Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial Fast‐track surgery: the next revolution in surgical care following laparoscopy Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. A systematic review of enhanced recovery protocols in colorectal surgery. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma Implementing Fast-Track Protocol for Colorectal Surgery: A Prospective Randomized Clinical Trial The future of fast‐track surgery [Application of the protocol of enhanced recovery after surgery in colorectal surgery]. Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Use of activity tracking in major visceral surgery—the Enhanced Perioperative Mobilization (EPM) trial: study protocol for a randomized controlled trial Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial) Fast-Track Surgery Improves Postoperative Clinical Recovery and Immunity After Elective Surgery for Colorectal Carcinoma: Randomized Controlled Clinical Trial Enhanced Recovery After Surgery Versus Conventional Perioperative Care in Rectal Surgery Enhanced Recovery After Surgery Protocols Are Valuable in Pancreas Surgery Patients. Surgical Stress Response and Postoperative Immune Function After Laparoscopy or Open Surgery With Fast Track or Standard Perioperative Care: A Randomized Trial A prospective study on the influence of a fast-track program on postoperative fatigue and functional recovery after major colonic surgery.
Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety Fast-track surgery , also named enhanced recovery after surgery ( ERAS ) , is in my opinion the most important innovation after the advent of laparoscopy ( in the 1990s ) in the field of  colorectal surgery  ( as in other fields of surgery ) . It is defined as a multimodal pathway aim ing to reduce surgical stress by using pain-free procedures with less organ dysfunction , less morbidity and better recovery . ERAS has been popularized by Henrik Kehlet and his team since the early 2000s [ 1 ] and has rapidly gained popularity around the world because of its remarkable benefits and safety . The concept of ERAS is to make use of the improvement of anaesthetic and analgesic techniques , the development of minimally invasive surgery and evidence -based perioperative care . It involves a number of items , beginning from the first medical visit before surgery to discharge . The items are all evidence based being derived from r and omized controlled trials or meta-analyses . The reader can find the references related to the ERAS items in the valuable consensus review published by the European ERAS group [ 2 ] and the paper of Kehlet and Wilmore [ 3 ] . Through this pathway , the patient can benefit from the best available evidence in anaesthesia , analgesia , perioperative fluid management , surgical procedures , nutrition and ambulation . I will focus in this editorial on the role of ERAS in colorectal surgery , but readers should be aware that ERAS has been applied and vali date d in other abdominal procedures , and in urology , gynaecology , vascular sugery , endocrine surgery , orthopaedic surgery , etc . [ 3 ] . The numerous items or components ( Figure 1 ) involve the preoperative , intra-operative and postoperative periods , necessitating close collaboration between surgeons ( no bowel preparation , no routine nasogastric tube , minimally invasive surgery , no routine abdominal drainage and early postoperative diet ) , anaesthesiologists ( fasting duration of two hours for liquids and six hours for solids , carbohydrate loading , no routine preoperative sedation , avoiding long-acting opioids , epidural analgesia , preventing postoperative nausea and vomiting , preventing intra-operative hypothermia , perioperative fluid restriction and postoperative analgesia ) and nurses and physiotherapists ( early nutrition and mobilisation ) . Several r and omized trials and four meta-analyses [ 4–7 ] have demonstrated the safety and efficacy of ERAS , not only in reducing total length of hospital stay and morbidity , but also in improving patient satisfaction when compared with conventional care . The metaanalyses included both r and omized and non-r and omized studies , the most recent and the largest [ 6 ] showing a reduction of 2.5 days in total hospital stay and significantly less morbidity ( OR 0.54 [ 0.45–0.69 ] ) in favour of the ERAS group , with no difference in readmission rate . A recent meta- analysis focusing on major colorectal surgery demonstrated that the ERAS programme can reduce morbidity by up to 50 % [ 7 ] . ERAS raises three questions . ( i ) What is the respective role of each ERAS item ? ( ii ) Does the ERAS protocol increase the workload of ward nursing staff ? ( iii ) How should this new paradigm be implemented ? Several anaesthesiologists are reluctant to use epidural analgesia in daily practice , mainly when patients are undergoing laparoscopic surgery . Epidural analgesia ( well known to be associated with less pain ) during laparoscopic surgery has been assessed in meta-analyses and r and omized trials but the conclusions are not concordant [ 8,9 ] . In my own daily practice , epidural analgesia is safe and efficacious in relieving pain and allowing early oral intake and mobilization , but it is obvious that its proper role in the ERAS protocol compared with other analgesic regimens such as non-opioid multimodal analgesia , local anaesthesia and continuous wound perfusion , in the era of laparoscopic surgery needs further evaluation . The roleof laparoscopyhas also been debated [ 10 ] . Two small r and omized trials have shown conflicting results [ 11,12 ] , but a recent large r and omized trial [ 13 ] involving four arms ( laparoscopy with ERAS vs laparoscopy with conventional care , vs open surgery with ERAS vs open surgery with conventional care ) has demonstrated a shorter hospital stay after laparoscopic colonic surgery with ERAS , the other outcomes being similar . The conclusion of the authors was that ‘ the most optimal perioperative treatment for patients requiring segmental colectomy for coloncancer is laparoscopic resection embedded in an ERAS program ’ , suggesting that laparoscopic surgery is an important component of ERAS . The same team has performed a futher multivariate linear regression analysis on the same data and showed that the components significantly associated with a successful ERAS programme were laparoscopic surgery , normal diet at postoperative days one , two and three and enforced mobilization at postoperative days one , two and three ( Vlug M , personal communication ) . There is a feeling that the ERAS programme could increase the workload of nursing staff . The nursing OBJECTIVES To study the impact of different adherence levels to the enhanced recovery after surgery ( ERAS ) protocol and the effect of various ERAS elements on outcomes following major surgery . DESIGN Single-center prospect i ve cohort study before and after reinforcement of an ERAS protocol . Comparisons were made both between and across periods using multivariate logistic regression . All clinical data ( 114 variables ) were prospect ively recorded . SETTING Ersta Hospital , Stockholm , Sweden . PATIENTS Nine hundred fifty-three consecutive patients with colorectal cancer : 464 patients treated in 2002 to 2004 and 489 in 2005 to 2007 . MAIN OUTCOME MEASURES The association between improved adherence to the ERAS protocol and the incidence of postoperative symptoms , complications , and length of stay following major colorectal cancer surgery was analyzed . RESULTS Following an overall increase in preoperative and perioperative adherence to the ERAS protocol from 43.3 % in 2002 to 2004 to 70.6 % in 2005 to 2007 , both postoperative complications ( odds ratio , 0.73 ; 95 % confidence interval , 0.55 - 0.98 ) and symptoms ( odds ratio , 0.53 ; 95 % confidence interval , 0.40 - 0.70 ) declined significantly . Restriction of intravenous fluid and use of a preoperative carbohydrate drink were major independent predictors . Across periods , the proportion of adverse postoperative outcomes ( 30-day morbidity , symptoms , and readmissions ) was significantly reduced with increasing adherence to the ERAS protocol ( > 70 % , > 80 % , and > 90 % ) compared with low ERAS adherence ( < 50 % ) . CONCLUSION Improved adherence to the st and ardized multimodal ERAS protocol is significantly associated with improved clinical outcomes following major colorectal cancer surgery , indicating a dose-response relationship INTRODUCTION Colorectal surgery has been associated with a complication rate of 15 - 20 % and mean post-operative inpatient stays of 6 - 11 days . The principles of enhanced recovery after surgery ( ERAS ) are well established and have been developed to optimise peri-operative care and facilitate discharge . The purpose of this systematic review is to present an up date d review of peri-operative care in colorectal surgery from the available evidence and ERAS group recommendations . METHODS Systematic search es of the PubMed and Embase ™ data bases and the Cochrane library were conducted . A h and search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy . RESULTS A total of 59 relevant studies were identified . These included six r and omised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria . These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates . CONCLUSIONS Review ing the data reveals that ERAS protocol s have a role in reducing post-operative morbidity and result in an accelerated recovery following colorectal surgery . Similarly , both primary and overall hospital stays are reduced significantly . However , the available evidence suggests that ERAS protocol s do not reduce hospital readmissions or mortality . These findings help to confirm that ERAS protocol s should now be implemented as the st and ard approach for peri-operative care in colorectal surgery BACKGROUND The ERAS ( enhanced recovery after surgery ) care has been shown in r and omized clinical trials to improve outcome after colorectal surgery compared to traditional care . The impact of different levels of compliance and specific elements , particularly out with a trial setting , is poorly understood . OBJECTIVE This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection . METHODS The international , multicenter ERAS registry data , collected between November 2008 and March 2013 , was review ed . Patient demographics , disease characteristics , and perioperative ERAS protocol compliance were assessed . Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication . FINDINGS A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries .  Median length of stay for colorectal resections was 6 days , with readmissions in 216 ( 9.2 % ) , complications in 948 ( 40 % ) , and reoperation in 167 ( 7.1 % ) of 2352 patients . Laparoscopic surgery was associated with reduced complications [ odds ratio ( OR ) = 0.68 ; P < 0.001 ] and length of stay ( OR = 0.83 , P < 0.001 ) . Increasing ERAS compliance was correlated with fewer complications ( OR = 0.69 , P < 0.001 ) and shorter primary hospital admission ( OR = 0.88 , P < 0.001 ) . Shorter hospital stay was associated with preoperative carbohydrate and fluid loading ( OR = 0.89 , P = 0.001 ) , and totally intravenous anesthesia ( OR = 0.86 , P < 0.001 ) ; longer stay was associated with intraoperative epidural analgesia ( OR = 1.07 , P = 0.019 ) . Reduced postoperative complications were associated with restrictive perioperative intravenous fluids ( OR = 0.35 , P < 0.001 ) . CONCLUSIONS This analysis has demonstrated that in a large , international cohort of patients , increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome Background : Enhanced Recovery After Surgery ( ERAS ) program applied to colorectal laparoscopic surgery is well known to reduce hospitalization improving short-terms outcomes . Its goal is to minimize the surgical stress response in order to maintain the physiological homeostasis altered by surgery . However , there is little knowledge about the involved dynamics in the reduction of the surgical stress that these programs allow . The primary aim of this study was to compare the level of immune and nutritional serum investigators across surgery in patients undergoing elective colorectal laparoscopic surgery within an ERAS protocol or according to a st and ard care program . Material s and Methods : One hundred forty patients undergoing major colorectal laparoscopic surgery  were enrolled and r and omized in 2 groups ( 70 per arm ) . Cortisol , C-reactive protein ( CRP ) , white blood cell count , prolactin , interleukin (IL)-6 levels were collected preoperatively , 1 , 3 , and 5 days after surgery . Transferrin , prealbumin , albumin , and triglyceride level were collected preoperatively , 1 and 5 days after surgery . Short-term outcomes were also prospect ively assessed . Results : IL-6 levels were lower in the ERAS group on 1 , 3 , and 5 days postoperatively ( P<0.05 ) . IL-6 levels in the enhanced group , differently from control group , returned to preoperative level 3 days after surgery . CRP level was lower in the enhanced group on day 1 , 3 , and 5 ( P<0.05 ) . There was no difference in cortisol and prolactin levels between groups . Prealbumin serum level was higher on day 5 ( P<0.05 ) compared to st and ard group . Conclusions : ERAS protocol applied to colorectal laparoscopic surgery affects surgical stress response , decreasing IL-6 and CRP levels postoperatively and improving prealbumin postoperative synthesis BACKGROUND & AIMS Postoperative ileus is characterized by delayed gastrointestinal ( GI ) transit and is a major determinant of recovery after colorectal surgery . Both laparoscopic surgery and fast-track multimodal perioperative care have been reported to improve clinical recovery . However , objective measures supporting faster GI recovery are lacking . Therefore , GI transit was measured following open and laparoscopic colorectal surgery with or without fast-track care . METHODS Patients ( n = 93 ) requiring elective colonic surgery were r and omized to laparoscopic or conventional surgery with fast-track multimodal management or st and ard care  , result ing in 4 treatment arms . Gastric emptying and colonic transit were scintigraphically assessed from days 1 to 3 in 78 patients and compared with clinical parameters such as time to tolerance of solid food and /or bowel movement and time until ( ready for ) discharge . RESULTS A total of 71 patients without mechanical bowel obstructions or surgical complications requiring intervention were available for analysis . No differences in gastric emptying 24 hours after surgery between the different groups were observed ( P = .61 ) . However , the median colonic transit of patients undergoing laparoscopic/fast-track care was significantly faster compared with the laparoscopic/st and ard , open/fast-track , and open/st and ard care groups . Multiple linear regression analysis showed that both laparoscopic surgery and fast-track care were significant independent predictive factors of improved colonic transit . Both were associated with significantly faster clinical recovery and shorter time until tolerance of solid food and first bowel movement . CONCLUSIONS Colonic transit recovers significantly faster after laparoscopic surgery and the fast-track program ; laparoscopy and fast-track care lead to faster recovery of GI motility and improve clinical recovery Objective This study aims to investigate the role of fast-track surgery in preventing the development of postoperative delirium and other complications in elderly patients with colorectal carcinoma . Methods A total of 240 elderly patients with colorectal carcinoma ( aged ≥70 years ) undergoing open colorectal surgery was r and omly assigned into two groups , in which the patients were managed perioperatively either with traditional or fast-track approaches . The length of hospital stay ( LOS ) and time to pass flatus were compared . The incidence of postoperative delirium and other complications were evaluated . Serum interleukin-6 ( IL-6 ) levels were determined before and after surgery . Results The LOS was significantly shorter in the fast-track surgery ( FTS ) group than that in the traditional group . The recovery of bowel movement ( as indicated by the time to pass flatus ) was faster in the FTS group . The postoperative complications including pulmonary infection , urinary infection and heart failure were significantly less frequent in the FTS group . Notably , the incidence of postoperative delirium was significantly lower in patients with the fast track therapy ( 4/117 , 3.4 % ) than with the traditional therapy ( 15/116 , 12.9 % ; p = 0.008 ) . The serum IL-6 levels on postoperative days 1 , 2 , and 3 in patients with the fast-track therapy were significantly lower than those with the traditional therapy ( p < 0.001 ) . Conclusions Compared to traditional perioperative management , fast-track surgery  decreases the LOS , facilitates the recovery of bowel movement , and reduces occurrence of postoperative delirium and other complications in elderly patients with colorectal carcinoma . The lower incidence of delirium is at least partly attributable to the reduced systemic inflammatory response mediated by IL-6 Background Fast-track protocol s are followed by an enhanced recovery , early return to bowel function and to complete nutrition , and a reduced hospital stay . Our study was design ed to implement fast-track protocol in our university hospital . Methods The 96 consecutive patients with colorectal neoplasm included in the study were r and omized in two equal groups : group 1 ( FT ) included patients undergoing colorectal surgery in a fast-track protocol , and group 2 ( C ) included patients undergoing colorectal surgery with a conventional care protocol .  As with other fast-track protocol s , our protocol included carbohydrate fluids load before operation , early mobilization and oral feeding , regular prokinetics , and multimodal postoperative analgesia .  Time to restoration of bowel function , to complete mobilization and feeding , length of hospital stay , and incidence of complications and readmissions were monitored . Results Time to mobilization , restoring of bowel function , and complete oral feeding were significantly shorter with fast-track protocol ( p = 0.001 , p = 0.042 , and p = 0.01 , respectively ) . Hospital stay also was shorter in the fast-track group ( p = 0.001 ) . The incidence of complications did not significantly differ with the study groups . Conclusions In our study , fast-track protocol result ed in a shorter time to mobilization , complete feeding , and discharge from hospital . Fast-track protocol did not increase the incidence of complications . However , we consider that our data require further confirmation with powered multicenter national studies Since its introduction in the 1990s , the concept of multimodal perioperative care ( fast-track surgery , enhanced recovery programmes ) has gained widespread acceptance and is now considered as a st and ard of care . Most studies that support this approach relate to colorectal surgery , but similar data have been published across surgical specialties with major economic benefits 1–4 . The implementation process has been described in detail and is essentially based on the simple question : ‘ Why is the postoperative patient in hospital today?’1,5 . The relevant question may therefore be asked – what next ? Postoperative length of stay is often seen as the key outcome for fast-track surgery and , although this may not always be appropriate , whatever is used as a primary outcome measure must be justified adequately . It should also be emphasized that significant progress in fast-track care dem and s inclusion and implementation of all of its basic components . Many studies have not implemented the most important aspects of the care programmes that were originally described , including patient information , effective thoracic epidural analgesia with sufficient local anaesthetic that facilitates early mobilization , reduced ileus and rapid re introduction of oral feeding , or the use of non-opioid analgesia , where appropriate , in open or minimally invasive surgery . An important issue that needs to be addressed in future is detailed analysis of ‘ medical ’ versus ‘ surgical ’ morbidity6 . To improve further our underst and ing of perioperative risk , future studies must analyse how one specific complication might lead to another : for instance , whether a pneumonia or myocardial infa rct ion led to an anastomotic dehiscence ; or a wound dehiscence with reoperation led to a subsequent pneumonia , myocardial infa rct ion or thromboembolic complication6 . Initial ‘ medical ’ morbidity may depend on perioperative care principles and pre-existing comorbidity , in contrast to an initial ‘ surgical ’ complication , which may depend on surgical technique , and therefore require a different approach from fast-track methodology . How might the fast-track approach evolve further , as surgeons perform an ever-increasing number of major procedures in older patients with comorbidities , with greater risks of postoperative complications , prolonged hospital stay and death6 ? Preoperative evaluation of operative risk may not be helpful unless evidence -based perioperative interventions are available and instituted . Thus , the specific role of preoperative morbidity , such as smoking , diabetes and cardiopulmonary disease , in determining the risk of postoperative morbidity needs to be reassessed in studies with a fully implemented fast-track procedure-specific programme6 . We also need to have a second look at the relative roles of the different components of the fast-track programme ( for example type of analgesia and fluid management1,5 ) and analyse where progress can be made in order to reduce perioperative risk and morbidity , instead of focusing on length of stay as the primary outcome . The surgical stress response is proportional to the degree of insult and the main factor that contributes to postoperative organ dysfunction1,2 . Every effort should therefore be made to reduce those responses that are undesirable . Regional anaesthetic techniques have a powerful effect on the catabolic response , reducing cardiac dem and s , pain , pulmonary dysfunction and ileus .  Regional anaesthesia should be used whenever possible on a procedure-specific basis7 . Inflammatory responses contribute to pain , fatigue and organ dysfunction . They can be modified pharmacologically by preoperative glucocorticoids8 . Significant reductions in pain , nausea and vomiting , and early fatigue have been demonstrated , facilitating early recovery , so far without demonstrable side-effects . More procedure-specific and dosefinding studies are required . A single preoperative glucocorticoid dose in a larger amount than used for conventional nausea and vomiting prophylaxis might , for instance , be an important contributory factor to improving fast-track programmes in high-risk patients . Minimally invasive surgery also reduces the inflammatory response , although the contribution that this plays in the context of fast-track programmes in colonic surgery is difficult to interpret , as the care programmes used in the ‘ open ’ groups have often not been fully implemented6,9,10 . Therefore , future efforts to assess early postoperative outcome effects of minimally invasive surgery should include r and omized studies with fully implemented fasttrack programmes11 . Newer developments in minimally invasive OBJECTIVE To evaluate  enhanced recovery after surgery(ERAS ) protocol in colorectal surgery . METHODS From september 2006 to February 2007 , 74 patients with colorectal cancer were r and omly assigned to ERAS group and control group . The stress index , nutrition and metabolism index , intraoperative index and postoperative index were evaluated . RESULTS Six patients were excluded , 3 in ERAS group ( 2 cases received hepatectomy concomitantly and 1 case received partial ileum resection ) , and 3 in control group ( 1 case received hepatectomy  and 1 case received colorectomy concomitantly , another presented asthma paroxysm ) . So there were 34 cases in ERAS group and 34 cases in control , with no statistical differences in sex , age , BMI index and operation types . Deviation of HOMA-IR index of ERAS was lower than the control ( P>0.05 ) , the same as plasma cortisol at the 1st day after operation ( P<0.05 ) , but plasma glucagons in the operation of ERAS group was higher than that of control ( P<0.05 ) . Plasma glucose 1st day after operation of ERAS group was lower than control ( P<0.05 ) , while plasma triglyceride intraoperation , at 1st day , 2nd day after operation of ERAS was higher than control ( P<0.05 ) . Nitrogen negative balance of ERAS group was higher than control at 2nd day after surgery , but is lower intraoperation and at 6th day after operation ( P<0.05 ) . The time of exhaust gas and stool , time to eat fluidity and semi-fluidity , out-of-bed time and exercise time per-day , residual time and complication rate in ERAS group were better than those of control ( P<0.05 ) . Post-operative expenses of ERAS was lower than that of control ( P<0.05 ) . CONCLUSION ERAS can decrease surgical stress , increase functional recovery and reduce complication rate Background This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery , and to provide grade d recommendations for items for an evidence d-based enhanced recovery protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omized controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( evidence grade : high or moderate ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , European Society for Clinical Nutrition and Metabolism ( ESPEN ) and International Association for Surgical Metabolism and Nutrition ( IASMEN ) present a comprehensive evidence -based consensus review of perioperative care for rectal surgery Background Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . Methods An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated “ high ” , “ moderate ” , “ low ” or “ very low ” . Recommendations were grade d as “ strong ” or “ weak ” . Results Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . Conclusions The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials BACKGROUND & AIMS Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . METHODS An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated " high " , " moderate " , " low " or " very low " . Recommendations were grade d as " strong " or " weak " . RESULTS Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . CONCLUSIONS The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials Background Enhanced recovery after surgery ( ERAS ) programs are aim ed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles . “ Early mobilization ” is one such principle , but the quality of assessment and monitoring is poor , and evidence of improved outcome is lacking . Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization . The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristb and s. Methods / design Patients undergoing elective open and laparoscopic surgery of the colon , rectum , stomach , pancreas , and liver for any indication will be included . Further inclusion criteria are age between 18 and 75 years , American Society of Anesthesiologists Physical Status class less than IV , and a signed informed consent form . Patients will be stratified into two subgroups , laparoscopic and open surgery , and will be r and omized 1:1 for automatic feedback of their step count using an activity tracker wristb and . The control group will have no automatic feedback . The sample size ( n = 30 patients in each of the four groups , overall n = 120 ) is calculated on the basis of an assumed difference in step count of 250 steps daily ( intervention group versus control group ) . The primary study endpoint is the average step count during the first 5 postoperative days ; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization ( step count ) targets , assessment of additional activity data obtained from the devices , assessment of preoperative mobility , length of hospital and intensive care unit stays , number of patients who receive physiotherapy , 30-day mortality , and overall 30-day morbidity . Discussion Early mobilization is a key element of ERAS . However , enhanced early mobilization is difficult to define , to assess objective ly , and to implement in clinical practice . Consequently , there is a discrepancy between ERAS targets and actual practice , especially in patients undergoing major visceral surgery . This study is the first r and omized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization . Trial registration Clinical Trials.gov identifier : NCT02834338 . Registered on 15 June 2016 Background This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery INTRODUCTION Laparoscopic surgery is well established in the modern management of colorectal disease . More recently , enhanced recovery after surgery ( ERAS ) protocol s have been introduced to further promote accelerated discharge and faster recovery . However , not all patients are suitable for early discharge . The purpose of this study was to evaluate the early outcomes of patients undergoing such a regime to determine which peri-operative factors may predict safe accelerated discharge . METHODS Data were prospect ively collected on consecutive patients undergoing laparoscopic colorectal surgery .  All patients followed the institution 's ERAS protocol and were discharged once specific criteria were fulfilled . Clinical characteristics and outcomes were compared between patients who were discharged before and after 72 h post-surgery . Thereafter , the peri-operative factors that were associated with delayed discharge were determined using a binary logistic model . RESULTS Three hundred patients were included in the analysis . The most common operation was laparoscopic anterior resection ( n = 123 , 41 % ) . Mean length of stay was 4.8 days ( st and ard deviation 5.9 ) , with 185 ( 62 % ) patients discharged within 72 h. Ten ( 3 % ) patients had a post-operative complication . Three independent predictors of delayed discharge were identified ; BMI ( OR 1.06 , 95%CI 1.01 - 1.11 ) , operation length ( OR 0.99 , 95%CI 0.98 - 0.99 ) and complications ( OR 16.26 , 95%CI 4.88 - 54.08 ) . CONCLUSIONS A combined approach of laparoscopic surgery and ERAS leads to reduced length of stay . This enables more than 60 % of patients to be discharged within 72 h. Increased BMI , duration of operation and complications post-operatively independently predict a longer length of stay Background Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track recovery programs . Both focus on a faster recovery and shorter hospital stay . The r and omized controlled multicenter LAFA-trial ( LAparoscopy and /or FAst track multimodal management versus st and ard care ) was conceived to determine whether laparoscopic surgery , fast track perioperative care or a combination of both is to be preferred over open surgery with st and ard care in patients having segmental colectomy for malignant disease . Methods / design The LAFA-trial is a double blinded , multicenter trial with a 2 × 2 balanced factorial design . Patients eligible for segmental colectomy for malignant colorectal disease i.e. right and left colectomy and anterior resection will be r and omized to either  open or laparoscopic colectomy  , and to either st and ard care or the fast track program . This factorial design produces four treatment groups ; open colectomy with st and ard care ( a ) , open colectomy with fast track program ( b ) , laparoscopic colectomy with st and ard care ( c ) , and laparoscopic surgery with fast track program ( d ) . Primary outcome parameter is postoperative hospital length of stay including readmission within 30 days . Secondary outcome parameters are quality of life two and four weeks after surgery , overall hospital costs , morbidity , patient satisfaction and readmission rate . Based on a mean postoperative hospital stay of 9 + /- 2.5 days a group size of 400 patients ( 100 each arm ) can reliably detect a minimum difference of 1 day between the four arms ( alfa = 0.95 , beta = 0.8 ) . With 100 patients in each arm a difference of 10 % in subscales of the Short Form 36 ( SF-36 ) question naire and social functioning can be detected . Discussion The LAFA-trial is a r and omized controlled multicenter trial that will provide evidence on the merits of fast track perioperative care and laparoscopic colorectal surgery in patients having segmental colectomy for malignant disease Background Few clinical studies or r and omized clinical trial results have reported the impact of fast-track surgery on human immunity . This study aim ed to investigate the clinical and immune impact of fast-track surgery in colorectal cancer patients undergoing elective open surgery . Methods A controlled r and omized clinical trial was conducted from November 2008 to January 2009 with a 1-month postdischarge follow-up . A total of 70 patients with colorectal carcinoma requiring colorectal resection were r and omized into two groups : a fast-track group ( 35 cases ) and a conventional care group ( 35 cases ) . All included patients underwent elective open colorectal resection with combined tracheal intubation and general anesthesia .  Clinical parameters and markers of immune function were evaluated in both groups postoperatively . Results In all , 62 patients completed the study : 32 in the fast-track group and 30 in the conventional care group . Our findings revealed a significantly shorter postoperative hospital stay and faster return of gastrointestinal function in patients undergoing fast-track rehabilitation . In addition , we found a quicker response of white blood cells in the fast-track group than in the conventional care group . We also found that blood levels of globulin , immunoglobulin G , and complement 4 on postoperative day 3 were higher in the fast-track group than in the conventional care group . Conclusions Fast-track surgery accelerates clinical recovery and improves postoperative immunity after elective open surgery for colorectal carcinoma BACKGROUND : Enhanced recovery after surgery programs have been developed to improve recovery , shorten hospital stays , and reduce morbidity . OBJECTIVE : The aim of the current study was to examine the effects of the enhanced recovery program on the outcome of rectal surgery . DESIGN : A cohort of patients who underwent open rectal surgery after an enhanced recovery program was compared with a historic case-matched control group receiving conventional perioperative care . Patients were matched for type of surgery , disease , comorbidity , and demographic characteristics . Data regarding fast-track targets , length of hospital stay , mortality , complications , relaparotomies , and readmissions were collected . RESULTS : Forty-one patients in the enhanced recovery group were compared with 82 case-matched patients receiving conventional care .  The length of hospital stay ( median : 8 days vs 12 days , P < .005 ) was reduced in the enhanced recovery after surgery group . There were no significant differences in epidural use , mortality , morbidity , and readmission rates between groups . LIMITATIONS : This study performed an intention-to-treat analysis for the multimodal enhanced recovery program in rectal surgery . Specific elements of the program were not analyzed separately . The study used nonr and omly assigned historic controls for comparison . CONCLUSION : Enhanced recovery after surgery programs help to reduce the length of hospital stay after rectal surgery BACKGROUND There is increasing interest in implementing comprehensive perioperative protocol s , including preoperative optimization and education , perioperative goal -directed fluid management , and postoperative fast tracking , to enhance recovery after surgery . Data on the outcomes of these protocol s in pancreatic surgery , however , are limited . STUDY DESIGN A retrospective review of a prospect ively maintained pancreas surgery data base at a single institution from August 2012 to April 2015 was undertaken . An enhanced recovery protocol was initiated in October 2014 , and patients were divided into groups according to pre protocol or post protocol implementation . Preoperative , intraoperative , and postoperative data were tabulated . Statistical analysis was performed with Student 's t-test and Fisher 's exact tests , as well as e quality of variances where appropriate , using SAS System software ( SAS Institute ) . RESULTS Three hundred and seventy-eight patients ( 181 men , mean age 54 years , BMI 28 kg/m(2 ) ) underwent elective pancreatic surgery during the study period , 297 patients pre protocol and 81 post protocol . There were no significant differences in preoperative or intraoperative characteristics . Mean postoperative length of stay was significantly lower in the Enhanced Recovery After Surgery group ( 7.4 vs 9.2 days ; p < 0.0001 ) . Hospital costs were similarly lower in the Enhanced Recovery After Surgery group ( $ 23,307.90 vs $ 27,387.80 ; p < 0.0001 ) . Readmission ( 29 % vs 32 % ) and pancreatic fistula ( 26 % vs 28 % ) rates were similar between groups . Delayed gastric emptying was lower in the Enhanced Recovery After Surgery group ( 26 % vs 13 % ; p = 0.03 ) . CONCLUSIONS Implementation of an enhanced recovery after pancreatic surgery protocol significantly decreased length of stay and hospital cost without increasing readmission or morbidity . Despite patient complexity and the potential need for individualization of care , enhanced recovery protocol s can be valuable and effective in high-risk patient population s , including pancreatic surgery patients Objective : To evaluate the effect of  laparoscopic or open colectomy with fast track or st and ard perioperative care on patient 's immune status and stress response after surgery . Methods : Patients with nonmetastasized colon cancer were r and omized to laparoscopic or open colectomy with fast track or st and ard care .  Blood sample s were taken preoperatively ( baseline ) , and 1 , 2 , 24 , and 72 hours after surgery . Systemic HLA-DR expression , C-reactive protein , interleukin-6 , growth hormone , prolactin , and cortisol were analyzed . Results : Nineteen patients were r and omized for laparoscopy and fast track care ( LFT ) , 23 for laparoscopy and st and ard care ( LS ) , 17 for open surgery and fast track care ( OFT ) , and 20 for open surgery and st and ard care ( OS ) . Patient characteristics were comparable . Mean HLA-DR was 74.8 in the LFT group , 67.1 in the LS group , 52.8 in the OFT group , and 40.7 in the OS group . Repeated- measures 2-way analysis of variance ( ANOVA ) showed this can be attributed to type of surgery and not aftercare ( P = 0.002 ) . Interleukin-6 levels were highest in the OS group . Repeated- measures 2-way ANOVA showed this can be attributed to type of surgery and not aftercare ( P = 0.001 ) . C-reactive protein levels were highest in the OS group . Following repeated- measures 2-way ANOVA , this can be attributed to type of surgery and not aftercare ( P = 0.022 ) . Growth hormone was lowest in the LFT group . Following repeated- measures 2-way ANOVA , this can be attributed to type of aftercare and not to type of surgery ( P = 0.033 ) . No differences between the groups were seen regarding prolactin or cortisol . No differences in ( infectious ) complication rates were observed between the groups . Conclusions : This r and omized trial showed that immune function of HLA-DR in patients undergoing laparoscopic surgery with fast track care remains highest . This can be attributed to type of surgery and not aftercare . These results may indicate a reason for the accelerated recovery of patients treated laparoscopically within a fast track program as described in the LAparoscopy and /or FAst track multimodal management versus st and ard care ( LAFA-Trial ) ( www.trialregister.nl , protocol NTR222 ) INTRODUCTION Enhanced Recovery After Surgery ( ERAS ) programs have demonstrated significant reduction in hospital stay for patients undergoing colonic surgery ;  however , their impact on long-term outcomes , such as postoperative fatigue ( POF ) , has not been fully established . AIM To assess the impact of an ERAS program on POF and recovery following elective open colonic surgery . METHOD In a prospect i ve study , 26 consecutive patients undergoing open colonic surgery under a conventional care plan were compared with 26 consecutive patients in an ERAS program .  RESULTS Demographic and clinical characteristics were comparable at baseline . The median duration of total hospital stay ( 4 versus 7 d , P < 0.001 ) , rates of urinary tract infections ( P = 0.028 ) and ileus ( P = 0.042 ) were significantly smaller in the ERAS group . Postoperatively , POF significantly increased in both groups . However , peak POF score was significantly lower in the ERAS group ( P = 0.001 ) . In the first 30 d after surgery , Fatigue Consequence scores were also significantly smaller in the ERAS group . Overall , the total fatigue experience ( P = 0.035 ) and the total fatigue impact ( P = 0.005 ) were significantly smaller in the ERAS group . CONCLUSION The impact of ERAS programs may extend beyond the commonly reported short-term outcomes , and ERAS may accelerate overall recovery and return to normal function
The present systematic review shows that , with the exception of laparoscopic surgery , objective evidence of the effect of individual components of ERAS protocol s in reducing the stress response following colorectal surgery is limited
Abstract Enhanced Recovery or Fast Track Recovery after Surgery protocol s ( ERAS ) have significantly changed perioperative care following colorectal surgery and are promoted as reducing the stress response to surgery .