3. Dogma: Back to the Past….
Senior surgeons had strong principles and they were
assumed as a dogma.
• Preoperative prolonged fasting, Mechanical bowel
preparation and nasogastric tubes were thought to be
necessary to
empty the bowel
to prevent intraoperative contamination
and to prevent early passage of bowel content through
an anastomotic suture line while it is healing.
• Drain tube was believed essential in any GIT surgery
• Prolonged bed rest were recommended to facilitate
abdominal wall healing.
5. An evidence-based concept for acceleration of
postoperative recovery ,convalescence by a multimodal
rehabilitation program
The term “fast track” was firstly used by
Professor Henrik Kehlet
In 1990 MD, PhD, Surgical Gastroenterologist
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13. Members of ERAS progrm
• Nurses
• Dietitians
• Physiotherapists
• Pain team
• Anaesthetists
• Surgeons
• Hospital management
14. Pre-Admission
• Counseling
• Oral Supplements
Pre-Operative
• Admission on the day of surgery
• Preoperative fasting and Carbohydrate Loading
• No Mechanical Bowel Preparation
• Prophylaxis: DVT, Antibiotic
• Perioperative opioid sparing analgesia
Anesthesia
• Normothermia
• Mid Thoracic Epidural Analgesia
• Avoidance of fluid overload
Surgical
Approach: Laparoscopy/ Short Incision/ Transverse Incision
Avoid Surgical Drains or Nasogastric tubes
Post-Operative
• Hydration
• Active, Multimodal and preventive pain control
• Aggressive management of nausea and vomiting
• Early oral feeding and mobilization
• Nutritional support
• Remove urinary catheters and drains
• Discharge criteria
“Fast Track Suergery” Components
15. Pre-admission
Pre admission counseling:
A clear explanation of what is to happen during hospitalization
Explanation of role of the patient about food intake, oral nutritional
supplements and mobilization after surgery
16. Pre-Operative
• Preoperative assessment and optimization of organ function seeks to
reduce operative risk.
• Alcohol and smoking cessation for a month preoperatively can reduce
the incidence of complications, e.g., bleeding, wound infections, and
cardiorespiratory complications .
• Bowel preparation leads to patient discomfort, dehydration, and
electrolyte imbalance,and is no longer recommended in elective
abdominal surgery . However, bowel preparation may have a role in
selected patients such as those undergoing rectal resection .
17. • Modern fasting guidelines recommend that the duration of
preoperative fasting should be 2 h for liquids and 6 h for
solids .
• Preoperative nutrition and good carbohydrate diet reduces
preoperative thirst, hunger and anxiety, and significantly
reduce postoperative insulin resistance.
18. Intra-operative
Intraoperative fluid therapy
Avoid Na and Fluid overload .
Goal directed fluid therapy via Oesophageal Doppler(OD) monitoring.
Fluid overload is associated with delayed gut function and increased
complication rates.
Maintenance of normothermia is important for preventing sympathetic
responses, cardiac arrhythmias, and wound complications.
Tubes and drains
No routine use of drains , nasogastric tube.
19. Anasthesia
epidural, spinal, or peripheral nerve block remains a key element of the
FT program and has been associated with attenuated endocrine stress
response, increased gut motility, reduced inflammatory response, and
optimal pain relief, but its application must be procedure-specific.
For lap. colectomy, spinal analgesia or patient-controlled analgesia may
be superior to epidural analgesia within a FT program .
Short-acting opioids are commonly used in FT surgery in combination
with regional anesthetic techniques to minimize the amount of
anesthetics used and to facilitate recovery.
20. Minimally invasive techniques
Short, Transverse Incision,Laparoscopy reduce in-patient stays,
lessen morbidity and lower postoperative pain.
oxygen therapy
may reduce the risk of wound infection and anastomotic complications.
Antimicrobial prophylaxis
is recommended to prevent infectious complications
Anticoagulants
minimizes thromboembolic events
21. Post-operative
Encourage Early Postoperative Oral Intake
• Facilitates early return of bowel function,
• Allows stopping of intravenous drips,
• Aids mobilization,
• Leads to faster recovery.
• Reduces postoperative morbidity and is not associated with an
increased risk of anastomotic dehiscence
Early remove of nasogastric tube , drains and catheters
22. Early mobilization
Bed rest
• ↑ insulin resistance , muscle loss and risk of thromboembolism.
• ↓ muscle strength, pulmonary function and tissue oxygenation .
• The aim is for patients to be out of bed for 2 h on the day of surgery, and for
6 h a day until discharge.
Post operative pain
Using
• NSAIDs
• Epidural and
• local infiltrating anasthesia is better
• Opiates are associated with decreased gut motility and delay recovery
23. Prevention of Postoperative Nausea and Vomiting (PONV)
and ileus
• PONV is unpleasant, delays gut function, affects mobility and has
metabolic consequences.
• Give prophylactic anti-emetics i.e. Ondansetron during anesthesia
around 30 min before the end of surgery.
• Ileus can be avoided by early ambulation ,laxatives, and electrolyte
balance.
24. Discharge criteria
• Patients can be discharged when they meet the following criteria:
• Good pain control with oral analgesia
• Taking solid food, no intravenous fluids
• Independently mobile or same level as prior to admission
• All of the above and willing to go home.
26. Evidence from clinical trials as well as expert opinions of surgeons in
the field suggest that fast-track programs can result in beneficial
outcomes for patients.
In particular, optimising conditions before, during and after surgery can
reduce the length of hospital stay for patients with no increase in
readmission rates, morbidity or mortality.
The available evidence suggests that fast-track protocols are as safe as
conventional treatment regimes.
27. Application of fast track surgery
• Colorectal surgery
• Bariatric surgery
• Liver and pancreatic resection
• Breast surgery
• Urological surgery i.e Lap. Prostatectomy
• Orthopedic operations “Hip and knee replacement”
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29. Enhanced Recovery After Surgery
• Saves money
• Saves resources
• Saves time
• With no inreased complication rate
30. Reference
• 1. Manual of Fast Track Recovery for Colorectal Surgery- Nader Francis, Robin H. Kennedy, Olle
Ljungqvist, Monty G. Mythen
• 2. Enhanced recovery programme in colorectal surgery: Does one size fit all?- Alison Lyon,
Christopher J Payne, Graham J MacKay World J Gastroenterol 2012 October 28; 18(40): 5661-5663
• 3. Multimodal Approach to control postoperative Pathophysiology and rehabilitation- Henrik
Kehlet. Brit. J A 1997; 78: 606-617
• 4. ERAS (Enhanced Recovery after Surgery) in Colorectal Surgery- Raúl Sánchez-Jiménez, Alberto
Blanco Álvarez, Jacobo Trebol López, Antonio Sánchez Jiménez, Fernando Gutiérrez Conde and
José Antonio Carmona Sáez
31. • Zargar-Shoshtari K, Sammour T, Kahokehr A, Connolly AB, Hill AG (2009) Randomized clinical trial of
the effect of glucocorticoids on peritoneal inflammation and postoperative recovery after colectomy.
Br J Surg 96:1253–1261
Vignali A, Di PS, Orsenigo E, Ghirardelli L, Radaelli G, Staudacher C (2009) Effect of prednisolone on
local and systemic response in laparoscopic vs. open colon surgery: a randomized, double-blind,
placebo-controlled trial. Dis Colon Rectum 52:1080–1088
Schmidt SC, Hamann S, Langrehr JM, Hoflich C, Mittler J, Jacob D, Neuhaus P (2007) Preoperative high-
dose steroid administration attenuates the surgical stress response following liver resection: results of
a prospective randomized study. J Hepatobiliary Pancreat Surg 14:484–492
Sammour T, Kahokehr A, Chan S, Booth RJ, Hill AG (2010) The humoral response after laparoscopic
versus open colorectal surgery: a meta-analysis. J Surg Res 164:28–37
