What are the benefits of using Enhanced Recovery After Surgery (ERAS) protocols compared to non-ERAS protocols in patients with intestinal obstruction?

Benefits of ERAS Protocols in Intestinal Obstruction

Enhanced Recovery After Surgery (ERAS) protocols significantly reduce hospital stay, accelerate bowel function recovery, and decrease complication rates in patients with intestinal obstruction compared to traditional care, and should be implemented with appropriate modifications for this patient population. 1

Evidence for ERAS in Intestinal Obstruction

Clinical Outcomes

• Hospital Stay: ERAS protocols reduce median hospital stay by 2.5-3 days in patients with intestinal obstruction (5.5 days vs. 8 days) 1, 2
• Bowel Function Recovery: Significantly faster return of:
  • Time to first flatus (1.25 days faster) 3
  • Time to first stool (1.8 days faster) 3
  • Time to first oral liquid diet (2.3 days faster) 2
  • Time to first solid diet (2.4 days faster) 2
• Complications: ERAS protocols reduce:
  • Overall complication rates by 50% (OR: 0.50) 2
  • Major complications by 40% (OR: 0.60) 2
  • Pulmonary complications by 62% (OR: 0.38) 2
  • Surgical site infections by 61% (OR: 0.39) 2
  • Paralytic ileus by 47% (OR: 0.53) 2

Safety Considerations

• No significant difference in 30-day mortality rates between ERAS and traditional care 2
• No increase in readmission rates (1.3% vs. 0% in one study) 4
• No increase in reoperation rates 2

Modified ERAS Components for Intestinal Obstruction

Preoperative Components

• Intensive preoperative counseling by surgeons and anesthesiologists 4
• Appropriate venous thromboembolism prophylaxis (mechanical and pharmacological) 5
• Avoid mechanical bowel preparation 5

Intraoperative Components

• Optimized fluid management (avoid sodium/fluid overload) 4
• Intraoperative warm air body heating 4
• Minimally invasive surgical approach when feasible 5

Postoperative Components

1. Early Feeding:

   • Early tube feeding (within 24h) when oral nutrition cannot be started 5
   • Early removal of nasogastric tubes 1
   • Progressive diet advancement as tolerated 4

2. Ileus Prevention:

   • Multifaceted approach including:
     • Optimized fluid management
     • Opioid-sparing analgesia
     • Early mobilization
     • Early oral intake
     • Laxative administration 5

3. Nutritional Support:

   • If oral/enteral intake will be inadequate (<50% of caloric requirement) for >7 days, early parenteral nutrition is indicated 5
   • Switch to enteral nutrition when gastrointestinal function recovers 5

4. Early Mobilization:

   • Enforced postoperative mobilization 4
   • Early ambulation protocols 1

Implementation Considerations

Patient Selection

• ERAS protocols can be safely applied to most patients with intestinal obstruction 1, 3
• Caution in patients with:
  • Severe sepsis/septic shock
  • Hemodynamic instability
  • Significant comorbidities (ASA ≥3) 3

Multidisciplinary Approach

• Requires coordination between surgeons, anesthesiologists, nurses, and nutritionists 4
• Standardized protocols with clear roles and responsibilities 6

Common Pitfalls and Caveats

1. Fluid Management: Balance between adequate resuscitation and avoiding fluid overload is crucial in emergency settings; aim for weight gain <3kg by postoperative day 3 5

2. Feeding Progression: In patients with gross intestinal edema or right-sided resections, start with small portions initially 5

3. Parenteral Nutrition: Don't delay parenteral nutrition when enteral feeding is contraindicated due to intestinal obstruction, ischemia, or high-output fistulae 5

4. Protocol Adherence: Success depends on adherence to multiple components; partial implementation may not achieve the same benefits 6

ERAS protocols represent a significant advancement in the management of patients with intestinal obstruction, offering substantial improvements in recovery time, complication rates, and hospital stay without compromising safety. The evidence strongly supports their implementation with appropriate modifications for the emergency setting.