ERAS in CRS-HIPEC: Time to Standardise the Indian Protocol

Enhanced Recovery After Surgery (ERAS) protocols have transformed peri-operative care across multiple surgical specialties over the last 25 years. From colorectal surgery, where the framework was first developed, to gynaecological oncology, where adoption has been more recent, the cumulative evidence has consistently shown that protocol-driven peri-operative optimisation produces shorter hospital stays, lower morbidity, faster return to baseline, and improved patient experience, with no compromise to oncological outcomes.

Cytoreductive surgery with HIPEC sits at the harder end of the surgical complexity spectrum. The operation is long, the physiological insult is substantial, the post-operative course is materially more challenging than most other oncological surgeries. For exactly these reasons, the case for systematic ERAS implementation in CRS-HIPEC is stronger than in most other settings.

This piece argues that the Indian sub-speciality community is now at the point where standardised ERAS protocols for CRS-HIPEC should be expected at any centre performing the procedure, not aspired to.

The ERAS framework in CRS-HIPEC, current international consensus

The ERAS Society published consensus guidelines for cytoreductive surgery in peritoneal malignancies in 2020. The framework spans 24 elements across pre-operative, intra-operative, and post-operative care. Among the more clinically impactful elements:

Pre-operative: – Structured pre-habilitation including nutritional optimisation and respiratory training – Avoidance of prolonged pre-operative fasting (clear fluids until 2 hours before surgery) – Carbohydrate loading – Multimodal analgesia planning before the patient enters the OT

Intra-operative: – Standardised anaesthesia protocols with avoidance of unnecessary opioids – Goal-directed fluid therapy rather than fixed-volume regimens – Active temperature management – Multimodal nausea/vomiting prophylaxis – Limited use of nasogastric tubes and drains where evidence does not support routine use

Post-operative: – Early enteral feeding (clear fluids on day 0–1 where tolerated, progressing rapidly) – Early mobilisation (sitting on day 0–1, walking on day 1–2) – Avoidance of routine catheterisation beyond 24 hours where not clinically indicated – Multimodal analgesia with opioid minimisation – Early discharge planning from admission

Each element has variable evidence strength. Some are well-established across multiple trials; others are extrapolated from colorectal ERAS data. The framework’s value is in the cumulative effect of consistent application across all elements rather than the individual contribution of any single intervention.

What ERAS actually changes in CRS-HIPEC outcomes

The published international experience with ERAS in CRS-HIPEC has documented several consistent findings:

• Reduction in median ICU stay from 3–5 days to 1–2 days
• Reduction in median total hospital stay from 12–16 days to 7–10 days
• Reduction in major complications (Clavien-Dindo ≥ III) in the range of 20–30% at most reporting centres
• Earlier initiation of adjuvant chemotherapy by 1–2 weeks, which has implications for oncological outcomes
• Improved patient-reported outcomes including pain scores, nausea, mobilisation, and quality of life metrics
• Reduced costs per hospital admission, even accounting for the additional pre-operative optimisation costs

The mortality and morbidity reductions are not trivial. They represent the kind of changes that materially affect a CRS-HIPEC programme’s overall outcomes, and they are achievable without changing the surgical procedure itself.

The Indian context, what’s working and what’s not

In the Indian sub-speciality CRS-HIPEC landscape, ERAS adoption is uneven. Some centres have implemented well-structured protocols with measurable outcome improvements. Other centres perform the procedure with older-style peri-operative care, prolonged fasting, routine nasogastric tubes, fixed fluid regimens, delayed feeding, slow mobilisation.

The institutional experience documented in the published Indian analysis of ERAS in CRS-HIPEC argues that the time for half-implementation is past. The protocol is well-defined, the elements are feasible in the Indian tertiary-hospital setting, and the outcome differences between protocol-driven and ad-hoc care are large enough to be ethically significant.

Specific elements that have shown clear feasibility in the Indian context:

1. Pre-habilitation programmes. Two to four weeks of structured nutritional support, respiratory physiotherapy, and exercise training before surgery materially improves post-operative trajectory. The infrastructure is straightforward, nutritionist consultation, respiratory therapist sessions, supervised exercise, and the cost is small relative to the procedure as a whole.
2. Goal-directed intra-operative fluid management. Replacement of fixed-volume crystalloid regimens with goal-directed protocols using arterial line variation, stroke volume optimisation, and lactate monitoring is now standard at experienced Indian CRS-HIPEC centres. The technology is available and the anaesthesia community is comfortable with the techniques.
3. Early enteral feeding. The historical practice of prolonged nil-by-mouth status after CRS-HIPEC is not supported by current evidence. Clear fluid on day 0–1 in selected patients, soft food by day 3, normal food by day 5–7 is the contemporary standard.
4. Multimodal analgesia. Combinations of regional anaesthesia (epidural or paravertebral block), paracetamol, NSAIDs (where renal function allows), gabapentinoids, and breakthrough opioids only as needed have substantially reduced opioid consumption while improving pain control.
5. Early mobilisation. Sit-up on day 0, walking with support on day 1–2, increasing distance day by day is now achievable with structured physiotherapy integration.

Where Indian implementation still struggles

Three structural issues continue to limit broader ERAS adoption in Indian CRS-HIPEC practice:

1. Anaesthesia practice variability. Goal-directed fluid therapy, regional anaesthesia, and opioid minimisation all require anaesthesia teams trained in the specific techniques. Centres without dedicated anaesthesia subspecialty for oncological surgery struggle with consistent implementation.
2. Hospital infrastructure differences. ERAS requires coordinated nursing care, dedicated physiotherapy, nutritional support, and pain management services available 7 days a week. Many Indian tertiary centres have these services available during weekdays but not weekends, which fragments protocol implementation.
3. Cultural and systemic factors. Family caregivers in Indian hospital culture often prefer the older “bed rest” model and resist early mobilisation. Education of patients and families about the rationale for ERAS is part of effective implementation. Without it, well-designed protocols fail at the bedside.

A standardised Indian protocol, what it should look like

For sub-speciality CRS-HIPEC programmes in India, a standardised ERAS protocol should include the following baseline elements as non-negotiable:

Pre-operative (2–4 weeks before surgery): – Comprehensive nutritional assessment with structured supplementation – Respiratory physiotherapy training – Supervised exercise programme appropriate to functional baseline – Patient and family education about peri-operative expectations – Multimodal analgesia plan finalised

Day of surgery (pre-OT): – Clear fluids until 2 hours before induction – Carbohydrate loading drink 2-3 hours before induction – Premedication for nausea prophylaxis – Skin preparation and warming

Intra-operative: – Active temperature management throughout – Goal-directed fluid therapy with appropriate monitoring – Standardised multimodal anti-nausea regimen – Regional anaesthesia where appropriate – Minimised use of opioids – Selective use of nasogastric tubes (not routine) – Selective use of urinary catheters with early removal plan – Selective use of drains based on procedural specifics

Day 0 (immediate post-operative): – Extubation in OT or early ICU when criteria met – Pain control with multimodal regimen – Initial mobilisation (sit-up in bed) – Initial sips of clear fluid where tolerated – Anti-thromboembolism prophylaxis initiated

Days 1–3: – Progressive mobilisation with structured physiotherapy – Diet advancement (clear fluids → soft diet → normal) – Drain removal as criteria met – Catheter removal as criteria met – Step-down from ICU when criteria met – Daily multidisciplinary rounds

Days 4–7: – Continued mobilisation – Normal diet – Multimodal analgesia transitioning to oral – Discharge planning intensified – Patient education about home recovery

Day 7+ and discharge: – Discharge when criteria met (tolerating oral diet, mobilising independently, pain controlled on oral medication, no clinical concerns) – Structured follow-up plan with first visit at 1–2 weeks

The specific timings within this framework should be adjusted based on the individual patient’s recovery, but the framework itself should be consistent across the programme.

The institutional case for adoption

For Indian tertiary hospitals performing CRS-HIPEC, the case for standardising ERAS protocols rests on three observations:

1. Clinical outcomes improve measurably. Reduced complications, shorter ICU and hospital stays, faster return to baseline, these are not marginal effects.
2. Costs reduce, even with the upfront investment in pre-habilitation and structured protocols. The reduction in ICU days alone usually exceeds the cost of the pre-operative optimisation.
3. Patient experience improves substantially. The single most consistent finding across ERAS implementations is improvement in patient-reported outcomes.

For sub-speciality fellowships training future Indian gynaec oncologists, integration of ERAS principles into core training is increasingly the expectation rather than an enhancement.

Where the field goes next

Future development of ERAS protocols specific to CRS-HIPEC is likely to focus on:

• Pre-habilitation refinement, better-defined criteria for who benefits most, what duration is optimal, what specific elements add most value
• Multimodal analgesia optimisation, better integration of regional techniques, optimal use of newer agents, opioid-sparing as a continued goal
• Discharge criteria standardisation, clearer criteria, less variability across centres
• Long-term outcome integration, linking peri-operative ERAS adherence to oncological outcomes beyond the immediate post-operative window

The framework is now mature enough that meaningful local adaptation rather than wholesale design is the appropriate next step for Indian centres.

The bottom line

ERAS in CRS-HIPEC is no longer experimental. The evidence base is mature, the implementation pathway is well-defined, and the outcome improvements are substantial. For Indian sub-speciality gynaec oncology, standardising ERAS implementation across CRS-HIPEC programmes is one of the highest-leverage quality improvements available, and increasingly an expectation rather than an aspiration.

For sub-speciality teams not yet operating under a structured ERAS protocol, this is the year to implement.

About the author

This piece was authored by Dr. Nishtha Tripathi Patel (MBBS, DGO, DNB, Fellowship in Gynaecological Oncology, ESGO-certified), an ESGO-certified gynaecological oncosurgeon in Ahmedabad with published academic work on ERAS implementation in cytoreductive surgery with HIPEC. Reach the practice at +91 76988 00333.