What are the recommendations for Enhanced Recovery After Surgery (ERAS) protocols in colon surgery?

Enhanced Recovery After Surgery (ERAS) for Colon Surgery

Implement a comprehensive multimodal ERAS protocol incorporating all evidence-based perioperative elements, as this approach reduces morbidity by 34% and shortens hospital stay by 2-3 days compared to traditional care. 1, 2

Preadmission Components

Patient Education and Counseling

• Provide detailed preoperative counseling about the surgical procedure, expected recovery timeline, and the patient's active role in recovery, using personal counseling, written materials, or multimedia formats 1, 3
• This reduces anxiety and enhances postoperative recovery 1

Nutritional Optimization

• Screen all patients for malnutrition and provide active nutritional support to those at risk 1
• Administer carbohydrate loading with 400ml oral carbohydrate-rich drink (50g CHO) 2 hours before surgery to reduce insulin resistance and catabolism 3, 4

Fasting Guidelines

• Allow clear fluids until 2 hours before anesthesia and solid food until 6 hours before anesthesia—prolonged fasting is harmful 3, 4

Bowel Preparation

• Avoid routine mechanical bowel preparation as it provides no benefit and causes dehydration and electrolyte disturbances 3, 4

Prophylaxis

• Administer single-dose antibiotic prophylaxis within 60 minutes before incision 3
• Implement thromboprophylaxis with well-fitting compression stockings and low molecular weight heparin 1, 3

Intraoperative Components

Surgical Approach

• Perform laparoscopic surgery when expertise is available as it reduces morbidity and accelerates recovery (high evidence for oncologic outcomes, moderate for length of stay) 1, 3
• Laparoscopy alone is insufficient—full ERAS compliance is essential for optimal outcomes 5

Anesthesia Management

• Use short-acting anesthetic agents to allow rapid awakening 3, 4
• Employ mid-thoracic epidural analgesia (T7-10) for open surgery using low-dose local anesthetic combined with opioids (high evidence) 1, 3
• For laparoscopic surgery, carefully administered spinal analgesia with low-dose long-acting opioid is an acceptable alternative to epidural 1

Fluid Management

• Administer goal-directed fluid therapy using cardiac output monitoring (flow measurements) to optimize hemodynamics and avoid fluid overload (high evidence for open surgery, moderate for laparoscopic) 1, 3
• Use vasopressors for epidural-induced hypotension in normovolemic patients rather than excessive fluid administration 1
• Transition to enteral fluids as early as possible and discontinue IV fluids promptly 1

Temperature Management

• Maintain normothermia with active warming devices and warmed IV fluids to keep body temperature >36°C (high evidence) 1, 3

PONV Prevention

• Implement multimodal PONV prophylaxis for all patients with ≥2 risk factors undergoing major colorectal surgery 1, 3

Tubes and Drains

• Remove nasogastric tubes before reversal of anesthesia—routine postoperative NG tubes should not be used (high evidence) 1, 3
• Avoid routine peritoneal drainage after colonic anastomosis as it impairs mobilization without benefit (high evidence) 1, 3

Urinary Catheterization

• Use transurethral bladder drainage for 1-2 days routinely, but remove early regardless of epidural use 1, 3

Postoperative Components

Pain Management

• Provide multimodal analgesia combining thoracic epidural (for open surgery), acetaminophen, and NSAIDs to minimize opioid requirements 3, 4

Ileus Prevention

• Utilize mid-thoracic epidural analgesia and laparoscopic surgery when possible (high evidence) 1
• Avoid fluid overload and nasogastric decompression (strong recommendation) 1
• Consider chewing gum (moderate evidence, strong recommendation) 1

Nutrition

• Encourage normal food intake as soon as the patient is lucid after surgery (high evidence for safety) 1, 3
• Resume oral diet within 24 hours postoperatively 3, 4
• Use oral nutritional supplements to supplement total intake if needed 1

Mobilization

• Mobilize patients out of bed within 24 hours after surgery and maintain at least 6 hours per day of activity thereafter 3, 4
• Prolonged immobilization increases pneumonia risk, insulin resistance, and muscle weakness 1

Glucose Control

• Avoid hyperglycemia as it increases complication risk 1
• The stress-reducing elements of ERAS protocols naturally improve glycemic control 1
• Use insulin judiciously in ward-based patients to maintain blood glucose as low as feasible 1

Expected Outcomes

Benefits of Full ERAS Implementation

• Overall morbidity reduction of 34% (risk ratio 0.66) compared to usual care 6
• Mean length of stay reduction of 2.6 days 6
• Reduced urinary tract infections (13% vs 24%) 2
• Lower readmission rates in most studies 2
• No increase in mortality, anastomotic complications, or surgical site infections 6

Critical Implementation Factors

• Full protocol compliance is essential—laparoscopy alone without complete ERAS adherence does not achieve optimal outcomes 5
• The ERAS pathway specifically reduces nonsurgical complications while maintaining similar rates of surgical complications 5
• Regular audit of outcomes and compliance is crucial for continuous improvement 3, 4

Special Populations

• Selected low-risk patients (ASA I-II) undergoing laparoscopic surgery may achieve safe discharge within 23 hours using accelerated protocols 7
• Protocols should be adapted for rectal surgery, which has higher complication rates than colonic surgery 3