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Enhanced recovery is a package of care for major surgery to remove cancer from the lining of the abdomen, sometimes with heated chemotherapy: stopping smoking and drinking, a nutrition check, treating anaemia, a short fast, four weeks of clot prevention, careful temperature and fluids in theatre, good pain relief, no routine nose tube, drinking from the day of surgery and getting up early.
The ERAS Society guideline for CRS with or without HIPEC (2020, two parts; 72 items graded by GRADE, consensus on 71 after a two-round Delphi of 24 experts, 37 strong recommendations, no consensus on preemptive fresh frozen plasma) is the only specialty guideline; only its abstracts could be read. Its item content is taken from the INDEPSO-ISPSM consensus (India, 2025), which reports it: preoperative counselling with smoking and heavy alcohol cessation; monitoring of intraperitoneal and core temperature, with active warming against hypothermia during CRS and against hyperthermia during HIPEC; at least two antiemetics; no prophylactic nasogastric drainage without risk factors for delayed gastric emptying; clear liquids on the day of surgery and solid food from day 1; preemptive enteral or parenteral nutrition for 7 days in selected patients; out of bed on the day of surgery with more than 2 hours of activity on day 2 and more than 6 hours after; urinary catheter out on the morning of day 3 when the bladder peritoneum was not stripped. The Indian consensus itself agreed on nutritional assessment, anaemia correction, fasting 6 to 8 hours for solids and 2 hours for liquids, carbohydrate loading, LMWH from 12 hours before surgery with pneumatic compression for 4 weeks, chlorhexidine-alcohol skin preparation, goal-directed fluids, and audit; it departed from ERAS by recommending drains for all patients and bowel preparation for left colonic or rectal resection. NICE NG180 (2020) offers enhanced recovery to everyone having elective major surgery.
Why: Smoking and heavy drinking both raise the risk of complications after major surgery; stopping beforehand helps.
“As per ERAS Society Recommendations, ( Hübner et al., 2020 ) patients should be offered preoperative counseling and advised for smoking cessation and abstinence from heavy alcohol consumption.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · ERAS 2020 as reported by the consensus; grade not read
Why: Malnutrition is common before this operation and raises the risk of complications.
“Nutrition assessment should be a part of preoperative assessment”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · INDEPSO-ISPSM consensus (above 70% agreement)
Why: Anaemia is common after chemotherapy and needs time to correct before a long operation with blood loss.
“It should be screened for at least four weeks before surgery to provide adequate time for correction by medical therapy (vitamin supplementation or intravenous iron supplementation),”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · Consensus discussion; not a graded recommendation
Why: Long fasting leaves people thirsty and weaker; a sugary drink before abdominal surgery is safe.
“Consider carbohydrate drinks before surgery for people having abdominal major or complex surgery .”
NICE 2020 · Not graded (NICE NG180 1.4.2, 'consider')
Why: Without prevention the risk of blood clots after this operation is very high, and it lasts after discharge.
“Thromboprophylaxis should be given 12 h preoperatively, with low-molecular-weight/equivalent heparin, and continued perioperatively with a pneumatic compression device till four weeks post-surgery.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · INDEPSO-ISPSM consensus (above 70% agreement)
Why: The right skin antiseptic reduces wound infection.
“Chlorhexidine-alcohol solution should be used for skin preparation unless contraindicated.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · INDEPSO-ISPSM consensus (above 70% agreement)
Why: People get cold during the long open phase and can overheat when heated chemotherapy is circulated; both cause complications.
“Prevention of intraoperative hypothermia during the CRS phase and hyperthermia during the HIPEC phase by use of active warming devices should be indicated routinely.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · ERAS 2020 as reported by the consensus; grade not read
Why: Large fluid shifts happen during this surgery; measured fluid replacement avoids both too little and too much.
“Goal-directed fluid management should be attempted using a combination of crystalloids and colloids. An arterial line/cardiac output monitoring may assist in achieving this goal.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · INDEPSO-ISPSM strong consensus (above 90% agreement)
Why: Nausea is common after major abdominal surgery and the chemotherapy can add to it.
“In CRS ± HIPEC candidates, a combination of atleast two antiemetic drugs (Ondansetron, Dexamethasone, Droperidol) should be indicated routinely to prevent PONV.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · ERAS 2020 as reported by the consensus; grade not read
Why: Good pain relief lets people breathe and move; an epidural also helps the bowel start working.
“Thus, thoracic epidural analgesia (TEA: T5-11) containing local anesthetics and short-acting opiates for 48–72 h after CRS ± HIPEC is safe and recommended to prevent postoperative ileus.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · Consensus discussion citing published studies; not a graded recommendation
Why: A nose tube slows the return of bowel function and is not needed for most people.
“Prophylactic nasogastric drainage for CRS ± HIPEC, in the absence of risk factors for delayed gastric emptying (resection of lesser omentum), should not be done, as nasogastric decompression has been associated with undesired effects of delayed resumption of gastrointestinal motility.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · ERAS 2020 as reported by the consensus; grade not read
Why: Early eating supports healing; some people, after very extensive surgery, will not manage enough by mouth.
“Early oral intake resumption after CRS ± HIPEC, aiming for clear liquids on the day of surgery and solid food from postoperative day 1, without risk factors for delayed gastric emptying (resection of lesser omentum), is recommended.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · ERAS 2020 as reported by the consensus; grade not read
Why: Moving early reduces chest infections, clots and muscle loss, and helps the bowel recover.
“Mobilization as early as the day of surgery (out of bed) with goals for more than two hours of physical exercises for postoperative day two and more than six hours after that should be performed routinely after CRS ± HIPEC to improve capacity to perform out-of-bed activities, facilitate resumption of gastrointestinal function and decrease postoperative complications.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · ERAS 2020 as reported by the consensus; grade not read
Why: Catheters left in longer raise the risk of urine infection and slow getting up.
“Removal of the urinary catheter as early as the morning of postoperative day three is recommended when peritonectomy over the bladder is not done.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · ERAS 2020 as reported by the consensus; grade not read
Why: Units that measure how often each element is delivered can improve it.
“Regular audits for compliance with ERAS should be conducted as it is critical to ensure adherence to protocol.”
INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · INDEPSO-ISPSM consensus (above 70% agreement)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The ERAS Society guideline for CRS with or without HIPEC (2020, Parts I and II) is the only specialty standard: 72 items graded by GRADE, 37 strong recommendations, consensus on all but preemptive fresh frozen plasma. Only its abstracts could be read, so its content is taken from the INDEPSO-ISPSM consensus (2025), which reports it and largely agrees. The two differ on drains (the Indian panel recommends them for all patients, which it says contradicts the ERAS guideline) and on mechanical bowel preparation (the Indian panel recommends it for left colonic and rectal resection). NICE NG180 (2020) supports an enhanced recovery programme and the 2-hour clear-fluid fast for all elective major surgery.
ERAS Society (European Journal of Surgical Oncology) 2020 · ERAS Society (European Journal of Surgical Oncology) 2020 · INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 · NICE 2020
Where it differs: Places intraperitoneal drains in every patient after CRS or HIPEC.
Evidence: Recommended by 79% of the Indian panel in round two; the consensus states this contradicts the ERAS guidelines, and it cites evidence that drains after elective surgery prolong stay and raise wound infection risk without earlier detection of collections.
Where it differs: Gives bowel preparation when a left colonic or rectal resection is planned.
Evidence: Indian consensus (79.6% in round two); named by the consensus as a departure from the ERAS guideline. The underlying trials of oral antibiotic and mechanical preparation are mixed (MOBILE and MOBILE2, as reported by the consensus).
Where it differs: Teaches every patient incentive spirometry before surgery.
Evidence: Indian consensus (87.5%); the consensus itself notes that the European Society of Anaesthesiology does not suggest preoperative incentive spirometry prevents pulmonary complications and that reviews disagree.
Where it differs: Continues antibiotics after surgery rather than giving prophylaxis only.
Evidence: Some groups do this, according to the Indian consensus; it states that additional postoperative doses are not required in clean contaminated surgery. The Indian panel left the antibiotic choice to each institution's policy.
Enhanced recovery pathways feed people sooner, limit drips and drains and get them walking the day after an operation. Sixteen randomised trials in bowel surgery found 40 per cent fewer complications and stays more than two days shorter, but in 151 American hospitals given a full implementation programme, most failed to improve compliance with its elements.
Anaesthetic guidelines since at least 2011 say adults can drink clear fluids up to two hours before planned surgery and eat up to six hours before. In a study of 50 women having breast cancer surgery published in 2026, the average fast was 15 hours from food and 12 hours from fluids.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| ERAS CRS/HIPEC guideline: consensus, strong recommendations and the one item without consensus “Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma.” | GRADE; two-round Delphi of 24 experts | ERAS Society (European Journal of Surgical Oncology) 2020 |
| Quality of evidence across the 72 items “Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively.” | GRADE quality of evidence | ERAS Society (European Journal of Surgical Oncology) 2020 |
| Where the Indian consensus departs from ERAS “Some of the panelists’ recommendations contradicted the standard ERAS guidelines, such as using intraperitoneal drains in all patients and mechanical bowel preparation for left-sided colonic or rectal resections.” | INDEPSO-ISPSM modified Delphi (consensus above 70%) | INDEPSO and ISPSM (Gynecologic Oncology Reports) 2025 |
| Offer an enhanced recovery programme for elective major or complex surgery “Offer an enhanced recovery programme to people having elective major or complex surgery .” | Not graded (NICE NG180 1.2.1) | NICE 2020 |
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Prehabilitation (the pre-treatment window), Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Cytoreductive surgery, Peritoneal metastases from bowel cancer, Peritoneal metastasis, Peritoneal mesothelioma.