typical ERP. Here specific protocols applied to colorectal surgery will be discussed:
Pre-operative Interventions
A.Pre admission Counseling:
A pre-operative discussion of milestones and discharge criteria should typically be performed with the
patient before surgery.
Standardized Discharge Criteria:
To tolerate of oral intake
Recovery of lower GI Function
Adequate pain control with oral analgesia
Ability to mobilize and perform self care
No evidence of complications & patient willingness to
leave the hospital
Ileostomy education, marking
and counseling on dehydration
avoidance should be included in
the preoperative setting when
assumed to be necessary.
4

5. B. Preoperative Nutrition and Bowel
Preparation:
1. A clear liquid diet may be continued less than 2 hours
before general anesthesia. It is shown to be safe and to
improve patient’s sense of well being in multiple
randomized controlled clinical trials.
It states that the ingestion of clear liquids within 2 to 4
hours of surgery versus >4 hours is associated with smaller
gastric volume and higher gastric PH at the time of surgery.
is supported by ASA
and European Society
of Anesthesiology
Practice Guidelines
5

6. 2. Carbohydrate loading should be encouraged before surgery for nondiabetic patients.
The use of preoperative carbohydrate rich beverages should be encouraged with the purpose to
attenuate insulin resistance included by surgery and starvation.
3. Mechanical bowel preparation plus oral antibiotics bowel preparation before colorectal surgery is
the preferred preparation and is associated with reduced complication rates.
C. Standardized Preset Order Sets
 ERPs are complex and require collaboration between many different stakeholders to ensure the
optimal care of surgical patient.
 Common to all of these protocols are preset orders, which include preoperative, intraoperative and
post operative sections that standardize care between all surgeons for all patients.
6

7. Peri-operative Interventions
A.Surgical Site Infection Prevention:
Implementation of a preventive SSI bundle:
SSI Care bundle is a small set of practices that have been proven to improve patient outcomes which includes pre
operative, per operative and post operative measures:
Pre Operative Measures Per Operative Measures Post Operative Measures
I. Chlorhexidine shower
II. MBP with antibiotics;
ertapenem within 1 hour of
incision
III. Standardization of
preparation of surgical field
with chlorhexidine.
I. Use of a wound protector
II. Double gloving
III. Gown and glove change before fascial
closure
IV. Use of a dedicated wound closure tray
V. Limited operating room traffic
VI. Reduction in intraoperative intravenous
fluid use
VII. Use of Penrose drain
VIII. Pulse lavage of subcutaneous tissue
I. Removal of the sterile dressing
withing 48 hours
II. Daily washing of the incision
with chlorhexidine
III. Others: Patient education,
euglycemia maintenance,
perioperative maintenance of
normothermia
7

8. 8
Penrose Drain
A,B: The Alexis Retractor has been placed to protect the wound from
fecal and tumoral contamination

9. B. Pain Control:
1. A multimodal, opioid-sparing pain management plan:
- Minimizing opioids and scheduled use of narcotic alternatives is associated with earlier rectum of bowel function.
Narcotic Alternatives:
• Acetaminophen
• NSAIDs
• Gabapentin
Side Effects:
 NSAIDs increase the risk of anastomotic leakage.
 Gabapentin may cause psychotropic adverse effects like dizziness and sedation that may impair immediate recovery
By recent meta analysis demonstration:
For patients receiving greater than 1 dose of
NSAIDs in the first 48 hours after surgery, the
risk of anastomotic leakage- not significantly
increased
9

10. 2. In case of Laparoscopic Surgery:
 Wound infiltration and abdominal trunk blocks with liposomal bupivacaine have shown promising results which can
also be used in case of open surgery
 Transversus Abdominis Plane (TAP) block with a local anesthetic has been associated with decreased length of stay
3. Per-operative use of Thoracic Epidural Analgesia:
It is considered the gold standard to control pain in patients undergoing open colorectal surgery. But it does not
support a faster recovery in case of laparoscopic surgery.
This delay may be due to higher incidence of hypotension and urinary tract infections.
10

11. C. Perioperative Nausea and Vomiting (PONV) Prevention:
1) Antiemetic Prophylaxis:
- A preemptive, multimodal antiemetic prophylaxis by combination of dexamethasone and ondansetron has shown
good results
Additional Strategies:
Use of total intravenous anesthesia with propofol to a multimodal antiemetic regimen is superior to a multimodal
antiemetic regimen with inhaled anesthetics
D. Intraoperative Eliud Management:
1. Maintenance infusion of crystalloids should be tailored to avid excess fluid administration and volume overload. A
maintenance infusion of 1.5-2 mL/kg/h of balanced crystalloid solution is sufficient to cover the needs derived from
salt-water homeostasis during major abdominal surgery
2. Use of balanced chloride restricted crystalloid solutions as maintenance infusion
3. Goal Directed Fluid Therapy : GDFT
Beneficial in high risk patients undergoing major colorectal surgery associated with significant intravascular loss
11

12. E. Surgical Approach:
1. A minimally invasive surgical approach should be used
2. The routine use of intra abdominal drains and nasogastric tubes for colorectal surgery should be avoided
Patients who do not receive nasogastric tubes tolerate oral intake
2 days earlier than patients who receive nasogastric tubes
suggesting that nasogastric decompression may unnecessarily
delay unimportant nutrition in the PO period.
12

13. Post-operative Interventions
A.Patient
Mobilization:
13
-Early mobilization has
shown to play role in
shortening length of stay
- In addition to walking,
using a formed exercise
program including core,
stretching and resistance
exercise is beneficial

14. B. Ileus Prevention:
I. Early feeding and returning to regular diet (<24 hour)
II. Sham feeding i.e. chewing
Sugar free gum for ≥ 10 minutes (3 to 4 times per day)
III. Use of Alvimopan in 12 mg doses
- has shown promising results to accelerate time to recovery of GI Function
- it is a peripherally acting u–opioid receptor antagonist works by protecting the bowel from constipation
- provides gastric stimulation
- early return of flatus and bowel
movement
14

15. 15

16. C. Post Operative Fluid Management
- Intravenous fluids should be discontinues in early post operative period after recovery from room discharge
- Clear fluids (≥ 1.75L/d of water) should be encouraged as tolerated soon after surgery
D. Management of Urinary Catheters:
In case of colonic or upper rectal resection:
Early removal - Catheter should be removed within 24 hours
- Decreases risk of UTI
Risk - may increase the risk of urinary retention
In case of mid rectal or lower rectal resections:
- Catheter should be removed within 48 hours
16

17. 17
Thank you