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3.1.1. Pre-admission Pre-operative optimization: it is focused on targeting areas to optimize patient comorbidities (previous or related to the presenting complaint) such as anemia, diabetic and blood pressure control, optimizing cardiovascular disease treatments, respiratory functioning,…. It is also imperative avoid smoking and alcohol consumption. Patient´s individualized Risk stratifica‐ tion is also important to make good patient information and treatment decision.
Information: It is shown that this information reduces the patient’s anxiety and facilitates the compliance of the program .
Patients and their families should be very knowledgeable about the process. It is very impor‐ tant to make them a partner in the process and give them the responsibility for their recovery and they should be clearly informated about the perioperative care, normal course of the protocol, discharge criteria, possible complications and the outpatient follow-up after dis‐ charge. Targets like postoperative oral intake or early mobilization are given in this stage to the patient.
Pre-operative nutritional management: drinks and any new medication and nutritional supplements should be given at this time.
3.1.2. Pre-operative care Admission on the day of surgery: because the patient has been prepared for surgery in the preadmission period.
Pre-operative fasting and carbohydrate loading:
• Fasting is required to reduce the risk of aspiration during a general anesthesia The duration of preoperative fasting should be two hours for liquids and six hours for solids (grade A recommendation) .
• Major surgery is associated with postoperative insulin-resistance. Non-diabetic patients should receive carbohydrate (CHO) loading pre-operatively because they increase glycerol deposits, reduce thirst, hunger and postoperative insulin resistance , reducing protein catabolism, postoperative ileus and loss of lean muscle mass. CHO has to be taken in the evening before surgery and 2 hours before anaesthetic induction .
Avoid mechanical bowel preparation:
Mechanical bowel preparation can cause dehydration and fluid and electrolyte abnormalities, particularly in elderly patients, increasing morbidity and post-operative ileus .
• Medication causing long-term sedation from midnight prior to surgery must not been used, in order to conserve the sleep pattern (grade A recommendation).
• Prophylaxis against thromboembolism with low-dose unfraccionated heparin or lowmolecular-weight heparin (grade A recommendation) and the use of elastic stockings or pneumatic compression are recommended.
• Antibiotic prophylaxis with single-dose antibiotic prophylaxis against both anaerobes and aerobes about one hour before surgery is recommended (grade A recommendation).
Changes in body temperature can lead to coagulopathy, adverse cardiac events, and decreased resistance to surgical wound infections. An upper-body forced-air heating cover should be used routinely (grade A recommendation).
Prevention of post-operative ileus:
Mid-thoracic epidural analgesia and avoidance of fluid overload are recommended to prevent post-operative ileus (grade A recommendation) , .
494 Colorectal Cancer - Surgery, Diagnostics and Treatment
The use of minimally invasive techniques, where possible is advisable. Laparoscopic approach is recommended if locally validated (grade A recommendation) . It has been shown to reduce the length of hospital stay, initial wound complications and time to return of gastro‐ intestinal tract function in colorectal surgery. If an open procedure is required, transverse incisions should be made preferentially to reduce postoperative pain.
Peri-operative fluid management:
Perioperative fluid management for fast-track protocols must be balanced between avoiding hypovolemia and excessive fluid administration. Overhydration has previously been common in the perioperative period, and comparisons of liberal and restrictive fluid regimes suggest that this may be detrimental.
Perioperative fluid overload can cause fluid retention and increase body weight; this is related with generalized edema (which can cause a descense in tissue oxygenation ), visceral edema (related with postoperative ileus), can impaire wound and anastomosis healing, can increase cardiorespiratory complications [20,21] and also thrombotic risk.
Intra-operative and post-operative fluid restriction in major colonic surgery with avoidance of hypovolaemia is safe (grade A recommendation) and reduce the time for return of gastro‐ intestinal tract function, improves healing, reduce length of hospital admission and avoid pulmonary dysfunction  and reduce overall postoperative complications by up to two thirds . Early commencement of oral intake also allows reducing intravenous fluids sooner.
Postoperative serious hypotension may best treated with vasopressors rather than large quantities of intravenous fluids.
No clear consensus exists regarding the optimal fluid (crystalloid or colloid), the fluid amount (liberal, restricted or supplemental) and the fluid administration (goal-directed fluid therapy by oesophageal Doppler-derived variables –such as stroke volume, the blood volume pumped with each beat- versus conventional haemodynamic variables) for fluid management after and during colectomy.
Fluid management can be then optimized using transesophageal monitoring of the cardiac stroke volume with goal-directed administration of fluid boluses. This methodology can improve outcome (patients recovered gut function significantly faster and suffered signifi‐ cantly less gastrointestinal and overall morbidity) in patients with significant medical comor‐ bidities allowing an earlier hospital discharge . These results have been confirmed with posterior literature review that showed a reduced hospital stay, fewer complications and ICU admissions, less requirement for inotropes and faster return of normal gastro-intestinal function .
In the last years literature reviews and metaanalyses have been published trying to give light to these doubts: which fluid, how many and how to control the administration. We want to highlight the one from Rahbari et al . Authors included nine randomized controlled trials, finding that restrictive fluid amount (OR 0.41 with 95% CI 0.22 to 0.77; P = 0.005) and goaldirected fluid therapy by means of oesophageal Doppler-derived variables (OR 0.43 with 955 ERAS (Enhanced Recovery after Surgery) in Colorectal Surgery 495 http://dx.doi.org/10.5772/57136 CI 0.26 to 0.71; P = 0.001) significantly reduced overall morbidity after colorectal resection compared with standard fluid amount and fluid therapy guided by conventional haemody‐ namic variables respectively. No significant differences were founded in mortality, cardio‐ pulmonary morbidity, wound infection, anastomotic failure, recovery of bowel function and hospital stay.
They should be inserted only if ileus develops. They are associated with discomfort and a delay in oral intake. Nasogastric tubes should not be used routinely in the elective situations in postoperative period (grade A recommendation) ,.
Drains are avoided, as there is no evidence of beneficial effect in reducing postoperative morbidity, mortality, or reduce the effect of anastomotic leakage ,. Short-term (24-hour) use of drains after low anterior resections may be advisable. They are not indicated following routine colonic resection above the peritoneal reflection.
The aim of their use is to reduce the dose of general anesthetic needed and the stress response to surgery. In order to reduce the release of stress hormones and post-operative insuline resistance it is very important start with the epidural analgesia before the surgery. (Grade A recommendation).
Maintenance of hydration, avoiding overcharge and encouraging the discontinuation of intravenous fluid therapy as soon as possible and early commencement of oral intake, including carbohydrate drinks.
Patients should receive continuous epidural mid-thoracic low-dose local anesthetic and opioid combinations (grade A recommendation) for approximately 48 hours following elective colonic surgery and approximately 96 hours following pelvic surgery. This provides postoperative analgesia and reduces postoperative ileus by blockade of the sympathetic nervous system. Low concentration local anesthetic mixtures reduce motor block and improve early mobilization. Intravenous analgesia is used with paracetamol and non-esteroid anti-inflam‐ matory drugs . Intravenous opioids are avoided because of increase sedation, ileus and respiratory complications.
Nausea and vomiting:
It is very important a risk stratification of patients during surgery using the Apfel scoring system with prophylaxis given for moderate or high risk patients. Risk factors are: female sex, non-smokers, administration of opioids postoperatively, motion sickness or previous postop‐ 496 Colorectal Cancer - Surgery, Diagnostics and Treatment erative nause and vomitig . Patients with two ore more risk factors should be treated.
Dexamethasone or 5HT3 receptor antagonist, droperidol or metoclopramide near the end of surgery are recomended. It is preferred those medication that have a minimal post-operative hang-over and effects on gastrointesinal motility. Also short-acting anesthetic and analgesic agents should be used, avoiding long-lasting opiates where possible .
Early commencement of an oral intake (frequently in theater recovery) after surgery should be encouraged (grade A recommendation). Oral nutritional supplements should be prescribed (approximately 200 mL, energy dense, 2-3 times daily) from the day of surgery until normal food intake is achieved. These supplements can be continued beyond the return of normal intake if pre-operative nutritional status is poor. Early resumption of oral intake is associated with fewer wound infections and shorter hospital admissions as well.
Early mobilization should occur in accordance with pre-operative plan and is a key element of ERAS in colorectal surgery . For patients to be out of bed for two hours on the day of surgery and six hours thereafter is recommended. The aim is to reduce muscle loss and improve respiratory function, reducing the risk of pneumonia, and maximizing oxygen delivery to tissues. This is also essential to reducing the risk of venous thromboembolism. The breathing exercises should be done, especially in patients with previous lung pathology and these exercises must be trained before surgery.
Urinary catheter and drains:
Urinary catheters and peritoneal drains should bre removed as soon as possible in order to reduce the incidence of urinary tract infection and because of early mobilization respectively
At the end, early discharge, when the discharge criteria have been reached, is the goal of fasttrack along with the early recovery and return to normal activity.
A summary of all of these commented components of the perioperative management can be seen on Figure 2.
4. From theory to practice — How to organize an ERAS program
• A well-educated multidisciplinary team will be needed composed by: surgeons, anesthesi‐ ologists and pain care specialists, nursing staff, physiotherapysts and occupational thera‐ pists and social workers
Figure 2. Components of the ERAS protocols
• It is necessary a review of the literature and a carefully study of the hospital resources where the ERAS program will be implemented.
• The program should be designed in agreement with consensus documents.
• A systematic audit should be performed including length of stay, morbidity, mortality and hospital readmissions to allow direct comparison with other institutions and provide motivation for staff and patients.
An example of an ERAS protocol in colorectal surgery can be seen on Table 1.
Table 1. An ERAS protocol example in colorectal resections.
5. Discharge criteria The goal of ERAS programs is an accelerated recovery and return to normal activity but it is not the only focus of the protocol . Discharge criteria and time-based discharge depends on the community support and possibility to follow-up.
Patients and their families should feel comfortable with the discharge. In this setting they should know that they will be followed as outpatient and they could return to hospital if required.
Discharge criteria must be previously established (see Table 2):
Discharge criteria Good mobilization Adequate oral intake for liquids and solids Gastrointestinal transit for gas Normal urinary function No wound problems Pain control No fever Patient know about possible complications and their detection Patient feel comfortable with discharge Table 2. Discharge criteria most usually used in colorectal surgery ERAS programs.
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The expanding evidence-based medicine shows that ERAS program benefits not only all patients (including the elderly or potentially malnourished patients) but also the health service .
Patients accomplish surgery in the best condition. They have better management during and after operation and the best post-operative recovery.