What are enhanced recovery after surgery (ERAS) programs for emergency GI surgical procedures?

Updated: Jan 20, 2021
  • Author: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed); Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
  • Print
Answer

Answer

Enhanced recovery after surgery (ERAS) programs are evidence-based protocols designed to standardize and optimize perioperative medical care. The time available for evaluating, diagnosing, and operating on patients in emergency surgical settings is considerably shorter than that in elective settings. Altered physiology gives rise to varied presentations, resulting in high morbidity and mortality. The ERAS protocol has been well established in elective surgery and has been implicated in all possible gastrointestinal (GI) and non-GI surgical procedures. However, it has not been as well established in emergency surgery.

The components of ERAS may be broadly divided into preadmission, preoperative, intraoperative, and postoperative phases, each of which includes various distinct components (see the image below). In emergency settings, the limited preadmission and preoperative periods pose challenges to the management of ERAS pathways; however, a multidisplinary approach enables the maximum possible implementation of care elements in all phases of an ERAS protocol. [1, 2]

Preoperative, intraoperative, and postoperative co Preoperative, intraoperative, and postoperative components of Enhanced Recovery After Surgery (ERAS). GDFT = goal-directed fluid therapy; MAS = minimal-access surgery; SA = short-acting; SBP = selective bowel preparation.

A number of subspecialties have started implementing ERAS in their patients and have shown improved postoperative outcomes. However, there remains some hesitation to implement ERAS in emergency settings, arising from the expected difficulty of properly executing all of the components of an ERAS protocol, especially the preoperative components (see below).

A better understanding of ERAS principles has led to the publication of many studies reporting on the use of ERAS in emergency settings. [3, 4, 5, 1, 2, 6]  The pioneers in this regard were Gonenc et al, who studied the outcomes of ERAS in patients undergoing laparoscopic repair of a perforated duodenal ulcer. [5] They reported a better outcome in the ERAS group with implementation of only the postoperative components of ERAS. This report was followed by a few other studies that evaluated the applicability and feasibility of ERAS in emergency surgical settings ranging from simple closure of a perforated peptic ulcer to major abdominal operations. [1, 2, 6]

A study by Roulin et al comparing patients who underwent elective colectomy and urgent colectomy found that most of the ERAS elements could be applied to emergency colectomy. [7]  In a retrospective cohort of 370 patients undergoing emergency major abdominal procedures, Wisely et al reported shorter hospital stays and better outcomes in the ERAS group. [6]

Studies from our center on emergency ERAS for perforated duodenal ulcer [1] and emergency small-bowel surgery [2] also established its feasibility and safety and documented its successful implementation. In both studies, there was a significant reduction in the length of hospital stay in the ERAS group with no increase in postoperative complications. In contrast to other studies that used limited intra- and postoperative care elements, the authors maximized the use of ERAS care elements in the study population, including the preoperative components whenever feasible and most of the intraoperative and postoperative components.

Greater awareness, additional trials with larger populations, and further work on identifying and eliminating the factors hindering implementation of ERAS will be the keys to integrating emergency ERAS into day-to-day practice. Every effort should be made to implement as many components of ERAS as possible in the context of an emergency setting.

In this article, we will summarize the various pre-, intra-, and postoperative components of emergency ERAS. We will also briefly discuss discharge criteria, further follow-up, and complications, with a final note on barriers to and limitations of implementation of ERAS protocols in emergency settings.


Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!