Enhanced recovery after endoscopic sinus surgery: Establishing comprehensive protocols for improvement of...

Enhanced recovery after surgery (ERAS) protocols for endoscopic sinus surgery (ESS) have not been widely implemented, and a critical review of ERAS recommendations and a comprehensive analysis of the supporting literature has not been undertaken. We describe an ESS ERAS protocol including key perioperative interventions for patients undergoing ESS and assess the available evidence.

A search was conducted of all relevant ERAS literature in otorhinolaryngology, anesthesia, and surgery using Medline (via PubMed), and Scopus. Keywords included "endoscopic sinus surgery," "sinus surgery," "FESS," and "ESS" for each area of intervention. Where applicable, the authors considered high-level evidence for recommendations devised for patient cohorts in otorhinolaryngology not undergoing ESS, as well as cohorts undergoing surgical procedures for which ERAS protocols have been extensively evaluated.

Studies received grades of "low," "moderate," or "high" quality evidence based on the Oxford Centre for Evidence-Based Medicine criteria. Each intervention was subsequently assigned a grade of "strong," "weak," or "conditional" based on the available evidence.

Strong recommendations include comprehensive patient education and counseling, minimization of preoperative fasting, application of topical/local anesthetics and vasoconstrictors, use of total intravenous anesthesia, avoidance of pharyngeal packing, and use of postoperative nasal irrigation and multimodal analgesia. Conditional recommendations include antibiotic prophylaxis. Weak recommendations include perioperative venous thromboembolism prophylaxis, controlled hypotension, and use of postoperative nasal packing/dressing.

A comprehensive ERAS protocol for ESS can include a variety of high yield, evidence-based interventions that would likely improve surgical outcomes and patient satisfaction.