Fast‐track surgery: the next revolution in surgical care following laparoscopy Laparoscopic-Assisted and Open High Anterior Resection within an ERAS Protocol A systematic review of enhanced recovery protocols in colorectal surgery. ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. EnROL: A multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme Local wound infiltration plus transversus abdominis plane (TAP) block versus local wound infiltration in laparoscopic colorectal surgery and ERAS program Surgical Stress Reduction in Elderly Patients Undergoing Elective Colorectal Laparoscopic Surgery within an ERAS Protocol. Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial. Detailed evaluation of functional recovery following laparoscopic or open surgery for colorectal cancer within an enhanced recovery programme The influence of preoperative nutritional status on the outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery Prospective study of colorectal enhanced recovery after surgery in a community hospital. Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients Influences on length of stay in an enhanced recovery programme after colonic surgery Two-day Hospital Stay After Laparoscopic Colorectal Surgery under an Enhanced Recovery after Surgery (ERAS) Pathway Adherence to Enhanced Recovery after Surgery Protocols across a High-Volume Gastrointestinal Surgical Service Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: EnROL. A prospective cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track multimodal management, for surgical patients with colon carcinomas (TAPAS study) The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Enhanced recovery in colorectal surgery: a multicentre study Enhanced Recovery After Surgery (ERAS) Versus Conventional Postoperative Care in Colorectal 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 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 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 : 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 INTRODUCTION Laparoscopic surgery is well established in the modern management of colorectal disease . More recently , enhanced recovery after surgery ( ERAS ) protocol s have been introduced to further promote accelerated discharge and faster recovery . However , not all patients are suitable for early discharge . The purpose of this study was to evaluate the early outcomes of patients undergoing such a regime to determine which peri-operative factors may predict safe accelerated discharge . METHODS Data were prospect ively collected on consecutive patients undergoing laparoscopic colorectal surgery .  All patients followed the institution 's ERAS protocol and were discharged once specific criteria were fulfilled . Clinical characteristics and outcomes were compared between patients who were discharged before and after 72 h post-surgery . Thereafter , the peri-operative factors that were associated with delayed discharge were determined using a binary logistic model . RESULTS Three hundred patients were included in the analysis . The most common operation was laparoscopic anterior resection ( n = 123 , 41 % ) . Mean length of stay was 4.8 days ( st and ard deviation 5.9 ) , with 185 ( 62 % ) patients discharged within 72 h. Ten ( 3 % ) patients had a post-operative complication . Three independent predictors of delayed discharge were identified ; BMI ( OR 1.06 , 95%CI 1.01 - 1.11 ) , operation length ( OR 0.99 , 95%CI 0.98 - 0.99 ) and complications ( OR 16.26 , 95%CI 4.88 - 54.08 ) . CONCLUSIONS A combined approach of laparoscopic surgery and ERAS leads to reduced length of stay . This enables more than 60 % of patients to be discharged within 72 h. Increased BMI , duration of operation and complications post-operatively independently predict a longer length of stay BACKGROUND The ERAS ( enhanced recovery after surgery ) care has been shown in r and omized clinical trials to improve outcome after colorectal surgery compared to traditional care . The impact of different levels of compliance and specific elements , particularly out with a trial setting , is poorly understood . OBJECTIVE This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection . METHODS The international , multicenter ERAS registry data , collected between November 2008 and March 2013 , was review ed . Patient demographics , disease characteristics , and perioperative ERAS protocol compliance were assessed . Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication . FINDINGS A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries .  Median length of stay for colorectal resections was 6 days , with readmissions in 216 ( 9.2 % ) , complications in 948 ( 40 % ) , and reoperation in 167 ( 7.1 % ) of 2352 patients . Laparoscopic surgery was associated with reduced complications [ odds ratio ( OR ) = 0.68 ; P < 0.001 ] and length of stay ( OR = 0.83 , P < 0.001 ) . Increasing ERAS compliance was correlated with fewer complications ( OR = 0.69 , P < 0.001 ) and shorter primary hospital admission ( OR = 0.88 , P < 0.001 ) . Shorter hospital stay was associated with preoperative carbohydrate and fluid loading ( OR = 0.89 , P = 0.001 ) , and totally intravenous anesthesia ( OR = 0.86 , P < 0.001 ) ; longer stay was associated with intraoperative epidural analgesia ( OR = 1.07 , P = 0.019 ) . Reduced postoperative complications were associated with restrictive perioperative intravenous fluids ( OR = 0.35 , P < 0.001 ) . CONCLUSIONS This analysis has demonstrated that in a large , international cohort of patients , increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome Background 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 Few data are available on TAP block in laparoscopic colorectal surgery and ERAS program . The aim of this prospect i ve study was to evaluate local wound infiltration plus TAP block compared to local wound infiltration in the management of postoperative pain , nausea and vomiting , ileus and use of opioids in the context of laparoscopic colorectal surgery and ERAS program . Methods From March 2014 to March 2015 , 48 patients were treated by laparoscopic resection and ERAS program for colorectal cancer and diverticular disease at the Division of General and Hepatobiliary Surgery , University of Verona Hospital Trust . Among these , 24 patients received local wound infiltration plus TAP block ( TAP block group ) and 24 patients received local wound infiltration ( control group ) . Results No differences were observed in baseline patient characteristics , clinical variables and surgical procedures between the two groups . Local wound infiltration plus TAP block allowed to achieve pain control despite a reduced use of opioid analgesics ( P = 0.009 ) . The adoption of TAP block result ed beneficial on the prevention of postoperative nausea ( P = 0.002 ) and improvement of essential outcomes of ERAS program as recovery of bowel function ( P = 0.005 ) , urinary catheter removal ( P = 0.003 ) and capability to tolerate oral diet ( P = 0.027 ) . Conclusions TAP block plus local wound infiltration in the setting of laparoscopic colorectal surgery and ERAS program guarantees a reduced use of opioid analgesics and good pain control allowing the improvement of essential items of enhanced recovery pathways ERAS program applied to colorectal laparoscopic surgery is well known to reduce hospitalization improving short terms outcomes and minimizing the Surgical Stress Response . However its effectiveness in elderly population is yet to be demonstrated . The primary aim of this study is to compare the level of immune and nutritional serum indexes across surgery in patients aged over 70 years old undergoing elective colorectal laparoscopic surgery within an ERAS protocol or according to a St and ard program . 83 patients undergoing colorectal laparoscopic surgery were enrolled and r and omized in two groups ( ERAS Group 40 , St and ard Group 43 ) within a larger r and omized trial on a general population . Surgical stress parameters were collected preoperatively , 1 , 3 and 5 days after surgery . Nutritional parameters were collected preoperatively , 1 and 5 days after surgery . Short Term Outcomes were also prospect ively assessed . IL-6 levels were lower in the EG on 1 , 3 , and 5 days post-operatively ( p 0.05 ) . IL-6 levels in the Enhanced group returned to pre operative level 3 days after surgery . C-reactive protein 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 . Postoperative outcomes in terms of normal bowel function and length of hospital stay were significantly improved in the ERAS group . Colorectal laparoscopic surgery within an ERAS prototcol in elderly patients affects Surgical Stress Response , decreasing IL-6 and CRP levels postoperatively and improving Prealbumin post operative synthesis BACKGROUND This study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine , when compared with systemic morphine , on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery ( ERAS ) programme for laparoscopic colonic resection . METHODS Fifty patients undergoing general anaesthesia were r and omly allocated  to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone ( spinal group ) or patient-controlled analgesia ( PCA group ) . The primary outcome was consumption of opioids during the first three postoperative days . Secondary outcomes were pain scores , return of bowel function and dietary intake , readiness to hospital discharge , and length of hospital stay . RESULTS Postoperative opioid consumption in the spinal group was significantly less over the first three postoperative days ( P<0.001 ) . The quality of analgesia at rest in the first 24 h was better in the spinal group ( P<0.005 ) . Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia . There were no differences between the two groups in other outcomes ( return of bowel function and dietary intake , readiness to hospital discharge , and length of hospital stay ) . CONCLUSIONS When ERAS programme is used for laparoscopic colonic resection , an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption , but has no other advantages over systemic opioids Background and aims Evidence demonstrating improved short-term outcomes with laparoscopic surgery compared with open surgery for colorectal cancer is accumulating . In addition , programmes optimising peri-operative care for major abdominal surgery are becoming widespread . Evaluating laparoscopic surgery and enhanced recovery programmes usually focuses on short-term recovery . The aim of this study was to compare recovery after laparoscopic and open surgery for colorectal cancer up to 1 year post-operatively , using a combination of self-report and observer data . Patients / Methods From January 2002 to March 2004 , 62 patients were r and omised ( 2:1 ) to receive laparoscopic ( n = 43 ) or open surgery ( n = 19 ) within an enhanced recovery programme .  Functional outcomes up to 1 year were assessed using interview-administered question naires . Results / Findings Question naire and health-related quality of life data were obtained in over 85 % of patients . Patients undergoing laparoscopic surgery  felt fully recovered and resumed driving more quickly than those having open surgery ( p = 0.016 and p = 0.048 respectively ) . Fifty-eight percent of patients having open surgery felt fully recovered by 12 months versus 88 % of laparoscopic patients .Interpretation/ Conclusion Within an enhanced recovery programme , patients undergoing laparoscopic surgery  recovered more quickly than after open resection . Both approaches however , were associated with slow recovery despite a relatively short hospital stay 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 IMPORTANCE Enhanced recovery after surgery ( ERAS ) colorectal programs have shown to be successful at reducing length of stay in many international and academic centers ; however , their efficacy in a community hospital setting remains unclear . OBJECTIVE To determine if favorable results could be reproduced in a community hospital setting using our ERAS program , which was developed using core ERAS guidelines with the goal of accelerated recovery while also addressing other important outcomes affecting patient experience and safety . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve study of ERAS program , a multidisciplinary effort involving anesthesia , preadmission staff , nursing , and surgery staff at a community hospital . The program was initiated in 2010 and was in full practice by 2011 . We assessed practice patterns and patient outcomes for all elective colon and rectal resection cases performed in 2009 ( prior to ERAS implementation ) , 2011 , and 2012 . MAIN OUTCOMES AND MEASURES Laparoscopic approach , narcotic use , length of stay , 30-day readmission , ileus ( defined as reinsertion of nasogastric tube ) , and intra-abdominal infection and association between colorectal cancer ( CRC ) diagnosis and these outcomes . RESULTS From 2009 to 2012 , the use of laparoscopy increased from 57.4 % to 88.8 % ( P < .001 ) . Length of stay decreased significantly ( 6.7 days vs 3.7 days , P < .001 ) , without an increase in 30-day readmission rate ( 17.6 % vs 12.5 % , P = .49 ) . Use of patient-controlled narcotic analgesia and duration of use decreased ( 63.2 % of patients vs 15 % , P < .001 ; 67.8 hours vs 47.1 hours , P = .02 ) . Ileus rate decreased from 13.2 % to 2.5 % ( P = .02 ) . Intra-abdominal infection decreased from 7.4 % to 2.5 % ( P = .24 ) . When comparing laparoscopic cases alone , similar results were observed . Following regression analysis , there were no statistically significant differences between CRC diagnosis and LOS , 30-day readmission rates , ileus , and intra-abdominal infection ( all P 's > .05 ) . Length of stay reductions result ed in an estimated cost savings of $ 3202 per patient ( 2011 ) and $ 4803 per patient ( 2012 ) . CONCLUSIONS AND RELEVANCE Implementation of this patient care-directed enhanced recovery program is feasible in a community hospital setting , and it is associated with decreased LOS without increased readmission or morbidity , as well as significant decreases in narcotic use and cost . Improved outcomes are independent of the laparoscopic approach and CRC diagnosis 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 Aim Enhanced recovery after surgery ( ERAS ) programmes have been shown to accelerate and enhance functional recovery after colonic surgery . We analysed prospect ively collected data to investigate potentially modifiable factors that may influence the length of stay ( LOS ) in the ERAS setting at a single institution 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 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 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 The present developments in colon surgery are characterized by two innovations : the introduction of the laparoscopic operation technique and fast recovery programs such as the Enhanced Recovery After Surgery ( ERAS ) recovery program . The Tapas- study was conceived to determine which of the three treatment programs : open conventional surgery , open ' ERAS ' surgery or laparoscopic ' ERAS ' surgery for patients with colon carcinomas is most cost minimizing ? Method / design The Tapas- study is a three-arm multicenter prospect i ve cohort study .All patients with colon carcinoma , eligible for surgical treatment within the study period in four general teaching hospitals and one university hospital will be included . This design produces three cohorts : Conventional open surgery is the control exposure ( cohort 1 ) . Open surgery with ERAS recovery ( cohort 2 ) and laparoscopic surgery with ERAS recovery ( cohort 3 ) are the alternative exposures . Three separate time periods are used in order to prevent attrition bias . Primary outcome parameters are the two main cost factors : direct medical costs ( real cost price calculation ) and the indirect non medical costs ( friction method ) . Secondary outcome parameters are mortality , complications , surgical-oncological resection margins , hospital stay , readmission rates , time back to work/recovery , health status and quality of life . Based on an estimated difference in direct medical costs ( highest cost factor ) of 38 % between open and laparoscopic surgery ( alfa = 0.01 , beta = 0.05 ) , a group size of 3 × 40 = 120 patients is calculated . Discussion The Tapas- study is three-arm multicenter cohort study that will provide a cost evaluation of three treatment programs for patients with colon carcinoma , which may serve as a guideline for choice of treatment and investment strategies in hospitals . Trial registration IS RCT N44649165 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 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 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 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
Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS , morbidity and readmission .
Conclusion Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection .
Reduced compliance increases LOS , morbidity and readmission to hospital .
The impact of compliance with individual ERAS protocol elements is insufficiently studied , and the lack of a st and ardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection
Objective To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery ( ERAS ) programmes following  laparoscopic colorectal surgery .
Background ERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit .
However , there is a minority of patients that do not benefit from these strategies and their identification is not well characterised .
The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood .