Enhanced Recovery Pathways After Colorectal Surgery

Background

Major surgery is usually followed by pain, stress-induced organ dysfunction, and catabolism. These sequelae increase the risk of cardiopulmonary, infectious, thromboembolic, and cognitive complications and functional impairment, prolong hospitalization, and require rehabilitation and readmission. The concept of “fast-track surgery” or “enhanced recovery programs” has evolved in response to the adverse effects of surgery and is based on a multimodal intervention encompassing all perioperative care principles. This concept has been tested across surgical specialties with major success; it has reduced organ dysfunction, medical morbidity, and the need for hospitalization and has achieved faster recovery.

Components of Evidence-Based Care

In the original colorectal fast-track studies, the components included thoracic epidural analgesia in open surgery, avoidance of nasogastric tubes, early feeding, avoidance of fluid overload, and early mobilization. Since then, the Enhanced Recovery After Surgery (ERAS) group has suggested 19 fast-track elements. Unfortunately, most of the available studies with the multicomponent program have not been able to repeat the early studies because of lack of sufficient compliance with the program. When discussing components of evidence-based care that are relevant to enhanced recovery, the focus should be on implementing the programs as originally described. However, many of the components from past ERAS programs obviously should be updated and optimized in future research.

Evidence for Improved Outcome