Early rehabilitation programs after laparoscopic colorectal surgery: Evidence and criticism

Table 3 Protocols used in previous studies for evaluating early rehabilitation programs after laparoscopic rectal surgery

Protocols	Lindsetmo et al[22], 2009	Chen et al[27], 2011	Stottmeier et al[28], 2012	Huibers et al[29], 2012	Lee et al[30], 2013
Preoperative stage
General considerations	Patient education	Patient education and ERP explanation	Thorough informationEstablishing a contract	ND	Operative risk assessmentCounseling, informed consent
Oral bowel preparation	Yes	Yes	No (enema for left-sided tumors)	No (2 enemas)	Yes
NPO	ND	8 h before surgery	Fluid until 2 h before surgery	2 h before surgery	8 h before surgery
Oral carbohydrate solution	No	No	No	Yes	No
Epidural analgesia	No	No	Yes	Yes	No
Prophylactic antibiotics	ND	Single dose	Single dose (ampicillin + metronidazole + gentamicin)	Single dose (cefalozine + metronidazole)	ND
DVT prophylaxis	ND	ND	LMWH 2 h before surgeryCompression stockings	LMWH until discharge	ND
Perioperative stage
Operation approach	Laparoscopic	Laparoscopic	Laparoscopic	Laparoscopic	Laparoscopic
Anesthesia	ND	Short-acting anesthetics	Propofol, remifentanyl and muscle relaxant	ND	ND
Fluid	ND	Perioperative fluid restriction	Avoid both hypovolemia and fluid overload	ND	ND
Urinary drainage	Urethral catheter	Urethral catheter	Suprapubic or urethral catheter	Urethral catheter	Urethral catheter
Nasogastric tube	Yes (orogastric tube, removed before extubation)	No	No	No	No
Intra-abdominal drain	Rarely	Yes	No	Yes (one)	Yes (one)
Postoperative stage
Pain control	IV PCA (12-18 h)KetorolacOral analgesia	Oral NSAIDs immediatelyafter surgeryOpioid for 1 d if needed	Epidural analgesiaParacetamol, ibuprofenOpioid if needed	Epidural analgesiaParacetamol, diclofenacOpioid avoided	IV PCA till POD 2
Sipping water	Immediately after surgery	Immediately after surgery	Immediately after surgery	Immediately after surgery	Immediately after surgery
Oral food intake	POD 1	POD 1	Evening of the day of surgery	Liquid diet in the evening	Semi-fluid diet, POD 1
Removal of urinary catheter	POD 1	POD 1	Immediately after surgery	POD 2	POD 3
Removal of intra- abdominal drain	No drain	POD 4	No drain	POD 2	ND
Mobilization	As soon as possible	Immediately after surgery	Two hours after surgery	POD 1	POD 1
Regular laxatives	ND	Sennoside	MgSO4 1 g two dimes daily	MgO	MgO
Routine discharge	ND	POD 5	POD 3	ND	ND
Discharge criteria	Tolerance of fluids and solid diet, adequate oral analgesia, passage of flatus or stool, adequate home support	No fever, no tachycardia, successful passage of flatus/stool, tolerance for 3 meals/d, comfort in taking oral non-opioid analgesics, independent ambulation, adequate self-care ability	Adequate bladder and bowel function, ability to drink, eat, walk without problems, manageable pain	No remaining lines or catheters, toleration of solid food, passage of stool, controllable pain, self-care ability	ND (Recovery: tolerance of diet for 24 h, analgesic-free, safe ambulation, afebrile status without major complications)

ERP: Early rehabilitation program; DVT: Deep vein thrombosis; LMWH: Low-molecular-weight heparin; NSAID: Non-steroidal anti-inflammatory drug; PCA: Patient-controlled analgesia; POD: Postoperative day; ND: Not described.