In recent years, there has been an international shift to more modern therapeutic approaches in terms of perioperative patient management with the aim of rapid and quality recovery without complications. And this is achieved with a series of interventions aimed at minimizing surgical stress.
What is surgical stress?
Surgical trauma triggers a multidimensional metabolic and inflammatory stress response, the effects of which can be detrimental to recovery (Figure 1).
Minimizing surgical stress is of major importance for a smooth postoperative course so that the patient can recover as soon as possible and return to his daily life without problems and complications.
About 30 years ago, Henrik Kehlet, a Danish professor of surgery, was the first to recognize the effects of surgical stress on the pathophysiology of postoperative morbidity and mortality, and published a list of risk factors and how they can be modified to reduce of the stress response.
In 2001, Henrik Kehlet along with four other surgeons created the first ERAS study group, with the goal of creating models of perioperative care to improve patient outcomes. A plethora of publications on practical implementation followed. It is worth noting that Professor Kehlet recently received the enviable and globally prestigious BJS Society Award in recognition of his long and extensive involvement with ERAS protocols that have changed clinical practice in surgery and improved the outcome of many patients around the world .
Therefore, based on the bibliographic data, the company ERAS has published guidelines (http://www.erassociety.org) for various types of surgical operations.
What is the ERAS protocol?
The ERAS protocol includes a series of interventions during the preoperative, intraoperative, and postoperative period, which are based on evidence-based medicine and aimed at minimizing surgical stress (Figure 2).
It is a coordinated effort involving health professionals from different specialties (surgeons, anesthesiologists, nurses, physiotherapists) who each deal with their own part but all work together as a coordinated team towards the ultimate goal which is the fastest and highest quality recovery of the patient without complications.
This new scientific approach challenges the traditional models of postoperative care where the operated patient remains bedridden and fasting for several days after surgery. Instead, the focus is on quick and safe mobilization that, in combination with respiratory physical therapy, reduces the risk of bed rest, muscle loss and thromboembolic events. A necessary condition is effective analgesia achieved by a combination of drugs and local techniques (e.g. peripheral nerve blocks or blocks) in order to minimize opioids and their adverse effects (e.g. dizziness, nausea, sedation, ileus). Good preparation also plays an important role so that the patient comes to the surgery in the best possible condition so that his body can cope with the increased demands due to the subsequent surgical stress.
What are the advantages of implementing ERAS protocols?
Studies show that ERAS programs are safer and more effective than conventional medicine. ERAS protocols are used internationally with strong evidence that adherence to these protocols reduces postoperative complications by 30-50%. An important advantage is that with the implementation of the ERAS protocol, the risk of postoperative ileus is reduced and bowel function is restored more quickly. There is also less risk of respiratory complications. Muscle strength is preserved and the patient returns more quickly to the functional capacity he had before surgery. In general, ERAS programs are associated with greater patient satisfaction and better quality of life than conventional medicine.
In which procedures are ERAS protocols applied?
The global ERAS society has issued guidelines for the implementation of ERAS programs in a wide range of surgical procedures.
At IASO Thessaly we have the necessary experience and know-how and safely apply the ERAS protocols in liver, stomach, colon and pancreas surgery.
Bibliography
1. Cusack, B., Buggy, DJ (2020). Anesthesia, analgesia, and the surgical stress response. BJA Education, 20(9), 321e328. https://doi.org/10.1016/j.bjae.2020.04.006
2. Kehlet, H. (1997). Multimodal approach to control postoperative pathophysiology and rehabilitation. British Journal of Anaesthesia, 78, 606–617. https://doi.org/10.1093/bja/78.5.606
3. Ljungqvist, O., Scott, M., and Fearon, KC et al (2017). Enhanced Recovery After Surgery A Review. JAMA Surgery, 152(3), 292-298. https://doi.org/10.1001/jamasurg.2016.4952
4. Lau, CSM, Chamberlain, RS (2017). Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis. World Journal of Surgery, 41, 899–913, https://doi.org/10.1007/s00268-016-3807-4
Despina Liotiri Anesthesiologist, Scientific Associate IASO Thessaly
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