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