Overview
Definition:
Enhanced Recovery After Surgery for Hepatopancreatobiliary (ERAS-HPB) is a multidisciplinary, evidence-based approach aimed at optimizing patient care before, during, and after major HPB surgery
It involves a bundle of interventions designed to reduce surgical stress response, accelerate functional recovery, and shorten hospital stay while improving outcomes and patient satisfaction.
Epidemiology:
HPB surgery is associated with significant morbidity and prolonged recovery due to the complexity of procedures and patient comorbidities
ERAS protocols have demonstrated efficacy across various surgical specialties, with growing evidence supporting their application in the demanding field of HPB surgery, where complications can significantly impact patient recovery and resource utilization.
Clinical Significance:
Implementing ERAS-HPB is crucial for improving patient outcomes, reducing hospital-acquired infections, minimizing delirium, enhancing pain control, and promoting early mobilization
This leads to shorter lengths of stay, reduced healthcare costs, and improved patient satisfaction
For DNB and NEET SS aspirants, understanding ERAS principles is vital for demonstrating knowledge of modern, evidence-based surgical care and improving patient management.
Preoperative Preparation
Patient Education:
Comprehensive pre-operative counseling on the ERAS pathway, expectations, and the patient's active role
Explanation of multimodal analgesia, early feeding, and mobilization
Addressing anxiety and fears.
Nutritional Optimization:
Assessment of nutritional status
Oral nutritional supplementation with carbohydrates 2-4 hours pre-operatively to improve glycogen stores and reduce insulin resistance
Consideration of immunonutrition in select high-risk patients.
Medication Management:
Continuation of essential medications
Avoidance of pre-operative fasting beyond prescribed carbohydrate loading
Prophylaxis against thromboembolism (e.g., heparin) and infection (e.g., appropriate antibiotics).
Bowel Preparation:
Generally avoided in most HPB surgeries unless specifically indicated for certain procedures or in cases of intestinal involvement
Emphasis on facilitating early oral intake postoperatively.
Intraoperative Management
Anesthesia Techniques:
Minimizing intra-operative opioid use through regional anesthesia (e.g., epidural) and judicious use of non-opioid analgesics
Avoiding routine use of nasogastric tubes unless indicated for gastric decompression
Maintaining normothermia to reduce metabolic stress and complications.
Fluid Management:
Goal-directed fluid therapy to maintain euvolemia and avoid fluid overload, which can contribute to ileus and pulmonary complications
Use of balanced crystalloids
Careful monitoring of urine output and hemodynamic parameters.
Surgical Technique:
Minimally invasive surgical approaches (laparoscopic or robotic) where feasible to reduce surgical trauma
Meticulous hemostasis to minimize blood loss and drain requirement
Avoidance of routine drains unless strictly indicated.
Postoperative Care
Pain Management:
Multimodal analgesia approach: continuation of pre-operative non-opioid analgesics (e.g., paracetamol, NSAIDs if not contraindicated), judicious use of opioids (IV or oral), and patient-controlled analgesia (PCA) if required
Epidural analgesia for major procedures
Early mobilization as a key analgesic adjunct.
Early Mobilization:
Encouraging ambulation within hours of surgery
Gradual increase in activity level
Physical therapy involvement to assist with mobility and prevent complications like venous thromboembolism and pneumonia.
Early Feeding:
Resumption of clear liquids as soon as tolerated, typically within hours post-operatively
Gradual advancement to a solid diet based on patient tolerance and absence of nausea/vomiting
No routine bowel preparation or prolonged NPO status.
Urinary Catheterization:
Early removal of urinary catheter, typically within 24 hours post-operatively, to reduce the risk of catheter-associated urinary tract infections and promote patient comfort and mobility.
Drain Management:
Early removal of surgical drains when output is minimal and no signs of leak or infection are present, usually within 24-72 hours
Avoidance of routine abdominal drains unless specific indications exist.
Complications And Monitoring
Common Complications:
Postoperative ileus, nausea and vomiting, surgical site infection, bile leak, pancreatic fistula, hemorrhage, deep vein thrombosis, pulmonary complications, and delirium.
Monitoring Strategy:
Close monitoring of vital signs, fluid balance, pain scores, mobilization status, and bowel function
Regular assessment for signs of infection, anastomotic leak, or bleeding
Early detection and management of complications.
Prevention Strategies:
Adherence to the entire ERAS-HPB bundle
Prompt recognition and management of deviations
Patient and staff education to ensure consistent protocol implementation.
Key Points
Exam Focus:
ERAS-HPB is a multimodal pathway
Key components include pre-operative optimization (education, nutrition), intra-operative goal-directed therapy (fluid, anesthesia), and aggressive post-operative care (early mobilization, feeding, pain control, early drain/catheter removal)
Understand the rationale behind each element for DNB and NEET SS exams.
Clinical Pearls:
Emphasize patient engagement and education as the cornerstone of successful ERAS implementation
Early mobilization and feeding are critical to overcoming post-operative ileus and improving recovery
Multimodal analgesia is superior to opioid-only regimens
Strict adherence to protocol leads to better outcomes.
Common Mistakes:
Not involving the entire multidisciplinary team
Inconsistent application of protocol elements
Over-reliance on opioids for pain
Prolonged NPO status or delayed mobilization
Failure to adequately educate the patient on their role in recovery.