What are the postoperative components of 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...
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Answer

Answer

Implementation of the postoperative components of ERAS depends on adequate preoperative and intraoperative care of the patient. These components include management of postoperative pain with nonopioid analgesics and epidural analgesia so as to facilitate early mobilization. Early removal of NG tubes, urinary catheters, and drains and early enteral feeding are important care elements in the postoperative phase. [11]

A study from the authors' center reported a shorter hospital stay (2.83 days) with an adapted ERAS protocol in patients undergoing emergency small-bowel surgery. [2] Postoperative analgesia in the initial hours was achieved by means of NSAIDs and epidural analgesia with bupivacaine infusion for 24 hours. On postoperative day (POD)-0, patients received diclofenac 75 mg IV q12hr; on POD-1, the schedule was changed to SOS (si opus sit; as the occasion requires). On POD-2, patients were switched to acetaminophen 500 mg PO q8hr; this was changed to SOS on POD-3. An IV formulation was used if resumption of enteral feeding was delayed, and opioids were used SOS for management of breakthrough pain.

In another study from the same center, adjuvant medications (eg, metoclopramide 10 mg IV q8hr) were used on POD-0 and POD-1 as prokinetic agents for reducing the gastric emptying time. [1] Proton pump inhibitors (PPIs) were administered, initially IV and later in oral formulations. In addition to postoperative pain management, the authors also employed antibiotic prophylaxis (initially, IV ceftriaxone and metronidazole; subsequently, oral cefixime and metronidazole) for the prevention of surgical-site infections (SSIs).

Ileus and immobilization are the principal factors that delay patient recovery after a surgical procedure. The etiology of postoperative ileus is multifactorial. Risk factors include the following [32] :

  • Elderly male
  • Low serum albumin preoperatively
  • Opioid usage
  • Previous abdominal surgery
  • Airway and vascular disease
  • Prolonged surgery
  • Emergency surgery
  • Sodium and water overload
  • Hemorrhage

Surgery triggers an immune-inflammatory response in the body. The somatic and visceral trauma causes activation of mast cells, monocytes, and macrophages; this, in turn, enhances production of histamine, tumor necrosis factor (TNF)-α, prostanoids, interleukins, and reactive oxygen species. [25] Gut handling, along with surgical trauma, causes sympathetic stimulation; gut handling and anastomosis also interfere with electromechanical coupling. Fluid overload leads to interstitial edema and stretch. Opioid analgesics decrease gut motility, and changes in gut peptides (eg, motilin, vasoactive peptide [VIP], and substance P) occur.

All of these factors ultimately lead to postoperative ileus, thus resulting in nausea, vomiting, distention, and absolute constipation. [11]  In the postoperative phase of ERAS, various measures can be taken to mitigate or prevent these contributing factors. For example, bowel-wall edema is prevented by means of GDFT, and insulin resistance is prevented by means of carbohydrate loading. Surgical stress–induced inflammation and sympathetic drive are counteracted with the help of NSAIDs and epidural analgesics. Laparoscopic surgery reduces tissue trauma, bowel handling, and the inflammatory reaction.

Alvimopan, an opioid antagonist that acts peripherally without crossing the blood-brain barrier, is known to reduce the risk of postoperative ileus. A meta-analysis that included 2195 patients undergoing major abdominal surgery assessed alvimopan against placebo with regard to the development of postoperative ileus. [33] The authors reported that recovery of gut function was 1.3 to 1.5 times quicker with alvimopan.  

Postoperative nausea and vomiting (PONV) is another distressing development after a surgical procedure. The vomiting center, or chemoreceptor trigger zone (CTZ), is triggered by abdominal distention, bowel handling, volume overload, and opioids, and PONV results. [34] A patient's risk for PONV is assessed on the basis of the Apfel score, which includes the following factors [35] :

  • Female sex
  • Nonsmoker
  • History of motion sickness
  • Opioid use

Preoperative risk stratification and prophylactic therapy are recommended in the prevention of PONV.

Until the 1940s, prolonged bed rest was considered a key component of early recovery after surgery. [36] It was believed that prolonged rest provided time for the body to heal, but advances in research eventually proved the opposite. Prolonged bed rest gives rise to multiple complications, including muscle atrophy, bone loss, development of insulin resistance, occurrence of VTE, atelectasis, and pressure injuries. [37] It is also known to cause postoperative fatigue, especially in patients with a malignancy, from the requirement for additional energy to perform a routine physical task.

ERAS pathways focus on eliminating the postoperative fatigue by enhancing early mobilization. [11] This includes early removal of NG tubes, Foley catheters, and drains. Incentive spirometry is performed preoperatively and postoperatively to prevent atelectasis, and prophylactic antithrombotic agents (eg, heparin) are administered in high-risk groups. Early enteral feeding helps prevent muscle wasting and  fatigue.

In a study of ERAS for repair of perforated duodenal ulcers, the average hospital stay was significantly shorter (4.41 days) in the ERAS group with implementation of the postoperative components. [1] Patients were ambulated from POD-0; those with an epidural catheter in place were encouraged to sit for 2 hours and then mobilized after its removal. Urinary catheters were removed once urine output was adequate over the preceding 24 hours (1 mL/kg/hr) without inotropes or diuretics. Drains were removed when output was 100 mL/day or less, irrespective of resumption of oral feeding; NG tubes were removed when output was 300 mL/day or less, irrespective of the presence or absence of bowel sounds.

Early enteral feeding is the key to resolving many of the complications that follow surgery, such as volume overload, loss of muscle and bone mass, postoperative fatigue, and immobilization. Patients can be started on oral feedings at the appearance of the first bowel sounds or the passage of the first flatus and can then gradually progress to a normal diet. [1] If enteral feedings are not tolerated, they can be temporarily withheld and then restarted as early as feasible. In the study mentioned above, [1] most of the patients tolerated oral feedings satisfactorily and experienced an enhanced recovery.

A meta-analysis focusing on ERAS in emergency abdominal surgery (N = 1334) found that ERAS was associated with decreases in length of hospital stay, time to first oral liquid diet, time to first oral solid diet, time to first flatus, and time to first defecation. [38] The authors also reported a significantly lower risk of complications (eg, SSI, paralytic ileus, and pulmonary complications) in patients treated according to ERAS protocols. The 30-day mortality, the need for readmission, and the need for reoperation were similar in ERAS and non-ERAS groups.

As noted, many studies have focused primarily on the postoperative components of ERAS in emergency surgery because these components are easier to implement in this setting. An additional important consideration is the need to obtain further information on outcomes. This can be done through weekly, monthly, or annual surgical audits, where various outcomes (eg, length of hospital stay, morbidity, mortality, and patient compliance with the ERAS protocol) can be discussed in the light of statistical data. Given that emergency ERAS is still evolving and under study, a surgical audit can help bring out its positive and negative aspects, thereby enabling formulation of a protocol that best fits emergency surgery.


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