Editorial
Copyright ©The Author(s) 2019.
World J Gastrointest Surg. Feb 27, 2019; 11(2): 41-52
Published online Feb 27, 2019. doi: 10.4240/wjgs.v11.i2.41
Table 1 Enhanced recovery after surgery elements used in 4 published trials comparing enhanced recovery after surgery vs non-enhanced recovery after surgery in emergency colorectal surgery
ERAS elementsLohsiriwat[8]Wisely et al[10]Shida et al[11]Shang et al[12]
Preoperative phase
Education and detailed counselingYYYY
Medical optimizationY
No bowel preparationYYYY
No pre-anesthetic medicationYYYY
Intraoperative phase
Use of epidural analgesiaYY
Active warmingYYY
Avoid sodium/fluid overloadYYYY
Prophylaxis of nausea and vomitingYYY
No intraabdominal drainageYY
Postoperative phase
Opioid-sparing multimodal analgesiaYYYY
Early removal of nasogastric tubeYYYY
Early feedingYYYY
Early removal of urinary catheterYYYY
Use of laxativesYYY
Early mobilizationYYYY
Table 2 Summary of study characteristics and clinical outcomes of three published studies comparing enhanced recovery after surgery vs non-enhanced recovery after surgery in emergency colorectal surgery
Lohsiriwat[8]Wisely et al[10]Shida et al[11]Shang et al[12]
Characteristics
Country, yearThailand, 2014Australia, 2016Japan, 2017China, 2018
Study designMatch case-controlPre-Post ERASPre-Post ERASMatch case-control
ERAS/non-ERAS20/4080/9742/80318/318
Inclusion criteriaObstructing colorectal cancerBenign diseases and malignancyObstructing colorectal cancerObstructing colorectal cancer
Exclusion criteriaNo bowel resection, concomitant bowel perforationLaparoscopic surgeryNo bowel resection, concomitant bowel perforationRecurrent tumor, no bowel resection, concomitant bowel perforation
Clinical outcomes
GI recovery timeSig. decreasedNANASig. decreased
ComplicationDecreasedSig. decreasedDecreasedSig. decreased
Hospital staySig. decreasedSameSig. decreasedSig. decreased
30-d mortalitySameSameSameSame
30-d readmissionSameSameSameSame
30-d reoperationNASameSameSame
Interval between surgery and chemotherapysig. decreasedNANAsig. decreased
Table 3 Evidence-based enhanced recovery after surgery protocol in emergency colorectal surgery
ERAS itemRecommendation
Preoperative phase
Education and detailed counselingPatients should routinely receive concise and practical preoperative education including stoma counseling
Medical optimizationPreoperative risk stratification and “targeted” optimization of general conditions are recommended
Glycemic controlPerioperative blood glucose should be maintained between 140 and 180 mg/dL
Intraoperative phase
Use of epidural analgesiaThoracic epidural analgesia may be used in patients with stable hemodynamic and no bleeding tendency
GDFTGDFT may be beneficial in patients with high-predicted postoperative mortality
Prevention of hypothermiaAll measures should be done to prevent or reverse intraoperative hypothermia
PONVA multimodal prophylaxis of PONV should be used in all patients based on their risk factors for PONV
Minimally invasive surgeryLaparoscopy may be performed in selected patients by experienced surgeons
Avoidance of intraperitoneal drainsIntraabdominal and pelvic drains should not be used routinely
Postoperative phase
Multimodal analgesiaOpioid-sparing multimodal analgesia should be tailored to the individual and the operation involved
Early removal of NGTNGT can be removed safely on postoperative day 1-2 unless paralytic ileus is evident
Early feedingOral intake can resume in stabilized patients and should progress moderately if patients can tolerate
Early removal of urinary catheterUrinary catheter can be removed safely on postoperative day 1-2
Breathing and coughing exercisePatients are encouraged to have sessions of deep breathing and coughing exercise postoperatively
Early mobilizationPatients are encouraged to have early independent mobilization as a part of physiotherapy and rehabilitation program