A systematic review of enhanced recovery protocols in colorectal surgery. Alvimopan Provides Additional Improvement in Outcomes and Cost Savings in Enhanced Recovery Colorectal Surgery Enhanced recovery in colorectal surgery: a multicentre study The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Cost-effectiveness of Enhanced Recovery Versus Conventional Perioperative Management for Colorectal Surgery 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 Enhanced Recovery Program following Colorectal Resection in the Elderly Patient The benefit of an enhanced recovery programme following elective laparoscopic sigmoid colectomy Urethral catheter‐less robotic‐assisted radical prostatectomy Implementing Fast-Track Protocol for Colorectal Surgery: A Prospective Randomized Clinical Trial Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial Adherence to Enhanced Recovery after Surgery Protocols across a High-Volume Gastrointestinal Surgical Service Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial EnROL: A multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme Laparoscopic-Assisted and Open High Anterior Resection within an ERAS Protocol An Enhanced-Recovery Protocol Improves Outcome After Colorectal Resection Already During the First Year: A Single-Center Experience in 168 Consecutive Patients Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: EnROL. Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: A randomized controlled trial. Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections Enhanced Recovery After Surgery Protocols Are Valuable in Pancreas Surgery Patients. Fast‐track surgery: the next revolution in surgical care following laparoscopy
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 Objective : To examine the impact of alvimopan on outcomes and costs in a rigorous enhanced recovery colorectal surgery protocol . Background : Postoperative ileus remains a major source of morbidity and costs in colorectal surgery . Alvimopan has been shown to reduce incidence of postoperative ileus in enhanced recovery colorectal surgery ; however , data are equivocal regarding its benefit in reducing length of stay and costs . Methods : Patients undergoing major elective enhanced recovery colorectal surgery were identified from a prospect ively-collected data base ( 2010–2013 ) . Multivariable analyses were employed to compare outcomes and hospital costs among patients who had alvimopan versus no alvimopan  by adjusting for demographic , clinical , and treatment characteristics . Results : A total of 660 patients were included ; 197 patients received alvimopan and 463 patients had no alvimopan .  In unadjusted analysis , the alvimopan group had a faster return of bowel function , shorter length of stay , and lower rates of ileus , Foley re-insertion , and urinary tract infection ( all P < 0.01 ) . After adjustment , alvimopan was associated with a faster return of bowel function by 0.6 day ( P = 0.0006 ) , and lower incidence of postoperative ileus ( odds ratio 0.23 , P = 0.0002 ) . With adjustment , alvimopan was associated with a shorter length of stay by 1.6 days ( P = 0.002 ) , and a hospital cost savings of $ 1492 per patient ( P = 0.01 ) . Conclusions : Alvimopan administration as an element of enhanced recovery colorectal surgery is associated with faster return of bowel function , lower incidence of postoperative ileus , shorter hospitalization , and a significant cost savings . These results suggest that alvimopan is cost-effective in the setting of enhanced recovery colorectal surgery protocol s , and should therefore be considered in these programs Background Major colorectal surgery usually requires a hospital stay of more than 12 days . Inadequate pain management , intestinal dysfunction and immobilisation are the main factors associated with delay in recovery . The present work assesses the short and medium term results achieved by an enhanced recovery program based on previously published protocol s. Methods This prospect i ve study , performed at 12 Spanish hospitals in 2008 and 2009 , involved 300 patients . All patients underwent elective colorectal resection for cancer following an enhanced recovery program .  The main elements of this program were : preoperative advice , no colon preparation , provision of carbohydrate-rich drinks one day prior and on the morning of surgery , goal directed fluid administration , body temperature control during surgery , avoiding drainages and nasogastric tubes , early mobilisation , and the taking of oral fluids in the early postoperative period . Perioperative morbidity and mortality data were collected and the length of hospital stay and protocol compliance recorded . Results The median age of the patients was 68 years . Fifty-two % of the patients were women . The distribution of patients by ASA class was : I 10 % , II 50 % and III 40 % . Sixty-four % of interventions were laparoscopic ; 15 % required conversion to laparotomy . The majority of patients underwent sigmoidectomy or right hemicolectomy .  The overall compliance to protocol was approximately 65 % , but varied widely in its different components . The median length of postoperative hospital stay was 6 days . Some 3 % of patients were readmitted to hospital after discharge ; some 7 % required repeat surgery during their initial hospitalisation or after readmission . The most common complications were surgical ( 24 % ) , followed by septic ( 11 % ) or other medical complications ( 10 % ) . Three patients ( 1 % ) died during follow-up . Some 31 % of patients suffered symptoms that delayed their discharge , the most common being vomiting or nausea ( 12 % ) , dyspnoea ( 7 % ) and fever ( 5 % ) . Conclusion The following of this enhanced recovery program posed no risk to patients in terms of morbidity , mortality and shortened the length of their hospital stay . Overall compliance to protocol was 65 % . The following of this program was of benefit to patients and reduces costs by shortening the length of hospital stay . The implantation of such programmes is therefore highly recommended 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 Objective : To determine the cost-effectiveness of enhanced recovery pathways ( ERPs ) versus conventional care for patients undergoing elective colorectal surgery . Background : ERPs for colorectal surgery are clinical ly effective , but their cost-effectiveness is unknown . Methods : A multi-institutional prospect i ve cohort cost-effectiveness analysis was performed . Adult patients undergoing elective colorectal resection at 2 university-affiliated institutions from October 2012 to October 2013 were enrolled . One center used an ERP , whereas the other did not . Postoperative outcomes were recorded up to 60 days . Total costs were reported in 2013 Canadian dollars . Effectiveness was measured using the SF-6D , a health utility measure vali date d for postoperative recovery . Uncertainty was expressed using bootstrapped estimates ( 10,000 repetitions ) . Results : A total of 180 patients were included  ( conventional care : n = 95 ; ERP : n = 95 ) . There were no differences in patient characteristics except for a higher proportion of laparoscopy in the ERP group . Mean length of stay was shorter in the ERP group ( 6.5 vs 9.8 days ; P = 0.017 ) , but there were no differences in complications or readmissions . Patients in the ERP group returned to work quicker and had less caregiver burden . There was no difference in quality of life between the 2 groups . The cost of the ERP program was $ 153 per patient . Overall societal costs were lower in the ERP group ( mean difference = −2985 ; 95 % confidence interval , −5753 to −373 ) . The ERP had a greater than 99 % probability of cost-effectiveness . The results were insensitive to a range of assumptions and subgroups . Conclusions : Enhanced recovery is cost-effective compared with conventional perioperative management for elective colorectal resection 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 enhanced recovery program ( ERP ) aims to reduce the metabolic response to surgery , hastening recovery and shortening hospital stay . Concerns exist regarding morbidity and hospital stay in elderly patients . The present study aim ed to compare the outcomes and compliance of elderly patients managed by an ERP protocol with a younger group . Methods A review was performed of a prospect i ve data base of patients undergoing colorectal resection managed under the ERP protocol between 2005 and 2010 . Patients were grouped into < 80 years and ≥80 years , and perioperative data were collated . The postoperative outcomes were compared with the goals set out by the ERP protocol . Results A total of 688 patients were included , 558 were < 80 years ( median : 66 years ; range : 17–79 years ) and 130 were ≥80 years ( median : 83 years ; range : 80–95 years ) . Some 96 % of operations were planned laparoscopically . Median total length of hospital stay was 6 days ( range : 1–108 days ) for the < 80 year group and 8 days ( range : 1–167 days ; P 0.363 ) for the elderly group , with a 30 day readmission rate of 8.6 % for the population and no significant differences between groups . The 30 day mortality was 5 % , with a significant difference between the two groups ( P < 0.0001 ) . Differences in protocol adherence were identified in the discontinuation of intravenous fluids , catheter removal , and early mobilization . Conclusions An enhanced recovery program is feasible for colorectal surgery patients ≥80 years of age , with similar compliance as the younger group to some aspects of the protocol and an acceptable readmission rate . Attention to improving compliance in the postoperative phase is necessary , particularly in such high-risk patients , as such improvement may reduce the morbidity and mortality Background Enhanced recovery programmes ( ERPs ) have demonstrated reduced morbidity and length of hospital stay in patients undergoing open elective colorectal resections . The application of laparoscopic techniques to colorectal surgery is associated with shorter length of stay and morbidity compared to open resections . In the setting of laparoscopic surgery , it is unclear whether there is an additive effect on length of stay and morbidity by combining these . The current study addresses the benefit of an ERP ( RAPID protocol ) in a cohort of matched patients undergoing laparoscopic sigmoid colon resection Material s and methods Consecutive patients over a 40-month period who underwent laparoscopic sigmoid colon resection  were assigned either to the RAPID protocol ( group 1 ) or traditional post operative care ( group 2 ) in a non-r and omised manner . Analysis was on an “ intention to treat ” basis . Primary and secondary endpoints were identified ; primary endpoints included length of hospital stay and readmission rate . Secondary endpoints included morbidity and mortality rate . Results Seventy-three consecutive patients were included . Group 1 included 37 patients . Group 2 included 36 patients .  Median length of hospital stay in groups 1 and 2 was 5 and 8 days , respectively ( p = 0.01 ) . Readmission rate in groups 1 and 2 was 8.1 % and 8.3 % , respectively ( p = 0.98 ) . Morbidity rate in groups 1 and 2 was 30 % and 22 % , respectively ( p = 0.61 ) ; there was one mortality in each group . Conclusion The application of the ERP ( RAPID ) to patients undergoing laparoscopic sigmoid colon resection results in a significant improvement in length of hospital stay , with comparable morbidity and readmission rates © 2 0 1 0 T H E A U T H O R S J O U R N A L C O M P I L A T I O N © 2 0 1 0 B J U I N T E R N A T I O N A L 1 2 0 1 8 Faiz O , Brown T , Colucci G , Kennedy RH . A cohort study of results following  elective colonic resection  within an enhanced recovery programme . Colorectal Dis 2009 ; 11 : 366–72 9 Lassen K , Soop M , Nygren J et al. Consensus review of optimal perioperative care in colorectal surgery . Enhanced Recovery After Surgery ( ERAS ) Group Recommendations . Arch Surg 2009 ; 144 : 961–9 10 Halaszynski TM , Juda R , Silverman DG . Optimizing postoperative outcomes with efficient preoperative assessment and management . Crit Care Med 2004 ; 32 ( Suppl . ) : S76–86 11 Guenaga KF , Matos D , Castro AA , Atallah A , Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery . Cochrane Data base Syst Rev 2005 ; ( 1 ) : CDOO1544 12 Shafii M , Murphy DM , Donovan MG , Hickey DP . Is mechanical bowel preparation necessary in patients undergoing cystectomy and urinary diversion . BJU Int 2002 ; 89 : 879–81 13 Smith AF , Pittaway AJ . Premedication for anxiety in adult day surgery : up date of Cochrane Data base Syst Rev 2000 : CD002192 . Cochrane Data base Syst Rev 2003 ; ( 1 ) : CD002192 14 Gerts WH , Pineo GF , Heit JA et al. Prevention of venous thromboembolism : the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy . Chest 2004 ; 126 : 338S–400S 15 Fearon KC , Luff R. The nutritional management of surgical patients : enhanced recovery after surgery . Proc Nutr Soc 2003 ; 62 : 807–11 16 Noblett SE , Watson DS , Huong H , Davison B , Hainsworth PJ , Horgan AF . Pre-operative oral carbohydrate loading in colorectal surgery : a r and omized controlled trial . Colorectal Dis 2006 ; 8 : 563–9 17 Wong PF , Kumar S , Bohra A et al. R and omized clinical trial of perioperative systemic warming in major elective abdominal surgery . Br J Surg 2007 ; 94 : 421–6 18 Ratnaraj J , Kabon B , Talcoff MR , Sessler DI , Kurz A. Supplemental oxygen and carbon dioxide each increase subcutaneous and intestinal intramural oxygenation . Anesth Analg 2004 ; 99 : 207–11 19 Grief R , Akça O , Horn EP , Kurz A , Sessler DI . Supplemental perioperative oxygen to reduce the incidence of surgical wound infection . Outcomes Research Group . N Engl J Med 2000 ; 342 : 161–7 20 Grief R , Laciny S , Rapf B , Hickle RS , Sessler DI . Supplemental oxygen reduces the incidence of post operative nausea and vomiting . Anesthesiology 1999 ; 91 : 1246–52 21 HTA . Full report : systematic review of the clinical effectiveness and cost effectiveness of oesophageal Doppler monitoring in critically ill and high risk surgical patients . Available at : http:// www.hta.ac.uk/project/.asp . Accessed 5 December 2009 22 Cepeda MS , Carr DB , Mir and a N , Diaz A , Silva C , Morales O. Comparison of morphine , ketorolac , and their combination for postoperative pain : results from a large , r and omised , double blind trial . Anaesthesiology 2005 ; 103 : 1225–32 23 Arumainayagam N , McGrath J , Jefferson KP , Gillatt DA . Introduction of an enhanced recovery protocol for radical cystectomy . BJU Int 2008 ; 101 : 698–701 24 Pruthi RS , Chun J , Richman M. Reducing time to oral diet and hospital discharge in patients undergoing radical cystectomy using a perioperative care plan . Urology 2003 ; 62 : 661–6 25 Chang SS , Baumgartner RG , Wells N et al. Causes of increased hospital stay after radical cystectomy in a clinical pathway setting . J Urol 2002 ; 167 : 208– 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 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 : 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 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 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 Background During the last two decades the use of laparoscopic resection and a multimodal approach known as an enhanced recovery programme , have been major changes in colorectal perioperative care . Clinical outcome improves using laparoscopic surgery to resect colorectal cancer but until recently no multicentre trial evidence had been reported regarding whether the benefits of laparoscopy still exist when open surgery is optimized within an enhanced recovery programme . The EnROL trial ( Enhanced Recovery Open versus Laparoscopic ) examines the hypothesis that laparoscopic surgery within an enhanced recovery programme will provide superior postoperative outcomes when compared to conventional open resection of colorectal cancer within the same programme . Methods / design EnROL is a phase III , multicentre , r and omised trial of laparoscopic versus open resection of colon and rectal cancer with blinding of patients and outcome observers to the treatment allocation for the first 7 days post-operatively , or until discharge if earlier . 202 patients will be recruited at approximately 12 UK hospitals and r and omised using minimization at a central computer system in a 1:1 ratio . Recruiting surgeons will previously have performed > 100 laparoscopic colorectal resections  and > 50  open total mesorectal excisions to minimize conversion . Eligible patients are those suitable for elective resection using either technique . Excluded patients include : those with acute intestinal obstruction and patients in whom conversion from laparoscopic to open procedure is likely . The primary outcome is physical fatigue as measured by the physical fatigue domain of the multidimensional fatigue inventory 20 ( MFI-20 ) with secondary outcomes including postoperative hospital stay ; complications ; reoperation and readmission ; quality of life indicators ; cosmetic assessment s ; st and ardized performance indicators ; health economic analysis ; the other four domains of the MFI-20 . Pathological assessment of surgical quality will also be undertaken and compliance with the enhanced recovery programme will be recorded for all patients . Discussion Should this trial demonstrate that laparoscopic surgery confers a significant clinical and /or health economic benefit this will further support the transition to this type of surgery , with implication s for the training of surgeons and re source allocation . Trial registration IS RCT N48516968 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 PURPOSE : This study was design ed to investigate the clinical outcome and recovery before and immediately after implementation of the enhanced recovery after surgery enhanced recovery after surgery protocol in colonic and rectal resection . METHODS : One hundred and sixty-eight consecutive patients in a single center underwent colorectal surgery before ( traditional , n = 69 ) and immediately after implementing enhanced recovery after surgery ( n = 99 ) . Rectal surgery was performed in 77 patients . Postoperative food and fluid intake , mobilization , physiologic function , and clinical outcome were measured prospect ively . RESULTS : Resumption of oral diet was achieved on postoperative day postoperative day 1 in the enhanced recovery after surgery group . In the enhanced recovery after surgery group , mobilization more than 6 hours daily was achieved on postoperative day 2 to 3 and passage of stool occurred on postoperative day 2 vs. postoperative day 5 in the traditional group ( P < 0.0001 ) . Muscle strength and lung function were less reduced in the enhanced recovery after surgery group ( P < 0.05 ) . Median hospital stay was reduced by 2 days ( P < 0.01 ) . Readmission rates increased ( 4 percent vs. 15 percent , P < 0.01 ) but total hospital stay was still lower in the enhanced recovery after surgery group ( P < 0.01 ) . After colonic resection , postoperative complications decreased in enhanced recovery after surgery ( 37 percent vs. 18 percent , P < 0.05 ) , whereas no change was found after rectal resection . CONCLUSION : Immediately after implementing enhanced recovery after surgery , recovery was improved and length of hospital stay was reduced . Notably , postoperative morbidity decreased only in patients undergoing colonic resection PURPOSE Laparoscopic resection and a multimodal approach known as an enhanced recovery program ( ERP ) have been major changes in colorectal perioperative care that have improved clinical outcomes for colorectal cancer resection . EnROL ( Enhanced Recovery Open Versus Laparoscopic ) is a multicenter r and omized controlled trial examining whether the benefits of laparoscopy still exist when open surgery is optimized within an ERP . PATIENTS AND METHODS Adults with colorectal cancer suitable for elective resection were r and omly assigned at a ratio of 1:1 to  laparoscopic or open surgery within an ERP , stratified by center , cancer site ( colon v rectum ) , and age group ( < 66 v 66 - 75 v > 75 years ) using minimization . The primary outcome was physical fatigue at 1 month postsurgery . Secondary outcomes included hospital stay , complications , other patient-reported outcomes ( PROs ) , and physical function . Patients and outcome assessors were blinded until 7 days postsurgery or discharge if earlier . Central independent and blinded pathologic assessment of surgical quality was undertaken . RESULTS A total of 204 patients ( laparoscopy , n=103 ; open surgery , n=101 ) were recruited from 12 UK centers from July 2008 to April 2012 .  One-month physical fatigue scores were similar in both groups ( mean : laparoscopy , 12.28 ; 95 % CI , 11.37 to 13.19 v open surgery , 12.05 ; 95 % CI , 11.14 to 12.96 ; adjusted mean difference , -0.23 ; 95 % CI , -1.52 to 1.07 ) . Median total hospital stay was significantly shorter after laparoscopic surgery ( median : laparoscopy , 5 ; interquartile range [ IQR ] , 4 to 9 v open surgery , 7 ; IQR , 5 to 11 days ; P=.033 ) . There were no differences in other secondary outcomes or in specimen quality after central pathologic review . CONCLUSION In patients treated by experienced surgeons within an ERP , physical fatigue and other PROs were similar in both groups , but laparoscopic surgery significantly reduced length of hospital stay 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 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 Enhanced recovery after surgery ( ERAS ) programs can accelerate recovery and shorten the hospital stay after colorectal resections . The RAPID ( remove , ambulate , postoperative analgesia , introduce diet ) protocol is a simplified ERAS program that consists of a simplified , user-friendly single-page pro forma schedule . This study aim ed to evaluate the impact of the RAPID protocol on patients undergoing both laparoscopic and open colorectal resections in two specialized colorectal units . Methods A prospect i ve , two-center study assessed 117 age-matched patients undergoing open or laparoscopic colorectal resection to compare the postoperative course for patients using the RAPID protocol with those treated in a traditional manner . Results Of the 117 patients studied , 70 underwent laparoscopic resection ( 55 with the RAPID protocol ) and 47 underwent open resection ( 25 with the RAPID protocol  ) . Patients undergoing laparoscopic resections with the RAPID protocol had a significantly shorter hospital stay ( p = 0.01 ) and tolerance of a full diet ( p = 0.002 ) . Similarly , patients undergoing open resections with the RAPID protocol also have a significantly shorter hospital stay ( p = 0.04 ) . Conclusion The RAPID protocol is a user-friendly , easy , and effective tool that facilitates earlier tolerance of diet and discharge from the hospital for patients undergoing laparoscopic or open colorectal resections 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 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
In predefined subgroup analyses , findings did not vary by surgical approach ( open vs laparoscopic ) or colorectal condition .
CONCLUSIONS : Enhanced recovery protocol s for adults undergoing colorectal surgery improve patient outcomes with no increase in adverse events .
Evidence was insufficient regarding which components , or component combinations , are key to improving patient outcomes .
BACKGROUND : Enhanced surgical recovery protocol s are design ed to reduce hospital length of stay and health care costs .
OBJECTIVE : This study aims to systematic ally review and summarize evidence from r and omized and controlled clinical trials comparing enhanced recovery protocol s versus usual care in  adults undergoing elective colorectal surgery with emphasis on recent trials , protocol components , and subgroups for surgical approach and colorectal condition .