ERAS — SAQ · MBBS SAQ

Question

10 marks10 min

Stem

A 55-year-old man is scheduled for an elective laparoscopic right hemicolectomy for colon cancer. The surgical team is implementing an ERAS (Enhanced Recovery After Surgery) protocol. [1]

Questions

a) What are the key principles of ERAS? (2 marks) [1]

ERAS is a MULTIMODAL, EVIDENCE-BASED perioperative care pathway that reduces the surgical stress response, maintains organ function, and promotes early recovery. Key principles: reduce fasting, minimise surgical stress, avoid fluid overload, early feeding, early mobilisation, opioid-sparing analgesia. [1]

b) Describe four pre-operative ERAS components. (4 marks) [1]

No prolonged fasting: clear fluids until 2 hours, solids until 6 hours before surgery.
Carbohydrate loading: maltodextrin drink 2 to 3 hours pre-op (reduces insulin resistance).
No routine mechanical bowel prep (except for low rectal anastomosis).
Patient education and counselling about expected recovery milestones. [1]

c) Describe four post-operative ERAS components. (4 marks) [1]

Early oral feeding within 24 hours (promotes gut recovery).
Early mobilisation on day 0 (evening of surgery) or day 1.
Opioid-sparing analgesia: paracetamol, NSAIDs, regional techniques (TAP block, epidural). Minimise opioids (prevent ileus, nausea).
Remove tubes/drains/catheters early (day 1) to enable mobilisation. [1]

d) What outcomes does ERAS improve? (bonus)

Reduces length of stay by 2 to 3 days
Reduces complications by approximately 50%
Reduces cost
No increase in readmission or mortality [1]

References

[1]Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg, 2017.PMID 28097305
[2]Kehlet H, Wilmore DW Multimodal strategies to improve surgical outcome. Am J Surg, 2002.PMID 12095591
[3]Kehlet H, Mogensen T Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg, 1999.PMID 10100792
[4]Fearon KCH, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr, 2005.PMID 15896435
[5]Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg, 2009.PMID 19841366
[6]Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2018. World J Surg, 2019.PMID 30426190
[7]Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr, 2010.PMID 20116145
[8]Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum, 2013.PMID 23575408
[9]Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev, 2011.PMID 21328298
[10]Melloul E, Lassen K, Roulin D, et al. Guidelines for perioperative care for pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019. World J Surg, 2020.PMID 32161987
[11]Melloul E, Hübner M, Scott M, Snowden C, Prentis J, Dejong CH, et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg, 2016.PMID 27549599
[12]Thorell A, MacCormick AD, Awad S, et al. Guidelines for perioperative care in bariatric surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg, 2016.PMID 26943657
[13]Yamagata Y, Yoshikawa T, Yura M, et al. Current status of the enhanced recovery after surgery program in gastric cancer surgery. Ann Gastroenterol Surg, 2019.PMID 31131351
[14]Beverly A, Kaye AD, Ljungqvist O, Urman RD Essential elements of multimodal analgesia in Enhanced Recovery After Surgery (ERAS) guidelines. Anesthesiology Clinics, 2017.PMID 28526156

Questions

a) What are the key principles of ERAS? (2 marks) [1]

b) Describe four pre-operative ERAS components. (4 marks) [1]

No prolonged fasting: clear fluids until 2 hours, solids until 6 hours before surgery.

Carbohydrate loading: maltodextrin drink 2 to 3 hours pre-op (reduces insulin resistance).

No routine mechanical bowel prep (except for low rectal anastomosis).

Patient education and counselling about expected recovery milestones. [1]

c) Describe four post-operative ERAS components. (4 marks) [1]

Early oral feeding within 24 hours (promotes gut recovery).

Early mobilisation on day 0 (evening of surgery) or day 1.

Opioid-sparing analgesia: paracetamol, NSAIDs, regional techniques (TAP block, epidural). Minimise opioids (prevent ileus, nausea).

Remove tubes/drains/catheters early (day 1) to enable mobilisation. [1]

d) What outcomes does ERAS improve? (bonus)

Reduces length of stay by 2 to 3 days

Reduces complications by approximately 50%

Reduces cost

No increase in readmission or mortality [1]

References

[1]Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg, 2017.PMID 28097305
[2]Kehlet H, Wilmore DW Multimodal strategies to improve surgical outcome. Am J Surg, 2002.PMID 12095591
[3]Kehlet H, Mogensen T Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg, 1999.PMID 10100792
[4]Fearon KCH, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr, 2005.PMID 15896435
[5]Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg, 2009.PMID 19841366
[6]Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2018. World J Surg, 2019.PMID 30426190
[7]Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, Ljungqvist O, Lobo DN The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr, 2010.PMID 20116145
[8]Zhuang CL, Ye XZ, Zhang XD, Chen BC, Yu Z Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum, 2013.PMID 23575408
[9]Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev, 2011.PMID 21328298
[10]Melloul E, Lassen K, Roulin D, et al. Guidelines for perioperative care for pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019. World J Surg, 2020.PMID 32161987
[11]Melloul E, Hübner M, Scott M, Snowden C, Prentis J, Dejong CH, et al. Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg, 2016.PMID 27549599
[12]Thorell A, MacCormick AD, Awad S, et al. Guidelines for perioperative care in bariatric surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg, 2016.PMID 26943657
[13]Yamagata Y, Yoshikawa T, Yura M, et al. Current status of the enhanced recovery after surgery program in gastric cancer surgery. Ann Gastroenterol Surg, 2019.PMID 31131351
[14]Beverly A, Kaye AD, Ljungqvist O, Urman RD Essential elements of multimodal analgesia in Enhanced Recovery After Surgery (ERAS) guidelines. Anesthesiology Clinics, 2017.PMID 28526156