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Contact us at firstname.lastname@example.org Chapter 19 ERAS (Enhanced Recovery after Surgery) in Colorectal Surgery Raúl Sánchez-Jiménez, Alberto Blanco Álvarez, Jacobo Trebol López, Antonio Sánchez Jiménez, Fernando Gutiérrez Conde and José Antonio Carmona Sáez Additional information is available at the end of the chapter http://dx.doi.org/10.5772/57136
1. Introduction Evidence-based medicine has led to an extensive investigation and development of new therapies and programs to improve the care of the surgical patient, both in the postoperative and in the pre-operative period, known as enhanced recovery after surgery (ERAS) programs, “fast-track” programs or multimodal rehabilitation programs.
1.1. Definition ERAS programs are evidenced-based protocols designed to standardize and optimize perioperative medical care in order to reduce surgical trauma, perioperative physiological stress and organ dysfunction related to elective procedures . In addition, improved out‐ comes, decreased hospital length of stay and faster patient recovery to normal life are expected to be obtained. Other advantages of this philosophy are the reduction of clinical complications and the health costs together with and increase of patient satisfaction. A diagram with all the core principles of an ERAS program can be seen on Figure 1.
This approach could not be understood and implemented without the participation and commitment of a multidisciplinary team including surgeons, anesthesiologists, nursing staff and hospital administration. Moreover, it is important to make the patient and theirfamilies a partner in their care and give them join responsibility for the recovery.
These kinds of programs are not exclusive of a type of surgery or surgical procedure since they can be applied to different specialties (digestive, vascular, thoracic, etc.), different procedures © 2014 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
488 Colorectal Cancer - Surgery, Diagnostics and Treatment (colon resection, pancreatic procedures, etc.) or different approaches (laparoscopic or open procedures).
In this chapter we will focus on ERAS protocols applied to colorectal surgery.
Patients undergoing major open colorectal surgery traditionally undergo prolonged rehabili‐ tation and complication rates even as high as 30% have been reported after this procedure .
Surgeons learned over the years that surgery was an aggression and that the bigger the procedure was, the bigger the aggression emerged. For example, surgeons understood that patients undergoing major open colorectal surgery suffered prolonged rehabilitation with profound changes in endocrine, metabolic, neural and pulmonary function during the postoperative period. However, the scientific interest was not focused on how to control these changes.
In digestive surgery there were some inviolable principles that were transferred between generation of surgeons over a long period of time. Senior clinicians had strong principles and
they were assumed as a dogma. We will highlight some of them:
• Preoperative prolonged fasting is necessary to empty the bowel, prevent intraoperative contamination and the early passage of bowel content through an anastomosis.
• Mechanical bowel preparation is imperative in colorectal surgery to prevent intraoperative contamination and the passage of faeces through a suture line while it is healing. This passage could increase leaking and dehiscence risk or infections.
• Systematic use of nasogastric tubes is imperative to empty stomach and prevent its content to come into the bowel protecting sutures.
• Drains usage is essential in all kind of digestive procedures.
• Extended periods of bed rest are recommended to facilitate abdominal wall healing.
• Postoperative period is a “resting time” in which surgeons are expecting spontaneous patient recovery.
The majority of these paradigms were only based on clinical experience instead of the scientific evidence and, subsequently, they were passed down from masters to disciples, who preserved them as a non-questionable tradition. However, stepwise, published studies have dispelled these and other “truths” and the evidence has taught us that some of them may be unnecessary and maybe they can contribute to postoperative functional deterioration. For example, the return of bowel function is essential for postoperative recovery and this is influenced nega‐ tively by several perioperative factors such as preoperative fasting and bowel mechanical preparation, opioid analgesic, fluid overload, immobilization and postoperative prolonged fasting. Thus, several reviews and meta-analyses have focused in the absence of benefits in routinely mechanical bowel preparation, routine nasogastric decompression or prolonged postoperative fasting .
In 1990’s, several revolutionary changes were seen: in the field of anesthesia the development of regional anesthetic techniques and new drugs to control pain and sedation; and in the field of surgery the widespread use of minimally invasive (laparoscopic) techniques. As a result, a great improvement in postoperative recovery and earlier return of patients to normal function were achieved. Moreover, it was thought that a minimally invasive approach, with reduced operative trauma, conducted to an earlier return of bowel function and allowed for early oral tolerance. The next step was the thinking that some of the improvements seen were simply due to overall changes in perioperative care attitudes.
490 Colorectal Cancer - Surgery, Diagnostics and Treatment In the late 1990´s, based on those findings, the “fast track” concept to major abdominal surgery was pioneered by Professor Henrik Kehlet and a solid doctrine concerning perioperative care was born. He was a researcher surgeon interested in perioperative medicine, from the Hvidovre University Hospital in Denmark. Kehlet and colleages were investigating in combined pain relief, early feeding and mobilization since 1995 , observing that no more complications were seen and that patients even could be discharged earlier . The concept of a “multimodal” approach was first published in 1997  and subsequently prospective studies appeared . The aims of Kehlet´s study were to reduce postoperative morbidity and mortality and to promote a faster recovery through a multimodal approach, thus minimizing the impact of the factors that lead to surgical stress. On the other hand, in the study of Basse et al the multimodal rehabilitation program significantly reduced the postoperative hospital stay in high-risk patients undergoing colonic resection (two days compared to more than 10 days in some historical series) and it might also reduce postoperative ileus and cardiopulmo‐ nary complications .
During the following decade published studies in this issue grew exponentially. Subsequently, cohort studies, controlled trials and several reviews and meta-analyses were published. It is important to highlight those from Wind , Goubas , and the meta-analyses directed by Cochrane Collaborative Group in 2011 that will be analyzed in the following chapter´s sections . Moreover, an ERAS Society was officially founded in 2010 as a natural evolution of the ERAS Study Group. This group started its works in 2001 trying to change from tradition to best-practice because there was a great discrepancy between the existing practices and those which were already known to be best practice based on the existing literature. More informa‐ tion is provided in the official website http://www.erassociety.org/.
To summarize, we can conclude that published results and their meta-analyses have shown the benefits of this package of measures, so that evidence-based medicine supports the ERAS concept. Nevertheless, recent surveys have demonstrated slow adaptation and implementa‐ tion of the fast-track methodology. In this setting, it has been shown by Kehlet et al in an international multicenter study based on 1,082 patients who had undergone elective colonic operations that strategies that could contribute to improved recovery and reduce complica‐ tions were not been applied and that major improvements in outcomes and reduction of costs could be obtained applying ERAS methodology .
Little by little, ERAS implementation and application in the clinical setting continued growing in the following years until the present. Nowadays ERAS protocols, with little modifications to adapt them to each center´s functioning, are been applied in a great number of colorectal units worldwide. The information communicated in different conventions and published makes us think that ERAS has changed from a promising “published” issue to a real application in the clinical practice.
The overall metabolic changes in the stress response involve protein and fat catabolism to provide energy. Protein from skeletal muscle and glycerol from fat breakdown are utilised in glucogenogenesis in the liver. In addition surgery induces hormonal, haematological and inmunological changes and activate the sympathetic nervous system (stimulated by hypoten‐ sion, hypoxaemia or metabolic acidosis, pain, anxiety and distress, autonomic and afferent nerves and directly hypothalamus) . The initial stimulus for this response comes from cytokines, especially IL-6 and TNF, release by leucocytes and endotelial cells present at the site of injury and they are the principal mediators of the response in the acute-phase. Postoperative levels of these cytokines are correlated with the magnitude of the surgery and the presence of complications. On the other hand, leucocytes are key effector cells in the response to surgery, they mobilize quickly to devitalizated or injured tissue to begin repair and prevent secondary microbial invasion. A few minutes after the start of surgery an ACTH, vasopresine, cortisol, catecholamines, aldosterone and glucagon release occur pretending to provide to the disabled organism energy, to retain liquid and salt, and supporting the cardiovascular homeostasis .
A randomized controlled trial has shown that Multimodal Rehabilitation programs attenuate the response to the surgical stress as it demonstrates a significant descent of IL-1, IL-6, TNFα and INF-gamma levels in the postoperative period.
Summarizing, the stress response to surgery increase the levels of ACTH, cortisol, GH, IGF1, ADH and glucagon, reduce the insulin, mobilizes glycogen (by glycogenolysis and skeletal muscle breakdown) and promotes formation of acute phase proteins and lipolysis.
This response also generates adverse effects; some of the most important are:
• Increased myocardial oxygen demand.
• Splanchnic vasoconstriction wich may impact intestinal anastomoses healing.
• Exhaustion of energy supplies and loss of lean muscle mass, leading to weakness of both peripheral and respiratory muscle if it is severe.
• Impaired wound healing and increased risk of infections.
• Hypercoagulability (risk of Deep Vein Thrombosis).
• Sodium and water retention.
The response to the surgical trauma is protective since his final target is the survival of the disabled organism. It depends on a delicate balance between pro-inflammatory and antiinflammatory mechanisms; nevertheless, it is known that it can be harmful when this balance is altered. Thus, if the pro-inflammatory component predominates, a Systemic Inflammatory Response Syndrome (SIRS) could be induced; on the other hand patients can suffer the effects derived from the inmunosupresion as infections or tumor progression if predominates antiinflammatory components.
492 Colorectal Cancer - Surgery, Diagnostics and Treatment
The aims of ERAS programs are:
• To standardize and optimize perioperative medical care.
• To atenuate the stress response to surgery: metabolic, endocrine and inflamatory response as well as reduce protein cathabolism.
• To decrease hospital length stay and a faster patient recovery to normal life.
• Regarding hospital discharge, factors such as pain, lack of gastrointestinal function and immobility complications are the main delaying patient discharge after colorectal surgery.
So ERAS objectives will be to promote pain control, to improve gastrointestinal function and to avoid immobility.
• Despite the discharge criteria with ERAS programs are similar than in traditional care, patients usually reach these criteria sooner.
3. ERAS protocol components ERAS programs are composed of preoperative, intra-operative and postoperative strategies
combined to form a multimodal pathway: