The ERAS Protocol

Surgery is associated with a systemic stress response. Many randomized controlled trials have contributed to define safe and effective protocols of Enhanced Recovery After Surgery (ERAS), based on a multidisciplinary and multimodal approach addressing issues that might delay the recovery and cause complications, changing the management according to a continuous evidence-based analysis and periodical internal audits. A meta-analysis on ERAS in colorectal surgery confirmed that it is associated with a reduction in complications and length of hospital stay, without affecting the readmission rate. ERAS protocols are based on common surgical and anesthesiological items including: evaluation of preoperative risk; prevention of postoperative nausea and vomiting; avoidance of intraoperative hypothermia; mini-invasive surgical approach; adequate opioid-sparing pain treatment; a personalized perioperative fluid administration; early mobilization; quick restart of oral intake. Bariatric patients present unique challenges in the management of perioperative risks. In 2016 the ERAS Society published the guidelines for bariatric surgery. A recent meta-analysis of ERAS in bariatric surgery demonstrated benefits in morbidity, operative time and length of hospital stay. To the best of our knowledge, no study has evaluated the feasibility, safety and efficacy of the ERAS protocol in emergency, non-bariatric obese patients. Due to the emergency of surgery, preadmission and preoperative optimization might often be not feasible. On the other hand, considering the benefits demonstrated in obese patients it seems reasonable to apply as completely as possible all the intraoperative and postoperative ERAS elements.