What is the Enhanced Recovery After Surgery (ERAS) protocol following colectomy (colon surgery)?

From the Guidelines

The Enhanced Recovery After Surgery (ERAS) protocol is the recommended approach for colon surgery, as it has been shown to reduce complications, shorten hospital stays, and improve outcomes by minimizing the physiological stress response to surgery, maintaining normal organ function, and reducing the metabolic demand during recovery 1.

Key Components of ERAS Protocol

• Preoperative carbohydrate loading with clear liquids containing 50g carbohydrates 2-3 hours before surgery
• Prophylactic antibiotics, typically cefazolin 2g IV and metronidazole 500mg IV, 30-60 minutes before incision
• Intraoperative goal-directed fluid therapy to maintain euvolemia, with crystalloids at 3-5 mL/kg/hr
• Postoperative early mobilization, starting within 24 hours, with patients sitting up and walking at least three times daily
• Oral intake resuming within 24 hours, starting with clear liquids and advancing as tolerated
• Multimodal pain management, including scheduled acetaminophen, NSAIDs, and limited opioids for breakthrough pain
• Alvimopan 12mg orally twice daily to prevent opioid-induced ileus until bowel function returns
• Early removal of urinary catheters and drains, within 24-48 hours

Benefits of ERAS Protocol

• Reduces complications by 50% after colorectal surgery 1
• Shortens hospital stays and improves outcomes by minimizing the physiological stress response to surgery, maintaining normal organ function, and reducing the metabolic demand during recovery 1
• Improves patient education and awareness of ERAS, reduces risk of postoperative nausea and vomiting, and optimizes fluid management 1

Implementation of ERAS Protocol

• Requires a multi-modal, multi-disciplinary, and evidence-based approach to perioperative care 1
• Involves counseling, education, optimization, stress reduction, and protocolized normalization 1
• Should be adapted to individual patient needs and tolerance, with regular audit of ERAS compliance 1

From the Research

ERAS Protocol After Colon Surgery

• The ERAS (Enhanced Recovery After Surgery) protocol is a set of perioperative measures aimed at improving patient recovery and decreasing length of stay and postoperative complications in colorectal surgery 2.
• The implementation of an ERAS protocol for colorectal surgery has been associated with a significant reduction in postoperative complications and length of stay 2.
• A study comparing the analgesic effect of patient-controlled oxycodone and fentanyl for pain management in patients undergoing colorectal surgery found that oxycodone provides similar effects for pain relief compared to fentanyl, despite a lower cumulative PCA dose 3.

Components of ERAS Protocol

• Multimodal pain management, including the use of acetaminophen, is a key component of ERAS protocols 4.
• The use of intravenous (IV) acetaminophen may be superior to oral acetaminophen in the early postoperative setting 4.
• Other components of ERAS protocols may include transverse abdominis plane blocks, celecoxib, and ketorolac medications 4.

Outcomes of ERAS Protocol

• The implementation of an ERAS protocol has been shown to reduce the number of patients with moderate or severe complications, as well as the length of stay, in colorectal surgery 2.
• A study found that patients who underwent colorectal surgery using an ERAS protocol had a lower rate of postoperative nausea and vomiting, and a shorter length of stay, compared to those who did not use an ERAS protocol 2.
• However, another study found that preoperative prescription opioid, sedative, or antidepressant use was associated with worse outcomes in colorectal surgery, highlighting the need for careful evaluation of medication use in the preoperative period 5.