Enhanced recovery after surgery (ERAS) in clinical practice

Robert Leger1, Jon Livelsberger1, Ashish Sinha2

1-Temple University Lewis Katz School of Medicine, 3401 N. Broad Street, Suite B30 Philadelphia, Pennsylvania 19140, USA.
2-4445 Magnolia Avenue; Riverside, CA 92501.

Correspondence: Ashish C. Sinha, MD, PhD, DABA, MBA, FASA, Professor, University of California Riverside, Designated Institutional Official (DIO) & Program Director, Anesthesiology, 4445 - Magnolia Avenue, Riverside, CA 92501, USA; Phone: 961 788 3577;
E-mail: Ashish.Sinha@HCAhealthcare.com; DrAshish.Sinha@gmail.com

Abstract
‘Enhanced Recovery After Surgery’ (ERAS) protocols are an evidence-based, multidisciplinary system for patient care that— since its emergence in 2001— has shown remarkable efficacy in reducing surgical complications, shortening length of stay (LoS), and the incidence of hospital re-admission. Unfortunately, wide spread acceptance of ERAS has been slow, as it conflicts with some traditional perioperative care practices. However, with protocol compliance >70%, studies have shown significant reduction in mortality and postsurgical complications, with 30-50% reduction in LoS and approximately a 50% reduction in complications. A primary objective of ERAS protocols is to maintain anabolic homeostasis, preventing protein breakdown, muscle loss, and insulin resistance. One key element of the ERAS protocol is the implementation of an auditing system to ensure compliance with the elements of the guidelines published by the international ERAS Society. This component of ERAS is essential for not only optimizing adherence, but also for the continuous updating of protocols to meet current evidence-based best practices. Through the implementation of the ERAS program, it is possible to facilitate the highest possible quality of patient outcomes and provide informed, modernized care. The content of this review will focus on the key elements of the ERAS protocol and institutional acceptance and implementation.
Key words: Enhanced Recovery After Surgery; ERAS; Enhanced Recovery Program; ERP; Fast track recovery; Surgical quality improvement; Hospital stay; Traditional care methods
Citation: Leger R, Livelsberger J, Sinha A. Enhanced recovery after surgery (ERAS) in clinical practice. Anaesth. pain intensive care 2020;24(3):335-345.

Received: 23 March 2020; Reviewed: 7 May 2020; Accepted: 14 May 2020

1.      Introduction
An extensive body of evidence-based research exists investigating the treatment and care surrounding surgical patients. Over the past two decades a transformational change has taken place.
Internationally, beginning with the landmark work of Danish surgeon Henrik Kehlet to implement modernized, fact-based changes in perioperative patient care. Kehlet and colleagues, over a series of articles demonstrated a truly revolutionary improvement in the reduction of patients’ length of stay (LoS) and postoperative surgical complications following gastrointestinal surgeries via the implementation of evidence-based care protocols versus more traditional methods.1-3 These recovery protocols became known as “fast-track” recovery procedures, which have since been re-termed as enhanced recovery after surgery (ERAS) pathways— to place emphasis on the improvement of patient  outcomes and not just on hospital LoS.4 Since its emergence in 2001, ERAS’s multidisciplinary, evidence-based approach to improving patient care has proven tremendously efficacious. Most notable amongst these outcomes is the marked reduction in postoperative complications by approximately 50%4-7 and reduction in the LoS, in some surgeries by greater than 2 days.2,3,7
Adoption and implementation of these proven and effective recovery pathways, however, has been slow and met with opposition.7-9 The international ERAS society has in response released a comprehensive series of guidelines for the implementation of evidence-based ERAS protocols catered to a growing array of surgical specialties and procedures: gastrectomy, bariatric surgery, pancreaticoduodenectomy, radical cystectomy, hepatic surgery, colonic surgery, rectal/pelvic surgery, breast reconstruction, and head and neck cancer surgery with free flap reconstruction.10-19 A unifying goal of these procedures is the drive to quickly return patients to normal daily function and mitigate the surgical stress and accompanied catabolic state, that have been attributed to cause a number of postoperative complications while delaying patient recovery.1,3,7,11,20-23 The contents of this review will focus on examining current evidence for ERAS pathways and discuss the implementation and associated obstacles to this much needed quality improvement.

2.      ERAS Protocols & Recommendations
The ERAS pathways have since the ERAS Society’s formation in 2010 diversified and expanded to include a progressively increasing number of surgeries across a growing number of surgical specialties.23 As such, these multidisciplinary guidelines disseminated by the society, include recommendations specific to the given type of surgery. However, the ERAS protocols are all linked by a set of unifying objectives— the reduction in the stress response of patients to surgery and the speedy resumption of normal daily function.1,3,7,11,20-23 The attenuation of patient stress via ERAS is aimed at minimizing the postoperative catabolic state experienced by the patient, which can lead to the detrimental outcomes of insulin resistance, muscle loss, infection, and delays in wound and anastamotic healing,20-22 inevitably leading to prolonged recovery and extended hospital stays and costs. ERAS protocols can be divided into three time points— preoperative, intraoperative, and postoperative; the key elements which unify the different ERAS guidelines will be discussed here.

2.1.    Preoperative Interventions & Recommendations
2.1.1.       Patient Counselling
One of the hallmark aspects of ERAS is the emphasis placed on preoperative patient counselling. It is believed that informing, educating, and discussing the procedure with the patient has beneficial effects on attenuating anxiety and fears of patients going into surgery.24-26 Stergiopolou et al. displayed that patients scheduled for laparoscopic cholecystectomy displayed lower levels of anxiety with higher level of knowledge about their procedure.26 Given the lack of associated risk and the known effects of stress on promoting catabolism,22 the benefits of this counselling are clear.

2.1.2.       Alcohol & Tobacco Cessation
Cessation of alcohol consumption and smoking prior to surgery has also been shown to be important for the reduction of postoperative complications.27,28 Depending on the amount of consumption, excessive alcoholism can increase the risk of postoperative complications from 50-200%— with infection, wound breakdown, cardiac ischemia, and/or arrhythmias, being the most recognized complications.29 Alcoholism can also increase the intraoperative risk of cardiomyopathy— especially during the induction of anesthesia.29 Smoking is associated with complications such as pneumonia, hypertension, atelectasis, bronchospasm, delayed wound healing, thromboembolic events, and respiratory failure.28,29 In a randomized controlled trial Sorensen and colleagues demonstrated the efficacy of presurgical smoking cessation programs, by showing that smokers who abstained for one month prior to surgery displayed significantly reduced wound infections compared to patients who continued to smoke up to the time of surgery.30 Current ERAS guidelines suggest to counsel the patients for complete abstinence from alcohol and tobacco use for one month prior to surgery,10-19 though of course counselling for long-term cessation in patients who abuse alcohol and tobacco is always advisable.

2.1.3.       Prehabilitation
Prehabilitation is the term for a series of efforts aimed at increasing functional capacity prior to surgery for the purposes of reducing the impact of surgical stress.31 Prehabilitation programs routinely consist of exercise and dietary regimens, as well as cognitive stress reduction techniques such as meditation.31 The benefits of exercise prior to surgery include its proven ability to reduce anxiety,32 as well as improved cardiopulmonary function.31 With regards to improving patients’ nutritional status, it has been shown that poor nutrition is a predictor for postsurgical complications and increased LoS.31,33,34 Inadequate nutrition is an especially pervasive problem within elderly patients,33 which make up a significant segment of the surgical patient population.

2.1.4.       Anti-microbial & Thromboembolic Prophylaxis
Prophylactic treatments for infections and thromboembolic events are other key elements of the preoperative care recommended by the ERAS guidelines.10-19 For the prevention of venous thromboembolism (VTE), ERAS pathways recommend the use of low-molecular-weight heparin (LMWH) as compared to traditional unfractionated heparin, unless otherwise indicated, because of its need to only be administered once daily and a lower risk of heparin-induced thrombocytopenia.16,22

A13-T1

 Unsurprisingly, the administration of prophylactic antibiotics has been shown to decrease the risk of surgical site infection in patients postoperatively.35 The current consensus for the administration for antimicrobial prophylaxis, is that it should occur approximately 60 min prior to surgical incision and be discontinued within 24 hours after surgery.36 In a meta-analysis of randomized controlled trials Mittendorf et al. determined that patients undergoing abdominal hysterectomies not receiving antibiotic prophylaxis developed infections in 21% of cases, compared to 9% for women who did receive prophylactic antimicrobial treatments— a clinically and statistically significant difference.37

2.1.5.       Preoperative Fasting & Carbohydrate Loading
Traditional care methods typically recommend fasting after midnight on the night prior to surgery for the purported purpose of preventing pulmonary aspiration; however, this practice has not been validated by evidence-based investigations.38-40 Evidence suggests that patients being “nil by mouth” for prolonged periods prior to surgery may not only impose additional stress due to hunger and excessive dry mouth, but also contribute to the increased endocrine-induced catabolism and insulin resistance experienced by many patients postoperatively.38,41 It is additionally true, that giving patients a carbohydrate-rich drink prior to surgery, as recommended by ERAS, has an additional benefit of reducing anxiety.38 ERAS protocols recommend that patients, in most cases, refrain from excessive fasting, allowing for the safe consumption of solids up to 6 hours and clear liquids up to 2 hours prior to the time of surgery.10-19
A summary of the key preoperative elements of the ERAS protocol are listed in Table 1.

2.2.     Intraoperative Interventions & Recommendations
2.2.1.       Minimally Invasive Approaches
Minimally invasive surgical approaches are, understandably, the preferred by the patients.42 The use of minimally invasive procedures was among the first investigated elements of ERAS, with studies showing that enhanced recovery methods combined with laparoscopy lead to shorter LoS and fewer complications,2,3 as well as decreases in postoperative inflammatory response.41 Vlug et al. in the first large-scale multicenter study on the topic, observed that the use of laparoscopy with enhanced recovery methods resulted in reductions in LoS greater than 2 days.43 More recent investigations have shown that laparoscopy is not only associated with shorter LoS, but also reduced pain postoperatively, and is associated with a lower risk for wound infection.44

2.2.2.        Preservation of Normothermia
The operating room setting poses an additional stressor to patients— with standard temperatures between 20º and 25ºC and anesthetic alteration of the homeostatic setpoint— semi-clad patients are subjected to cold stress and are often at risk of intraoperative hypothermia.41 Hypothermia may also adversely affect patients via its ability to impair immune function,45 leaving patients susceptible to postoperative infections. Evidence-based studies have shown warming patients intraoperatively both decreases the rate of surgical wound infections and reduces the total LoS.45,46 It has also been proposed that prophylactic warming of patients prior to surgery may have beneficial effects at mitigating postoperative infections. In a randomized controlled trial Melling and colleagues investigated a sample of 421 patients. Out of  whom half were artificially warmed for 30 min prior to surgery, while the other half were not, concluding that significantly fewer surgical site infections occurred in patients who received prophylactic warming compared to those who did not.47

2.2.3.       Management of Fluid Balance & Hemostasis
An extremely important aspect of the ERAS protocols is the careful and appropriate management of patients’ fluid balance and hemostasis, ensuring that patients are not transfused or administered excess of fluids intraoperatively.10-19 Adequate fluid administration is vital for preserving cardiac output, perfusion and tissue oxygenation,5 while administration of fluids in excess of losses can lead to complications such as pulmonary and bowel edema48,49 and delays in wound and anastomotic healing.22 Surprisingly, perioperative fluid administration has often exceeded losses occurring during surgery.22 Decreases in fluid administration below that typical of traditional care has also been associated with significantly faster returns to normal gastrointestinal function and shorter LoS in patients undergoing colonic resection.50 It has been identified that careful attention to fluid balance is an especially important consideration during procedures such as cardiac surgery with cardiopulmonary bypass, where up to 2 L of priming fluid are routinely used, putting patients at an elevated risk for developing complications.20 Current ERAS guidelines have even outlined the use of transesophageal doppler for the monitoring of patient fluids, in high-risk cases.12,20

2.2.4.        Nausea & Vomiting Prophylaxis
Postoperative nausea and vomiting (PONV) is a relatively common anesthetic complication that occurs in 20-30% of patients following general anesthesia.51 In rare cases it has been associated with aspiration, dehydration, electrolyte imbalances, bleeding, and wound dehiscence.51 In some patients it has been identified as potentially more stressful than postoperative pain.22 The use of volatile anesthetics and the administration of opioids have both been identified as risk factors for PONV.51 Accordingly, the intraoperative use of pharmacological prophylactic agents— ondansetron, dexamethasone or droperidol—has also been outline in ERAS protocols.19 ERAS also recommends the minimization of opioids and avoiding general anesthesia, if possible, in part to reduce the risk of PONV.11

2.3.     Anesthetic Recommendations
Anesthetic recommendations for ERAS typically focus on techniques that minimize the use of opioids— especially long-acting ones— and promote early mobilization and pain management.10-19 This typically includes the preferential use of neuraxial anesthesia if not contraindicated and the avoidance of long-acting opioids and sedative/hypnotics in patients over 70.20,22 The opioid abuse is the leading cause of overdose and death from prescription drugs, with concomitant benzodiazepine use acting as a prevalent contributor to opioid-related morbidity and mortality.52 Moreover, the use of both benzodiazepines and opioids is associated with prolonged postoperative delirium in elderly patient populations.53
Preferential use of neuraxial anesthesia over general anesthesia has also been shown to improve postoperative outcomes.54,55 In a meta-analysis, that included 16,555 patients, Liu et al. demonstrated that patients undergoing knee arthroplasty had a significantly lower incidence of both pneumonia and surgical site infection within a 30 day period, when receiving neuraxial anesthesia compared to general anesthesia.54 This is believed to be due to the lesser impact that neuraxial anesthesia has on immune function and the comparatively lower degree of surgical stress.54
A summary of the key intraoperative elements of the ERAS protocol are listed in Table 2.

2.4.     Postoperative Interventions & Recommendations
2.4.1.        Early Mobilization & Oral Feeding
Surgical patients typically qualify to leave the hospital when they can resume eating and drinking normally, have controlled their pain through oral analgesics, and have sufficient mobility to care for themselves and accomplish the normal activities of daily living.5 As such, it is unsurprising that ERAS protocols call for the early mobilization and resumption of oral feeding by patients as soon as possible following surgery.10-19 Prolonged bed rest has been associated with adverse effects such as increased catecholamine secretion and reduced maximal oxygen uptake56 as well as increasing the risk of VTE,41,57 whereas restricted oral intake following surgery has been associated with contributing to catabolism and the loss of weight and skeletal muscle.41

2.4.2.        Avoidance/Early Removal of Nasogastric Tubes, Catheters, & Drains
ERAS pathways also emphasize the avoidance or early removal of nasogastric (NG) tubes, urinary catheters, and drains in surgical patients.10-19 The traditional view of NG tubes was that they decreased the incidence of PONV, aspiration, anastomotic leak, and wound dehiscence.58 Whereas, NG tubes are often reported by patients as one of the most painful aspects of their care,59 further complicating postoperative care.
Although avoidance of NG tubes may somewhat increase the risk of vomiting postoperatively, their avoidance is associated with shorter LoS and a decreased incidence of fever, atelectasis, and pneumonia.58 Similarly, evidence has shown little or no efficacy in the use of drainage systems for a myriad of surgical procedures.60-62
A13-T2

In a recent meta-analysis of randomized controlled trials, Picchio et al. examined a sample of 1,939 patients undergoing laparoscopic cholecystectomy, either with or without the use of a drain.60 They observed significantly lower morbidity in the no drain group, with a lower incidence of wound infection and less reported postoperative pain 24 h after surgery compared to patients with a drainage system.60 In contrast, the use of urinary catheterization is necessary following certain procedures associated with voiding dysfunction.63 However, urinary tract infections secondary to prolonged catheterization is the leading cause of nosocomial infections, accounting for 40% of infections in the hospital setting.64 Early removal of urinary catheters, within one day postoperatively, is recommended.63

2.4.3.        Analgesic Recommendations
ERAS makes a number of recommendations for optimizing postoperative analgesia to maximize patients’ return of function. Neuraxial analgesia, multimodal analgesia, and local anesthetic infiltration are the most recommended.10-19 In a meta-analysis of randomized controlled trials, Block et al. showed that epidural analgesia was superior to parenteral opioid analgesia at any postoperative timepoint, regardless of the analgesic agent used.65 Interestingly, epidural analgesia may also hasten lung recovery following laparoscopic surgery.11 The usage of local anesthetic infiltration and peripheral nerve blocks for the control of postoperative pain have also been shown to have favorable outcomes for patients compared to standard methods, with patients displaying less postoperative pain, less opioid use, and less need for rescue analgesia.66,67 Local anesthetic infiltration has even shown an association with decreased postoperative cortisol and glucose responses, indicating an attenuation in patients’ stress responses to surgery.66 With the use of these local anesthetics, ERAS guidelines have suggested the longer-acting local anesthetics such as ropivacaine and levobupivacaine as opposed to lidocaine,11 to maximize analgesic efficacy. In cases where neuraxial blocks and local anesthetics are not indicated, ERAS pathways recommend the use of multimodal analgesia— combining opioids with non-steroidal anti-inflammatory drugs (NSAID), acetaminophen, and gabapentin— to limit the opioid administration to the patient.16,20 Preemptive administration of multimodal analgesia preoperatively may also contribute to lowering postoperative pain,20 improving patients’ postoperative experience.
A summary of the key postoperative elements of the ERAS protocol are listed in Table 3.
Table 3: Postoperative ERAS recommendations and purpose.
Intervention Purpose
Early Resumption of Oral Feeding To reduce the risk of insulin resistance
Early Mobilization To support the quick return to normal function and reduce the risk of pneumonia & VTE
Avoidance of NG tubes, catheters, & drains To reduce pain, discomfort, and the risk of pneumonia, while promoting the resumption of oral feeding
Multimodal Analgesia To control pain while sparing excessive opioid usage
Local anesthetic infiltration & nerve blocks To control pain while sparing excessive opioid usage
3.      Audit

The ERAS pathways recommend the implementation of a structured, institutional system of auditing, to ensure that the various aspects of the ERAS protocols are adhered to and kept up to date.10-19 The effectiveness of such audits in the implementation of quality improvement initiatives has been somewhat controversial. In a meta-analysis Jamtvedt et al. found that audits were able to improve professional practice; however, the researchers found the magnitudes of improvement to be only small to moderate.68 Nonetheless, given the lack of any associated risks, these audits have still been routinely recommended for institutions adopting ERAS programs.

3.1.     Adoption & Implementation of ERAS
Despite its clear and proven benefits, the international adoption of ERAS has been slow.8,22 Past analyses of this issue have revealed key barriers to the adoption of ERAS protocols in clinical practice. The most frequently cited is a resistance to change from traditional practices,8,22,69 even those practices which have been found unnecessary and even harmful such as mechanical bowel preparation.10-15,17 In a qualitative study to determine which factors were impeding the adoption of ERAS protocols, Pearsall and colleagues identified resistance to change, poor communication/collaboration, and patient factors as the largest obstacles to implementation.69 Respondents to this investigation also frequently agreed that a standardized guideline for ERAS protocols would be essential;69 fortunately, the ERAS society has published just such guidelines for patients receiving a number of surgeries— which are continuously updated with new evidence.23 Regrettably, within the culture of medicine it has been shown that empirical research findings are neither rapidly nor routinely translated into changes in clinical care.70 Within the United States, McGlynn et al. showed that the patients received only 55% of the recommended care, ranging from 79% to 11% depending on the type of surgery.71 This gap between evidence-based care and standard care in the practice of medicine is irreconcilable with the ethical ideals of medicine, which promote the best interest of patients. Furthermore, studies have shown that apart from not receiving recommended care, 20-30% of patients may be receiving care that is either unnecessary or even harmful.70
Previous investigations— fortunately— have made determinations on which practices are successful and important for the implementation of quality improvement (QI) programs such as ERAS. The spread of practices between departments has been identified as an important factor in the successful implementation and continued, long-term compliance with QI programs.8 De Groot et al. conducted a multicenter examination of the spread of ERAS protocols from the gastrointestinal surgical teams to the gynecological surgical teams at a number of Dutch hospitals where ERAS pathways were in practice.8 They concluded that almost no spread of ERAS protocols took place between the related departments, even in hospitals with mixed wards for gastrointestinal and gynecological patients.8 This presents a clear avenue for future efforts at ERAS implementation to focus on. Other identified factors associated with successful QI implementation are engaged clinicians, an important problem, an understanding of the QI’s processes, a method to improve them, face-to-face communication, institutional structure, patient participation, and  a sustainable system for measurement, audit, and feedback.6,9,72 Many of these components— such as patient involvement, an important problem, and a system for audits— are built into the ERAS pathway.10-19 However, it remains clear that increased efforts are needed to make ERAS implementation universal.
Even within centers where ERAS has been adopted, varying degrees of successful implementation and compliance have been reported.73 Improved compliance rates have been shown to be important for eliciting the reported beneficial aspects of ERAS.  Different levels of compliance with ERAS protocols have been cited as being necessary for observing effects on patient outcomes— from 50-90%23 to more recently 70-80%.5 In one study, compliance greater than 70% was associated with a 42% decline in mortality for patients with colorectal cancer.5 In a recent prospective study Pisarska et al. stratified patients in high (> 90%), moderate (70-90%), and low (< 70%) compliance with ERAS guidelines and investigated differences in patient outcomes. Even between the moderate and high compliance groups significantly better outcomes were observed— with respective complication rates of 16.4%, 36.4%, and 35.7%.73 Improvement was also observed on secondary measures of recovery: LoS and the rates of oral feeding and mobilization that occurred on postoperative day 1.73 It is, however, worth noting that compliance may decline in circumstances where ERAS protocols are contraindicated by the patient’s conditions and/or co-morbidities. Selective non-compliance with aspects of ERAS protocols were found by one study to be medically justifiable in as many as 80% of cases in centers where ERAS was in place.22 Maximizing implementation in all cases where ERAS protocols are indicated is, however, of the utmost importance for improving and modernizing the standard of care and providing patients with the healthcare they deserve.

4.      Conclusions
There is a strong consensus that ERAS is not only safe and feasible, but also represents the best available standard of perioperative care for surgical patients based on existing evidence. The application of ERAS recommended guidelines has been proven to reduce complications, shorten the length of hospital stay, and reduce postoperative pain— while simultaneously diminishing economic costs for hospitals and patients. The primary barriers to successful implementation of ERAS internationally is an ingrained resistance to change and the systemic failure of communication both within and between different specialties. Although these obstacles are not insurmountable, drastic changes are needed to close the gap between evidence-based care and outdated traditional practices.

5.      Authors’ Contribution
RL: collection and review of literature, drafting and review of manuscript, production of tables
JL, AS: concept, review of literature, design of the manuscript, final editing and critical review

6.      Conflicts of Interest
The authors of this article have no conflicts of interest of any kind with the topics discussed in this article, nor was there any receipt of funds from any institution with regards to this research.

7.      References
  1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997 May;78(5):606-617. [PubMed] DOI: 1093/bja/78.5.606
  2. Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg. 1999;86(2):227-230. [PubMed] DOI: 1046/j.1365-2168.1999.01023.x
  3. Bardram L, Funchjensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilization. Lancet. 1995;345(8952):763-764. [PubMed] DOI: 1016/s0140-6736(95)90643-6
  4. Slim K. Laparoscopy within fast-track or within enhanced recovery after surgery? Ann Surg.2014;259(2):E24. [PubMed] DOI: 1097/SLA.0000000000000290
  5. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292-298. [PubMed] DOI: 1001/jamasurg.2016.4952
  6. Slim K, Delaunay L, Joris J, Léonard D, Raspado O, Chambrier C, et al. How to implement an enhanced recovery program? proposals from the francophone group for enhanced recovery after surgery (GRACE). J Visc Surg. 2016;153(6):S45-S49. [PubMed] DOI: 1016/j.jviscsurg.2016.05.008
  7. Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clin Nutr. 2010;29(4):434-440. [PubMed] DOI: 1016/j.clnu.2010.01.004
  8. de Groot JJA, Maessen JMC, Dejong CHC, Winkens B, Kruitwagen RFPM, Slangen BFM, et al. Interdepartmental spread of innovations: a multicentre study of the enhanced recovery after surgery programme. World J Surg. 2018;42(8):2348-2355. [PubMed] DOI: 1007/s00268-018-4495-z
  9. Huber GF, Dort JC. Reducing morbidity and complications after major head and neck cancer surgery: the (future) role of enhanced recovery after surgery protocols. Curr Opin Otolaryngol Head Neck Surg. 2018;26(2):71-77. [PubMed] DOI: 1097/MOO.0000000000000442
  10. Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, Braga M, et al. Consensus guidelines for enhanced recovery after gastrectomy enhanced recovery after surgery (ERAS®) society recommendations. Br J Surg. 2014;101(10):1209-1229. [PubMed] DOI: 1002/bjs.9582
  11. 1Thorell A, MacCormick AD, Awad S, Reynolds N, Roulin D, Demartines N, et al. Guidelines for perioperative care in bariatric surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg. 2016;40(9):2065-2083. [PubMed] DOI: 1007/s00268-016-3492-3
  12. Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, et al. Guidelines for perioperative care for pancreaticoduodenectomy: enhanced recovery after surgery (ERAS®) society recommendations. World J Surg. 2013;37(2):240-258. [PubMed] DOI: 1007/s00268-012-1771-1
  13. Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: enhanced recovery after surgery (ERAS®) society recommendations. Clin Nutr. 2013;32(6):879-887. [PubMed] DOI: 1016/j.clnu.2013.09.014
  14. Melloul E, Hübner M, Scott M, Snowden C, Prentis J, Dejong CH, et al. Guidelines for perioperative care for liver surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg. 2016;40(10):2425-2440. [PubMed] DOI: 1007/s00268-016-3700-1
  15. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, et al. Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS®) society recommendations. World J Surg. 2013;37(2):259-284. [PubMed] DOI: 1007/s00268-012-1772-0
  16. Dort JC, Farwell DG, Findlay M, Huber GF, Kerr P, Shea-Budgell MA, et al. Optimal perioperative care in major head and neck cancer surgery with free flap reconstruction: a consensus review and recommendations from the enhanced recovery after surgery society. JAMA Otolaryngol Head Neck Surgery. 2017;143(3):292-303. [PubMed] DOI: 1001/jamaoto.2016.2981
  17. Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS®) society recommendations. World J Surg. 2013;37(2):285-305. [PubMed] DOI: 1007/s00268-012-1787-6
  18. Temple-Oberle C, Shea-Budgell MA, Tan M, Semple JL, Schrag C, Barreto M, et al. Consensus review of optimal perioperative care in breast reconstruction: enhanced recovery after surgery (ERAS) society recommendations. Plast Reconstr Surg. 2017;139(5):1056e-1071e. [PubMed] DOI: 1097/PRS.0000000000003242
  19. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466-477. [PubMed] DOI: 1016/j.clnu.2005.02.002
  20. Yang L, Kaye AD, Venakatesh AG, Green MS, Asgarian CD, Luedi MM, et al. Enhanced Recovery after cardiac surgery: an update on clinical implications. Int Anesthesiol Clin. 2017;55(4):148-162. [PubMed] DOI: 1097/AIA.0000000000000168
  21. Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: time to change practice? Can Urol Assoc J. 2011;5(5):342-348. [PubMed] DOI: 5489/cuaj.11002
  22. Pędziwiatr M, Mavrikis J, Witowski J, Adamos A, Major P, Nowakowski M, et al. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol. 2018;35(6):95. [PubMed] DOI: 1007/s12032-018-1153-0
  23. Ljungqvist O. ERAS-enhanced recovery after surgery: moving evidence-based perioperative care to practice. J Parenter Enter Nutr. 2014;38(5):559-566. [PubMed] DOI: 1177/0148607114523451
  24. Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med. 2004;32(4):S76-S86. [PubMed] DOI: 1097/01.ccm.0000122046.30687.5c
  25. Carli F, Charlebois P, Baldini G, Cachero O, Stein B. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can J Anaesth. 2009;56(11):837-842. [PubMed] DOI: 1007/s12630-009-9159-x
  26. Stergiopoulou A, Birbas K, Katostara I, Mantas J. The effect of interactive multimedia on preoperative knowledge and postoperative recovery of patients undergoing laparoscopic cholecystectomy. Methods Inf Med. 2007;46(4):406-409. [PubMed] DOI: 1160/me0406
  27. Tonnesen H, Rosenberg J, Nielsen HJ, Rasmussen V, Hauge C, Pedersen IK, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ. 1999;318(7194):1311-1316. [PubMed] DOI: 1136/bmj.318.7194.1311
  28. Khullar D, Maa J. The impact of smoking on surgical outcomes. J Am Coll Surg. 2012;215(3):418-426. [PubMed] DOI: 1016/j.jamcollsurg.2012.05.023
  29. Kennedy ND, Winter DC. Impact of alcohol & smoking on the surgical management of gastrointestinal patients. Best Pract Res Clin Gastroenterol. 2017;31(5):589-595. [PubMed] DOI: 1016/j.bpg.2017.10.005
  30. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: A randomized controlled trial. Ann Surg. 2003;238(1):1-5. [PubMed] DOI: 1097/01.SLA.0000074980.39700.31
  31. Minnella EM, Carli F. Prehabilitation and functional recovery for colorectal cancer patients. Eur J Surg Oncol. 2018;44(7):919-926. [PubMed] DOI: 1016/j.ejso.2018.04.016
  32. Bahrke MS, Morgan WP. Anxiety reduction following exercise and meditation. Cogn Ther Res. 1978;2(4):323-333.
  33. van Stijn MFM, Korkic-Halilovic I, Bakker MSM, van der Ploeg T, van Leeuwen PAM, Houdijk APJ. Preoperative nutrition status and postoperative outcome in elderly general surgery patients: a systematic review. J Parenter Enter Nutr. 2013;37(1):37-43. [PubMed] DOI: 1177/0148607112445900
  34. Goonetilleke KS, Siriwardena AK. Systematic review of peri-operative nutritional supplementation in patients undergoing pancreaticoduodenectomy. Jop. 2006;7(1):5-13. [PubMed]
  35. Nelson RL, Glenny AM, Song F. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001181. [PubMed] DOI: 1002/14651858.CD001181.pub3
  36. Bratzler DW, Houck PM; Surgical Infection Prevention Guideline Writers Workgroup. Antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project. Am J Surg. 2005;189(4):395-404. [PubMed] DOI: 1016/j.amjsurg.2005.01.015
  37. Mittendorf R, Aronson MP, Berry RE, Williams MA, Kupelnick B, Klickstein A, et al. Avoiding serious infections associated with abdominal hysterectomy-a metaanalysis of antibiotic prophylaxis. Am J Obstet Gynecol. 1993;169(5):1119-1124. [PubMed] DOI: 1016/0002-9378(93)90266-l
  38. Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg. 2003;90(4):400-406. [PubMed] DOI: 1002/bjs.4066
  39. Phillips S, Hutchinson S, Davidson T. Preoperative drinking does not affect gastric contents. Br J Anaesth. 1993 Jan;70(1):6-9. [PubMed] DOI: 1093/bja/70.1.6
  40. Maltby JR, Sutherland A, Sale J, Shaffer E. Preoperative oral fluids: is a five-hour fast justified prior to elective surgery? Anesth Analg. 1986;65(11):1112-1116. [PubMed]
  41. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-641. [PubMed] DOI: 1016/s0002-9610(02)00866-8
  42. Slim K. Fast-track surgery: the next revolution in surgical care following laparoscopy. Colorectal Dis. 2011;13(5):478-480. [PubMed] DOI: 1111/j.1463-1318.2011.02589.x
  43. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery a randomized clinical trial (LAFA-study). Ann Surg. 2011;254(6):868-875. [PubMed] DOI: 1097/SLA.0b013e31821fd1ce
  44. Sauerland S, Jaschinski T, Neugebauer EAM. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2010 Oct 6;(10):CD001546. [PubMed] DOI: 1002/14651858.CD001546.pub3
  45. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. N Engl J Med. 1996;334(19):1209-1215. [PubMed] DOI: 1056/NEJM199605093341901
  46. Eng OS, Raoof M, O'Leary MP, Lew MW, Wakabayashi MT, Paz IB, et al. Hypothermia Is associated with surgical site infection in cytoreductive surgery with hyperthermic intra-peritoneal chemotherapy. Surg Infect. 2018;19(6):618-621. [PubMed] DOI: 1089/sur.2018.063
  47. Melling AC, Ali B, Scott EM, Leaper DJ. Effects of preoperative warming on the incidence of wound infection after clean surgery: a randomised controlled trial. Lancet. 2001;358(9285):876-880. [PubMed] DOI: 1016/S0140-6736(01)06071-8
  48. Singh B, Kulshrestha A. Diagnosis, prevention and management of postoperative pulmonary edema. Ann Med Health Sci Res. 2012;2(2):180-185. [PubMed] DOI: 4103/2141-9248.105668
  49. Codner PA, Patel J, Rosenthal M, Carrot P, McClave SA. Fluid management, volume overload, and gastrointestinal tolerance in the perioperative period. Curr Surg Rep. 2016;4(4):8.
  50. Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet. 2002;359(9320):1812-1818. [PubMed] DOI: 1016/S0140-6736(02)08711-1
  51. Apfel CC, Heidrich FM, Jukar-Rao S, Jalota L, Hornuss C, Whelan RP, et al. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth. 2012;109(5):742-753. [PubMed] DOI: 1093/bja/aes276
  52. Hwang CS, Kang EM, Kornegay CJ, Staffa JA, Jones CM, McAninch JK. Trends in the Concomitant Prescribing of Opioids and Benzodiazepines, 2002-2014. Am J Prev Med. 2016;51(2):151-160. [PubMed] DOI: 1016/j.amepre.2016.02.014
  53. Pisani MA, Murphy TE, Araujo KL, Slattum P, Van Ness PH, Inouye SK. Benzodiazepine and opioid use and the duration of ICU delirium in an older population. Crit Care Med. 2009;37(1):177-183. [PubMed] DOI: 1097/CCM.0b013e318192fcf9
  54. Liu JB, Ma CJ, Elkassabany N, Fleisher LA, Neuman MD. Neuraxial anesthesia decreases postoperative systemic infection risk compared with general anesthesia in knee arthroplasty. Anesth Analg. 2013;117(4):1010-1016. [PubMed] DOI: 1213/ANE.0b013e3182a1bf1c
  55. Zorrilla-Vaca A, Grant MC, Mathur V, Li JL, Wu CL. The impact of neuraxial versus general anesthesia on the incidence of postoperative surgical site infections following knee or hip arthroplasty a meta-analysis. Region Anesth Pain Med. 2016;41(5):555-563. [PubMed] DOI: 1097/AAP.0000000000000437
  56. Convertino VA. Cardiovascular consequences of bed rest: Effect on maximal oxygen uptake. Med Sci Sports Exerc. 1997;29(2):191-196. [PubMed] DOI: 1097/00005768-199702000-00005
  57. Wang CL, Cui FP, Li JQ, Yuan X, Wang J, Liu L, et al. risk factors for venous thromboembolism in hospitalized patients in the chinese population. Open Life Sci. 2018;13(1):82-89. DOI: 1515/biol-2018-0012
  58. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995;221(5):469-476. [PubMed] DOI: 1097/00000658-199505000-00004
  59. Gallagher EJ. Nasogastric tubes: hard to swallow. Ann Emerg Med. 2004;44(2):138-141. [PubMed] DOI: 1016/j.annemergmed.2004.04.009
  60. Picchio M, Lucarelli P, Di Filippo A, De Angelis F, Stipa F, Spaziani E. Meta-analysis of drainage versus no drainage after laparoscopic cholecystectomy. JSLS. 2014;18(4):e2014.00242. [PubMed] DOI: 4293/JSLS.2014.00242
  61. Ritter MA, Keating EM, Faris PM. Closed wound drainage in total hip or total knee replacement- a prospective randomized study. J Bone Joint Surg-Am.1994;76(1):35-38. [PubMed] DOI: 2106/00004623-199401000-00005
  62. Merad F, Yahchouchi E, Hay JM, Fingerhut A, Laborde Y, Langlois-Zantain O. Prophylactic abdominal drainage after elective colonic resection and suprapromontory anastomosis: a multicenter study controlled by randomization. Arch Surg. 1998;133(3):309-314. [PubMed] DOI: 1001/archsurg.133.3.309
  63. Benoist S, Panis Y, Denet C, Mauvais F, Mariani P, Valleur P. Optimal duration of urinary drainage after rectal resection: A randomized controlled trial. Surgery. 1999;125(2):135-141. [PubMed]
  64. Chenoweth C, Saint S. Preventing catheter-associated urinary tract infections in the intensive care unit. Crit Care Clin. 2013;29(1):19-32. [PubMed] DOI: 1016/j.ccc.2012.10.005
  65. Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA, Wu CL. Efficacy of postoperative epidural analgesia: A meta-analysis. JAMA. 2003;290(18):2455-2463. [PubMed] DOI: 1001/jama.290.18.2455
  66. Kahokehr A, Sammour T, Soop M, Hill AG. Intraperitoneal use of local anesthetic in laparoscopic cholecystectomy: systematic review and metaanalysis of randomized controlled trials. J Hepato-Biliary Pancreat Sci. 2010;17(5):637-656. [PubMed] DOI: 1007/s00534-010-0271-7
  67. Le-Wendling L, Enneking FK. Continuous peripheral nerve blockade for postoperative analgesia. Curr Opin Anesthesiol. 2008;21(5):602-609. [PubMed] DOI: 1097/ACO.0b013e32830a4be6
  68. Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2006(2):CD000259. [PubMed] DOI: 1002/14651858.CD000259.pub2
  69. Pearsall EA, Meghji Z, Pitzul KB, Aarts MA, McKenzie M, McLeod RS, et al. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Ann Surg. 2015;261(1):92-96. [PubMed] DOI: 1097/SLA.0000000000000604
  70. Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7:50. [PubMed] DOI: 1186/1748-5908-7-50
  71. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003 Jun 26;348(26):2635-2645. [PubMed] DOI: 1056/NEJMsa022615
  72. McCormack B, Rycroft-Malone J, Decorby K, Hutchinson AM, Bucknall T, Kent B, et al. A realist review of interventions and strategies to promote evidence-informed healthcare: a focus on change agency. Implement Sci. 2013;8:107. [PubMed] DOI: 1186/1748-5908-8-107
  73. Pisarska M, Pędziwiatr M, Małczak P, Major P, Ochenduszko S, Zub-Pokrowiecka A, et al. Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study. Int J Surg. 2016;36:377-382. [PubMed] DOI: 1016/j.ijsu.2016.11.088