Clin Nutr Res.

2018 Oct;7(4):297-302
https://doi.org/10.7762/cnr.2018.7.4.297
pISSN 2287-3732·eISSN 2287-3740 CLINICAL NUTRITION RESEARCH

Case Report Diet Modification Based on the

Enhanced Recovery After Surgery
Program (ERAS) in Patients
Undergoing Laparoscopic Colorectal
Resection
Ji Yeon Kim,1 Gyung Ah Wie,1 Yeong Ah Cho,1 So Young Kim,1 Dae Kyung Sohn,2
Suk Kyoung Kim,2 Mee Duck Jun2

Department of Clinical Nutrition, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
1

Center for Colorectal Cancer, Research Institute & Hospital, National Cancer Center, Goyang 10408, Korea
2

Received: Sep 17, 2018

Revised: Oct 19, 2018
ABSTRACT
Accepted: Oct 21, 2018
The enhanced recovery after surgery (ERAS) program aims to maximize the recovery of
Correspondence to patients by minimizing pre- and postoperative complications and stress. The program
Gyung Ah Wie
recommends providing preoperative carbohydrate (CHO) supplements and starting an early
Department of Clinical Nutrition, Research
Institute & Hospital, National Cancer Center,
postoperative diet to reduce the fasting duration. Based on these recommendations, we
323 Ilsan-ro, Ilsandong-gu, Goyang 10408, implemented preoperative CHO supplementation and initiated an early postoperative diet
Korea. in patients undergoing laparoscopic colorectal resection. We observed 3 patients as follows:
E-mail: [email protected] a non-ERAS case, preoperative ERAS case, and pre- and postoperative ERAS case. The
preoperative well-being and compliance of patients improved after implementation of the
Copyright © 2018. The Korean Society of
Clinical Nutrition ERAS program. Moreover, the length of hospital stay was reduced. Therefore, we consider
This is an Open Access article distributed that the ERAS program may be helpful for the recovery of patients undergoing laparoscopic
under the terms of the Creative Commons colorectal resection.
Attribution Non-Commercial License (https://
creativecommons.org/licenses/by-nc/4.0/) Keywords: Carbohydrate loading diet; Early postoperative diet; Colorectal surgery; ERAS
which permits unrestricted non-commercial
use, distribution, and reproduction in any
medium, provided the original work is properly
cited. INTRODUCTION
Conflict of Interest
The authors declare that they have no
Maintaining fasting prior to gastrointestinal surgery is traditionally regarded as a standard
competing interests. guideline, as it reduces the risk of aspiration by eliminating gastric residuals [1]. Initiating
an oral diet intake after the resumption of postoperative bowel movement is also common
practice. Recently, the enhanced recovery after surgery (ERAS) program was developed,
comprising a multimodal perioperative care program designed to promote early recovery
in patients undergoing major surgery, including gastrectomy, pancreaticoduodenectomy,
elective colonic surgery, elective rectal pelvic surgery, and radical cystectomy [2,3].

The ERAS program allows patients to consume solid food up to 6 hours and a 12.5%
maltodextrin-form carbohydrate (CHO) supplement drink up to 2 hours prior to surgery
to reduce the fasting period. The ERAS program demonstrated that this guideline reduces
the risk of complications caused by aspiration during the induction of anesthesia because

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Diet Modification Based on ERAS in Colorectal Resection CLINICAL NUTRITION RESEARCH

it leaves no gastric residuals, significantly improves discomforts such as hunger, thirst, and
anxiety, lowers insulin resistance, and maintains lean body mass after surgery [4,5].

In addition, the program recommends starting a liquid diet within 24 hours after surgery [1].
A solid diet is then introduced according to the patient's ability to comply. A shorter time to
achieve adequate nutritional intake after colectomy has been associated with better recovery
of bowel movement, a shorter hospital stay, and fewer postoperative complications [4]. There
is evidence showing that the implementation of the ERAS program in colorectal surgery
helps to reduce the complication rate and improves postoperative recovery [6,7].

Conventionally, patients undergoing colorectal surgery at our institution, the National

Cancer Center (NCC), only consumed water or ionic beverages 2 days prior to surgery
for bowel preparation, and fasted from midnight the day before surgery. In addition, the
postoperative diet starts after confirming the passage of flatus and phases in soft fluid
diet (SFD), soft blend diet (SBD), and normal regular diet. The diet protocol for patients
undergoing laparoscopic colorectal resection at the NCC was modified based on the ERAS
program recommendations. We administered preoperative CHO supplements and initiated
early postoperative diet.

The purpose of this case report is to share our experience of applying the ERAS program in
patients undergoing laparoscopic colorectal resection. This study was approved by the Ethics
Committee of our institution (NCC 2017-0052).

CASE
We observed the following 3 patients undergoing laparoscopic colorectal resection: a non-
ERAS case (patient 1), preoperative ERAS case (patient 2), and pre- and postoperative ERAS
case (patient 3). The cases were matched in terms of sex, age, diagnosis, and nutritional status
to avoid bias. The general characteristics of the patients are described in Table 1. All 3 patients
were admitted by preoperative day 2 and given Coolprep® (Taejoon Pharmaceutical Co., Ltd.,
Seoul, Korea) for bowel preparation. They were asked to score their subjective well-being
using a 10-cm visual analog scale, and their nutritional status was evaluated using the patient
generated-subjective global assessment (PG-SGA) by a clinical dietitian prior to surgery. The

Table 1. General characteristics of the patients

Variables Patient 1 Patient 2 Patient 3
Non-ERAS Preop ERAS Pre and postop ERAS
Sex Male Male Male
Age, yr 55 61 65
Diagnosis Sigmoid colon cancer Sigmoid colon cancer Sigmoid colon cancer
TNM T1NOMO T2N1MO T1NOMO
Operation Laparoscopic-anterior resection Laparoscopic-hemicolectomy Lapa-anterior resection
Height, cm 168.4 165.0 163.7
body weight, kg 79.2 75.8 62.5
BMI, kg/m2 28.7 27.8 23.3
PG-SGA Well-nourished Well-nourished Well-nourished
Serum albumin, g/dL 4.0 4.2 3.9
Total lymphocyte count, cell/mm3 1,980.7 3,136.3 2,528.4
Characteristics of the patients are shown below the data: Non-ERAS, traditional diet; Preop ERAS, preoperative carbohydrate supplement; Pre and postop ERAS,
preoperative carbohydrate supplement + early postoperative diet; TNM, tumor size; lymph node status, distant metastasis by Union for International Cancer Control.
ERAS, enhanced recovery after surgery; Preop, preoperative; Postop, postoperative; TNM, tumor, node, metastasis; BMI, body mass index; PG-SGA, patients
generated-subjective global assessment.

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Diet Modification Based on ERAS in Colorectal Resection CLINICAL NUTRITION RESEARCH

Oncology Nutrition Dietetic Practice Group of the American Dietetic Association adopted the
scored PG-SGA as a standard nutritional assessment tool for cancer patients.

The preoperative ERAS program was implemented as follows. A preoperative CHO

supplement diet was developed in accordance with the ERAS program recommendation. The
diet consisted of a total of 1,200 kcal of commercial 12.5% maltodextrin CHO supplement
beverage (300 kcal/3 cans/meal) every 4 meals prior to surgery (Table 2). Dextrose was not
administered intravenously. A clinical dietitian explained the preoperative CHO diet to the
patients, providing information on how to take the supplement. The early postoperative diet
comprising a SBD was initiated at postoperative day 2 regardless of the postoperative passage
of flatus (Table 2).

Patient 1 was a 55-year-old man who was diagnosed with sigmoid colon cancer and well-
nourished based on the PG-SGA. He was moderately obese with a body mass index (BMI) of
28.7 kg/m2. He was given the traditional perioperative diet. After ingesting a small amount
of rice at lunch on the day of admission, he drank only water prior to surgery. The patient
received intravenous dextrose. The patient's subjective well-being scores were as follows:
hunger, 8; thirst, 6; discomfort, 0; anxiety, 5; depression, 2; and fatigue, 3 (Table 3). His
fasting time prior to surgery was 43 hours, and he started receiving SFD on postoperative day
3 (73 hours) after passage of flatus. The length of hospital stay was 10 days (Table 4).

Table 2. Comparison of pre-and postoperative diet in patients

Patient 1 Patient 2 Patient 3
Non-ERAS Preop-ERAS Pre and postop-ERAS
Pre-OP day #2 SOW Preop CHO diet Preop CHO diet
Pre-OP day #1 SOW Preop CHO diet Preop CHO diet
OP NPO NPO NPO
POD#1 SOW SOW SOW
POD#2 SOW SOW SBD (1)
POD#3 After passage of flatus SBD (2)
SFD SFD
POD#4 SBD (1) SBD (1) NRD
POD#5 SBD (2) SBD (2) NRD
POD#6 NRD NRD Discharge
POD#7 NRD Discharge NA
POD#8 Discharge NA NA
Characteristics of the patients are shown below the data: Non-ERAS, traditional diet; Preop ERAS, preoperative carbohydrate supplement; Pre and postop ERAS,
preoperative carbohydrate supplement + early postoperative diet; Preop CHO diet (meal), 300 kcal, carbohydrate, 76.8 g; SFD, 900 kcal, carbohydrate, 180 g,
protein, 21 g; SBD (1), 1,100 kcal, carbohydrate, 180 g, protein, 45 g; SBD (2), 2,100 kcal, carbohydrate, 285 g, protein, 110 g; NRD, 2,200 kcal, carbohydrate, 305 g,
protein, 115 g.
ERAS, enhanced recovery after surgery; Preop, preoperative; Postop, postoperative; OP, operative; POD, postoperative day; NPO, nil per os; SOW, sips of water;
CHO, carbohydrate; SFD, soft fluid diet; SBD (1), soft blend diet step 1; SBD (2), soft blend diet step 2; NRD, normal regular diet.

Table 3. Subjective well-being of the patients*

Variables Patient 1 Patient 2 Patient 3
Non-ERAS Preop ERAS Pre and postop ERAS
Hunger 8 2 2
Thirst 6 0 2
Discomfort 0 0 2
Anxiety 5 0 2
Depression 2 0 2
Fatigue 3 0 2
Characteristics of the patients are shown below the data: Non-ERAS, traditional diet; Preop ERAS, preoperative carbohydrate supplement; Pre and postop-ERAS,
preoperative carbohydrate supplement + early postoperative diet. Value are presented as score.
ERAS, enhanced recovery after surgery; Preop, preoperative; Postop, postoperative.
*Visual analog scale rated by patients.

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Diet Modification Based on ERAS in Colorectal Resection CLINICAL NUTRITION RESEARCH

Table 4. Comparison of the results according to the ERAS program

Variables Patient 1 Patient 2 Patient 3
Non-ERAS Preop ERAS Pre and postop ERAS
Intake of preoperative CHO supplement, kcal 0.0 1,200.0 1,200.0
Preop intravenous fluid, kcal 720.0 0.0 0.0
Preop fasting time, hr 43.0 16.6 17.9
Postop first flatus, hr 68.0 61.0 53.0
Postop first diet, hr 73.0 61.0 39.0
Length of stay, day 10.0 9.0 8.0
Weight loss, kg (%) 1.3 (1.6) 2.0 (2.7) 0.3 (0.5)
Characteristics of the patients are shown below the data: Non-ERAS, traditional diet; Preop ERAS, preoperative carbohydrate supplement; Pre and postop ERAS,
preoperative carbohydrate supplement + early postoperative diet.
ERAS, enhanced recovery after surgery; Preop, preoperative; Postop, postoperative; CHO, carbohydrate.

Patient 2 was a 61-year-old man who was diagnosed with sigmoid colon cancer and well-
nourished based on the PG-SGA. He was moderately obese, with a BMI of 27.8 kg/m2. He
received a preoperative CHO supplement of 1,200 kcal/4 meals. The patient's subjective
well-being scores were as follows: hunger, 2; thirst, 0; discomfort, 0; anxiety, 0; depression,
0; and fatigue, 0 (Table 3). He started SFD at postoperative day 3 (61 hours) after passage of
flatus. The length of hospital stay was 9 days (Table 4).

Patient 3 was a 65-year-old man who was diagnosed with sigmoid colon cancer and well-
nourished based on the PG-SGA. His BMI was 23.3 kg/m2. He received preoperative CHO
supplementation and started an early postoperative diet. The patient's subjective well-
being scores were as follows: hunger, 2; thirst, 2; discomfort, 2; anxiety, 2; depression,
2; and fatigue, 2 (Table 3). He started SBD on postoperative day 2, although passage of
flatus occurred 53 hours after surgery. The patient experienced no discomfort when the
postoperative diet was initiated. The length of hospital stay was 8 days (Table 4).

DISCUSSION
Nutritional status is an important indicator of successful postoperative outcomes [2].
Unfortunately, surgery-related stress due to certain factors, such as underlying disease and
surgical procedures, can impair the nutritional status. Prolonged fasting prior to surgery may
result in complications, such as distress, postoperative nausea and vomiting, and increased
insulin resistance [8-10].

Daniele et al. [11] reported the prevalence of risk of malnutrition and stated that the
malnutrition rate in patients undergoing surgery for colorectal carcinoma was 70.6%.
Surgical patients are at high risk of malnutrition, which could lead to delayed wound healing,
exposure to infection, gastrointestinal pathogenic bacteria proliferation, and reduced
immunity. Accordingly, the ERAS program recommends preoperative CHO supplementation.

The preoperative CHO diet in the ERAS program has been shown to reduce postoperative
insulin resistance and loss of nitrogen and protein, as well as preoperative thirst, hunger,
and anxiety. A Cochrane Review showed that when patients consumed CHO supplements,
their anxiety and hunger levels lowered correspondingly [12,13]. In our previous study,
preoperative CHO supplementation was applied in hepatobiliary and pancreatic surgery.
The present study demonstrated an improved preoperative well-being without an increase in
insulin resistance.

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Diet Modification Based on ERAS in Colorectal Resection CLINICAL NUTRITION RESEARCH

In the present study, patient 1 showed increasing preoperative discomfort (hunger, thirst,
and anxiety) compared with patients 2 and 3 (Table 3). In contrast to patient 1, 2, and 3, who
received CHO supplementation, showed a decreasing trend in preoperative discomfort in
terms of these 3 variables. The patient 2 and 3 are similar results of well-being score. The mean
duration of hospital stay was 9.0 ± 0.8 (range, 8–10) days, and the mean postoperative weight
loss was −1.2 ± 0.6 (1.6% ± 0.8%) kg. Patient 3 had a shorter length of hospital stay compared
with patients 1 and 2. Patient 3 showed the lowest weight loss among the 3 patients.

Fasting after surgery contributes to exacerbation of catabolism accompanied by weight

loss [11]; however, an early postoperative diet may help improve the recovery of patients. In
addition, the length of hospital stay and risk of complications decreased. The ERAS program
considers an early postoperative diet as essential nutritional support for postoperative
recovery [14].

Therefore, for conscious patients able to swallow, consuming a diet within 24–48 hours
prior to all types of surgery could help promote postoperative recovery, reduce infectious
complications, and shorten length of hospital stay. El Nakeeb et al. [6] showed that early
oral feeding within 24 hours after colorectal resection was safely tolerated by 80%–90% of
patients. Our pre- and postoperative ERAS case demonstrated improved patient compliance
and reduced weight loss and length of hospital stay.

In conclusion, implementation of the ERAS program could improve postoperative recovery in

patients undergoing colorectal resection. Further studies on the application of this program
in various cases are required to validate the findings of this study.

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