This document discusses enhanced recovery after surgery (ERAS), which aims to help patients recover faster and return to normal function after major surgery. It outlines the key elements of an ERAS protocol, which includes preoperative counseling and carbohydrate drinks before surgery, multimodal pain relief without opioids, early oral intake and mobilization after surgery, and clear discharge criteria focused on independence rather than length of stay. ERAS requires collaboration between medical professionals and has been shown to reduce costs and resource use while maintaining low complication rates.

1. Enhanced Recovery After Surgery
Kaya YORGANCI MD, Professor of Surgery &
Critical Care
Hacettepe University Faculty of Medicine
Department of General Surgery
Ankara - Turkey

2. Background
• Average length of hospital stay after colorectal
abdominal surgery was still 10–15 days
• OR and hospital beds shortage
• Looooong waiting lists
• ERAS originated in colorectal surgery in
Denmark

3. Background
• Key actors that keep a patient in hospital after
uncomplicated major abdominal surgery
– the need for parenteral analgesia (persistent
pain),
– intravenous fluids (persistent gut dysfunction),
– bed rest (persistent lack of mobility).

4. What is Enhanced Recovery After
Surgery ?
• Transformed perioperative care
• Patients’ optimal return to normal function after
major surgery.
• The term ERAS was coined in 2001 by a group of
academic clinicians (the ERAS Group) to replace
the expression of ‘Fast Track’ surgery, and to
emphasise the quality of the patients’ recovery,
rather than the speed of discharge.
• This group formed the ERAS Society for
perioperative care ( www.erassociety.org )

5. • Enhanced recovery is now becoming firmly
established across a range of disciplines
– Within the UK, including colorectal, musculoskeletal,
gynaecological and urological surgery.
• Quicker recovery
• Efficient use of resources
• Successful implementation requires close
collaboration between surgeons, anaesthetists,
nurses, dietitians and experts in rehabilitation

7. Elements of enhanced recovery
protocol

8. Members of
the multidisciplinary team
• Nurses
• Dietitians
• Physiotherapists
• Pain team
• Theatre staff
• Anaesthetists
• Surgeons
• Hospital management
• Audit team

9. Preadmission Information and
Counselling
• Explicit preoperative patient information can
facilitate postoperative recovery
• Pain control, particularly in patients who exhibit
the most denial and highest levels of anxiety
• A clear explanation of what is to happen during
hospitalisation
• Patient should also be given a clear role with
specific tasks to perform, including targets for
food intake and mobilisation

10. Preoperative Fasting and Metabolic
Conditioning
• Fasting after midnight has been standard practice to avoid
pulmonary aspiration in elective surgery
– clear fluids up until 2 h before surgery
– 6 h fast for solid food
• Patients should be in a metabolically fed state rather than
fasted when they go to OR
– Clear carbohydrate-rich beverage before midnight and 2–3 h before
surgery.
• reduces preoperative thirst, hunger and anxiety
• Significantly reduces postoperative insulin resistance
• This also results in patients being in a more anabolic state with less
postoperative nitrogen and protein losses,
• better maintained lean body mass and muscle strength

11. Anaesthetic Protocols
• The evidence to direct the choice of the optimal
anaesthetic method for ER procedures is complex and
controversial.
– However, it is rational to use short-acting agents (propofol,
remifentanil)
– Long-acting i.v. opioids (morphine, fentanyl) should be avoided.
– Shortacting inhalational anaesthesia is a reasonable alternative
to total intravenous anaesthesia.
• Mid-thoracic epidural catheter
– blocks stress hormone release and attenuates postoperative
insulin resistance
– Analgesia
– Prevents gut paralysis

12. Surgical Technique
• Minimal invasive surgery, if possible
• Fine surgical technique
– Less bleeding
– Less trauma
– Respect to tissues and organs
– Avoid hypothermia

13. Surgical Incisions
• Transverse or curved incisions cause less pain
and pulmonary dysfunction than vertical
incisions following abdominal procedures
• incision length affects patient recovery

14. Multimodal Pain Relief
• Continuous epidural local anaesthetic
• NSAID’s
• Avoid opioids

15. Promoting Early Oral Intake
• Postoperative ileus is a major cause of delayed
discharge from hospital
– Epidural analgesia
– Avoiding fluid overloading during ,and following
surgery
– Laparoscopic surgery
– Avoidance of routine nasogastric intubation
– Control of post-op nausea and vomiting
– Access to adequate normal food, access to oral
nutritional supplements

16. Early Mobilisation
• Bed rest increases insulin resistance and
muscle loss,
• Decreases muscle strength, pulmonary
function and tissue oxygenation
• The aim is for patients to be out of bed for 2 h
on the day of surgery, and for 6 h a day until
discharge.

17. Discharge Criteria
• Patients can be discharged when they meet
the following criteria:
– Good pain control with oral analgesia
– Taking solid food, no intravenous fluids
– Independently mobile or same level as prior to
admission
– All of the above and willing to go home.
• The discharge process starts at the
preadmission counselling session

19. Enhanced Recovery After Surgery
• Saves money
• Saves resources
• Saves time
• With no inreased complication rate