Presentation highlighting how dietitians can make use of ERAS principles to get patients fed sooner.

1. Utilising ERAS to improve
meal advancement post
operatively.
Nathan Billing-Surgical Dietitian

2. Acknowledgement
 Some slides taken from others presentations
found online.
 Emma Osland
 Carli Schwartz
 Other slides from AERAS study group slides
 Mattias Soop

3. Overview
 Overview of Enhanced recovery programs
 Increasing intake after surgery
 Key Nutritional components of ERAS
 Early Oral Feeding – Identifying issues
 Traditional vs Early post operative diet
advancement
 Clear Oral fluids versus Free Oral Fluids
 Providing guidance to surgical team
 Rationalisation of diets available
 ? Recommended for diet advancement

4. Enhanced Recovery Program
 Pioneered by Henrik Kehlet group in Denmark
 Identified factors which delay postoperative
recovery
 Pain
 Gut dysfunction
 Immobilization
 Combined a series of interventions to reduce
perioperative stress and organ dysfunction1
1. Kehlet H. Multimodal approach to control postoperative pathophysiology and
rehabilitation. Br J Anaesth 1997; 78:606–617.

5. Recovery After Surgery
What are we trying to achieve?
 Reduce the surgical stress response and
support basic body functions by 1, 2
– Use of optimised analgesia
– Early mobilisation
– Early return to normal diet
 These interventions have been shown to
improve postoperative outcomes 3,4
1. Fearon, et al, Clinical Nutrition 2005; 24: 466–477.
2. Kehlet, Lancet 2008; 371: 791–793.
3. Khoo, et al, Annals of Surgery 2007; 245: 867–872.
4. Wind, et al. British Journal of Surgery 2006; 93: 800–809.

6. Multimodal steps of ERAS protocol
• Optimised health /
medical condition
• Informed decision and
patient education
• Pre operative health &
risk assessment
• Optimised hydration &
nutrition
• Reduced starvation
• Patient information and
expectation managed
• Discharge planning
• No / Reduced bowel
prep (bowel surgery)
• Minimally invasive
surgery
• Use of transverse
incisions
• No nasogastric tubes
(bowel surgery)
• Use of Local
anaesthetic with
sedation
• Epidural management
(inc thoracic)
• Optimised fluid
management
• Planned mobilisation
• Rapid hydration &
nourishment
• Appropriate IV therapy
• No wound drains
• No NG ( bowel surgery)
• Catheters removed early
• Regular oral analgesia –
paracetamol and
NSAIDS
• Avoidance of opiate-
based analgesia where
possible or administered
topically
• Estimated
discharge date as
planned
• Full information
and ongoing
support
• Allied Health
professional
follow up where
required
• Personal follow
up from clinical
team (home calls)
Pre Operative Intra Operative Post Operative Discharge

7. Increasing oral intake after surgery
Day 0 patients receive
 Sandwich for day of surgery
 2 x supplements post operatively
Day 1 onwards patients receive
 progress to standard diet
 3 x supplements post operatively

8. Use of nutritional supplements in malnourished
patients post operatively (600kcal/day)
Beattie A Het al. Gut 2000;46:813-818
©2000 by BMJ Publishing Group Ltd and British Society of Gastroenterology

9. Fluid input:
ERAS vs Conventional Care
Teeuwen, et al, J Gastrointestinal Surgery 2010; 14:pp88–95.
61 ERAS patients vs 122 historical matched controls
ERAS total IV fluid intake ≠ > 2 l/24 h

10. Effect of mobilization on oral
intake
0
0.2
0.4
0.6
0.8
1
Intervention Control
Mean Protein intake
 Patients in intervention
group encouraged to
active mobilization from
day 1
 Control mobilized in
traditional manner
without specific aims
 Main part of meals was
eaten while sitting at a
table and not in a bed
0
20
40
60
80
Intervention Control
Mean Energy Intake
Henriksen, et al, Nutrition 2002; 18(3): pp:263–267.
Kj/kg/day
g/kg/day

11. Importance of team approach
 Agreement between
anaesthesia and
surgical teams
 FTE requirement
importance of ERAS
nurse
 Need surgeon buy in

12. ERAS alone is not enough
Influence of compliance
with the separate care
elements on length of stay
on various components on
length of hospital stay
Hazzard ratio above 1
indicates a better chance of
early discharge whereas a
value below 1 indicates a
lower chance.
Maessen, et al, British Journal of Surgery 2007; 94: pp224-231.

13. Oral feeding
Nutrition 2002; 18:944-948
Factors that limit or promote post operative feeding

14. Feeding the patient:
Postoperative Nutrient Provision

15. Traditional Postoperative Diet
Advancement
Traditional practice
 NBM prior to surgery
 NBM and gastric
decompression until
bowel function resumed
post surgery
 Diet progression once
gut working
 Clear fluids 
 free fluids 
 soft/light diet 
 full diet
Rationale
 Initially adopted to combat
post operative vomiting
and subsequent concerns
 Aspiration pneumonia
 Increase abdominal
pressure  anastomotic
rupture
 Also thought to “protect
the anastomosis” by
allowing gut rest and
avoiding food passing the
surgical site

16. Clear Oral Fluids vs
Free Oral Fluids
 Aim: To provide a diet
of liquid foods that
require no chewing.
 Includes more protein
high in saturated fat
and low in fibre, and
may require vitamin
and mineral
supplementation.
ClearOral Fluids Free Oral fluids
 Aim: To replace or
maintain the body’s
water balance and
leave minimum
residue in the
intestinal tract
 Meets anaesthesia
fasting guidelines
 Inadequate in all
nutrients

17. Early Postoperative Feeding
Early post-op feeding
 Clear fluids to 3-4hrs
pre-anaesthetic
 Fluids or diet from first
postoperative day
irrespective of
resumption of bowel
function
 No NGT post op
 Often in the context of
multimodal approach
including
 earlier mobilisation,
 non-opioid analgesia,
 key-hole surgery
Rationale
 Gut secretes and reabsorbs
~7L fluid/d irrespective of
oral intake, so “protecting the
anastomosis” is based on a
false premise
 Many patients already
malnourished  more
postoperative complications
 Nausea/vomiting is much
less of a problem with new
anaesthetic agents
 Some evidence that early
feeding reduces the body’s
stress response to
surgery/trauma

18. The research …
 Increasing numbers of studies investigating this
topic dating from 1978
 Tube feeding  early liquids  early solids
 Individual studies do not demonstrate major
adverse outcomes with early feeding
 Some suggestion of organisational benefits
 May decrease length of hospital stay and cost of
treatment
 Reported adverse outcomes
 Nausea, vomiting, NG reinsertion (common)

19. Previously conducted meta-analyses
Nutritional issues
• Inclusion of immune-modulating EN products
• Inclusion of studies feeding both proximal and distal to
anastomoses
• Nutrition provided at 24hrs post op may have included clear
fluids  little nutritional value
General issues
 Appears to contain inconsistencies in inclusion criteria of studies
included
Criteria for this meta-analysis
 Early feeding provision of diet (excluding COFS) and enteral
feeding given within 24 hours postoperatively.
 Traditional postoperative management = withholding nutrition
provision until bowel function had resumed, as evidenced by
either passage of flatus or bowel motion

20. Early vs Traditional PostOp feeding
• Fifteen studies involving a total of 1240 patients were analysed in meta-
analysis.
• To investigate impact of early feeding vs traditional postoperative feeding and
• Mortality
• Anastamotic Leaks
• Days to passing Flatus
• Length of stay
• Postoperative Complications

21. Results - Mortality
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 481

22. Results – Anastamotic Leaks
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 481

23. Results – Days to passing flatus
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 482

24. Results – Length of Stay
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 483

25. Results – Postoperative
Complications (Nausea and Vomiting
excluded)
Study
pre 2000
Sagar
Ryan
Schroeder
Binderow
Beier-Holgersen
Carr
Ortiz
Hartsell
Nessim
Stewart
subtotal
post 2000
Han-Geurts
Delaney
Lucha
Zhou
Han-Geurts
subtotal
POOLED
Early
3 of 15
2 of 7
4 of 16
0 of 32
8 of 30
0 of 14
17 of 93
1 of 29
3 of 27
10 of 40
48 of 303
12 of 56
7 of 31
1 of 26
23 of 161
22 of 46
65 of 320
113 of 623
Traditional
5 of 15
7 of 7
7 of 16
0 of 32
19 of 30
4 of 14
18 of 95
1 of 29
4 of 27
12 of 40
77 of 305
13 of 49
10 of 33
1 of 25
70 of 155
20 of 50
114 of 312
191 of 617
OR
0.53
0.03
0.46
1
0.22
0.08
0.96
1
0.75
0.78
0.55
0.76
0.69
0.96
0.21
1.37
0.62
0.55
L
0.08
0
0.07
0.02
0.05
0
0.24
0.07
0.11
0.17
0.34
0.18
0.14
0.07
0.06
0.33
0.26
0.35
U
3.78
0.94
2.91
61.41
1.08
2.06
3.77
13.42
5.01
3.56
0.9
3.27
3.38
12.99
0.74
5.61
1.51
0.87
0.1 2.0 4.0 6.0
favour Early favour Traditional
Osland et al, JPENJPare nte r Ente ralNutr 2011 35(4):p 479

26. Conclusions of Meta-analyisis
 No merit in withholding nutrition provided
proximal to the anastomosis until bowel
function is resumed.
 Statistically significant reductions in total
complications in the postoperative course with
early feeding.
 No negative effect of early feeding was
demonstrated with regard to in hospital
mortality, anastomotic dehiscence, LOS, and
time to recovery of bowel function

27. Recommending Diet Advancement
 Advance diet to full liquids followed by solid
foods, depending on patient’s tolerance.
 Consider the patient’s disease state and any
complications that may have come about since
surgery.
 Liaise closely with surgical teams
 Provide guidance of meal choices available in your
kitchen.
 Define meal advancement.
 Standardize practices.

28. Liasing with Surgical teams
 What does “E & D as tolerated” mean?
 Review of diet codes available for use
i.e. Light diet vs Low Residue Diet vs Post Op Diet
 When to use Modified consistency diets
 e.g. Upper GI surgery vs Lower GI surgery
Upper GI surgery could have impact on peristalsis so
may require liquid or pureed meals
 ?Sham feeding (i.e. Chewing gum)

29. Type of Surgery /
Underlying Condition
Recommended
diet post op
Rationale
Recurrent Small bowel
obstruction
Low residue diet A diet low in fibre to minimise chance of further
obstructions occurring
UpperGI surgery:
•Nissens Fundoplication
•Oesophagectomy
•Ivor Lewis Gastrectomy
Liquid Diet
or
Pureed Diet
or
Low residue diet
As this surgery would have an impact on the
mechanical ability to swallow feed and lead to a
degree of dysphagia. A liquid or pureed diet is
recommended initially to help minimise
difficulties in swallowing
Small bowel resections Liquid Diet
or
Low residue diet
or
Standard diet
As this surgery may result in anastamotic joins
in small intestine low residue foods are
recommended to minimise pressure on these
joins initially.
Colorectal surgery Standard diet
or
High Energy protein
diet
As this surgery involves the lower GI tract, most
food is well digested by the time it reaches the
colon and regardless of the type of food should
be pretty well digested
Cholecystectomy Standard diet
As gut motility or function has not been altered
by surgery no special requirements or surgery
Non Gut surgery
Standard diet As gut motility or function has not been altered
by surgery no special requirements or surgery
Alternative to E+D as tolerated?

30. Tailor made protocols
Specific surgeries /conditions that will have own specialist diet progression
pathway and dietetic input
Bariatric Surgery
•Gastric Bypass (Roux en Y)
•Gastric Sleeve
•Duodenal Switch
Water only
Optifast
Fluid diet
Pureed diet
Patients need to adjust to smaller stomach
volume and advance their diet slowly after
surgery. There is close working with surgeons
and set plans for these patients in place.
Chylous ascites and Chyle leaks Specialist diet with
reduced fat and high
MCT content
Dietary chylomicrons are absorbed in the small
intestines and gradually pass along larger
omental lymphatics. Reducing the intake of fat
has been shown to be beneficial at minimising
Pancreatic surgery orother
fistulas
Potential enteral NJ
feeding and or
IVN/TPN
Stimulation of pancreatic or other GI secretions
may be an issue and may need to be minimised.
Dietitian input is recommended.
As per
Surgeon

31. Questions
 References:
 Anderson et al. Early enteral nutrition within 24h of colorectal surgery versus later commencement of
feeding for postoperative complications. Cochrane Database Syst Rev, 2006 (4): CD002080.
 Franklin, G.A., McClave, S.A., Hurt, R.T., Lowen, C.C., Stout, A.E, et al., 2011. Physician- Delivered
Malnutrition: Why do patients receive nothing by mouth or a clear liquid diet in a university hospital
setting? Journal of Parental and Enteral Nutrition. 35(3):pp337-342.
 Hancock, S., Cresci, G., Martindale, R., 2002. The clear Liquid Diet: When is it appropriate? Current
Gastroenterology reports. 4: pp324-331.
 Jeffery, K.M., Harkins, B., Cresci, G.A., Martindale, R.G., 1996. The clear liquid diet is no longer a
necessity in the routine postoperative management of surgical patients. The American Surgeon
62(3):167-70.
 Kawamura, Y.J., Kuwahara Y., Mizokami K., et al., 2010. Patient’s appetite is a good indicator for
postoperative feeding: a proposal for individualized postoperative feeding after surgery for colon
cancer. Int JColorectal Dis.;25:pp239-243.
 Lewis et al. Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: a systematic
review and meta-analysis of controlled trials. BMJ, 2001, 323 (7316) 773-776
 Lewis et al. Early enteral nutrition within 24h of intestinal surgery versus later commencement of
feeding: A systematic review and meta-analysis. JGastrointest Surg, July 16 2008
 Story, S.K., Chamberlain, R.S,. 2009 A Comprehensive Review of Evidence-Based Strategies to
Prevent and Treat Postoperative Ileus. Digestive Surgery 2009; 26:265–275.
 Warren, J., Bhalla, V., Cresci, G., 2011. Postoperative Diet Advancement: Surgical Dogma vs
Evidence based Medicine. Nutrition in Clinical Practice. 26(2): pp115-125.