Issue 140 Enhanced recovery after surgery

CLINICAL

ENHANCED RECOVERY AFTER SURGERY (ERAS) Rebecca Gasche Registered Dietitian, Countess of Chester Hospital NHS Trust Rebecca has a keen interest and specialises in gastroenterology dietetics. She currently works in the community setting in the Chester area, running clinics and group sessions to manage a wide range of gastroenterology conditions.

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How we treat patients before, during and after surgical procedures has changed dramatically over recent years. Due to evidence showing that surgical intervention leads to an endocrine and metabolic stress reaction, which slows down recovery,1 ERAS programmes were developed to support patient’s recovery post-surgery.

ERAS was first described in 2000, with the first protocol being published in 2005 by Professor Henri Kehlet. ERAS programmes are patient-centred, optimising surgical outcomes. They integrate a range of perioperative interventions which have been proven to maintain physiological function, reduce stress response and facilitate postoperative recovery.2 The ERAS team is often multidisciplinary, made up of preassessment and ward nurses, theatre staff, consultant surgeons, consultant anaesthetists, physiotherapists, occupational therapists, dietitians, stoma nurse specialists, pain control specialists, colorectal nurse specialists and ERAS nurse specialists.3 It is recommended that continual research into and audits on ERAS programmes are undertaken to ensure developments are made. The ERAS Society is dedicated to this, with its mission statement being ‘to develop perioperative care and to improve recovery through research, education, audit and implementation of evidence-based practice’.4 WHAT DOES ERAS INVOLVE?

ERAS programmes are a collection of strategies aiming to ease the loss of, and improve the restoration of, functional capacity after surgery. Morbidity is reduced and recovery enhanced by reducing surgical stress - usually involving strategies such as optimal control of pain, early oral diet and early

mobilisation. As a consequence, length of stay in hospital and, therefore, costs are reduced.

ERAS targets pre-, peri- and postoperative surgery. Examples of preoperative interventions include patient education, ensuring good nutritional status and the use of ONS if indicated. Perioperatively, Trusts have implemented strategies such as goal directed fluid therapy, minimal tissue handling and minimising operating times.

Postoperative examples of ERAS could be early enteral nutrition, postoperative drugs to manage nausea and vomiting and ensuring follow-up after discharge.

THE EVIDENCE

There have been many studies showing that measures to reduce the stress of surgery can minimise catabolism (the breakdown of complex molecules into simpler forms) and support anabolism (the building of larger molecules from simpler forms) throughout surgical treatment, improving recovery time, even after major operations.5 A cohort study by Pascal et al6 compared mortality, morbidity and length of stay between ERAS patients and historical controls. The study concluded that ERAS reduces morbidity and length of hospital stay for patients undergoing elective colonic or rectal surgery.

The strongest evidence for ERAS implementation is in the care of patients undergoing open colonic resection.

Many interventions which have previously shown to benefit outcomes

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Getting Nan back to her old tricks again!

is a powdered, neutral-tasting carbohydrate loading drink mix for the pre-operative dietary management of patients undergoing surgery. has been shown An Enhanced Recovery Programme including the use of to significantly reduce post-operative hospital stay with a return towards earlier gut function when compared with fasting or supplementary water.1 Helping patients get back to doing the things that they enjoy sooner.

Preload™ is a Food for Special Medical Purposes and must be used under strict medical supervision.

1. Noblett S, Watson D, Huong H, Davidson B, Hainsworth P, Horgan A (2006) Pre-operative oral carbohydrate loading in colorectal surgery: A randomized controlled trial. Colorectal Disease: 8, 563-569.

A Nestlé Health Science Company

www.vitaflo.co.uk Nutritional Helpine: 0151 702 4937

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CLINICAL in this population, have now been successfully applied to laparoscopic colon resections, as well as to other surgical specialties such as urology, orthopaedics, and gynaecology.7 Until quite recently, patients undergoing colorectal resection were counselled to accept a 20 to 25% risk of complications and a seven- to 10-day postoperative stay in hospital. Studies throughout the 1980s to 1990s showed that the length of stay in hospital and complication rates improved even if a single component of care was changed. With this, the idea of incorporating many of these elements into a comprehensive care pathway was developed.8 NUTRITION AND ERAS

Nutrition plays an important role in ERAS, with many of its interventions linked directly, or indirectly, to nutrition. ERAS advocates that nutritional management becomes an integral component for all patients undergoing major surgery.9 WHAT ARE THE GUIDELINES?

The ESPEN guidelines on clinical nutrition in surgery,10 released in 2017, outline a number of recommendations, summarised here: Preoperatively • Preoperative fasting from midnight is unnecessary in most patients. Patients undergoing surgery, who are considered to have no specific risk of aspiration, can drink clear fluids until two hours before anaesthesia. Solids are allowed until six hours before anaesthesia.

• In order to reduce perioperative discomfort and to impact postoperative insulin resistance and hospital length of stay, oral preoperative carbohydrates can be considered in patients undergoing major surgery. This can be administered the night before and two hours before surgery.

• It is recommended to assess the nutritional status before and after major surgery.

• Patients with severe nutritional risk should receive nutritional therapy for a period of around seven to 14 days, prior to major surgery.

• ONS should be given to all malnourished cancer and high-risk patients undergoing major abdominal surgery.

• Enteral nutrition/ONS should preferably be administered prior to hospital admission to avoid unnecessary hospitalisation and to lower the risk of infections.

• Preoperative parental nutrition should be administered only in patients with malnutrition or at severe nutritional risk where energy requirements cannot be adequately met by enteral nutrition. A period of seven to 14 days is recommended.

• Regular assessment of nutritional status and qualified dietary counselling is required while monitoring patients on the waiting list before transplantation.

• There is currently no clear evidence for the use of formulae enriched with immunonutrients vs standard ONS exclusively in the preoperative period.

Perioperatively • Perioperative nutritional therapy is recommended to start as soon as possible in patients with malnutrition and those at nutritional risk, and/or if it is anticipated that the patient will be unable to eat for more than five days. It is also recommended in patients expected to have low oral intake and who cannot maintain above 50% of recommended intake for more than seven days.

• Peri- or at least postoperative administration of specific formula enriched with immunonutrients (arginine, omega-3 fatty acids, ribonucleotides) should be given in malnourished patients undergoing major cancer surgery.

• Establish metabolic control, eg, of blood glucose.

• Minimised time on paralytic agents for ventilator management in the postoperative period.

• Early mobilisation to facilitate protein synthesis and muscle function.

Postoperatively • Oral nutritional intake should be continued after surgery without interruption, with oral intake (including clear liquids) being initiated within hours after surgery in most patients.

• Regular reassessment of nutritional status during the stay in hospital and, if necessary, continuation of nutrition therapy, including qualified dietary counselling after discharge, is advised for patients who have received

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CLINICAL nutrition therapy perioperatively and still do not cover appropriately their energy requirements via the oral route.

• After heart, lung, liver, pancreas and kidney transplantation, early intake of normal food, or enteral nutrition, is recommended within 24 hours.

• Even after transplantation of the small intestine, enteral nutrition can be initiated early, but should be increased very carefully within the first week.

• Early oral intake can be recommended after bariatric surgery.

Enteral nutrition • It is recommended to adapt oral intake according to individual tolerance and to the type of surgery carried out, with special caution to elderly patients.

• If the energy and nutrient requirements cannot be met by oral and enteral intake alone (<50% of calorific requirement) for more than seven days, a combination of enteral and parenteral nutrition is recommended.

• Whenever feasible, the oral/enteral route is preferred.

• Early tube feeding (within 24 hours) should be initiated in patients whose early oral nutrition cannot be started and their oral intake will be inadequate.

• In most patients, a standard whole protein formula is appropriate.

• Due to risk of tube blockages and the risk of infection, the use of kitchen-made (blended) diets for tube feeding is not recommended.

• With special regard to malnourished patients, placement of a nasojejunal tube (NJ), or needle catheter jejunostomy (NCJ), should be considered for all candidates for tube feeding who are undergoing major upper gastrointestinal and pancreatic surgery.

• If tube feeding is indicated, it should be initiated within 24 hours after surgery.

• It is recommended to start tube feeding with a low flow rate and to increase the feeding rate carefully and individually due to limited intestinal tolerance. The time to reach the target intake can be very different and may take five to seven days.

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• If long-term tube feeding (>4 weeks) is necessary, such as in severe head injury, placement of a percutaneous tube (eg, percutaneous endoscopic gastrostomy [PEG]) is recommended.

Parenteral nutrition (PN) • Parenteral glutamine supplementation may be considered in patients who cannot be fed adequately enterally and, therefore, require exclusive PN. • Postoperative PN including omega-3 fatty acids should be considered only in patients who cannot be adequately fed enterally and, therefore, require PN. • PN should be administered as soon as possible if nutrition therapy is indicated and there is a contraindication for enteral nutrition, such as in intestinal obstruction.

ONS • When patients do not meet their energy needs from diet alone it is recommended to encourage these patients to take ONS. • Malnutrition is a major factor influencing outcome after transplantation, so monitoring of the nutritional status is recommended. In malnutrition, additional ONS or even tube feeding is advised.

• Standardised operating procedures (SOP) for nutritional support are recommended to secure an effective nutritional support therapy.

CONCLUSION

ERAS has been proven to improve outcomes for patients undergoing not only colorectal surgery, but for a number of other surgical procedures too. An ERAS team should be in place to ensure procedures are implemented and followed correctly, thus improving patient outcomes. Nutrition plays a key role in ERAS from preventing malnutrition pre- and postoperatively, to initiating feeding soon after surgery and the use of enteral nutrition and PN when required.

All components of ERAS help to improve outcomes for patients, speed up recovery times and ultimately reduce the costs of surgeries happening in our hospitals every day.

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