Enhanced recovery for colorectal surgery: Practical hints, results and future challenges

Table 1 Types of enhanced recovery after surgery protocols adopted

Ref.	Preoperative	Intraoperative	Postop (first 24 h)	Day 1	Day 2	Day 3	Day 4	Additional comments
Kahokehr et al[8,9]	Nutritional supplementation	Thoracic epidural	All IV fluid stopped	Removal of urinary catheter	Removal of epidural			Early mobilization and physiotherapy
	NBM two hours preinduction	Short acting anaesthetics	Prophylactic antiemetics
	Carbohydrate loading	Intraoperative fluids: 1000 mL of crystalloid and 500 mL of colloid	Early oral feeding
	No bowel preparation	Prophylactic antiemetics at induction (Dexamethasone)	Nutritional supplementation
	Functional assessment and goal setting	No drains or NG tubes	No opioids
King et al[12-14]	Nutrition supplementation	Thoracic epidural	Free fluid	All IV fluid stopped	Removal of epidural Regular NSAIDS	Removal of urinary catheter for rectal resections		Aim for discharge on day 3 for colonic or day 5 for rectal resection
Blazeby et al[15]	Optimised pre-morbid health status	Intraoperative fluids: 2000 mL of crystalloid	Nutritional supplementation	Regular paracetamol	Morphine for breakthrough			Provision of hospital contact numbers, review on ward if problems within 2 wk
Faiz et al[16]	Functional assessment and goal setting	Minimal-access surgery	Patient sat out in chair	3 high-protein/high-calorie drink				Review in outpatient clinic on day 12
	Stoma nurse	Local anaesthetic infiltration to the largest wound		Normal diet offered
	Bowel preparation in left-sided resections	No drains or NG tubes		Patient sat out in chair
				Start walking
				Removal of urinary catheter for colonic resections
				Laxatives
Jottard et al[7]	Nutrition supplementation	Thoracic epidural	Free fluid	All IV fluid stopped				Use of anti-emetics
	Functional assessment and goal setting	Standard anesthetic protocol		Normal diet offered				Early mobilization
	No bowel preparation	Prevention of intraoperative hypothermia						Postoperative nutritional care
		No drains or NG tubes
Maessen et al[20,21]	Nutrition supplementation1	Thoracic epidural	Oral analgesia	All IV fluid stopped	Removal of epidural Removal of urinary catheter
Nygren et al[22]	Functional assessment and goal setting	Prevention of intraoperative hypothermia	Patient sat out in chair	Nutritional supplements > 400 mL
Hendry et al[23]	No bowel preparation	Transverse/curved incision	Nutritional supplements	Normal diet offered
			Free fluid > 800 mL	Patient sat out in chair
Soop et al[26]	Nutrition supplementation	Thoracic epidural	Prophylactic antiemetics	Regular paracetamol and NSAIDS	Patient sat out in chair	Patient sat out in chair	Epidural removed (at least)
				Patient sat out in chair
Raymond et al[28]	Nutrition supplementation Functional assessment and goal setting	Thoracic epidural						Early mobilization/resumption of diet
		Intra-operative targeted fluid management
		No NG tube
Turunen et al[10]	Functional assessment and goal setting	Thoracic epidural		Removal of urinary catheter				Early mobilization/resumption of diet
	Preoperative feeding	High-oxygen P						No routine opioids, regular paracetamol and NSAIDS
	Bowel preparation	Prevention of hypothermia						Fluid restriction
		No drains or NG tubes
Senagore et al[35]		No NG tube	PCA	Removal of urinary catheter
			Free fluids	Normal diet offered
				regular NSAIDs, gabapentin, hydroxycodone if needed
				No drains
Wennstrom et al[11]	Functional assessment and goal setting	Thoracic epidural	Free fluid		Epidural removed
	No bowel preparation	Short acting anaesthetics	Patient sat out in chair		Urinary catheter removal
	Preoperative oral hydration	No opioids
Mohn et al[18]	Nutrition supplementation	Thoracic epidural	Patient sat out in chair	Removal of urinary catheter Patient sat out in chair	Epidural removed			Regular laxatives twice daily
	Functional assessment and goal setting	Total intravenous anaesthesia		Normal diet offered
	Bowel preparation	Intra-operative targeted fluid management		Regular paracetamol and NSAIDs, opioids for breakthrough				Restricted postoperative intravenous fluids
		Prophylactic antiemetics
		Short midline incisions
		No drains or NG tubes
Teeuwen et al[17]	Nutrition supplementation	Thoracic epidural	Free fluids	Normal diet offered	Epidural removed
	Bowel preparation in left-sided resections	Transverse incisions except in Crohn's disease and rectal surgery	Nutritional supplements	Intravenous fluid administration	Urinary catheter removal
		Intra-operative targeted fluid management (hypotension treated with vasopressors)	Patient sat out in chair	Start walking	Regular Paracetamol NSAIDs, opioids for breakthrough
		Prophylactic antiemetics
		No drains or NG tubes
Ahmed et al[24,25]	Nutrition supplementation	High inspired oxygen	Free fluids	Start walking				Regular paracetamol NSAIDs, opioids for breakthrough
	Functional assessment and goal setting	Concentration	Soft diet offered
	No bowel preparation	Transverse incisions	Patient sat out in chair
		No drains or NG tubes
Kirdak et al[19]	Nutrition supplementation	Thoracic epidural	Start walking	NG tubes and urinary catheters removed (except pelvic dissection)	Removal urinary catheter (low pelvic operations) and drains	Epidural removed
	Bowel preparation	Pelvic drains with rectal dissections		Soft diet offered		Regular paracetamol
		Urinary, central venous, and nasogastric catheters were routinely used		Patient sat out in chair		Central venous catheters removed
				Start walking		Normal diet

¹These authors followed Kearon for the nutritional supplementation. NBM: Nihil by mouth; NG: Nasogastric; IV: Intravenous; NSAIDs: Non-steroidal antinflammatory drugs; PCA: Patient-controlled analgesia.

Table 2 Clinical characteristics of studies examined

Ref.	Type of study	Patients (n)	Sex (males%)	Age (yr)	Type of surgery	Approach	Length of stay (d)	Morbidity	Mortality	Readmission	Comments
King et al[14]	Prospective case series	60	31 (52)	72 ± 11		ERAS	5.8	11 (18%)	2 (3%)	7 (12%)	ERAS ↓ hospital stay
		86	45 (52)	70 ± 11		Conventional	10.7 (P < 0.001)	24 (28%)	6 (7%)	8 (9%)
Maessen et al[20]	Observational study	425	-	-	Resections above peritoneal reflection	ERAS	5 d	-	-	-	Delay in discharge was due to the development of major complications
Maessen et al[21]	Case series	121	67 (55)	66 ± 12	Resections above peritoneal reflection without stoma	ERAS	Discharge delay = 1 d	-	-	-	↓ in hospital stay may relate to changes in organization of care and not to a shorter recovery period
		52	22 (42)	64 ± 12	Resections above peritoneal reflection without stoma	Conventional	Discharge delay = 2 d
Jottard et al[7]	Prospective ERAS group matched with historical data	36	-	-		ERAS	6 (3-27)	-	-	-	ERAS was implemented in a district general hospital
		92	-	-		Conventional	9 (3-64)	-	-	-
Hendry et al[23]	Prospective case series	1035	498 (48.10)	59 (69-78)		ERAS	6 (4-8)	294 (28.40%)	17 (1.60%)	86 (8.60%)	Higher ASA, advanced age, sex (male) and rectal surgery associated with delayed mobilization, morbidity and prolonged stay
Mohn et al[18]	Prospective ERAS group matched with historical data	94	40 (43)	66		ERAS		29 (31%)	1 (1%)	14 (15%)	ERAS ↓ hospital stay
		153	68 (44.40)	71 (15-90)		Conventional	11 (5-108)	27 (18%)	1 (1%)	-
Nygren et al[22]	Prospective ERAS group matched with historical data	99	-	-		ERAS	-	18%1	-	15%1	ERAS ↓ time to resumption of oral diet, mobilization and passage of stool, improved lung function, ↓ morbidity and hospital stay but ↑ readmissions
		69	27	65 ± 2		Conventional	8.6 ± 0.6/7 for colonic resection	17 (37%) for colonic	0	2 (4%) for colonic
							12.7 ± 1.2/11 for rectal resection	12 (52%) for rectal resection		1 (4%) for rectal
Ahmed et al[24]	Retrospective case series	231	101 (44)	68 (56-76)	Elective open bowel resection	ERAS	6 (5-9)		-	-	Lower ASA grade, use of epidurals and avoidance of regular oral opiates are associated with an earlier discharge
Kahokehr[9]	Prospective case series	100	-	68 (31-92)		ERAS	4 (3-46)	-	-	-	Lower ASA score, transverse incision laparotomy and laparoscopy associated with earlier discharge
Teeuwen et al[17]	Prospective ERAS group matched with historical data	61	22 (36.1)	57 ± 17.6	elective open colonic or rectal resection	ERAS	6 (3- 50)	9 (14.8%)	0%	2 (3.3%)	ERAS ↓ morbidity and hospital stay
		122	-	-		Conventional	9 (3-138)	33.60%	1.60%	1.60%
Bryans et al[34]	Retrospective case series	20	-	-	Colorectal surgery with stoma (excluding abdominoperineal resection)	ERAS	mean = 7	-	-	-	ERAS ↓ hospital stay and ability to manage stoma
		20				Conventional	mean = 20
Kahokehr et al[8]	Prospective case series	74	-	-	Open right hemicolectomy	ERAS	Median (43-28)	-	-	-	No difference in morbidity or surgical recovery
		39			Laparoscopic right hemicolectomy	Conventional	5 (2-18)

¹Significant difference. ERAS: Enhanced recovery; ASA: American society of anesthesiologists score; QOL: Quality of life.

Table 3 Other colorectal studies involving enhanced recovery after surgery patients

Ref.	Type of study	Patients (n)	Approach	Comments
Soop et al[26]	RCT	9 vs 9	Complete or hypocaloric postoperative enteral nutrition on ERAS	Complete enteral nutritions was associated with minimal postop insulin resistance, hyperglycemia and nitrogen losses
King et al[12]	RCT	43 vs 19	Lap vs open resections on ERAS patients	Reduced hospital stay and with laparoscopic resections
King et al[13]	RCT	41 vs 19	Lap vs open resections on ERAS patients	Laparoscopic surgery achieves quicker return to daily activities
Kirdak et al[19]	RCT	14 vs 13	Preop. dexamethasone vs placebo on ERAS patients	Preoperative dexamethasone has no significant effects on the inflammatory response or outcomes
Turunen et al[10]	RCT	29 vs 29	Epidural anesthesia vs control for laparoscopic resection on ERAS	The epidural G. needed less oxycodone than the control G. Until 12 h postop. Epidural alleviated pain, reduced opioids requirements
Raymond et al[28]	Retrospective case series	179 vs 144	Lap vs open resections on ERAS patients	Laparoscopic surgery achieves quicker return to daily activities
Blazeby et al[15]	Prospective	20	Laparoscopic assisted and open	QOL evaluation. Patients liked quicker discharges, few were dissatisfied due to complications requiring readmissions
Senagore et al[35]	RCT	22 vs 21 vs 21	Standard vs lactated Ringer’s vs hetastarch-lactated Ringer’s periop fluid	Individualized intraoperative fluid management with crystalloid reduced overall fluid administration compared to colloid
Faiz et al[16]	Prospective non-randomized	191 vs 50	Lap vs open resections on ERAS patients	Laparoscopic has advantages over open approach also in ERAS patients
Wennstrom et al[11]	Prospective	32	ERAS	Postoperative survey on QOL following discharge: fatigue, nausea and bowel disturbances
Ahmed et al[25]	Case series	100 vs 95	ERAS audit protocols application vs ERAS clinical practice	Observance to ERAS protocol was lower outside clinical trials

RCT: Randomized controlled trial; ERAS: Enhanced recovery after surgery; QOL: Quality of life; Preop.: Preoperative; Postop.: Postoperative.