Fast‐track surgery: the next revolution in surgical care following laparoscopy Enhanced Recovery After Surgery (ERAS) Versus Conventional Postoperative Care in Colorectal Surgery Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients Compliance with enhanced recovery after surgery criteria and preoperative and postoperative counselling reduces length of hospital stay in colorectal surgery: results of a randomized controlled trial The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial A systematic review of enhanced recovery protocols in colorectal surgery. Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: A randomized controlled trial. Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. The effect of formalizing enhanced recovery after esophagectomy with a protocol. Two-day Hospital Stay After Laparoscopic Colorectal Surgery under an Enhanced Recovery after Surgery (ERAS) Pathway Safety and efficacy of an “enhanced recovery after surgery” protocol for patients undergoing colon cancer surgery: a multi-institutional controlled study Laparoscopic-Assisted and Open High Anterior Resection within an ERAS Protocol Initial Experiences of an Enhanced Recovery Protocol in Esophageal Surgery Adherence to Enhanced Recovery after Surgery Protocols across a High-Volume Gastrointestinal Surgical Service ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: Impact of measures to improve adherence. Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. Dexamethasone reduces emesis after major gastrointestinal surgery (DREAMS) Does enhanced recovery reduce postoperative ileus after colorectal surgery? The influence of preoperative nutritional status on the outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery
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 Background Enhanced Recovery After Surgery ( ERAS ) programs are associated with reduced hospital morbidity and mortality . The aim of the present study was to evaluate whether the introduction of ERAS care improved the adverse events in colorectal surgery . In a cohort study , mortality , morbidity , and length of stay were compared between ERAS patients and carefully matched historical controls . Methods Patients were matched for their type of disease , the type of surgery , P-Possum ( Portsmouth-Possum ) , CR-Possum ( Colorectal-Possum ) Physiological and Operative Score for Enumeration of Mortality and Morbidity ( POSSUM ) , gender , and American Society of Anesthesiologists ( ASA ) grade . The primary outcome measures of this study were mortality and morbidity . Secondary outcome measures were fluid intake , length of hospital stay , the number of relaparotomies , and the number of readmissions within 30 days . Data on the ERAS patients were collected prospect ively . Results Sixty-one patients treated according to the ERAS program were compared with 122 patients who received conventional postoperative care .  The two groups were comparable with respect to age , ASA grade , P-Possum ( Portsmouth-Possum ) , CR-Possum ( Colorectal-Possum ) score , type of surgery , stoma formation , type of disease , and gender . Morbidity was lower in the ERAS group compared to the control group ( 14.8 % versus 33.6 % respectively ; P = < 0.01 ) . Patients in the ERAS group received significantly less fluid and spent fewer days in the hospital ( median 6 days , range 3–50 vs. median 9 days , range 3–138 ; P = 0.032 ) . There was no difference between the ERAS and the control group for mortality ( 0 % vs. 1.6 % ; P = 0.55 ) and readmission rate ( 3.3 % vs. 1.6 % ; P = 0.60 ) . Conclusion Enhanced Recovery After Surgery program  reduces morbidity and the length of hospital stay for patients undergoing elective colonic or rectal surgery Aim : Enhanced recovery after surgery ( ERAS ) is a multimodal approach that aims to optimize perioperative treatment . Whether elderly patients receiving colorectal surgery can adhere to and benefit from an ERAS approach is uncertain . The aim of this study was to compare patients in different age groups participating in an ERAS program .  Method : In this sub study of a r and omized controlled trial , we analyzed the interventional ERAS arm of adult patients eligible for laparoscopic or open colorectal resection with regard to the importance of age . Patients were divided into three groups based on age : ≤65 years ( n = 79 ) , 66 - 79 years ( n = 56 ) , and ≥80 years ( n = 19 ) . The primary end point was total postoperative hospital stay ( THS ) . Secondary end points were postoperative hospital stay , postoperative complications , postoperative C-reactive protein levels , readmission rate , mortality , and patient adherence to the different  ERAS elements . All parameters and measuring the adherence to the ERAS protocol were recorded before surgery , on the day of the operation , and daily until discharge . Results : There were no significant differences in length of THS between age groups ( ≤65 years , median 5 [ range 2 - 47 ] days ; 66 - 79 years , median 5.5 [ range 2 - 36 ] days ; ≥80 years , median 7 [ range 3 - 50 ] days ; p = .53 ) . All secondary outcomes were similar between age groups . Patient adherence to the ERAS protocol was as good in the elderly as it was in the younger patients . Conclusion : Elderly patients adhered to and benefited from an ERAS program , similar to their younger counterparts The aim of this r and omized clinical trial was to compare patients treated using a multimodal approach [ enhanced recovery after surgery ( ERAS ) ]  , with a special focus on counselling , to patients treated in a st and ard conventional care pathway , who underwent elective colorectal resection 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 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 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 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 & AIMS Evidence of the advantages of enhanced recovery after surgery ( ERAS ) protocol s following pancreaticoduodenectomy ( PD ) is limited . The aim of this study was to examine the efficiency of ERAS protocol s in patients following PD . METHODS Between June 2014 and October 2016 , patients undergoing PD were r and omly assigned to receive ERAS protocol s or st and ard care . The primary endpoint was the postoperative length of stay . Secondary endpoints included postoperative complications , postoperative quality -of-life ( QoR-40J ) , readmission , and medical cost . RESULTS Of 80 eligible patients , 74 were analyzed in intention-to-treat principles : 37 in the control group and 37 in the ERAS group . The mean length of stay in the ERAS group was significantly shorter than that in the control group ( 20.1 ± 5.4 vs 26.9 ± 13.5 days , P < 0.001 ) . The ERAS group had a significantly lower percentage of postoperative complications ( 32.4 % vs 56.8 % , P = 0.034 ) and readmissions ( 0 % vs 8.1 % , P = 0.038 ) . Quality -of-life was also significantly better in the ERAS group ( 184 ± 12.4 vs 177 ± 14.5 , P = 0.022 ) . The total medical cost was lower in the ERAS group , but not significantly ( $ 25,445 ± 5065 vs $ 28,384 ± 9999 , P = 0.085 ) . CONCLUSIONS The optimization of ERAS protocol s in patients undergoing PD  is safe and accelerates perioperative recovery and quality -of-life , thereby reducing the length of stay . Morbidity was significantly decreased in the ERAS group without compromising surgical outcome . REGISTRATION NUMBER UMIN000014068 Background Colorectal cancer ( CRC ) is the second most prevalent type of cancer in the world . Surgery is the only curative option . However , postoperative complications occur in up to 50 % of patients and are associated with higher morbidity and mortality rates , lower health related quality of life ( HRQoL ) and increased expenditure in health care . The number and severity of complications are closely related to preoperative functional capacity , nutritional state , psychological state , and smoking behavior . Traditional approaches have targeted the postoperative period for rehabilitation and lifestyle changes . However , recent evidence shows that the preoperative period might be the optimal moment for intervention . This study will determine the impact of multimodal prehabilitation on patients ’ functional capacity and postoperative complications . Methods / design This international multicenter , prospect i ve , r and omized controlled trial will include 714 patients undergoing colorectal surgery for cancer . Patients will be allocated to the intervention group , which will receive 4 weeks of prehabilitation ( group 1 , prehab ) , or the control group , which will receive no prehabilitation ( group 2 , no prehab ) . Both groups will receive perioperative care in accordance with the enhanced recovery after surgery ( ERAS ) guidelines . The primary outcomes for measurement will be functional capacity ( as assessed using the six-minute walk test ( 6MWT ) ) and postoperative status determined with the Comprehensive Complication Index ( CCI ) . Secondary outcomes will include HRQoL , length of hospital stay ( LOS ) and a cost-effectiveness analysis . Discussion Multimodal prehabilitation is expected to enhance patients ’ functional capacity and to reduce postoperative complications . It may therefore result in increased survival and improved HRQoL. This is the first international multicenter study investigating multimodal prehabilitation for patients undergoing colorectal surgery for cancer . Trial registration Trial Registry : NTR5947 – date of registration : 1 August 2016 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 Enhanced recovery after surgery ( ERAS ) pathways aim to accelerate functional return and discharge from hospital . They have proven effective in many forms of surgery , most notably colorectal . However , experience in esophagectomy has been limited . A recent study reported significant reductions in pulmonary complications , mortality , and length of stay following the introduction of an ERAS protocol alone , without the introduction of any clinical changes . We instituted a similar change 16 months ago , introducing a protocol to provide a formal framework , for our existing postoperative care . This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change . Data were collected from prospect ively maintained secure web-based multidisciplinary data bases . Complication severity was classified using the Clavien-Dindo scale . Operative mortality was defined as death within 30 days of surgery , or at any point during the same hospital admission . Lower respiratory tract infection was defined as clinical evidence of infection , with or without radiological signs . Respiratory complications included lower respiratory tract infection , pleural effusion ( irrespective of drainage ) , pulmonary collapse , and pneumothorax . Statistical analysis was performed using SPSS v21 . One hundred thirty-two patients underwent esophagectomy ( 55 protocol group ; 77 before ) . All were performed open . There were no differences between the two groups in terms of age , gender , operation , use of neoadjuvant therapy , cell type , stage , tumor site , or American Society of Anesthesiologists grade . Median length of stay was 14.0 days ( protocol ) compared with 12.0 before ( interquartile range 9 - 19 and 9.5 - 15.5 , respectively ; P = 0.073 , Mann-Whitney U-test ) . Readmission within 30 days of discharge occurred in five ( 9.26 % ) and six ( 8.19 % ; P = 1.000 , Fisher 's exact test ) . There were four in-hospital deaths ( 3.03 % ) : one ( 1.82 % ) and three ( 3.90 % ) , respectively ( P = 0.641 ) . There were no differences in the severity of complications ( P = non-significant ; Pearson 's chi-squared ) . There were no differences in the type of complications occurring in either group . The protocol was completed successfully by 26 ( 47.3 % ) . No baseline factors were predictive of this . In contrast to previous studies , we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol . Consequently , improvements in short-term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care . Consequently , we would recommend that centers introducing new ( or review ing existing ) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such st and ardized pathways Background The present study aims to examine the feasibility and safety of a two-day hospital stay after  laparoscopic colorectal resection ( LCR )  under an enhanced recovery after surgery ( ERAS ) pathway . Methods Between 2003 and 2010 , 882 consecutive patients undergoing LCR were analyzed . Patients were grouped and analyzed according to whether their hospital stay was 2 days ( group A ) or longer ( group B ) . Demographic , surgical , and postoperative data were compared . To identify independent predictive factors related to a short hospital stay , a multivariate analysis was also performed . Results Group A represented 10.3 % of this series ( 91 patients ) . There were no differences regarding age , gender , BMI , ASA , and previous abdominal surgeries between groups . Group A had a lower incidence of rectal cancer and anterior resections than group B ( 6.6 vs. 17.7 % [ p = 0.006 ] and 14.3 vs. 23.4 % [ p = 0.048 ] ) , respectively , and a lower mean operative time ( 170 min vs. 192 min ; p = 0.002 ) . Group A had a lower overall morbidity rate than group B ( 5.5 vs. 16.9 % ; p = 0.004 ) and a lower incidence of surgery-related complications ( 5.5 vs. 14.9 % ; p = 0.001 ) . The overall conversion rate was 10 % ( only one patient in group A required conversion ) , and the difference in conversion rate between groups was statistically significant ( 1.2 vs. 10.7 % ; p = 0.003 ) . Group A had a lower readmission rate ( 0 vs. 4.9 % ; p = 0.089 ) . Multivariate analysis showed that conversion , postoperative morbidity , and rectal prolapse were independently associated with the length of hospital stay . Conclusions A two-day hospital stay after LCR is safe and feasible under an ERAS pathway , without compromising the readmission or complication rate Purpose The aim of this multi-institutional study was to prospect ively evaluate the safety and efficacy of an enhanced recovery after surgery ( ERAS ) protocol for colonic surgery . Methods The subjects of this study were 320 patients with an American Society of Anesthesiologists ( ASA ) grade I or II physical status . Patients underwent elective open or laparoscopic colonic resection or high anterior resection between April 2011 and January 2014 at one of six institutions . Three hospitals implemented an ERAS protocol ( n = 159 ) , and three administered conventional care ( n = 161 ) . The primary outcome measure was the surgical complication rate . Results Most operations , irrespective of group , were performed laparoscopically . The incidence of a surgical complication was 17.0 % in the ERAS group vs. 16.1 % in the conventional group ( P = 0.842 ) , in which several non-surgical complications also arose . Oral food intake was implemented earlier for the ERAS group vs. the conventional group , after a median ( range ) of 1 ( 1–31 ) vs. 3 ( 1–9 ) days for the ERAS vs. conventional care groups , respectively ( P < 0.001 ) . The median length of postoperative hospital stay was reduced by 5.5 days for the ERAS group , being 8.5 ( 5–41 ) vs. 14 ( 7–56 ) days for the ERAS vs. conventional care groups , respectively ( P < 0.001 ) . Conclusion This multi-institutional controlled study clearly demonstrated that an ERAS protocol was efficient , without increasing the complication risk Background Due to potentially superior short-term outcomes compared with open colorectal surgery , laparoscopic surgery is currently being implemented in clinical practice worldwide . In parallel , enhanced recovery after surgery ( ERAS ) programs are shown to improve postoperative recovery in open colorectal surgery . This study reports outcomes in laparoscopic versus open surgery in conjunction with compliance to the ERAS protocol . Methods The association between surgical approach ( laparoscopic or open surgery ) , compliance to the ERAS protocol , postoperative symptoms , complications , and length of stay after surgery was studied . Between January 2007 to December 2010 , 114 consecutive patients underwent elective high anterior resection with laparoscopic-assisted ( n = 55 ) or open resection ( n = 59 ) . All clinical data ( 114 variables ) were prospect ively recorded . Results The overall preoperative ERAS- protocol compliance was 77 % for both the laparoscopic and open group . Laparoscopic surgery result ed in shorter total length of stay ( median 4 vs. 6 days , p = 0.04 ) , earlier pain control ( median 2 vs. 3 days , p = 0.008 ) , shorter need for intravenous infusions , improved mobilization on the first postoperative day ( POD1 ) , and lower inflammatory response ( CRP ( POD1 ) 54 ± 24 vs. 67 ± 31 mg/l , p = 0.017 ) compared with open resection . The trends in fewer postoperative complications ( 9.1 vs. 16.9 % ; odds ratio ( OR ) 0.55 ; 95 % confidence interval ( CI ) 0.17–1.81 ) and overall postoperative symptoms delaying recovery ( 20 vs. 30.5 % ; OR 0.63 ; 95 % CI 0.22–1.34 ) in laparoscopic surgery were not statistically significant . Conclusions The use of laparoscopy in colorectal surgery within an ERAS protocol results in faster recovery compared with open resection Background A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery ( ERAS ) programs . Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce . We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease . Methods The ERAS program was initiated in 2009 . Patients who underwent esophagectomy and were treated according to the ERAS program were included . Items of ERAS included preoperative nutrition , early extubation , early removal of nasogastric tube , and early mobilization . Primary outcome parameters were hospital stay and the incidence of postoperative complications . Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol . A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient . Results Between 2008 and August 2010 , 181 patients in our department underwent esophagectomy .  Of these , 103 patients were included in the ERAS program ( ERAS+ group ) and were compared to 78 patients who had undergone an esophagectomy in 2008 ( ERAS– group ) .  Overall hospital stay was 14 days versus 15 days ( ERAS+ and ERAS– , respectively ; p = 0.013 ) . There were no significant differences in the incidence of postoperative complications in either group . The percentage of achieved items varied between 42 and 93 % per item . Conclusions The implementation of an ERAS program in esophageal surgery was feasible and result ed in a small but significant reduction in overall hospital stay , whereas overall morbidity was not affected Background and Aims : Enhanced recovery after surgery ( ERAS ) has been shown to improve outcomes for patients following gastrointestinal surgery . Data on protocol adherence and how this impacts on outcome are limited . This study examines how protocol adherence changes over time and determines how this impacts on outcome across a large-volume gastrointestinal surgical service . Material s and Methods : A prospect i ve review of patients eligible for colorectal , liver and oesophagogastric ERAS over two 3-month periods in 2010 and 2011 was performed . End points included : length of stay ( LOS ) , overall protocol adherence , individual modality adherence , reason for pathway deviation and patient outcomes . Results : 172 patients ( 110 colorectal , 31 liver and 31 oesophagogastric ) were evaluated . For each sub-speciality , the introduction of ERAS led to significant reductions in LOS that were sustained for the duration of the study . Adherence was achieved across 60 % ( colorectal ) , 75 % ( liver ) and 88 % ( oesophagogastric ) of individual pathway modalities . The major causes of pathway deviation were : post-operative nausea and vomiting ( colorectal ) , pain ( liver ) and pulmonary complications ( oesophagogastric ) . Conclusions : Large-scale implementation of ERAS at a high-volume centre is feasible and offers many of the benefits demonstrated in controlled trials , but adherence may diminish over time 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 Perioperative treatment of patients with colorectal cancer according to the Enhanced Recovery After Surgery ( ERAS ) protocol has proven to reduce complications and duration of stay . However , strict adherence remains a challenge and the benefits may decrease with lower adherence . In this study , we report on 8 years of adherence to the ERAS protocol and its effect on postoperative outcome in patients with colon cancer . METHODS In 2006 , the ERAS protocol was introduced for treatment of colon cancer patients in the Medical Center Alkmaar , a large teaching hospital . Patients scheduled for elective colon cancer resection were included in this study . Adherence to ERAS items was monitored and along with clinical data prospect ively gathered in a data base . In 2011 , several measures to improve adherence were implemented . RESULTS In total , 816 patients were included .  Mean adherence rate was 73 % in 2006 and 2007 , 66 % in 2008 and 2009 , 63 % in 2010 and 2011 , and 82 % in 2012 and 2013 . There was a shorter duration of stay in the years with high adherence ( 5.7 days ) compared with the years with low adherence ( 7.3 days ; P < .001 ) . The ERAS items that were the strongest predictors for a shorter duration of stay were no nasogastric tube , early mobilization , early oral nutrition , early removal of epidural , early removal of catheter , and nonopioid oral analgesia . CONCLUSION It is possible to improve adherence to the ERAS protocol and related outcomes with specific measures . Adherence to the ERAS protocol was related inversely to duration of stay . Only postoperative items of the ERAS protocol were predictive for a shorter duration of stay . Keeping adherence optimal remains an ongoing challenge that requires repeated training and dedicated personnel OBJECTIVE Enhanced recovery after surgery ( ERAS ) has led to a paradigm shift in various surgical specialties . Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process . Still , ERAS remains relatively new to spine surgery . The authors report their 5-year experience , focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures , including anterior lumbar interbody fusion ( ALIF ) . METHODS A multimodal ERAS protocol was applied between November 2013 and October 2018 . The authors analyze hospital stay , perioperative outcomes , readmissions , and adverse events obtained from a prospect i ve institutional registry .  Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive ( MI ) anterior or posterior fusion cases were included . Their institutional ERAS protocol contains 22 pre- , intra- , and postoperative elements , including preoperative patient counseling , MI techniques , early mobilization and oral intake , minimal postoperative restrictions , and regular audits . RESULTS A total of 2592 consecutive patients were included , with 199 ( 8 % ) undergoing fusion . The mean hospital stay was 1.1 ± 1.2 days , with 20 ( 0.8 % ) 30-day and 36 ( 1.4 % ) 60-day readmissions . Ninety-four percent of patients were discharged after a maximum 1-night hospital stay . Over the 5-year period , a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed ( p < 0.001 ) , with a concomitant decrease in adverse events in the overall cohort ( p = 0.025 ) and without increase in readmissions . For fusion procedures , the rate of 1-night hospital stays increased from 26 % to 85 % ( p < 0.001 ) . Similarly , the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days ( p < 0.001 ) , with a notable concomitant decrease in variance , result ing in an estimated reduction in nursing costs of 46.8 % . CONCLUSIONS Application of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures , including ALIF , for treatment of degenerative spine conditions was safe and effective , without increase in readmissions . The data from this large case series stress the importance of the multidisciplinary , iterative improvement process to overcome the learning curve associated with ERAS implementation , and the importance of a dedicated perioperative care team . Prospect i ve trials are needed to evaluate spinal ERAS on a higher level of evidence Background Postoperative nausea and vomiting is one of the most common complications affecting patients after surgery and causes significant morbidity and increased length of hospital stay . It is accepted that patients undergoing surgery on the bowel are at a higher risk . In the current era of minimally invasive colorectal surgery combined with enhanced recovery , reducing the incidence and severity of postoperative nausea and vomiting is particularly important . Dexamethasone is widely , but not universally used . It is known to improve appetite and gastric emptying , thus reduce vomiting . However , this benefit is not established in patients undergoing bowel surgery , and dexamethasone has possible side effects such as increased risk of wound infection and anastomotic leak that could adversely affect recovery . Design DREAMS is a phase III , double-blind , multicenter , r and omized controlled trial with the primary objective of determining if preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing elective gastrointestinal resections . DREAMS aims to r and omize 1,350 patients over 2.5 years . Patients undergoing laparoscopic or open colorectal resections for malignant or benign pathology are r and omized between 8 mg intravenous dexamethasone and control ( no dexamethasone ) . All patients are given one additional antiemetic at the time of induction , prior to r and omization . Both the patient and their surgeon are blinded as to the treatment arm . Secondary objectives of the DREAMS trial are to determine whether there are other measurable benefits during recovery from surgery with the use of dexamethasone , including quicker return to oral diet and reduced length of stay . Health-related quality of life , fatigue and risks of infections will be investigated . Trial registration IS RCT INTRODUCTION While enhanced recovery after surgery ( ERAS ) has been proven to improve results in colorectal operations with regard to morbidity and duration of hospital stay , its impact on recovery of bowel motility is poorly documented . The aims of this study were to assess the impact of ERAS on bowel motility recovery , and to assess the consequences of the definition of postoperative ileus on its reported incidence in the literature . MATERIAL AND METHODS This is a single-center prospect i ve observational study of consecutive patients who underwent colorectal resection with anastomosis over a period of 17 months .  Global resumption of intestinal transit ( GROT ) was defined as passage of stool combined with alimentary tolerance of solid food . RESULTS One hundred and thirty-one patients were included . A median of 14 items ( range : 13 - 16 ) was complied out of 19 observable items in the protocol . Median time to passage of flatus ( MTPF ) was 2 days and the GROT was 3 days . The time interval to MTPF as well as to GROT decreased as adherence to the ERAS protocol increased ( respectively P<0.001 , r2=0.11 and P=0.04 , r2=0.06 ) . The incidence of postoperative " ileus " varied from 1.5 % to 61.8 % depending on the interval chosen to define ileus ( cut-off from 1 to 7 days ) . Adherence to≥85 % of the items in the ERAS protocol protected patients from " prolonged ileus " , i.e. , lasting≥4 days ( OR=0.35 ; 95 % CI=0.15 to 0.83 ) . CONCLUSION The implementation of and compliance with an ERAS protocol allowed a reduction in the time to GROT . There is a need for a consensual definition of postoperative ileus Background The aim of the present study was to evaluate the effects of preoperative nutritional status on the short-term outcomes of an enhanced recovery after surgery ( ERAS ) programme for colorectal cancer surgery . Methods This prospect i ve observational study included 149 patients who underwent elective resection of colorectal cancer with ERAS from January 2011 to January 2014 in a university hospital .  Subjective global assessment ( SGA ) was used to determine preoperative nutritional status . Primary outcomes included the length of postoperative stay , postoperative morbidity , gastrointestinal recovery , and 30-day readmission . Results The patients were divided into 3 groups according to the SGA classification . There were 96 patients ( 64.4 % ) in SGA-A ( well-nourished ) , 48 ( 32.2 % ) in SGA-B ( mild to moderately malnourished ) , and 5 ( 3.4 % ) in SGA-C ( severely malnourished ) . Patients in SGA-A had the median length of postoperative stay of 4 days ( range 2–23 ) , which was significantly shorter compared to SGA-B ( 5 days ; range 2–16 ; p < 0.01 ) and SGA-C ( 7 days ; range 4–17 ; p < 0.01 ) . The overall complication rates of SGA-A , SGA-B , and SGA-C patients were 11 , 31 % ( adjusted OR 3.76 ; 95 % CI 1.36–10.36 ; p < 0.01 ) and 40 % ( adjusted OR 2.15 ; 95 % CI 0.07–63.64 ; p = 0.66 ) . Mean time to resumption of normal diet and time to first defecation were 1.6 ± 1.3 and 2.2 ± 0.9 days in SGA-A , 2.6 ± 1.7 and 3.1 ± 1.6 days in SGA-B ( p < 0.01 compared to SGA-A ) and 3.2 ± 2.4 days and 2.6 ± 1.5 days in SGA-C ( p = 0.07 and p = 0.1 compared to SGA-A , respectively ) . No 30-day mortality occurred in any group . One patient in SGA-A ( 1 % ) , and 3 patients in SGA-B ( 6 % ) had unplanned 30-day re-admission ; p = 0.11 . Conclusions Within an ERAS programme for colorectal cancer surgery , malnourished patients were at risk for increased postoperative morbidity , delayed recovery of gastrointestinal function , and prolonged length of hospital stay
Other outcome parameters were unsuitable for meta- analysis , but seemed to favour ERAS .
Analysis shows a reduction in overall complications , but major complications were not reduced .
Length of stay was reduced significantly .
We state that ERAS seems safe , but the quality of trials and lack of sufficient other outcome parameters do not justify implementation of ERAS as the st and ard of care .
Within ERAS protocol s included , no answer regarding the role for minimally invasive surgery ( i.e. laparoscopy ) was found .
BACKGROUND In recent years the Enhanced Recovery after Surgery ( ERAS ) postoperative pathway in (ileo-)colorectal surgery , aim ing at improving perioperative care and decreasing postoperative complications , has become more common .
OBJECTIVES We investigated the effectiveness and safety of the ERAS multimodal strategy , compared to conventional care after (ileo-)colorectal surgery .
The primary research question was whether ERAS protocol s lead to less morbidity and secondary whether length of stay was reduced .