In the present digital era, patients turn to the Internet to find information about where and by whom to undergo surgical treatment. Increased patient expectations, cost of the treatment, and attention to safety outcomes by national regulatory bodies have generated significant interest in quantitative assessment of the quality of health care. One way of assessing the quality of surgical care is by using direct outcomes measures. These indicators include length of stay, readmission rate, complication rate, patient satisfaction, functional health status, etc. The operation itself has long been perceived to be the single most important factor that influences surgical outcomes, but in reality pre-, intra- and postoperative care may be equally as important as the operation.

The concept of fast-track protocols was introduced by Kehlet in the 1990s to achieve early recovery after major surgical procedures [1]. Subsequently, the concept was modified by the Enhanced Recovery After Surgery (ERAS) Study Group, with a focus more on enhancing recovery than shortening length of stay [2]. Using a multidisciplinary team approach, enhanced recovery program (ERP) protocols focus on key elements including preoperative patient counseling, optimization of perioperative nutrition, standardized analgesic and anesthetic regimens, and early mobilization. A downstream effect is potential minimization of health care costs by reducing complications, use of tests, and hospital stay [2–6] (Fig. 14.1).

Preoperative fasting, previously one of the most important dogmas prior to surgery, has been dramatically changed by the ERP approach (see Chap. 4, preoperative fasting and carbohydrate treatment). In contrast to prior instruction regarding having nothing to eat or drink after midnight before an operation, patients are allowed to drink clear liquids up to 2 h before the surgical intervention. Carefully performed studies have shown that drinking clear liquids up to 2 h before the induction of anesthesia does not increase the volume of gastric contents or acidity, and does not increase the risk of aspiration [7–9]. In a study performed by Nygren et al., gastric emptying was not affected by carbohydrate-rich drinks consumed before elective surgery, and did not differ between experimental and control group [10]. According to a study performed by Gustaffson et al. on 25 patients with type 2 uncomplicated diabetes and 10 healthy volunteers, carbohydrate-rich drinks given 180 min before the induction of anesthesia did not increase the risk of aspiration, hyperglycemia, or delay gastric emptying in patients with diabetes compared with healthy volunteers [11]. Thus, the diagnosis of diabetes is not a contraindication for enrollment into an ERP protocol, in the absence of an additional diagnosis of gastroparesis.

Intake of complex carbohydrate-rich drinks up to 2 h before operation has been shown to reduce hunger, anxiety, and thirst in surgical patients in perioperative period [12–14]. A study performed by Wang et al. demonstrated that patients who received preoperative carbohydrate-rich beverages also had a reduced degree of insulin resistance, a marker of physiologic stress, in the postoperative period [15]. The clinical significance of postoperative insulin resistance was further illustrated in a prospective randomized study performed by a Belgian group in the setting of the surgical ICU [16]. Maintenance of euglycemia (the blood glucose concentration 80–110 mg/dl) in surgical patients in the intensive care unit resulted in a significant reduction in postoperative mortality, risk of infection, and use of antibiotics. Postoperative insulin resistance is most pronounced at postoperative day zero and lasts for about 3 weeks after uncomplicated elective major abdominal operations. It can be an important factor determining the length of postoperative hospital stay [17, 18]. Tamura et al. showed that fasting-induced insulin resistance in healthy participants could be reversed by preoperative oral administration of an 18 % carbohydrate solution [19]. It is essential to appreciate that the beneficial effect of carbohydrate loading is time dependent and that if the carbohydrate load is given longer than 2 h before surgery, the reduction of post-op insulin resistance secondary to the insulin peak induced by the CHO load is lost. This is a major practice point that is often forgotten.

Avoiding preoperative fasting also lowers the extent of the catabolic state as indicated by a reduction in blood ketone body levels [19], and reduced postoperative loss of urinary nitrogen [20]. The early initiation of postoperative nutrition can also ameliorate the metabolic response to surgery by reducing insulin resistance, loss of muscle strength, and negative nitrogen balance [21, 22]. With respect to postoperative care, Kehlet pioneered a dramatic change from nil per mouth to early implementation of diet in the immediate postoperative period [4, 5]. All patients are allowed clear liquid diet (water, juice, protein-enriched juices) as soon as they are awake and can advance to low residue diet on postoperative day 1 with supplementation of a protein drink with each meal. In some centers the emphasis is more on normal food than the use of oral supplements, but with the goal of achieving the same net intake. Normal food should be easily accessible to patients and should be of an attractive nature to further encourage spontaneous intake. Some programs rearrange the ward environment so that patients eat at a common dining table rather than being immobilized and isolated in their own beds. This encourages early mobilization and communication of common experiences between patients. It is important to appreciate that within an ERP protocol, although patients are encouraged to eat, this is not tolerated by all patients. Gastrointestinal dysfunction with nausea, vomiting, and paralytic ileus still occurs in a proportion of patients and it is important to modify the program according to patient progress. Equally it is vital that patients are closely supervised so that the rare case of acute gastric dilatation is promptly and correctly managed with placement of a nasogastric tube.

Clearly, maintenance of gut function in the post-op period is vital if early return of spontaneous dietary intake is to be achieved. To this end, the ERP protocols generally emphasize the use of nausea and vomiting prophylaxis especially in high-risk groups and avoidance/minimal use of systemic opiates.

Despite the fact that most of the patients have no limitations in their diet before an elective colonic resection, it is important to obtain information regarding nutritional status and make plans before surgery. In a randomized clinical trial involving patients undergoing moderate to major lower gastrointestinal abdominal surgery, Smedley et al. showed significantly lower weight loss and a reduced complication rate in the group receiving oral nutritional supplements in the form of protein drinks before and after the surgical intervention [23]. Following discharge from the hospital, patients taking oral nutritional supplements had better nutritional intake at 2 weeks, but by 4 weeks the total intake was similar to that in the control group. The latter trial was undertaken in the context of traditional rather than ERP perioperative care and it may be that if all patients are provided with optimal nutritional and metabolic care in the perioperative period (i.e., ERP), then the impact of malnutrition may be less than previously thought.

Prolonged bed rest is associated with pulmonary complications, insulin resistance, reduced work capacity, and loss of muscle mass and strength [24, 25]. In older patients, deconditioning can be seen after as little as 2 days of hospitalization [26]. Early mobilization is an important step in accelerating postoperative recovery and is a key component of ERPs. A multivariate linear regression analysis of data collected during the LAFA trial supported the hypothesis that mobilization on postoperative days 1–3 is significantly associated with successful outcome of ERP [27]. Patients in ERPs spend more time out of bed compared to traditional care [28] but even within established programs, overall adherence to mobilization may be low [29].

However, there are no standard definitions of mobilization, and programs may set very different goals for activity using different benchmarks such as time (hours out of bed, sitting or walking) or distance (e.g., number of “laps” in the hallway, meters, or steps to achieve). There are no randomized trials comparing one approach to another. It is unclear whether patient outcomes are improved if physiotherapists or other caregivers are involved in mobilization. It is important to involve nurses in all phases of the development of the protocol so that there is support for helping patients mobilize as early as possible. Patients who begin an exercise program preoperatively (“prehabilitation”) remain more active postoperatively compared to controls [30]. Compliance may be improved by setting out daily goals in the preoperative patient education, and reinforcing these goals with posters on the ward, diaries, or pedometers. Pain, drains, and IVs reduce ambulation and demonstrate the interrelationship between several aspects of the pathway.