24 04 2023
The Enhanced Recovery After Surgery (ERAS) protocol comprises a series of specific procedures and measures that aim to accelerate postoperative recovery and decrease complications by 50%. The main objectives of the ERAS protocol are to implement a standardized treatment approach that reduces differences in care, integrates all phases of treatment to improve outcomes and enhances patient satisfaction.
The ERAS protocol involves appropriate preoperative preparation of the patient’s physical and mental condition, modification of the intraoperative procedure through the standardization of minimally invasive surgery and early extubation, and individualized analgesia and standardized physiotherapy in the postoperative period. The protocol is implemented before hospitalization, during the preoperative, intraoperative, and postoperative periods. The patient is referred by their primary healthcare provider for a preoperative assessment and preparation, followed by admission to the hospital, surgery, postoperative care, and regular follow-up.
In the primary healthcare institution, before hospitalization, the patient’s preoperative state of health and accompanying diseases are optimized. This includes correcting anaemia, glycemia, renal function, elevated blood pressure, and discontinuing smoking and alcohol intake. Preoperative preparation in the hospital includes counselling the patient, assessing operative risk, and correcting and consulting some comorbidities not adequately managed in the primary healthcare institution. The aim is to shorten preoperative hospitalization, fasting, fluid and carbohydrate intake, and prevent nausea, vomiting, thrombosis, and infections.
During the operation, appropriately combined analgesia, normothermia, maintenance of hemodynamic stability, optimal oxygenation, and minimally invasive surgery are applied.
In the postoperative course, adequate analgesia, treatment of postoperative nausea or vomiting, and early removal of the nasogastric tube and urinary catheter are provided. Postoperative nutrition begins as early as possible, and after liver surgery, if the digestive tube is not compromised, eating can start on the first day after surgery. The patient is mobilized after the effects of the drugs administered as part of general anaesthesia cease. The stay in the Intensive Care Unit is minimized. The ERAS protocol aims to shorten the patient’s hospital stay after surgery as much as possible, given the known effect of the home environment on the psycho-physical status and recovery of the patient who has undergone surgery.
The 2022 recommendations from the ERAS Association for liver operations encompass various specific measures. Several of these measures are focused on the preoperative period, including an interview with the patient, prehabilitation for high-risk patients 4-6 weeks prior to the surgery, biliary drainage (for serum bilirubin levels above 50mmol/L), cessation of smoking and alcohol consumption, appropriate nutrition (7-14 days before surgery), immunonutrition, premedication, thromboprophylaxis (elastic stockings and anticoagulant therapy), and antibiotic prophylaxis. The ERAS protocol incorporates modern minimally invasive surgery, which facilitates faster and easier recovery. During the operation, it is essential to provide adequate multimodal analgesia and prevent intraoperative hypothermia.
In the postoperative course, the focus is on early nutrition, glycaemic control, preventing delayed gastric emptying, promoting peristalsis, early mobilization from bed, prophylaxis of nausea and vomiting, fluid replacement, and monitoring vital parameters.
Source: Joliat GR et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022. World J Surg (2023) 47:11–34.
