Fast-Track and ERAS®

Operating rooms are increasingly open to the elderly, and this scenario poses a cost problem for the Italian National Health Service (NHS). Reducing the resources required for the management of elderly surgical patients is important, as is finding new resources to treat chronic diseases (cardiovascular diseases, diabetes, neurologic disorders, cancer, etc). Enhanced Recovery After Surgery (ERAS®) is a multimodal perioperative management approach designed to prepare patients, improve outcomes, enhance recovery, and ultimately reduce these increasing costs. After determining a patient’s preoperative frailty through the Comprehensive Geriatric Assessment (CGA), we must evaluate perioperative risk, postoperative morbidity, increased hospital stay, increased mortality, higher level of care at discharge, and higher readmission rates. Prehabilitation is extremely important for older patients and consists of correcting anemia and nutritional status, evaluating neurologic, cardiac and respiratory disorders, improving overall functional capacity, and optimizing body functions. The most common endpoints used in elderly ERAS® are: complication rate, duration of hospital stay, return to the same home, maintaining quality of life, and avoiding loss of autonomy. A dedicated multidisciplinary team that includes geriatricians is necessary. The ERAS® pathway for colorectal surgery in the elderly is now established as the best standard of care, and it is very unlikely that future trials will change this. In addition, there is growing interest in extending the application of ERAS® protocols also beyond colorectal surgery, particularly in specialties such as orthopedic, urologic, and thoracic surgery, where elderly patients constitute a large proportion of the surgical population. Several pilot studies suggest that the same philosophy of minimizing stress, encouraging early mobilization and optimizing perioperative physiology can also yield benefits in these areas, even though further high-quality randomized trials are still needed.