Introduction
An enhanced recovery approach for colorectal surgery includes minimizing surgical trauma and postoperative pain, reducing complications, improving surgical results, and decreasing hospital stay. Multiple steps include such as perioperative opioid-sparing analgesia (different analgesics are given for safe and effective pain therapy), a laparoscopic approach for the colorectal resection (minimally invasive surgery), avoidance of nasogastric tubes (inserted into the stomach through the nose for feeding purpose), early oral feedings, early walk independently after surgery and management of postoperative nausea and vomiting. This approach is achieved by cooperation between the patient, surgeons, anesthesiologists, nurses, and hospital administration.
What Is Colorectal Cancer?
It is a condition where the colon and rectum (parts of the large intestine) cells grow abnormally without control and may develop into polyps, which develop into cancer. The polyps may be adenomatous (gland-like growths on the mucous membrane lining the large intestine; if developed into cancer, they are called adenocarcinoma, which is the most common type of cancer), hyperplastic and inflammatory polyps (rare to develop into cancer), and sessile serrated polyps (flat or slightly raised polyps and may develop into cancer); these polyps grow into the wall and then into blood and lymph vessels reaching nearby lymph nodes and distant parts of the body.
What Is the Preoperative Phase Of the ERAS Approach?
The preoperative phase of the ERAS approach includes:
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Patient Education: Every patient should receive a detailed protocol for every phase.
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Nutrition: Patients should stay hydrated and have carbohydrate-rich food two days before the surgery. A day before surgery, the patient should drink 0.7 liters of Gatorade. A nutritional supplement drink is given 3 hours before anesthesia.
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Infection Control: The patient should bathe with liquid chlorhexidine soap two days before and on the day of surgery, mechanical preparation is done to clear fecal material from the bowel by giving two to four Dulcolax pills followed by one bottle of Miralax in 1.8 liters of clear liquid is taken after an hour, and antibiotic prophylaxis (Neomycin 1,000 milligrams or Metronidazole 500 milligrams; Neomycin 1,000 milligrams or Erythromycin 500 milligrams) is given after one hour of mechanical preparation.
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Analgesia: Preemptive analgesia is given two hours before the surgery, Acetaminophen 1,000 milligrams, and Gabapentin 600 milligrams is given orally.
What Is the Perioperative Phase Of the ERAS Approach?
The perioperative phase of the ERAS approach includes:
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Anesthesia: Short-acting anesthetic agents are preferred (Propofol or Fentanyl) and regional anesthetic blocks can be used intraoperatively; the temperature is monitored using an esophageal probe every five minutes, and glucose levels should be monitored every hour.
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Antiemetics: Perioperative prophylaxis for nausea and vomiting is given to the patient. Decadron four to six milligrams intravenous is given early in the case, Zofran 4 milligrams intravenous is given 30 minutes before the end of the case, and Haldol 1 milligrams intravenously is used at any point of time during surgery.
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Fluid Management: Fluids are not administered to patients in the preoperative phase. If hypotension occurs after giving anesthesia, a bolus of five to seven milliliters per kilogram of crystalloid is administered. It should be maintained up to 2 milliliters per kilogram per hour for laparoscopic cases and 3 milliliters per kilogram per hour for open cases.
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Infection Control: Preoperative antibiotic regimen within 60 minutes of the incision should be received; Chloraprep (broad-spectrum antiseptic) is used for skin preparation. There should be different tables for sterile and used instruments. A surgeon should use a wound protector in case of open surgery.
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Drains Or Tubes: Intra-abdominal drains and nasogastric tubes should be avoided, which helps in recovery. If Foley catheters (tubes inserted into the urethra to drain urine) are used, they should be removed in the operating room.
What Is the Postoperative Phase Of the ERAS Approach?
The postoperative phase of the ERAS approach includes:
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Enhanced Recovery After Surgery Colorectal Order Template: A standard set of ERAS postoperative order sets that include all components. All hospital faculty should receive this checklist.
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Early Mobilization: Patients should start walking independently from bed to chair within three hours of arriving at the anesthetic care unit. On a postoperative day 1, the patient should be able to walk in the hallway three times. If patients have undergone abdominoperineal resection (done in case of low-lying rectal carcinoma) they should not sit for two days.
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Analgesia and Antiemetics: With the help of an epidural catheter, pain can be relieved by using epidural analgesics in case of open surgery and transversus abdominis plane (TAP) block (provides analgesia to the anterior and lateral abdominal wall) in case of laparoscopic surgery and mid thoracic epidural analgesia; which helps in early recovery of bowel function and intake of diet. Epidural catheters are removed by the second day, and pain management is achieved by using NSAIDs (non-steroidal anti-inflammatory drugs).
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Fluid Management: This includes the introduction of fluids to maintain hemodynamic stability while preventing complications like fluid overload and edema (swelling). Crystalloids (liquids containing mineral salts and water-soluble molecules) should be given at one milliliter per kilogram per hour and stopped after 6 hours postoperatively. In case of systolic blood pressure greater than 15 percent from the average), mean blood pressure less than 65, or urine output less than 0.25 milliliter per kilogram per hour three boluses (single dose of the drug given for a short period) of 250 milliliters of crystalloid are given.
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Nutrition: Early and safe intake of clear fluids should be performed immediately after the patient is awake; if patients are clinically progressing, the diet should be introduced on day 1 of postoperative after liquid breakfast, therefore improving bowel function and less hospital stay. If nausea and vomiting occur, the patient can delay the diet until the symptoms resolve.
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Urinary Catheter: Urinary catheters, which may cause urinary tract infection (a tube that collects urine in the drainage bag) placed during the surgery, should be removed in the operating room in case of colonic resection and 72 hours for rectal resections. For urinary retention purposes, doctors can remove it within 48 hours.
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Things To Consider While Discharging the Patient: The patient must have a sufficient oral diet that makes up for nutritional needs. A patient is not required to stay at the hospital until he has normal bowel movements. Post-operative pain should be managed properly using a multimodal oral pain regimen, which includes Gabapentin, Tylenol, Oxycodone, and Ibuprofen, and patients should take their medications for two weeks.
Conclusion:
Enhanced recovery can be achieved only by collaboration and open communication between the patient, surgeons, anesthesiologists, nurses, and hospital administration. They should follow the proper approach for the preoperative, perioperative, and postoperative phases of patient care.
