Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendationsClinical nutrition, 2012. J. Nygren a, j,*,k, J. Thacker b,k, F. Carli c,k, K.C.H. Fearon d,k, . Norder!al e,k, ".N. #obo $,k, %. #jung&!i't g,k,(. oo) h,k, J. *a+ire, i,kEvidence base and recommendationse ERAS items :1. -reo)erati!e coun'elling.. tandard anae'thetic )rotocol1/. -erio)erati!e glycae+ic control2. -reo)erati!e o)ti+i'ation10, Na'oga'tric intubation10. 1arly +obili'ation2. -reo)erati!e bo3el )re)aration11. -erio)erati!e 4uid +anage+ent1.. 5udit and outco+e +ea'ure'6. -reo)erati!e $a'ting 12. "rainage o$ the )eritoneal ca!ity or )el!i'7. -reo)erati!e treat+ent 3ith carbohydrate'12. 8rinary drainage9. -reanae'thetic +edication16. -re!ention o$ ileu'/. -ro)hyla:i' again't thro+boe+boli'+17. -o'to)erati!e analge'ia0. 5nti+icrobial )ro)hyla:i' and 'kin )re)aration -ro)hylacticantibiotic'19. -erio)erati!e nutritional care1. -reo)erati!e coun'elling Preoperative counselling targeting epectations about surgical and anaesthetic procedures may diminish fear and aniety and enhance postoperative recovery and discharge! Summary and recommendation: patients should receiveroutine dedicated preoperative counselling.Evidence level: low.Recommendation grade: strong.Summary and recommendation: patients should receiveroutine dedicated preoperative counselling.Evidence level: low.Recommendation grade: strong.2. -reo)erati!e o)ti+i'ation-reo)erati!e e!aluation 'hould be u'ed to identi$y +edical condition' and ri'k $actor' $or )o'to)erati!e +orbidity and +ortality. %)ti+i'ation o$ anae+ia, diabete' +ellitu' ;"(< and hy)erten'ioncessation of smoking andalcohol intake 4 weeks before rectal surgery is recommended.Increasing exercise preoperatively may be ofbenet. !reoperative specialised nutritional support shouldbe considered for malnourished patients.cessation of smoking andalcohol intake 4 weeks before rectal surgery is recommended.Increasing exercise preoperatively may be ofbenet. !reoperative specialised nutritional support shouldbe considered for malnourished patients.2. -reo)erati!e bo3el )re)aration(echanical bo3el )re)aration ;(=-< i' a''ociated 3ith dehydration, and change' in electrolyte balance ;)articularly in the elderlyanaly'i' $ro+ 'tudie' $ocu'ing on colonic 'urgery, 'ho3' no clinical bene?t $ro+ (=-.Summary and recommendation: in general" #$! should not beusedinpelvicsurgery.%owever"whena diverting ileostomy isplanned"#$!maybenecessary&althoughthis needs to bestudied further.Evidence level'nterior resection: &not use #$!( high)otalmesorectalexcision&)#E(withdiverting stoma: &use#$!( lowRecommendation grade'nterior resection: strong)#E with diverting stoma: weak.Summary and recommendation: in general" #$! should not beusedinpelvicsurgery.%owever"whena diverting ileostomy isplanned"#$!maybenecessary&althoughthis needs to bestudied further.Evidence level'nterior resection: &not use #$!( high)otalmesorectalexcision&)#E(withdiverting stoma: &use#$!( lowRecommendation grade'nterior resection: strong)#E with diverting stoma: weak.6. -reo)erati!e $a'tingFa'ting $ro+ +idnight ha' been 'tandard )ractice in the belie$ that thi' reduce' the ri'k o$ )ul+onary a')iration in electi!e 'urgery. Ho3e!er, a Cochrane re!ie3 o$ 22 *CT' 'ho3ed that $a'ting $ro+ +idnight did not reduce ga'tric content, increa'e the )H o$ ga'tric 4uid, or a@ect the )re!alence o$ co+)lication' co+)ared 3ith )atient' allo3ed $ree intake o$ clear 4uid' u) until 2 h be$ore anae'the'ia $or 'urgery.Summary and recommendation: inta"e of clear fluids up until# $ h before the induction of anaesthesia is allo%ed! &nta"e of solids should be %ithheld at ' h before anaesthesia!Evidence level: moderateRecommendation grade: strongSummary and recommendation: inta"e of clear fluids up until# $ h before the induction of anaesthesia is allo%ed! &nta"e of solids should be %ithheld at ' h before anaesthesia!Evidence level: moderateRecommendation grade: strong7. -reo)erati!e treat+ent 3ith carbohydrate'=y )ro!iding a clear 4uid containing a de?ned ;12A< concentration o$ co+)le: carbohydrate' 2 h be$ore anae'the'ia, )atient' can undergo 'urgery in a +etabolically $ed 'tate. Thi' treat+ent reduce' the )re!alence o$ )reo)erati!e thir't, hunger, and an:ietySummary and recommendation: preoperative oral carbohydrate loading should be administered to all non*diabetic patients.Evidence levelReduced postoperative insulin resistance: moderate.Improved clinical outcomes: low.Summary and recommendation: preoperative oral carbohydrate loading should be administered to all non*diabetic patients.Evidence levelReduced postoperative insulin resistance: moderate.Improved clinical outcomes: low.9. -reanae'thetic +edication-atient' undergoing rectal 'urgery are an:iou' about the, 'urgery and outco+e. 1ducation and rea''urance can allay an:iety, but )har+acological inter!ention' to reduce an:iety can be indicated, )articularly in younger )atient' be$ore )rocedure' 'uch a' in'ertion o$ an e)idural or arterial catheter.Summary and recommendation: no advantages in using longacting ben+odia+epines.Short*acting ben+odia+epines can be used in young patientsbefore potentially painful interventions &insertion of spinal or epidural" arterial catheter(" but they should not be used inthe elderly &age ,-. years(.Evidence level: moderate.Recommendation grade: strong.Summary and recommendation: no advantages in using longacting ben+odia+epines.Short*acting ben+odia+epines can be used in young patientsbefore potentially painful interventions &insertion of spinal or epidural" arterial catheter(" but they should not be used inthe elderly &age ,-. years(.Evidence level: moderate.Recommendation grade: strong./. -ro)hyla:i' again't thro+boe+boli'+-atient' 3ith e:ten'i!e co+orbidity, +alignant di'ea'e, 3ho are taking cortico'teroid' )reo)erati!ely, 3ho ha!e undergone )re!iou' )el!ic 'urgery, and tho'e in hy)ercoagulable 'tate' ha!e an increa'ed ri'k o$ BT1Summary and recommendation: patients should wear welltting compression stockings" and receive pharmacological prophylaxis with /#0%. Extended prophylaxis for 12 days should be considered in patients with colorectal cancer or other patients with increased risk of 3)E.Evidence level: high.Recommendation grade: strong.Summary and recommendation: patients should wear welltting compression stockings" and receive pharmacological prophylaxis with /#0%. Extended prophylaxis for 12 days should be considered in patients with colorectal cancer or other patients with increased risk of 3)E.Evidence level: high.Recommendation grade: strong.0. 5nti+icrobial )ro)hyla:i' and 'kin )re)aration -ro)hylactic antibiotic'u++ary and reco++endationC )atient' 'hould recei!e anti+icrobial )ro)hyla:i' be$ore 'kin inci'ion in a 'ingle do'e. *e)eated do'e' +ay be nece''ary de)ending on the hal$>li$e o$ drug and duration o$ 'urgery. 1!idence le!elC high*eco++endation gradeC 'trong kin )re)aration u++ary and reco++endationC a recent rando+i,ed trial ha' 'ho3n that 'kin )re)aration 3ith a 'crub o$ chlorhe:idine>alcohol i' 'u)erior to )o!idone>iodine in )re!enting 'urgical>'ite in$ection'. 1!idence le!elC +oderate *eco++endation grade For 'kin )re)aration in generalC 'trong )eci?c choice o$ )re)arationC 3eak.. tandard ana'thetic )rotocolu++ary and reco++endationC to attenuate the 'urgical 'tre'' re')on'e, intrao)erati!e +aintenance o$ ade&uate hae+odyna+ic control, central and )eri)heral o:ygenation, +u'cle rela:ation, de)th o$ anae'the'ia, and a))ro)riate analge'ia i' 'trongly reco++ended. 1!idence le!el1)iduralC +oderate.DB #idocaineC lo3.*e+i$entanilC lo3.High o:ygen concentrationC high. *eco++endation grade C1)iduralC 'trong.DB #idocaineC 3eak.*e+i$entanilC 'trong.High o:ygen concentrationC 'trong.10. Na'oga'tric intubation5 +eta>analy'i'in 1..7 'ho3ed that routine na'oga'tric deco+)re''ion 'hould be a!oided a$ter colorectal 'urgery becau'e $e!er, atelecta'i', and )neu+onia are reduced in )atient' 3ithout a na'oga'tric tubeSummary and recommendation: postoperative nasogastrictubes should not be used routinely.Evidence level: high.Recommendation grade: strong.Summary and recommendation: postoperative nasogastrictubes should not be used routinely.Evidence level: high.Recommendation grade: strong.11. -erio)erati!e 4uid +anage+entu++ary and reco++endationC 4uid balance 'hould be o)ti+i'ed by targeting cardiac out)ut and a!oiding o!erhydration. Judiciou' u'e o$ !a'o)re''or' i' reco++ended 3ith arterial hy)oten'ion. Targeted 4uid thera)y u'ing the oe'o)hageal "o))ler 'y'te+ i' reco++ended. 1!idence le!elC +oderate.*eco++endation gradeC 'trong.12. "rainage o$ the )eritoneal ca!ity or )el!i'The u'e o$ a 'uction drain in the )el!ic ca!ity a$ter rectal 'urgery ha' been traditionally ad!ocated to e!acuate )otential blood or 'erou' collection' and )re!ent ana'to+otic leakage.Summary and recommendation: pelvic drains should not beused routinely.Evidence level: low.Recommendation grade: weak.Summary and recommendation: pelvic drains should not beused routinely.Evidence level: low.Recommendation grade: weak.12. 8rinary drainagein$ection, accounting $or al+o't 60A o$ all no'oco+ial in$ection'. Dn $a't>track 'urgery, urinary drainage 'hould be a' 'hort a' )o''ible ;ideally 26 h/2 h in !ie3 o$ the 'u)erior &uality o$ )ain relie$ co+)ared 3ith 'y'te+ic o)ioid'. Dntra!enou' ad+ini'tration o$ lidocaine ha' al'o been 'ho3n to )ro!ide 'ati'$actory analge'ia, but the e!idence in rectal 'urgery i' lacking. D$ a la)aro'co)ic a))roach i' u'ed, e)idural or intra!enou' lidocaine, in the conte:t o$ 1*5, )ro!ide' ade&uate )ain relie$ and no di@erence in the duration o$ #%H and return o$ bo3el $unction. *ectal )ain can be o$ neuro)athic origin, and need' to be treated 3ith +ulti+odal analge'ic +ethod'. There i' li+ited e!idence $or the routine u'e o$ 3ound catheter' and continuou' T5- block' in rectal 'urgery.19. -erio)erati!e nutritional careu++ary and reco++endationC an oral ad>libitu+ diet i' reco++ended 6 h a$ter rectal 'urgery.1!idence le!elC +oderate.*eco++endation gradeC 'trong.1/. -erio)erati!e glycae+ic controlu++ary and reco++endationC +aintenance o$ )erio)erati!e blood 'ugar le!el' 3ithin an e:)ert>de?ned range re'ult' in better outco+e'. There$ore, in'ulin re'i'tance and hy)erglyce+ia 'hould be a!oided u'ing 'tre''>reducing +ea'ure' or i$ already e'tabli'hed by acti!e treat+ent. The le!el o$ glycae+ia to target $or inter!ention at the3ard le!el re+ain' uncertain, and i' de)endent u)on local 'a$ety a')ect'.1!idence le!el 8'e o$ 'tre''>reducing +ea'ure'C +oderate. #e!el o$ glycae+ia $or in'ulin treat+entC lo3.*eco++endation grade 8'e o$ 'tre''>reducing treat+ent'C 'trong.Dn'ulin treat+ent ;non>diabetic'< at the 3ard le!elC 3eak.10. 1arly +obili'ation1:tended bed re't i' a''ociated not only 3ith an increa'e ri'k o$ thro+boe+boli'+ but al'o 3ith 'e!eral un3anted e@ect' 'uch a' in'ulin re'i'tance, +u'cle lo'', lo'' o$ +u'cle 'trength, )ul+onary de)re''ion, and reduced ti''ue o:ygenation.Summary and recommendation: patients should be nursed inan environment that encourages independence and mobilisation. ' care plan that facilitates patients being out ofbed for 1 h on the day of surgery and - h thereafter isrecommended.Evidence level: lowRecommendation grade: strongSummary and recommendation: patients should be nursed inan environment that encourages independence and mobilisation. ' care plan that facilitates patients being out ofbed for 1 h on the day of surgery and - h thereafter isrecommended.Evidence level: lowRecommendation grade: strong1.. 5udit and outco+e +ea'ure'u++ary and reco++endationC all )atient' 'hould be audited $or )rotocol co+)liance and outco+e'.1!idence le!elC lo3.*eco++endation gradeC 'trong.)hank you