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Enhanced recovery programs (ERPs) seek to improve the quality of surgical care by decreasing costs, decreasing complications, and increasing patient satisfaction and outcomes. It is well known that variations in surgical and anesthetic practice lead to variable outcomes, and as such, enhanced recovery programs seek to combine evidence-based recommendations to reduce complications. Additionally, a major tenet of ERP is to minimize physiologic disruption for the patient by using minimally invasive techniques and allowing for the return to homeostasis as soon as possible after surgery. Enhanced recovery programs are considered to be “modular” in that practices may adopt parts of the program that suit their needs and incorporate others as they evolve. Enhanced recovery programs are divided into three distinct phases: preoperative, intraoperative, and postoperative.


Enhanced recovery programs initially started as “fast track” recovery programs after colorectal surgery in the mid-1990s. In the early part of the millennium, formal studies were conducted, and the enhanced recovery after surgery (ERAS) programs were started in Europe. With the success of the early collaboratives, the ERAS Society was founded in 2010.1 Since then, the ERAS Society has pioneered the development of protocols for numerous types of surgery. They have partnered with numerous medical societies around the world. Additionally, many institutions have undertaken their own initiatives, which collectively fall under the concept of enhanced recovery programs.


The preoperative phase incorporates many concepts central to the perioperative medicine principle of “medical optimization” and incorporates them into a single framework. A successful ERP addresses modifiable risks to the patient weeks to months before surgery. Central lifestyle modification concepts include the use of prehabilitation, smoking cessation, and limiting alcohol intake. In addition to these lifestyle changes, ERPs also focus on optimizing nutritional status and managing comorbid medical conditions in the preoperative phase. Another central tenet of ERP is patient education. Establishment of perioperative assessment clinics staffed in a multidisciplinary fashion with anesthesiologists, internists, and allied health providers such as nutritionists can help standardize preoperative care among numerous surgical specialties at an institution.

In line with the philosophy of minimal disruption of physiologic functions, preoperative management in ERP protocols also target the following three areas: bowel preparation, preoperative fasting, and carbohydrate loading.

Thoughtful Use of Mechanical Bowel Preparation

For years, patients have dreaded the bowel preparation they must undergo before elective abdominal surgery. Mechanical bowel preparations have the unintended effect of being uncomfortable and increase the likelihood of preoperative dehydration, in contravention with ERPs that seek to minimize physiologic disturbance with no difference in outcomes. As such, ERPs call for the judicious use of mechanical bowel preparations.

Preoperative Fasting

Despite new guidelines in 2017, the standard order of “NPO after midnight” is still pervasive. ERP encourages limited fluid intake in line ...

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