Initial Experiences of an Enhanced Recovery Protocol in Esophageal Surgery The effect of formalizing enhanced recovery after esophagectomy with a protocol. A systematic review of enhanced recovery protocols in colorectal surgery. Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial A prospective study on the influence of a fast-track program on postoperative fatigue and functional recovery after major colonic 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 Fast‐track surgery: the next revolution in surgical care following laparoscopy 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 influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. Adherence to Enhanced Recovery after Surgery Protocols across a High-Volume Gastrointestinal Surgical Service Enhanced Recoveryafter Colorectal Surgery. Results from Aprospective Observational Two-Centre Study Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Enhanced Recovery After Surgery (ERAS) Versus Conventional Postoperative Care in Colorectal Surgery Laparoscopic-Assisted and Open High Anterior Resection within an ERAS Protocol The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations An enhanced recovery pathway decreases duration of stay after esophagectomy. Local wound infiltration plus transversus abdominis plane (TAP) block versus local wound infiltration in laparoscopic colorectal surgery and ERAS program Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial [Application of the protocol of enhanced recovery after surgery in colorectal surgery]. Recovery after open and laparoscopic right hemicolectomy: a comparison.
Background A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery ( ERAS ) programs . Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce . We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease . Methods The ERAS program was initiated in 2009 . Patients who underwent esophagectomy and were treated according to the ERAS program were included . Items of ERAS included preoperative nutrition , early extubation , early removal of nasogastric tube , and early mobilization . Primary outcome parameters were hospital stay and the incidence of postoperative complications . Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol . A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient . Results Between 2008 and August 2010 , 181 patients in our department underwent esophagectomy .  Of these , 103 patients were included in the ERAS program ( ERAS+ group ) and were compared to 78 patients who had undergone an esophagectomy in 2008 ( ERAS– group ) .  Overall hospital stay was 14 days versus 15 days ( ERAS+ and ERAS– , respectively ; p = 0.013 ) . There were no significant differences in the incidence of postoperative complications in either group . The percentage of achieved items varied between 42 and 93 % per item . Conclusions The implementation of an ERAS program in esophageal surgery was feasible and result ed in a small but significant reduction in overall hospital stay , whereas overall morbidity was not affected Enhanced recovery after surgery ( ERAS ) pathways aim to accelerate functional return and discharge from hospital . They have proven effective in many forms of surgery , most notably colorectal . However , experience in esophagectomy has been limited . A recent study reported significant reductions in pulmonary complications , mortality , and length of stay following the introduction of an ERAS protocol alone , without the introduction of any clinical changes . We instituted a similar change 16 months ago , introducing a protocol to provide a formal framework , for our existing postoperative care . This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change . Data were collected from prospect ively maintained secure web-based multidisciplinary data bases . Complication severity was classified using the Clavien-Dindo scale . Operative mortality was defined as death within 30 days of surgery , or at any point during the same hospital admission . Lower respiratory tract infection was defined as clinical evidence of infection , with or without radiological signs . Respiratory complications included lower respiratory tract infection , pleural effusion ( irrespective of drainage ) , pulmonary collapse , and pneumothorax . Statistical analysis was performed using SPSS v21 . One hundred thirty-two patients underwent esophagectomy ( 55 protocol group ; 77 before ) . All were performed open . There were no differences between the two groups in terms of age , gender , operation , use of neoadjuvant therapy , cell type , stage , tumor site , or American Society of Anesthesiologists grade . Median length of stay was 14.0 days ( protocol ) compared with 12.0 before ( interquartile range 9 - 19 and 9.5 - 15.5 , respectively ; P = 0.073 , Mann-Whitney U-test ) . Readmission within 30 days of discharge occurred in five ( 9.26 % ) and six ( 8.19 % ; P = 1.000 , Fisher 's exact test ) . There were four in-hospital deaths ( 3.03 % ) : one ( 1.82 % ) and three ( 3.90 % ) , respectively ( P = 0.641 ) . There were no differences in the severity of complications ( P = non-significant ; Pearson 's chi-squared ) . There were no differences in the type of complications occurring in either group . The protocol was completed successfully by 26 ( 47.3 % ) . No baseline factors were predictive of this . In contrast to previous studies , we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol . Consequently , improvements in short-term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care . Consequently , we would recommend that centers introducing new ( or review ing existing ) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such st and ardized pathways INTRODUCTION Colorectal surgery has been associated with a complication rate of 15 - 20 % and mean post-operative inpatient stays of 6 - 11 days . The principles of enhanced recovery after surgery ( ERAS ) are well established and have been developed to optimise peri-operative care and facilitate discharge . The purpose of this systematic review is to present an up date d review of peri-operative care in colorectal surgery from the available evidence and ERAS group recommendations . METHODS Systematic search es of the PubMed and Embase ™ data bases and the Cochrane library were conducted . A h and search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy . RESULTS A total of 59 relevant studies were identified . These included six r and omised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria . These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates . CONCLUSIONS Review ing the data reveals that ERAS protocol s have a role in reducing post-operative morbidity and result in an accelerated recovery following colorectal surgery . Similarly , both primary and overall hospital stays are reduced significantly . However , the available evidence suggests that ERAS protocol s do not reduce hospital readmissions or mortality . These findings help to confirm that ERAS protocol s should now be implemented as the st and ard approach for peri-operative care in colorectal surgery Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety INTRODUCTION Enhanced Recovery After Surgery ( ERAS ) programs have demonstrated significant reduction in hospital stay for patients undergoing colonic surgery ;  however , their impact on long-term outcomes , such as postoperative fatigue ( POF ) , has not been fully established . AIM To assess the impact of an ERAS program on POF and recovery following elective open colonic surgery . METHOD In a prospect i ve study , 26 consecutive patients undergoing open colonic surgery under a conventional care plan were compared with 26 consecutive patients in an ERAS program .  RESULTS Demographic and clinical characteristics were comparable at baseline . The median duration of total hospital stay ( 4 versus 7 d , P < 0.001 ) , rates of urinary tract infections ( P = 0.028 ) and ileus ( P = 0.042 ) were significantly smaller in the ERAS group . Postoperatively , POF significantly increased in both groups . However , peak POF score was significantly lower in the ERAS group ( P = 0.001 ) . In the first 30 d after surgery , Fatigue Consequence scores were also significantly smaller in the ERAS group . Overall , the total fatigue experience ( P = 0.035 ) and the total fatigue impact ( P = 0.005 ) were significantly smaller in the ERAS group . CONCLUSION The impact of ERAS programs may extend beyond the commonly reported short-term outcomes , and ERAS may accelerate overall recovery and return to normal function 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 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 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 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 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 and Aims : Enhanced recovery after surgery ( ERAS ) has reduced the median hospital stay from 8–10 days with traditional peri-operative routines to four days . The aim of the present study was to introduce the principles of ERAS in our hospital and measure the effect on hospital stay , complications and quality of life after discharge from hospital . Material and Methods : 94 consecutive patients , 40 males , 54 females , median age 66 years , were included in a prospect i ve non-r and omised observational study at Haukel and University Hospital and Haugesund Hospital from October 2000 until February 2003 . After a three-month preparation period , the principles of ERAS were implemented . The results were evaluated with question naires and by follow-ups 8–10 and 30 days after surgery . The results were compared to the results of colorectal surgery before introduction of accelerated recovery . Results : 45 ( 48 % ) and 73 ( 78 % ) patients were discharged within three and five days after surgery with ERAS , compared to zero and seven ( 5 % ) patients with traditional recovery . The complication rate with ERAS was 31 % , and the readmission rate was 15 % . After one week , 57 % had resumed their daily activities at home . After 30 days , 65 % of the patients had resumed their normal and leisure activities . Conclusion : After a proper preparation period , ERAS principles may be implemented in surgical department , and is followed by a reduced median hospital stay and rapid return to normal daily activities for most patients after colorectal surgery 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 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 Background Due to potentially superior short-term outcomes compared with open colorectal surgery , laparoscopic surgery is currently being implemented in clinical practice worldwide . In parallel , enhanced recovery after surgery ( ERAS ) programs are shown to improve postoperative recovery in open colorectal surgery . This study reports outcomes in laparoscopic versus open surgery in conjunction with compliance to the ERAS protocol . Methods The association between surgical approach ( laparoscopic or open surgery ) , compliance to the ERAS protocol , postoperative symptoms , complications , and length of stay after surgery was studied . Between January 2007 to December 2010 , 114 consecutive patients underwent elective high anterior resection with laparoscopic-assisted ( n = 55 ) or open resection ( n = 59 ) . All clinical data ( 114 variables ) were prospect ively recorded . Results The overall preoperative ERAS- protocol compliance was 77 % for both the laparoscopic and open group . Laparoscopic surgery result ed in shorter total length of stay ( median 4 vs. 6 days , p = 0.04 ) , earlier pain control ( median 2 vs. 3 days , p = 0.008 ) , shorter need for intravenous infusions , improved mobilization on the first postoperative day ( POD1 ) , and lower inflammatory response ( CRP ( POD1 ) 54 ± 24 vs. 67 ± 31 mg/l , p = 0.017 ) compared with open resection . The trends in fewer postoperative complications ( 9.1 vs. 16.9 % ; odds ratio ( OR ) 0.55 ; 95 % confidence interval ( CI ) 0.17–1.81 ) and overall postoperative symptoms delaying recovery ( 20 vs. 30.5 % ; OR 0.63 ; 95 % CI 0.22–1.34 ) in laparoscopic surgery were not statistically significant . Conclusions The use of laparoscopy in colorectal surgery within an ERAS protocol results in faster recovery compared with open resection BACKGROUND 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 This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery PURPOSE Enhanced recovery pathways ( ERP ) decrease morbidity and duration of stay after colorectal surgery . There is little information about their role in complex procedures , such as esophagectomy . The purpose of this study was to determine the impact of an ERP on duration of stay , complications , and readmissions after esophagectomy . METHODS Patients undergoing esophagectomy for cancer or high- grade dysplasia from June 2009 to December 2011 were identified from a prospect ively maintained data base . Beginning in June 2010 , all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan , indications for intensive care admission , early structured mobilization , and diet and drain management . Short-term ( 30-day ) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway . Data are expressed as median values [ interquartile range ] . RESULTS We identified 106 patients ; 47 underwent esophagectomy before ERP implementation and 59 after . Patients were similar with respect to age , gender , diagnosis , and operative time .  Hospital stay was shorter in the ERP group ( 8 [ 7 - 17 ] vs 10 [ 9 - 17 ] days ; P = .01 ) . There were no differences in rates of complications ( 59 % vs 62 % ) or readmissions ( 6 % vs 5 % ) . CONCLUSION Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay , without an increase in complications or readmissions 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 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 : 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 OBJECTIVE To evaluate  enhanced recovery after surgery(ERAS ) protocol in colorectal surgery . METHODS From september 2006 to February 2007 , 74 patients with colorectal cancer were r and omly assigned to ERAS group and control group . The stress index , nutrition and metabolism index , intraoperative index and postoperative index were evaluated . RESULTS Six patients were excluded , 3 in ERAS group ( 2 cases received hepatectomy concomitantly and 1 case received partial ileum resection ) , and 3 in control group ( 1 case received hepatectomy  and 1 case received colorectomy concomitantly , another presented asthma paroxysm ) . So there were 34 cases in ERAS group and 34 cases in control , with no statistical differences in sex , age , BMI index and operation types . Deviation of HOMA-IR index of ERAS was lower than the control ( P>0.05 ) , the same as plasma cortisol at the 1st day after operation ( P<0.05 ) , but plasma glucagons in the operation of ERAS group was higher than that of control ( P<0.05 ) . Plasma glucose 1st day after operation of ERAS group was lower than control ( P<0.05 ) , while plasma triglyceride intraoperation , at 1st day , 2nd day after operation of ERAS was higher than control ( P<0.05 ) . Nitrogen negative balance of ERAS group was higher than control at 2nd day after surgery , but is lower intraoperation and at 6th day after operation ( P<0.05 ) . The time of exhaust gas and stool , time to eat fluidity and semi-fluidity , out-of-bed time and exercise time per-day , residual time and complication rate in ERAS group were better than those of control ( P<0.05 ) . Post-operative expenses of ERAS was lower than that of control ( P<0.05 ) . CONCLUSION ERAS can decrease surgical stress , increase functional recovery and reduce complication rate BACKGROUND Enhanced Recovery after Surgery ( ERAS ) programs have gained popularity with potential to accelerate recovery and reduce morbidity after colectomy . We were interested in comparing recovery after open right colectomy within an ERAS program compared with laparoscopic right colectomy in a st and ard care perioperative environment . METHODS Between October 2005 and June 2009 , prospect i ve data were collected on consecutive patients undergoing elective open right colectomy within an established ERAS setting ( OpERAS ) . Similarly , between March 2008 and June 2009 , data were collected on consecutive patients undergoing laparoscopic right hemicolectomy with conventional care ( LapCon ) . Exclusion criteria for both groups were : ASA > or= 4 , formation of a stoma , and dementia or mental illness rendering the patient unable to comply with instructions . Perioperative variables were collected . The surgical recovery score ( SRS ) was used as a vali date d means to measure convalescence on d 1 , 3 , 7 , 30 , and 60 postoperatively . RESULTS There were 74 patients in the OpERAS and 39 patients in the LapCon groups . At baseline , there were no significant demographic differences except that more patients had malignancy in OpERAS group .  Mean operating time was longer in the LapCon group . Median day stay was 4 ( 3 - 28 ) in OpERAS and 5 ( 2 - 18 ) in LapCon ( P = 0.032 ) . There was no statistical difference in the incidence of complications or the severity of complications . There were no significant differences in SRS after surgery at any time point . CONCLUSION When perioperative care is optimized , recovery after elective open right hemicolectomy is comparable with laparoscopic resection . Studies looking at the combination of laparoscopy and ERAS are warranted
Overall , there is little direct evidence for components of ERAS , with much derived from nonesophageal thoracoabdominal surgery .
ERAS in principle seems logical and safe for esophagectomy .
OBJECTIVE This article aims to provide the first systematic review of enhanced recovery after surgery ( ERAS ) programs for  esophagectomy  and generate guidelines .
BACKGROUND ERAS programs use multimodal approaches to reduce complications and accelerate recovery .
Although ERAS is well established in colorectal surgery , experience after esophagectomy has been minimal .
However , esophagectomy remains an extremely high-risk operation , commonly performed in patients with significant comorbidities .
Consequently , ERAS may have a significant role to play in improving outcomes .
No guidelines or review s have been published in esophagectomy .