|Year : 2015 | Volume
| Issue : 4 | Page : 923-927
A study on enhanced recovery after abdominal surgery
Soliman El-Shakhs1, Alaa El-Sisy1, Ashraf Eskander2, Ahmed Gaber1, Eslam Elshafey3
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Anaesthesia and Intensive Care, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of General Surgery, Mansoura International Hospital, Mansoura, Egypt
|Date of Submission||21-Dec-2014|
|Date of Acceptance||18-Feb-2015|
|Date of Web Publication||12-Jan-2016|
Abo Allam st, Meniet Samanoud, Aga, Dakahlia Governorate
Source of Support: None, Conflict of Interest: None
Enhanced recovery after surgery or fast-track surgery is a set of protocols aimed to reduce the physiological burden of surgery, thus improving outcomes. Fast-track surgery aims to use evidence-based practice to reduce complications, improve postoperative quality of life, and decrease hospital length of stay.
The aim of the study was to investigate the effect of applying enhanced recovery after surgery (ERAS) protocols on patients undergoing different abdominal operations.
Settings and design
The study was a prospective observational study that was conducted on 25 patients of ASA grades I-III, aged between 15 and 65 years, with different abdominal pathologies who were to undergo elective operations between August 2013 and May 2014.
Materials and methods
Patients were subjected to ERAS protocols. All patients were monitored in the hospital as needed until the patient fulfilled the discharge criteria (adequate oral intake; pain well controlled with oral analgesics; ability to void without difficulty; able to ambulate independently or at baseline levels; the patient believing he is ready for discharge and able to look after himself at home). Statistical analysis was performed using SPSS. Descriptive statistics were expressed as mean ± SD unless otherwise stated.
The ERAS program has been proven to be safe, not only in reducing postoperative hospital stay and morbidity but also in improving patient convalescence.
The ERAS program had a significant role in reducing the duration of hospital stay as well as morbidity in patients undergoing major abdominal surgery.
Keywords: abdominal surgery, enhanced recovery after surgery, fast-track surgery, hospital stay
|How to cite this article:|
El-Shakhs S, El-Sisy A, Eskander A, Gaber A, Elshafey E. A study on enhanced recovery after abdominal surgery. Menoufia Med J 2015;28:923-7
|How to cite this URL:|
El-Shakhs S, El-Sisy A, Eskander A, Gaber A, Elshafey E. A study on enhanced recovery after abdominal surgery. Menoufia Med J [serial online] 2015 [cited 2020 Mar 30];28:923-7. Available from: http://www.mmj.eg.net/text.asp?2015/28/4/923/173674
| Introduction|| |
Enhanced recovery after surgery (ERAS) protocols is a relatively new set of protocols that was pioneered by Professor Henrik Kehlet in Denmark in the early 1990s  .
The ERAS protocols incorporate evidence-based medicine and other new developments in the understanding of perioperative physiology to improve surgical outcome through optimization of preoperative, intraoperative, and postoperative care for elective surgical patients  .
The majority of the evidence for ERAS comes from colorectal surgery, although these components ([Figure 1]) apply equally for other applications such as gynecological, urological, or orthopedic surgery  .
Because of reduction in both the physiological and psychological stresses associated with operations, and minimization of pain and discomfort, proponents of fast-track surgery argue that there is less organ dysfunction and hence a reduction in the need for hospitalization, with earlier hospital discharge  .
Fast-track surgery incorporates not only surgeons but also anesthesiologists, nurses, and physical therapists as active participants of the care team  .
Studies investigating the effects of standard/conventional care have been performed, and show that many of the traditional approaches to surgical care, such as preoperative bowel clearance, use of nasogastric tubes, drains placed in cavities, enforced bed rest, and use of graduated diets, are unnecessary or even harmful  .
The present work aimed to observe and study the outcomes of patients undergoing abdominal operations subjected to ERAS protocols.
| Materials and methods|| |
The study is a prospective observational study that was conducted on 25 patients of ASA grades I-III, aged between 15 and 65 years, with different abdominal pathologies, who were to undergo elective operations between August 2013 and May 2014.
All patients were subjected to history taking, full physical examination (general and local), laboratory investigations, and radiological investigations. All of them underwent surgery (according to the pathology), and the incidence of early complications and the length of hospital stay were recorded.
Patients were subjected to ERAS protocols as follows: no bowel preparations; fluid and carbohydrate loading with no fasting (prepared solution contained 12.5 g of carbohydrates/100 ml water, given 2 h before surgery); thromboembolism prophylaxis (LMWH and compression stocking); antimicrobial prophylaxis (third-generation cephalosporin 1 g, metronidazle drip 500 mg, ampicillin and sulbactam combination 1.5 g); no routine nasogastric intubation (if needed during the course of the surgery it was removed in the operation room or at the time of patient recovery); general anesthesia with short-acting anesthetic drugs or midthoracic epidural anesthesia and analgesia; avoidance of sodium fluid overload; laparoscopic surgery or choice of small surgical incisions; no routine intraperitoneal drain insertion (if needed it was removed 24 h postoperatively); non steroidal anti informatory drugs (NSAIDs and epidural analgesia were used instead in the form of 2.5-5.0 ml/h bupivacaine 0.125% according to patient need, and supplementary 75 mg diclofenac Na when anesthesia was not sufficient for the patient); prevention of nausea and vomiting (through a combination of metoclopramide and dexamethazone); early stimulation of gut motility and early enteral feeding (after audible intestinal sounds); early removal of catheter in the operation theater or as early as possible after patient recovery from anesthesia; and early mobilization on the day of surgery.
Patients were monitored in the recovery room for a minimum of 2 h, and then monitored in the hospital as needed until he or she fulfilled the discharge criteria (adequate oral intake; pain well controlled with oral analgesics; ability to void without difficulty; able to ambulate independently or at baseline levels; the patient believes he is ready for discharge and is able to look after himself at home).
Patients were evaluated at 24, 48 h, 7, and 14 days after surgery, had been reviewed, and had answered a previously established protocol.
The objective of the follow-up of this study was to observe and study the outcomes of patients undergoing abdominal operations subjected to ERAS protocols.
Statistical analysis was performed using SPSS (Chicago, Illinois USA). Descriptive statistics were expressed as mean ± SD unless otherwise stated.
| Results|| |
Sociodemographic data show that the mean age of the studied group was 42.8 ± 14.98 years. Most patients in the studied group were female (80%) ([Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]).
|Table 2 Illustration of blood loss/ml, operative time/min, postoperative NPO period/h and hospital stay period/days |
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|Table 6 The relation between postoperative analgesia and hospital stay period |
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|Table 7 The relation between use of drains and urinary catheters postoperatively and hospital stay period |
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Fourteen patients had lower GIT lesions (56%), whereas 11 had upper GIT lesions (44%).
The proportion of total laparoscopic surgeries was 60% of total surgeries, whereas open surgeries were only 40%. The mean ± SD of blood loss was 132 ± 69.04 ml and the mean ± SD operative time was 44.64 ± 37.7 min.
The most commonly seen complication during this study was superficial wound infection, which occurred in three patients (12%). Two patients (8%) had anastomotic dehiscence; one of them had persistent vomiting and the other had urinary tract infection as well. In this study we did not face any respiratory, cardiac, or thromboembolic complications.
The mean ± SD of the postoperative NPO/h period was 29.28 ± 25.6 h, whereas the mean ± SD of hospital stay was 3.48 ± 2.77 days.
There was a relation between the duration of hospital stay and the type of postoperative analgesia. It was observed that patients who received only epidural analgesia had a mean hospital stay duration of 4.4 days, whereas patients who received epidural with NSAIDS had a mean of 3.1 days.
There was a significant relation between the duration of hospital stay and use of drains and urinary catheters postoperatively as patients having drains with urinary catheters had a mean hospital stay duration of 4.5 days and patients with only drains and no urinary catheters had a mean hospital stay of 2.5 days. Patients without drains and catheters had a mean hospital stay of only 2.0 days.
From the questionnaire administered during the follow-up period, we obtained information about factors relating to quality of life, such as fatigue, nausea, pain, use of medication, and daily activity. Most patients recovered rapidly after surgery. One week after discharge, more than half of the patients had already resumed their daily activities at home.
| Discussion|| |
The present work aimed to study the outcomes of patients undergoing abdominal operations following ERAS protocols.
The total number of patients in this study was 25. Sociodemographic data show that most of the studied patients were female (five male and 20 female patients); the mean age of the patients was 42.8 years.
All patients were in need of elective abdominal surgery for different pathological lesions (upper GIT lesions, lower GIT lesions, splenic lesions, hepatobiliary lesions, pancreatic lesions, and renal and suprarenal lesions).
During the study, implementation of ERAS protocols was tailored using the main guidelines of ERAS protocols according to the pathology and type of surgery, with the aim to study many aspects of preoperative, intraoperative, and postoperative elements of the protocol.
The duration of hospital stay was measured as the time in days from start of anesthesia to the time of discharge from hospital. The mean duration of hospital stay was 3.48 days. These results are similar to those of Delaney et al.  , who reported a reduced length of stay among patients who underwent complex pelvic and abdominal procedures such as total proctocolectomies and abdominoperineal resections in the fast-track setting  . Our results also agreed with those of Miller et al.  , who reported that implementation of an enhanced recovery protocol for major abdominal surgery (colorectal surgery) was associated with a significantly reduced hospitalization period  .
The duration of hospital stay was shorter in patients who underwent laparoscopic surgery, with lower blood loss (mean blood loss/ml was 132 ml). The results comply with those reported by Wind et al.  and Vlug et al.  ,who reported that laparoscopic surgery appears to have more benefits with respect to recovery (improved quality of life, less ileus, and less pain) , . However, MacKay et al.  reported that there were no large differences in the duration of ileus or hospital stay between those treated with open surgery and those treated with laparoscopic surgery within an enhanced recovery program  .
The postoperative NPO period/h showed a positive correlation with the hospital stay period/day. This is in keeping with a meta-analysis of 11 randomized trials by Lewis et al.  , who showed that early enteral feeding may be beneficial for patients undergoing gastrointestinal surgery  . It is also commensurate with a meta-analysis by Heslin et al.  , who showed that any type of enteral feeding started within 24 h after abdominal surgery led to a small but significant reduction in the mean length of hospital stay by 0.84 days (from 6 to 14 days in the early-feeding group and from 7 to 19 days in the control group). Skipper  also reported that duration of hospitalization significantly reduced on early feeding  .
This study showed that there was no significant relation between bowel preparation and rate of complications. This complies with the results of a Cochrane Review group that performed a meta-analysis including 13 centers, totaling 4777 patients. These compiled data showed that bowel preparation does not add value to colorectal surgeries and thus should be removed from daily practice  . The results also comply with those of Bucher et al.  , who found no significant differences in the rate of anastomotic leakages or abdominopelvic abscesses. In all of the randomized studies analyzed in his meta-analysis, the rate of anastomotic leakage was 1-12% in the bowel preparation group and 1-5% in the nonbowel preparation group  . Ram et al.  reported that with improvements in surgical technique and more effective prophylactic antibiotics, the proposed benefits of bowel preparation are questionable. Furthermore, patients undergoing mechanical bowel preparation find the procedure distressing and they report greater discomfort, dehydration, abdominal pain, bloating, and fatigue  .
In this study there was a significant decrease in the hospital stay period for those patients who received general anesthesia with epidural analgesia. All patients were given epidural analgesia in the form of 2.5-5.0 ml/h bupivacaine 0.125%. Nine patients did not require further analgesia, whereas 16 patients were controlled with an added dose of NSAIDs in the form of supplementary 75 mg diclofenac Na. None of the patients required opiates to control pain. These results comply with those of a systematic review that identified 141 randomized-controlled trials in which 9559 patients were randomly allocated to one of two groups: those receiving intraoperative neuroaxial blockade (epidural anesthesia) with or without general anesthesia and those not receiving neuroaxial blockade. In this review Rodgers et al.  concluded that neuroaxial blockade reduces postoperative mortality and significantly reduces common postoperative complications and enhances early mobilization  . Carli et al.  also concluded that there are advantages in epidural anesthesia and analgesia after colonic surgery compared with patient-controlled opioid analgesia  .
Further support for epidural anesthesia and postoperative epidural analgesia was provided by Block et al.  , who published a similar meta-analysis concluding the benefits of epidural anesthesia and analgesia over opioids in postoperative pain control  . Liu et al.  also reported after studying several randomized-controlled trials that intraoperative epidural anesthesia followed by postoperative epidural analgesia results in the return of normal gastrointestinal function 2-3 days earlier compared with general anesthesia and postoperative opioid analgesia, and thus enhances recovery after major abdominal surgeries , .
Despite strong evidence-based research supporting the integration of epidural anesthesia and analgesia as a fast-track component, Borghi et al.  reported that the potential complications of epidural anesthesia have acted somewhat as a barrier to its implementation. Complications like neurovascular injury, meningitis, and epidural abscess are extremely rare. However, critics cite bradycardia and hypotension as two possible complications resulting from inhibition of sympathetic nerve fibers by epidural anesthesia  , but in this study we did not face such problems as we used epidural analgesia and not anesthesia.
In the study it was found that the use of drains and catheters prolonged the hospitalization period, which is in compliance with the study by Pascal et al.  , who reported that there was considerable benefit if no drains were used in abdominal surgery, except in rectal surgery  .
The complications seen in this study and its ratio agreed with those seen in the study by Zargar-Shoshtari et al.  , who reported that most studies on major abdominal surgeries reported complication rates of 20-40%, whereas pooled data on ERAS recovery showed only a trend toward fewer complications of between 18 and 30%  .
| Conclusion|| |
It can be concluded that ERAS protocols are safe and yield good outcome in patients undergoing abdominal operations, by decreasing the hospital stay period and postoperative morbidity.
Anesthetic factors and epidural analgesia are important elements in ERAS protocols.
Implementation of fast-track elements mandates a multidisciplinary collaboration between surgeons, anesthesiologists, and surgical nurses, a high rate of protocol compliance, and a good organizational.
| Acknowledgements|| |
First and foremost we thank ALLAH, the most beneficent, the most merciful, for his blessings. The authors are grateful to all who helped during the course of this study, for their efforts, support, and cooperation.
Conflicts of interest
There are no conflicts of interest.
| References|| |
White PF, Kehlet H, Neal JM, Schricker T, Carr DB, Carli F, Fast-Track Surgery Study Group. The role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. Anesth Analg 2007; 104
Kehlet H, Wilmore DW. Fast-track surgery. Br J Surg 2005; 92
Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al
. Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009; 144
Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183
Kumar A, Hewett PJ. Fast-track or laparoscopic colorectal surgery? ANZ J Surg 2007; 77
Delaney CP, Fazio VW, Senagore AJ. ′Fast track′ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 2001; 88
Miller TE, Thacker JK, White WD, Mantyh C, Migaly J, Jin J, et al.
Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014; 118
Wind J, Hofland J, Preckel B, Hollmann MW, Bossuyt PM, Gouma DJ, et al.
Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial). BMC Surg 2006; 6
Vlug MS, Wind J, van der Zaag E, Ubbink DT, Cense HA, Bemelman WA. Systematic review of laparoscopic vs open colonic surgery within an enhanced recovery programme. Colorectal Dis 2009; 11
MacKay G, Ihedioha U, McConnachie A, Serpell M, Molloy RG, O′Dwyer PJ. Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery. Colorectal Dis 2007; 9
Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus ′nil by mouth′ after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001; 323
Heslin MJ, Latkany L, Leung D, Brooks AD, Hochwald SN, Pisters PW, et al
.. A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy. Ann Surg 1997; 226
Annalynn Skipper. A. Dietitian′s handbook of enteral and parenteral nutrition. Jones & Bartlett Publishers USA. 2012;3:570-589.
Soop M, Nygren J, Ljungqvist O. Optimizing perioperative management of patients undergoing colorectal surgery: what is new? Curr Opin Crit Care 2006; 12
Bucher P, Mermillod B, Gervaz P, Morel P. Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Arch Surg 2004; 139
Ram E, Sherman Y, Weil R, Vishne T, Kravarusic D, Dreznik Z. Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Arch Surg 2005; 140
Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al.
. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321
Wu CL, Cohen SR, Richman JM, Rowlingson AJ, Courpas GE, Cheung K, et al.
Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005; 103
Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 2002; 97
Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan Jr JA, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 2003; 290
Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 1995; 82
Borghi B, Casati A, Iuorio S, Celleno D, Michael M, Serafini P, et al.
Frequency of hypotension and bradycardia during general anesthesia, epidural anesthesia, or integrated epidural-general anesthesia for total hip replacement. J Clin Anesth 2002; 14
Teeuwen PH, Bleichrodt RP, Strik C, Groenewoud JJ, Brinkert W, van Laarhoven CJ, et al
. Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery. J Gastrointest Surg 2010; 14
Zargar-Shoshtari K, Connolly AB, Israel LH, Hill AG. Fast-track surgery may reduce complications following major colonic surgery. Dis Colon Rectum 2008; 51
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]