European Journal of Cardiovascular Medicine

Introduction

The diagnosis and treatment of disorders affecting colon,rectum,anus and the surrounding structures are dealt with in a specialised field of medicine called colorectal surgery. It includes benign and malignant diseases which require surgery.

Historical perspective:

• Early 20th century: Open colectomies and abdominoperineal resections were standard.
• 1980-1990s: Introduction oflaparoscopic techniques revolutionised the field.
• 21st century: Adoption of robotic surgery, transanal total mesorectal excision(TaTME), and ERAS protocols.^[1]

Further ERAS implementation:

• 2002 - Colonic, rectal and pancreatic surgery.
• 2003 - Cystectomy surgery
• 2004 - Gastric resection surgery
• 2006 - Anaesthesia protocols, pathophysiology and Major gynaecology surgery
• 2007 –Head and Neck surgery, liver resection and bariatric surgery.

Upcoming - Oesophageal resection and Thoracic non cardiac surgery. Professor Kehlet’s worked at several different European centers and the adoption of these ERAS principles is fast growing across US and all other countries including India.

Patients' surgical care and management are going through a significant change. Prolonged fasting, mechanical bowel preparation, and keeping patients NPO with nasogastric tubes for several days until there is a clear recovery from paralytic ileus with bowel movements are examples of peri-operative surgical care methods that were part of traditional care that have been discontinued. ERAS protocols have been developed to incorporate these significant pre-, intra-, and post-operative modifications.

Commonly performed colorectal surgeries are described below:

• Right hemicolectomy: for conditions such as Adenocarcinoma of ascending colon/ caecum/ adenocarcinoma of hepatic flexure, Crohn’s disease(strictures and massive bleed), Ileocaecal tuberculosis(refractory cases), perforation or trauma to right colon.
• Left hemicolectomy: Indications: Tumours of descending colon/ splenic flexure to sigmoid colon, diverticulitis(complicated/recurrent), ischemic colitis.
• Sigmoidectomy:Indications: perforation, stricture, fistula, volvulus(non-reducible sigmoid volvulus).
• Low anterior resection(LAR): Indications: Mid and/or upper rectal carcinoma
• Abdominoperineal resection (APR): Indications: Low rectal cancer(<5cm from anal verge, invading sphincters), recurrent anal cancers, severe perianal trauma.
• Total proctocolectomy: Indications: Ulcerative colitis(refractory to medical therapy/dysplasia), familial adenomatous polyposis(FAP)
• Reconstruction options: Ileal pouch-anal anastomosis(IPAA) (no stoma), End ileostomy(if IPAA is contraindicated)
• Transanal minimally invasive surgery(TAMIS/TaTME): Indications:Early T1 rectal cancers(after staging), benign rectal polyps, selected T2 tumors(neoadjuvant therapy responders)
• Stoma creating surgeries: Loop ileostomy/ colostomy (to protect distal anastomosis example-after LAR), End colostomy: APR, Hartmann’s procedure.

Colorectal cancer is the third most common form of cancer worldwide, second only to lung and breast cancer, accounting for approximately 1.8 million new cases per year. About 0.9 million people die from the disease each year, making colorectal cancer the second most common cause of cancer-related death in the world today. Western Europe, Australia and New Zealand show the highest incidence, compared to a low incidence in Africa. Colorectal cancer is mostly a disease appearing at high age, with only about 5 % of the cases presenting before the age of 40. Median age at diagnosis, for colorectal cancer overall, is 60 years. Rectal cancer accounts for 35% of all colorectal cancer incidences. Globally, the incidence of right-sided colon cancer is increasing  and there are data describing an increased incidence in left-sided tumours and rectal cancers in younger people, under age 50.

"Enhanced Recovery after Surgery" (ERAS) was formerly referred to as "enhanced recovery protocol" (ERP) or "fast track" surgery. A shorter hospital stay after a number of surgical operations, including gastrointestinal surgery, has been the goal in recent decades. There are numerous explanations for this, starting with growing efficiency and knowledge. A novel approach to enhancing the experience of patients requiring major surgery is enhanced recovery. It speeds up recovery for patients so that things can get back to normal as soon as possible. . A novel approach to enhancing the experience of patients requiring major surgery is enhanced recovery. It speeds up recovery for patients so that things can get back to normal as soon as possible. For a surgical specialty and facility culture, it refers to patient-centered, evidence-based, and interdisciplinary team-developed paths that minimize the surgical stress response, maximize physiologic function, and speed recovery. In order to minimize surgical stress, preserve postoperative physiological function, and hasten recovery for patients undergoing major surgery, ERAS protocols combine a number of perioperative patient care techniques with a multidisciplinary team approach.

“Enhanced Recovery after Surgery” (ERAS) was known as “fast track” surgery or “enhanced recovery protocol” (ERP). In the previous decades, there has been a tendency to aim for a shorter hospital stay following several surgical procedures, including colorectal surgery. There are many reasons for this: firstly, increasing knowledge. Secondly, the aim to reduce hospital stay based on economic efficiency. Enhanced recovery is a new way of improving the experience of patients who need major surgery. It helps patients recover sooner so life can return to normal as quickly as possible. It refers to patient-centered, evidence-based and interdisciplinary team developed pathways for a surgical specialty and facility culture to reduce the patient’s surgical stress response, optimize their physiologic function and facilitate recovery. (ERAS) protocols comprise a combination of various perioperative patient care methods using a multidisciplinary team approach.

Preoperative counselling, no fasting, optimal hydration management, reduced tube use, opioid-sparing analgesia, and early mobilization are the main focuses of ERAS protocols, which include pre, intra, and postoperative components. Despite improvements in surgical and anaesthetic treatment, the morbidity rate following abdominal surgery remains high, with over 234 million major surgical procedures carried out annually worldwide. With the goal of reducing the loss of functional capacity and hastening the healing process, the Fast-track or accelerated recovery after surgery (ERAS) therapeutic pathways have been developed to improve the quality of perioperative treatment. Because the ERAS pathways lessen surgical stress and preserve postoperative physiological functioning, they shorten the time it takes to fully recover from major abdominal surgery. It has been demonstrated that the ERAS pathways have a good effect on lowering surgical morbidity, which in turn lowers length of hospital stay (LOSH) and associated expenses. About 50% of postoperative problems and 30% of care time has been observed to be reduced.Specialties include pancreatic, gynaecologic, cardiovascular, and thoracic, paediatric, orthopaedic, colorectal, and urologic surgery have effectively adopted ERAS protocols.

The annual incidence rates for colon cancer and rectal cancer in men are 4.4 and 4.1 per 100000, respectively. Although a highly common procedure with approximately 330,000 cases per year.¹

The 5 year relative survival rate for CRC  has increased moderately from 50% in the mid-1970 to 64% during 2009-2015.² To improve outcomes for colorectal surgery patients, the Enhanced Recovery After Surgery(ERAS) protocol was developed by a Danish surgeon, Henrik Kehlet, in the early 1990s. It was initially known as “Fast Track Surgery” the protocol involved a bundle of interventions that were focused on expediting recovery & improve perioperative outcomes of the patients by^4.

ERAS represents a comprehensive approach to perioperative care aimed at minimizing surgical stress and promoting rapid postoperative recovery ^[5]. This paradigm shift in perioperative management focuses on a standardized package of care, encompassing the entire patient journey from the preoperative, intraoperative, and postoperative phases [^6]. The success of ERAS programs relies on the collaborative efforts of a multidisciplinary team, comprising surgeons, anesthesiologists, nurses, and other allied healthcare professionals ^[6].

ERAS programs have been associated with notable improvements in patient outcomes and cost-effectiveness, demonstrating their role in value-based care ^[7]. In comparison to conventional perioperative management, implementation of ERAS has been linked to decreased hospital stays, fewer postoperative complications, and an earlier return to baseline functional status ^[8].

The global adoption of ERAS protocols has expanded significantly, demonstrating efficacy in diverse healthcare settings, including resource-limited environments and regional centers, with recent studies reporting faster return to baseline functional status, shorter hospital stays, and fewer complications in these settings as well ^[9,10,11].

While ERAS has shown benefits across various surgical disciplines, its impact on outcomes following colorectal surgery continues to be explored ^[12]. This systematic review compares ERAS protocols with conventional care methods, focusing on patient outcomes in colorectal surgery and addressing gaps in the current literature, particularly in the areas of elderly patient outcomes, nutritional and immune recovery, and individual recovery milestones, with the goal of delivering a comprehensive analysis of the impact of ERAS protocols on various aspects of postoperative recovery within this surgical domain.

The purpose of this study was to assess the safety and effectiveness of ERAS guidelines for patients undergoing colorectal surgery. A multimodal perioperative care pathway called ERAS was created to help patients who are having major surgery recover quickly. The conventional methods are re-examined by ERAS first then it’s substituted with evidence-based best practises where needed. Secondly, it encompasses every aspect of the patient's experience during the surgical procedure. The necessity for parenteral analgesia, the requirement for intravenous fluids due to intestinal dysfunction, and bed rest brought on by immobility are the main reasons why patients remain in the hospital following surgery. These important criteria are addressed by the core components of the ERAS pathway, which also helps to explain how they interact to impact patient recovery. Furthermore, the ERAS pathway offers direction to all peri-operative care providers, assisting them in collaborating as a cohesive team to deliver optimal care. About 30% of the care time is reduced. Patient’s recovery was much faster after their operation which in turn decreases the need for staying in hospital by around 30% or 2days after any major abdominal surgery. No increase in readmissions was seen even though patients were discharged earlier.^[7]

Reduce complications by up to 50%:

According to a recent study, ERAS programs help patients recover from major abdominal surgery considerably more quickly, which reduces the requirement for hospitalization by roughly 30% or more than two days. Re- admissions did not rise in spite of earlier hospital discharges. Cut complications by as much as 50%: Major problems following abdominal surgery can be reduced by up to 40% using ERAS. Particularly, there is a noticeable decrease in non-cardiac problems, like those originating from the cardiovascular and pulmonary systems. Even while each component works well on its own, all of them should be combined to gain the most advantage. The hospital stay can be shortened to two or four days with Eras procedure. When all discharge requirements are met, the period of hospital stay is shortened. Therefore, compared to traditional procedures, eras is beneficial in achieving full recovery for the patient with the shortest duration of hospitalization. The basic mechanism of ERAS is reducing the stress response of the organs to surgery which is indicated by early recovery of gastrointestinal function.

AIM AND OBJECTIVES

AIM:

To evaluate the outcomes of ERAS protocol in colorectal surgeries.

OBJECTIVES:

1. Length of hospital stay.
2. Post op complications.
3. Readmissions.
4. Time of tolerance of diet.

COMPONENTS OF ERAS

Preoperative advice includes:

1. “Patient and attendant counselling and information.”
2. “Shorter fasting duration.”
3. “Overload of carbohydrates.”
4. "Avoidance of preparations for the bowel."
5. "Prophylactic DVT."
6. "Prophylactic use of antibiotics."

Preoperative advice:

1. "Excessive O2 concentration during surgery"
2. "Preventing hypothermia."
3. "Fluid therapy with a goal."
4. "Use transverse and shorter incisions."
5. "Avoidance of tubes for DT and NG."
6. "Use epidural analgesia and local block"

Recommendations following surgery:

1. "Avoiding opiates"
2. "Early enteral feeding"
3. "Early mobilization."
4. "Restricted IV fluid intake.”

FIGURE 1: PREOPERATIVE. OPERATIVE AND INTRAOPERATIVE INTERVENTIONS

FIGURE 2: FLOW CHART OF ERAS PROTOCOL

FIGURE 3: COMPONENTS OF ERAS PROTOCOL

PRE-OPERATIVE COMPONENTS

1. Detailed information and counselling

For their convenience, the material can be presented either orally or in writing. These must be included in the information: "The essential elements of eras and their advantages"

1. What might the patient anticipate while they are in the hospital?
2. Delay in discharge may be due to many issues like lack of social support

Early mobilization, early enteral nutrition, and breathing exercises require clear directions. Patients can be actively involved in own healing by encouragement.Even prior to surgery, patients who may need a stoma should receive the proper training to ensure they are proficient in stoma care.

Patient satisfaction and results have improved as a result of this pre-operative counselling.

2. Decreased Fasting and Carbohydrate Loading: Prior to general anaesthesia, patients are permitted to consume clear fluids for upto two hours and should fast for a solid diet for approximately six hours. Patients should be permitted to consume clear liquids two to three hours prior to surgery and solid foods till midnight. 800ml of high carbohydrate should be given to patient’s ore bed and 400ml 2 hours before on day of surgery hours prior to anaesthesia.

The traditional method of preparing a patient for surgery was to have them fast overnight with NPO for eight hours prior to the procedure. This has been used to lessen stomach contents, which stops aspiration, vomiting, and regurgitation. However, it has been demonstrated that allowing patients to consume clear fluids for up to two hours prior to surgery during a brief period of fasting improves their overall health. It has been demonstrated that feeding the patient with carbohydrates and fasting for a brief period of time preserves nitrogen balance and lowers insulin resistance after surgery. A clear, residue-free beverage is ideal for carbohydrate loading.

Patients with Diabetes

It has been demonstrated that loading carbohydrates is safe for diabetic persons who do not require insulin.

Research has indicated that neither delayed stomach emptying nor hyperglycaemia is brought on by this carbohydrate loading. Glucose levels need to be checked often.

3. Avoidance Of Mechanical Bowel Preparation

Traditionally patients were prepared for gastro-intestinal surgeries with oral mechanical bowel preparation. It was being done so as to reduce sepsis even if there anastomotic leak has occurred. Patients should also avoid any dietary restrictions before taking the MBP and should continue to consume clear liquids following. For patients undergoing open or laparoscopic colorectal procedures (including segmental resections, APR, TPC, IPAA, etc.) other than LAR± diverting stomas, MBP is not necessary, there should be no dietary restrictions, and a Fleet enema should be used if the patient is undergoing a left-sided anastomosis. Serious side effects, such as fluid imbalance, might result from the mechanical bowel preparation, especially in older patients.

4. DVT prophylaxis:

Depending on their risk factors for thromboembolism, patients having surgery should be divided into low, moderate, or high risk groups. For low-risk patients, graduated compression stockings may be employed. Pneumatic compression devices can be employed intraoperative. Low molecular weight heparin (enoxaparin 20 mg, subcutaneous) should be begun in patients in the moderate and high risk groups for thromboembolism the night before surgery and continued until the patient is discharged. . Patients in hypercoagulable states or those with a higher risk of thromboembolic consequences, such as those with a history of thrombosis or residual cancer, should continue taking heparin for up to one month following surgery. Since low molecular weight heparin is simple to use and has fewer bleeding and other side effects than unfractionated heparin, it has been suggested as a single daily dose for the prevention of deep vein thrombosis. For efficient DVT prevention, LMWH can be used in conjunction with graduated compression stockings.

FIGURE 4: TYPES OF DVT PROPHYLAXIS

5. Prophylactic use of antibiotics

Prior to skin incision, all patients should get a preventative dose of antibiotics. Both aerobic and anaerobic organisms should be covered by the antibiotic selection. A second dose of antibiotic should be given for procedures lasting more than four hours or if there is more blood loss than 1500 millilitres. Prophylactic antibiotic use has been demonstrated to be highly successful in lowering the infection rate of wounds. Multiple doses increases risk of infections like Clostridium difficile. Therefore single dose is beneficial and could be repeated on certain circumstances.

FIGURE 5: RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS

6. Optimisation Of Co-Morbidities

Smoking:

Emphysema, peripheral vascular and ischemic heart disease, cerebrovascular disease, and chronic obstructive pulmonary disease are among the comorbidities that smokers frequently have and can independently raise the risk of perioperative problems. Smokers who do not have these comorbidities are nonetheless at higher risk during surgery, primarily because of poor wound and tissue repair, which can result in wound infection and cardiac problems such chest infection. Research has been conducted to determine whether short-term quitting smoking can lead to better results.Better wound healing is promoted by quitting smoking for four weeks before surgery. Preoperative smoking cessation is facilitated by the use of counselling and nicotine replacement therapy (NRT). There are further pharmaceutical treatments accessible.

Two preoperative 20 minute standardize counselling sessions, before 1 week of surgery and then after 10 to 12weeks has proven to enhance the long term abstinence of smoking but did not lower the postoperative complications when compared to placebo.However, varenicline-treated patients had nausea more often (13.3%vs. 3.7%, P = 0.004).Although there is little information on antidepressants like bupropion in the peri-operative context; they also appear to help people quit smoking.

Recommendation: It is advised to stop drinking and smoking at least four weeks before to surgery. Pharmaceutical treatment and individual counselling should be provided in all smokers and alcoholics undergoing elective surgery as encouraging patients are insufficient.Improvement of health issues, including cardiovascular illnesses, anaemia, diabetes, chronic obstructive pulmonary disease, nutritional condition, and frailty, and ought to adhere to global guidelines.

Glycaemic control (Preoperative):

The degree of hyperglycaemia during and after elective surgery depends on the patient's metabolic status (fasting, fed, or diabetic), the type of anaesthesia and analgesia used, and the extent of surgical tissue damage. There is compelling evidence that even modest elevations in blood glucose levels are linked to negative consequences.

Patients with random blood glucose levels>11.1mmol/l or >mmol/l of fasting glucose levels in general surgical wards were seen to have a higher in-hospital death probability.

The level of preoperative glycaemic management is equally crucial according to more recent findings.Indeed, it has been discovered that elevated HbA1c values indicate difficulties following abdominal and heart surgery.

Glycaemia and clinical outcomes, for example, may not necessarily indicate a direct cause-and-effect link. There is currently not enough data to show that stringent glycaemic control—keeping blood glucose levels within a normal, limited range—is better than traditional care for surgical patients. Similar to the ICU scenario, there is still a trade-off between the advantages of lowering blood sugar levels and the dangers of hypoglycaemia. The issue of nursing staffing and their ability to supervise patients undergoing intense insulin treatment is another consideration for the surgical patient on the ward.

A review of the relationship between glycaemic control and the incidence of surgical site infections was inconclusive due in large part to the small number of studies (n = 5), patient population heterogeneity, insulin administration routes, outcome measure definitions, and the fact that glycaemic targets varied and/or were not met. As a result, the optimal glucose level to enhance clinical outcomes is currently unknown.

Therefore, without sacrificing safety, glucose concentrations should be maintained as near to normal as feasible. It is advised to use perioperative therapies that lower insulin resistance without resulting in hypoglycaemia

Hemodynamic management Preoperative period:

The preoperative hydration deficit may be impacted by the patient's comorbidities, prior fasting, and the use of preoperative mechanical bowel preparation (MBP).Significantly fewer intraoperative fluids are needed now that prolonged preoperative fasting, Avoidance of use of preoperative carbohydrate(CHO) and MBP has been done. Patients are advised to drink, however when MBP is recommended, fluid and electrolyte imbalances happen. Personalized intraoperative fluid administration techniques, as opposed to anecdotal "textbook recipes," should be the foundation for replacing preoperative intravascular deficiencies.

1. Use of epidural analgesia and blocks:

Epidural analgesia is recommended to be prescribed to patients having colorectal procedures prior to the giving of general anaesthesia.For 48 hours, analgesics can be given via the epidural catheter. Verify that the apparatus doesn't impede the patient's ability to move around. A local aesthetic solution (Bupivacaine 0.15%) is given when the epidural catheter is inserted into the epidural space at the level of T9 and T10. The spinal nerves become blocked as a result. By inhibiting sympathetic activity, epidural analgesia has demonstrated efficacy in lowering the post-operative surgical stress response and enhancing gastrointestinal function.

However, this inhibition of sympathetic activity may result in hypotension, which is insensitive to intravenous fluids. Patients who experience nonresponsive hypotension should be sent to the intensive care unit (ICU) and given vasopressors or ionotrophes. Epidural analgesia with local analgesic infiltration could be substituted with other modalities, such as transverse abdominis blocks. Since there is a decreased need for analgesics following laparoscopic surgery, epidurals could not be beneficial and instead raise the risk of problems related to the procedure. If the surgeon or anaesthetist determines that epidural analgesia is safe and effective in their local context, this should not prevent them from using it for laparoscopic surgery.

Abdominal trunk blocks:

Transverse abdominis plane (TAP) block alongside rectus sheath block.

Ultrasound-guided single-shot TAP blocks have been shown to significantly reduce pain intensity and opiate usage, but only within the first 24 hours following surgery. Before sealing the abdominal wall, surgeons can alternatively conduct TAP blocks from the peritoneal cavity or under laparoscopic guidance

2. High inspired O2 concentrations peri-operatively:

It is necessary to administer a high inspired oxygen concentration of 80%both during anaesthesia and for six hours after surgery.A face mask will need to be utilized for giving this high O2 concentration. After surgery, polymorph nuclear cells use this molecular oxygen to create free radicals, which serve as an efficient barrier against infections. This promotes angiogenesis and collagen synthesis, which aid in wound healing. This elevated oxygen content has been demonstrated to lower wound infections and enhance vascular perfusion, which aids in anastomotic site healing. Additionally, there is proof that it reduces nausea and vomiting following surgery.

3. Hypothermia Prevention

During surgery, hypothermia should be avoided until the patient has fully recovered. Warm air blankets can be used for this. Active warming is required until the temperature rises above 36degrees Celsius. If the procedure will take longer than an hour, warm intravenous fluids should be used. GA can cause hypothermia by interfering with the body's natural thermoregulatory functions. The incidence of SSI rises with hypothermia. Hypoxia brought on by peripheral vasoconstriction causes SSI. Other complications of hypothermia include coagulopathy, increases cardiac morbidity and increases levels of circulating catecholamine with a resultant exaggerated catabolic response. Hypothermia prevention has been shown to reduce blood loss and prevent infective and cardiac complications. If the procedure is expected to last for more than an hour, Warm IV fluids should be used.

4. Intra-operative Fluid Management: 

The goal of fluid management in intra-operative scenarios should be determined by the parameters that are accessible. These measures include blood pressure, heart rate, urine output, and ECG, among others. Fluid therapy should be titrated to maximize cardiac performance or stroke volume in some situations where monitors to evaluate cardiac output and stroke volume are available (Level of evidence) :Rather than absolute values that must be maintained, perioperative hemodynamic should be viewed in relation to baseline values. Each patient should have their own hemodynamic changes permitted, although generally speaking, variations in blood pressure and heart rate of less than 20% from baseline are permissible (Level of evidence: Moderate-High). 

When hypovolemia is suspected, a fluid challenge of either crystalloid or colloid (200–250 ml) should be administered. The available hemodynamic parameters should be used to re-evaluate the response. If there is a positive reaction, such as a 10% increase in stroke volume or blood pressure, the fluid challenge may be repeated. Changes in heart rate, blood pressure before and after the fluid challenge, and  The intra-operative fluid rate for maintenance should not A balanced salt solution (either Ringer's Lactate or Plasmolyte) should be used for intra-operative crystalloid administration(Level of evidence: Moderate-Low).  Measurement or estimation of the pulse pressure fluctuation can all be used to track a patient's clinical reaction to the challenge. Repeating the fluid challenge is advised until the clinical parameters have improved and/or the stroke volume has stopped increasing.  

It is best to avoid administering fluids for purposes other exceed 1.2 millilitres per kilogram per hour. It may be possible to lower the risk of fluid overload by using an infusion pump (Level of evidence: Low).Than optimizing the intravascular fluid volume. Using an injection site as close to the patient as feasible, for instance, 23 can minimize the amount of crystalloid used as a carrier for Crystalloid up to 500ml could be used to make up for this fluid deficit in patients who have had a mechanical bowel medication administration by preventing the need to flush in significant amounts of crystalloid with the pharmaceuticals (Level of evidence: Moderate-Low).  Preparation when calculating the dosage of crystalloids, response to fluid challenge should be taken into account minor blood loss can be replaced with crystalloid during surgery, acute blood loss can be substituted by colloids or crystalloids.

When an intravascular volume needs to be replaced quickly, colloids should be taken into consideration (Level of Colloids can be used to replace acute blood loss during surgery at a 1:1 ratio (Level of evidence: Moderate-Low). Patients with hyponatremic or hypochloremic conditions (such as those with substantial stomach fluid drainage or pre-existing derangements from diuretic usage) should be the only ones to use normal saline (Level of evidence: Moderate-Low).

An oesophageal Doppler probe should be used to continually measure the cardiac output, and fluid delivery should be titrated in accordance with variations in the cardiac output.

Conventional monitoring may fail to detect intra-operative splanchnic hypoperfusion, which delays the recovery of gut function. Bacterial translocation over the gut wall could result in sepsis.

Excessive fluid administration following surgery may also cause cardiac morbidity and a delayed recovery of gastrointestinal function. An oesophageal Doppler probe enables guided fluid management and can be used to assess hemodynamic state during the peri-operative phase. LiDCO plus and LiDCO quick are two less intrusive techniques for maximizing fluid balance that can be employed in place of the  oesophageal Doppler. These devices provide continuous real-time data and rely on a lithium dilution approach to assess changes in hemodynamic parameters, such as cardiac output and stroke volume. Fluid administration using Oesophageal Doppler.

Hemodynamic management Intra-operative period

Administering balanced crystalloid solutions to meet the demands of salt-water homeostasis is the goal of intra-operative fluid therapy. This contrasts with volume therapy, which treats objective signs of hypovolemia by administering goal-directed boluses of intravenous solutions, therefore increasing intravascular volume and circulatory flow. During intra-operative fluid administration, a minimal fluid balance should be maintained, and considerable weight gain over 2.5 kg should be avoided.

A basal crystalloid infusion rate of 32ml/kg/h can satisfy intra-operative fluid requirements. Excess crystalloid raises the risk of delayed recovery, extended ileus, and pulmonary problems.

It is best to avoid 0.9% saline solutions and instead use balanced crystalloid isotonic solutions. Increased 30-day mortality and kidney dysfunction have been linked to hyperchloraemia brought on by the usage of 0.9%saline solutions.

5. Avoidance of DT and NG tubes

Nasogastric tubes and abdominal drains should not be inserted in a routine manner. In the event that surgery calls for stomach decompression, an NG tube may be placed and taken out at the conclusion. Decompression of the nasogastric tubes delays the recovery of gut function. Additionally, it induces fever and respiratory problems, which lengthen hospital stays. Abdominal drains are typically inserted to drain any anastomotic leak and remove collections at the surgical site. It makes mobility inconvenient and difficult.

POST-OPERATIVE COMPONENTS

1. Use of Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDS) and the opiates avoidance:

Patients should be administered paracetamol as an analgesic of choice after surgery. For breakthrough pain, NSAIDS such as Diclofenac or Ibuprofen might be utilized. Antiemetic should always be used before using opiates to avoid nausea and vomiting. It has been demonstrated that the use of opiates contributes to the delay in the recovery of gastrointestinal function. They also induce vomiting and nauseaOpiods such as codeine and tramadol are avoided. Patients must be given NSAIDS and paracetamol in place of opiates.

2. Early postoperative diet:

On the night of the procedure, patients must begin taking oral fluids. They must then progress to a liquid diet for the first pod, a semisolid diet for the second, and a solid diet for the third. A dietician should evaluate patients who, 72 hours after surgery, are not fulfilling their dietary needs. Recent research has demonstrated that early enteral feeding—within 24 hours after surgery—is safe. It has also been demonstrated that early enteral feeding shortens hospital stays and lowers the risk of infections and anastomotic leak.

FIGURE 6: POST-OPERATIVE COMPONENTS OF ERAS PROTOCOL

3. Early mobilisation:

On the night after operation, patients must be assisted into a chair, and on the same day or possibly on the first or second postoperative day, they must be made mobile.

Patients should receive early mobilization assistance from the physiotherapist. It is advised that patients get ongoing education about the advantages of mobilization. Avoiding bedside entertainment devices is a practical way to promote mobilization, according to a randomised trial.

4. Restricted amounts of fluid management

If electrolyte replacement is necessary, patients with inadequate oral intake should receive no more than 75 ml/hr of 2/3‐1/3 with 20 mEq potassium/day, or a comparable rate using a balanced salt solution. It is recommended to discourage the regular use of saline (Level of evidence: Moderate-Low). Prior to administering fluid boluses after surgery, the volume status should be evaluated. Low blood pressure or low urine output alone should not be the reason for administering boluses.Rather, the patients' heart rate, blood pressure, urine production, and mental state should all be taken into account. Additionally, when deciding on the postoperative volume status, the preoperative blood pressure should be taken into account (Level of evidence: Moderate‐Low)

5. Hemodynamic management postoperative period

After abdominal surgery, it is best to promote early oral intake of meals and water. If oral intake is tolerated after PACU discharge, routine IV fluid treatment should be discontinued and only resumed as clinically necessary. If there are no surgical losses, patients should be instructed to drink 25–35 ml/kg of water daily (1.75–2.75 l for an average person) to meet their physiological needs. After it has been shown that a hypotensive patient receiving epidural analgesia is normovolaemic, vasopressors should be given.

FIGURE 7: INTRA-OPERATIVE AND POSTOPERATIVE COMPONENTS

Special Circumstances

Elderly patients and those with high co-morbidity:

These patients ought to be a part of these programs since they have been demonstrated to benefit from improved recovery. Although there is little research in this area, there is no need to be concerned about integrating ASA 3 and 4 patients into ERAS programs. If no one is there to help them, elderly patients may not be able to manage at home after being discharged. Given that the main goal of ERAS is to improve post-operative recovery rather than to send patients home sooner, this could postpone patient discharge. After being discharged, the elderly may need some assistance, which could take the form of routine phone calls, a home visit from a medical expert, or even a visit from a family member. Due to the higher danger of fluid overload, Doppler guided fluid treatment, for instance, may be especially helpful for high risk and elderly patients, for whom precise fluid delivery may be more crucial. Sustained auditing should enable the early detection of such issues and the required adjustments to discharge standards to guarantee the highest quality of care for patients. Findings should be shared and audited on a regular basis. It is advised to have an active research program on ERAS-related topics whenever feasible. Local ERAS protocols that are adapted to the particular needs of the organization can be developed more easily with the help of routine audit and study.

AIM AND OBJECTIVES

AIM:

To evaluate the outcomes of ERAS protocol in colorectal surgeries.

OBJECTIVES:

1. Length of hospital stay.
2. Post op complications.
3. Readmissions.
4. Time of tolerance of diet.

MATERIALS AND METHODS:

The following study was conducted in ESIC MEDICAL COLLEGE BANGLORE and KIDWAI MEMORIAL INSTITUTE OF ONCOLOGY. It is a prospective descriptive, the source of the study being patients admitted in general surgery wards for colorectal surgeries. The study was conducted from March 2023to August 2025. Inclusion and exclusion criteria were made, only those patients satisfying both those criteria’s were included in the study.

• Source of data: All patients getting admitted for elective abdominal surgeries in Department of General surgery in ESICMC & PGIMSR and KIDWAI MEMORIAL INSTITUTE OF ONCOLOGY Bengaluru.
• METHODS OF COLLECTION OF DATA
  1. Study of design: A Prospective Study.
  2. Duration of study: March2023-August2025.
  3. Place of study: ESICMC & PGIMSR Rajajinagar ,
  4. Sample size: Convenience sampling method.

The sample size was calculated using the G Power Software V.3.9.7. Considering the effect size to be measured at 0.9 for‘t tests - Means: difference between two independent means’ with α err prob at 0.05. The total sample size was estimated at 54 with a power of 90 %. Adding a 10% fall off rate, the final sample size will be 62.

INCLUSION CRITERIA:

1. Patient willing to give informed consent for the study
2. All patients aged >18years undergoing colorectal surgeries

EXCLUSION CRITERIA

1. Patients who are unfit for surgery
2. Pregnant women
3. Patients not willing to participate in the study
4. Immunocompromised patients.

Methodology:

• Patients who met the inclusion criteria and signed their informed consent were accepted in the study after obtaining permission and clearance from the institutional ethics committee.
• Case record form with follow up chart . After admission detailed history was taken and physical examination was conducted on each patient, necessary investigations were done and admitted under General Surgery requiring colorectal surgery. Patients requiring colorectal surgery and fulfilling the inclusion criteria were offered to participate in the study, all the necessary information regarding the study was explained to the patients or their valid guardian. Patients and their guardians who had agreed to take part in the trial gave their informed written consent. In all cases, a comprehensive physical examination was carried out.

All patients received preoperative, intra-operative and postoperative ERAS protocol components.

Patients were carefully being monitored; a note was made about the day of starting oral feeds, post-operative complications, length of hospital stay and readmissions.

Preoperatively all the patients received counselling, shorter fasting duration, mechanical bowel preparation only when necessary, DVT prophylaxis (compression stockings), and prophylactic antibiotics.

Intra-operatively patients received local blocks, epidural anaesthesia, fluid therapy, use of shorter incisions, prevention of hypothermia and avoidance of tubes and drains.

Post-operatively patients received proper pain management, early oral feeds, and early mobilization.

PREOPERATIVELY

• PRE-OP COUNSELLING:

Out of 62 patients who were planned for colorectal surgeries, each patient and their attainders were counselled properly. Detailed instructions were provided about the following

• The nature of disease
• The surgical procedure to be done
• Core components and its benefits.
• What the patient and attenders should expect during the period of stay in the hospital.
• Instructions about earliermobilisation, early starting of oral feeds and exercises after surgery.
• Benefits of active participation of patients themselves in the recovery after surgery.
• Patients who could have stoma were well trained for care of stoma. And counselled regarding quality of life with stoma even before surgery.
• Patient’s satisfaction was better after the pre-operative counselling and education.
• Allay anxiety.

• OPTIMISATION OF CO-MORBIDITIES:
• Patients were given adequate breathing exercises.
• Abstinence from smoking and consuming alcohol
• Nutritional status was improved.

After correcting other medical co-morbidities patients were made fit for surgery.

• MINIMAL STARVATION AND CARBOHYDRATE LOADING:
• Maximum of 6 hours of nil by mouth for solids, were kept before surgery.100ml of 25% dextrose and 500ml of 0.9%NaCl was given two hours before surgery.
• AVOIDANCE OF MECHANICAL BOWEL PREPARATION:
• Avoidance of oral mechanical bowel preparation was done.
• Some patients were given enema where it was found to necessary, particularly in left sided anastomosis of colon surgery patients
• DEEP VEIN THROMBOSIS PROPHYLAXIS:

 Prophylaxis was started for deep vein thrombosis

• They were given injection. Enoxaparin (low molecular weight heparin 20Microgram via subcutaneous route,on the night before surgery and it was continued till the duration of stay in the hospital as OD dosage.
• Upto one month of DVT prophylaxis was given for high risk patients.

• ANTIBIOTIC PROPHYLAXIS:
• Just before the skin incision Inj.Xone(ceftriaxone)1g IV stat was given
• The second dose was administered when in case of prolonged surgeries(>5 hours)

INTRA OPERATIVELY

• EPIDURAL ANALGESIA AND LOCAL BLOCKS:
• Patients were provided with epidural analgesia and epidural analgesia was carried on till 48 hoursafter surgery.
• In some patients blocks such as transverse abdominis plane block was given

• AVOIDANCE OF POST-OPERATIVE DRAINS,NASOGASTRIC

TUBES AND URINARY CATHETERS:

• Nasogastric tube was not inserted as a routine norm, it was avoided whenever possible.
• In cases in which nasogastric tube was placed, it was removed after the purpose was completed.

POST OPERATIVE COMPONENTS

• AVOIDANCE OF OPIATES:
• For about 48hours epidural anaesthesia was given.
• Whenever patient complained of severe pain, and when epidural catheter was removed-inj.paracetamol, Diclofenac/brufen was administered.

• EARLY POSTOPERATIVE DIET:
• On 1st post-operative day patients were started on oral fluids.
• Within 24 hours post-operatively oral feeds was started for colostomy patients.
• On 2nd POD semisolid diet was initiated.

• EARLY POSTOPERATIVE MOBILISATION:
• On the evening of surgery the patients were assisted to sit on a chair
• Closely monitoring of vitals such as PR, BP, SpO2, input/output was done
• CBC, RFT, S.ELECTROLYTES were done every day and assessed.
• Complaints by patients were attended to immediately.

Regular wound dressings were done.Antibiotics and wound dressings were given to infections at the surgical site patients based on their sensitivity and culture.

Patients with enterocutaneous fistulas gradually recovered, and other issues, such as anastomotic leak with enterocutaneous fistula, were treated conservatively in accordance with the protocol, paying special attention to hydration, food, antibiotics, and frequent vitals monitoring.

After being discharged, all patients were monitored for a month with weekly reviews, and any difficulties that arose were also recorded.

Statistical analysis:

All the data collected was compiled and entered in Microsoft excel worksheet. The qualitative variables were presented in frequency, percentages and graphs. The data will be analysed using statistics software

The study was conducted among 62 participants.

AGE

The participants were 51.82 ± 11.8 years old on average (± SD).

FIGURE 8: AGE DISTRIBUTION AMONG STUDY PARTICIPANTS

TABLE 1: AGE DISTRIBUTION OF STUDY PARTICIPANTS

GENDER

FIGURE 9: GENDER DISTRIBUTION AMONG STUDY PARTCIPANTS

TABLE 2: GENDER DISTRIBUTION OF STUDY PARTICIPANTS

DIAGNOSIS

TABLE 3:  DIAGNOSIS

FIGURE 10: DIAGNOSIS

FIGURE 11: COMORBIDITIES

TABLE 4: COMORBIDITIES

TREATMENT: PROCEDURE

TABLE 5: TYPE OF SURGERY

COUNSELLING

FIGURE 13: COUNSELLING

TABLE 6: COUNSELLING

MECHANICAL BOWEL PREPARATION

FIGURE 14: MECHANICAL BOWEL PREPARATION

TABLE 8: MECHANICAL BOWEL PREPARATION

DRAIN

FIGURE 15: DRAIN

TABLE 9: DRAIN

DVT PROPHYLAXIS

FIGURE 16: DVT PROPHYLAXIS

TABLE 10: DVT PROPHYLAXIS

NORMOTHERMIA

FIGURE 17:  NORMOTHERMIA

TABLE 10:  NORMOTHERMIA

FIGURE 18:  ANTIBIOTIC PROPHYLAXIS

TABLE 11: ANTIBIOTIC PROPHYLAXIS

EPIDURAL ANALGESIA

FIGURE19: EPIDURAL ANALGESIA

TABLE 12: EPIDURAL ANALGESIA

MOBILISATION

FIGURE 20: MOBILISATION

TABLE 16: MOBILISATION

START OF ORAL FEEDING

FIGURE 21: START OF FEEDING

TABLE 17: START OF FEEDING

COMPLICATIONS

FIGURE 22: COMPLICATIONS

TABLE 18: COMPLICATIONS

READMISSION

FIGURE 23: READMISSION

TABLE 19: READMISSION

LENGTH OF STAY IN HOSPITAL

FIGURE 24: LENGTH OF STAY IN HOSPITAL

TABLE 20: LENGTH OF STAY IN HOSPITAL

In this study of outcomes of ERAS protocol in colorectal surgeries totally 62 patients participated.

Age distribution:

Patients getting colorectal operations were 51 years old on average in current study.

• Patients under age of 20 were 1 i.e. 1.6%.
• Patients’ 21 to 30 was 2 i.e. 3.2%.
• Patients’ 31 to 40 were 7 i.e. 11.3%.
• Patients’ 41 to 50 were 13 i.e. 21%.
• Patients’ 51 to 60 were 26 i.e. 41.9%.
• Patients’ 61 to 70 were 11 i.e. 17.7 %.
• Patients’ 71 to 80 were 2 i.e. 3.2%.

Gender distribution:

The sex distribution of patients undergoing colorectal surgeries is almost same in the study.

• Of the patients in this study, 33 patients, or 53.2%, were female.
• Of the study's patients, 29 (46.8%) were male.

In this study it is observed that incidence of colorectal diseases is more in females than in males.

Co-morbidities:

Out of 62 patients 3 had hypothyroidism that is 4.8%.

• 10 patients had type 2 diabetes mellitus, which is 16% of the students.
• 16(25%) patients had hypertension
• 3 patients had other co-morbidities like asthma, CVD, anaemia.

Length of hospital stay

• In this study of outcomes of ERAS protocol, 35 patients stayed in hospital for less than 15days, which is 56.5%.
• About 27 patients stayed in hospital for more than 15 days, which is 43.5% of the patients.

Early mobilization

Early mobilization was achieved in most of the patients.

• Patients who mobilized on day 0 were 1patient.
• Patients who mobilized on day 1 are 77.4% that is about 48 patients.
• By day 2 -20.9 % of patients mobilized that accounts for about 13 patients.

Counselling:

Out of 62 patients

• 37 patients received counselling about the diagnosis, plan of management, possible complications and about ERAS protocol.
• 25 patients did not receive counselling.

Mechanical bowel preparation:

In this study of outcomes of ERAS protocol in colorectal surgeries out of 60 patients undergoing colorectal surgeries

• 46 patients received mechanical bowel preparation that is 74 % of patients.
• Whereas 25 % of patients didn’t receive mechanical bowel preparation that is 16 patients.

Antibiotic prophylaxis:

All the 62 patients in the study received prophylactic antibiotics.

Epidural analgesia:

Out of 62 patients who participated in the study

• 85% received epidural anaesthesia that is 52 patients received epidural anaesthesia along with general/ spinal anaesthesia.
• 15% patients which accounts for 9 patients, didn’t receive epidural anaesthesia.

Start of oral feeds:

• On day 0 to day 2:- 48 patients started to take feeds orally which is 77.4%.
• After day 2:- 14 patients were started on oral feeds that are 22.5 % of the patients.

Complications:

Patients were monitored for various types of complications and the following finding was noted.

In this study of 62 people undergoing colorectal surgeries

• 13 patients had complication of surgical site infection which is 20 % of the patients.
• 4 patients suffered from anastomotic leak.
• Overall 17 out of 62 patients had post-operative complications.

Readmissions:

In this study patients were followed up for 6 months post surgery to make a note of readmissions of the patients.

Following finding were noted 6 got readmitted which is 9.7 % of the patient were re-admitted in the hospital ,that is about 53 patients out of 62 patients were not re-admitted.

SUMMARY

This study is a prospective descriptive study with sample size of 62 patients. After diagnosis of the patient preoperative, intra-operative and postoperative ERAS intervention was done after obtaining consent from the patient, whichrevealed multiple advantages of implementing ERAS for colorectal surgeries.

The results of this study with respect to the objectives are summarised as below:

• 5%patients stayed in hospital for less than 15daysand 43.5% of patients stayed for more than 15 days.
• 27% of patients in our study developed complications which is comparable to that of conventional protocols (20-40%)
• 7% of the patients had readmissions
• 4% of patients were started on oral feeds before day 2 who tolerated well

There was decrease in hospital stay, early start of oral feeds, early ambulation /mobilization of the patient without comparable post-operative complications. The findings indicate that ERAS protocols can improve recovery and reduce hospital stay after colorectal surgeries without compromising safety, thereby advocating for their wider adoption in this complex procedure, which could yield benefits for both patients and healthcare systems through enhanced outcomes and resources efficiency.

This study highlights the importance of specific ERAS components, including preoperative optimization (elimination of bowel preparation and administration of pre-medications), intra-operative management (goal directed fluid therapy and preservation of normothermia) and post-operative care (timely starting of oral feeds, early mobilization of the patient. The standard evidence based methodology of ERAS signifies a substantial improvement in the perioperative care of patients undergoing colorectal surgeries.

The findings of this study have significant implications for clinical practice, health care resource allocation, and patient experience. The adoption of ERAS protocol for colorectal surgeries needs to be regarded as a standard care, due to their proven advantages in minimizing hospital durations while ensuring safety is not compromised.

Future research focus on optimizing individual ERAS components, enhancing protocol adherence and addressing limitations.

LIMITATIONS AND RECOMMENDATIONS

This limited sample size constitutes a constraint that may have limited the study’s capacity to identify significant differences in some outcomes, especially rarer complications like DVT. The study being descriptive study, no comparison was done in a group where ERAS protocol wasn’t implemented.

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