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Page 4 of 18 Tebala et al. Mini-invasive Surg 2018;2:32 I http://dx.doi.org/10.20517/2574-1225.2018.37

Preoperative counseling/stoma education
Optimization - pre-habilitation
Preoperative nutrition
Selective bowel preparation

No fluid overload
Antibiotic and DVT prophylaxis
Short-acting anaesthetic agents
Minimal use of opioids
Prevention of hypothermia
Mini-invasive technique
Selective use of drains, < 24 h
No nasogastric tube
Bladder catheter < 24 h

Multimodal postoperative analgesia
Ideally no morphine > 24 h
PONV prevention
Prevention of postoperative ileus
Early feeding
Early mobilization

Quality control/audit

Figure 1. ERAS flowchart

technique, postoperative diet, mobilization/rehabilitation and pain control. In particular, the discharge
must be prepared well in advance, in the preoperative period, and all the systems must be put in place for
a safe return home. Involvement of the patient and their family (not only providing information) is cru-
cial. A recent non-blinded randomized controlled trial from Norway clearly showed the value of extensive
counseling within an ERAS programme in colorectal surgery. Patients who received repeated information
preoperatively showed a more efficient engagement in some elements of the ERAS programme such as early
feeding and early mobilization after surgery, thus reducing their LOS by 2 days with respect to the patients
who received only standard information .
[21]

In our practice, the patient has at least 3 important meetings before surgery: (1) with the consultant sur-
geon, who communicates the diagnosis, offers and discusses the treatment and introduces ERAS; (2) with
the anaesthetist, who provides preoperative optimization of the patient, discusses the pre, intra and post-
operative anaesthesiological management and explains the ERAS in more detail; and (3) with the colorec-
tal nurse who is responsible for a holistic approach and oversees some particular elements of the ERAS
protocol. Sometimes the colorectal specialist nurse can be in charge of the ERAS protocol as well as the
preoperative stoma teaching and site marking. In fact, the creation of a stoma is itself a contributory factor
of prolonged LOS, therefore with the ERAS protocol we should aim at reducing the impact of stomas on
[22]
the postoperative recovery. Stoma education is more effective if initiated in the preoperative period . It is
[23]
mandatory that that criteria and pathway for discharge are discussed with the patient at this stage .
Optimization
During the preoperative meetings, all the comorbidities are fully investigated and the patient is optimized
for surgery, including quitting smoking and alcohol, rebalancing their sugar levels and addressing their nu-
tritional needs. Clearly, the optimization process needs time, and the ERAS Society guidelines suggest that