Enhanced recovery after colorectal surgery: an update on current practice Dhivya Subramaniam
Alan F Horgan
The concept of ‘enhanced recovery’ after surgery gained traction in the 1990s and has continued to evolve over the last three decades. It incorporates a host of evidence-based interventions into the patient care pathway and aims to eliminate those practices that were based in tradition and slowed the patient’s recovery. The pathway is designed to involve the patient and the wider surgical team along with primary care and support services. Enhanced recovery pathways have been emerging for a wide range of surgical subspecialties and the principles are applicable to all non day-case surgical interventions. Enhanced re-
covery after surgery pathways can be divided for simplicity into preop- erative, intraoperative and postoperative care and some of the important elements are described in this article along with the support- ing evidence.
Keywords Enhanced recovery; perioperative care
‘Enhanced recovery after surgery’ (ERAS) programmes are now
considered to be standard practice after colorectal surgery and
are fast becoming the norm for all major surgical procedures in
any of the surgical specialties. Programmes differ in certain re-
spects depending on the specialty and geographical location but
have certain common themes, the basic principles of which are
the involvement of the patient and family in decision-making
preoperatively and the involvement of the wider hospital team
in formulation and execution of a complete patient pathway of
care which is evidence-based, leading to a quicker recovery for
the patient with less chance of physiological derangement at any
stage of the perioperative period.
Education of the patient and family regarding the nature of their
illness, the decisions which need to be made, the options avail-
able and their consequences and the nature of the perioperative
Dhivya Subramaniam BMedSci BMBS is a Trainee in Surgery at the Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared.
Alan F Horgan MD FRCS (Gen) is a Consultant Surgeon in the Department of Colorectal Surgery at the Freeman Hospital, Newcastle upon Tyne, UK. Conflicts of interest: none declared.
SURGERY 35:2 98
pathway are all integral parts of an effective enhanced recovery
programme. Written information leaflets are useful and
commonly available to inform patients about their illness and
treatment options. It is essential that patients about to undergo
any form of major surgery are given contact details for the
appropriate nurse specialist in case they have any further ques-
tions prior to their surgery and further consultation should be
encouraged in the event of confusion or concern.
Assessment and optimization of comorbidities
All patients undergoing major surgery are now routinely seen at
an anaesthetic preoperative assessment clinic. In addition to
providing patient information these clinics are essential in order
to assess and optimize any coexisting medical comorbidities, and
to stratify the patient so that the appropriate level of post-
operative care can be arranged in advance. Stratification is now
generally performed by exposing the patient to a physically
‘stressful’ environment (usually on a cycle or treadmill), in order
that the physiological response of the patient can be assessed.
The anaerobic threshold (AT) is the point at which the patient
moves from aerobic to anaerobic metabolism and gives a good
indication of how the patient will respond to major surgery. The
VO2Max is another good indicator of this and represents the
maximum amount of oxygen that the patient can utilize in a
minute per kilogram of body weight. This is covered in more
detail elsewhere in this issue.
Curtailed fasting and carbohydrate loading
The traditional practice of overnight fasting to prevent risk of
aspiration during anaesthetic induction is now considered
obsolete. Prolonged fasting is associated with poorer post-
operative outcomes due to increased insulin resistance and risk
of hypovolaemia. The standard practice at present is a fasting
period of 6 hours for solids and 2 hours for clear liquids prior to
surgery and does not increase the risk of aspiration at induction.
Perioperative carbohydrate intake has been shown to
decrease postoperative insulin resistance, minimize post-
operative protein and nitrogen loss from catabolism and preserve
lean body mass. Clinically, this is manifested by a faster recovery
period and shorter duration of stay in hospital.1 A clear oral fluid
containing a high concentration of complex carbohydrate (typi-
cally 12.5% maltodextrin) should be given to all patients the
night before and 2 hours prior to surgery as part of the ERAS
pathway. This is considered safe in patients with uncomplicated
type 2 diabetes mellitus but large-scale studies of its safety in
patients with gastroparesis is currently lacking.
Selective bowel preparation
Use of mechanical bowel preparation has been linked to signifi-
cant fluid and electrolyte shifts and prolonged postoperative
ileus. At present, it is not routinely recommended in enhanced
recovery pathways for colorectal surgery. A recent meta-analysis
showed that the use of bowel preparation did not prevent against
anastomotic leak and had comparable mortality, reoperation rate
and incidence of wound infections with patients who had no
bowel preparation or rectal enema alone.2 There may, however,
be specific indications for the use of mechanical bowel prepara-
tion in cases of low rectal anastomoses with a proximal diverting
stoma. A 2010 randomized controlled trial demonstrated
� 2016 Published by Elsevier Ltd.
significantly increased postoperative morbidity in patients with a
diverting stoma who did not receive mechanical bowel prepara-
tion, with a trend towards a higher risk of anastomotic leak in
this group.3 Further studies will be necessary to evaluate the full
significance of these findings.
The use of minimally invasive techniques is strongly advocated
where possible in elective colorectal surgery and is at least as
safe as the open approach with comparable long-term oncolog-
ical outcomes.4 The benefits of laparoscopic and laparoscopic-
assisted colorectal resections are well-documented and lead to
a shorter duration of inpatient stay.5 The stress response to
surgery is minimized due to the considerably smaller degree of
trauma to the abdominal wall. Postoperative recovery is signifi-
cantly accelerated due to decreased pain and opiate requirement
which in turn prevents respiratory complications and facilitates
earlier mobilization. Minimally invasive surgery is also associ-
ated with earlier return of gut function postoperatively.
Other minimally invasive techniques such as robotic-assisted
colorectal resection, single-incision laparoscopic surgery (SILS)
and natural orifice transluminal endoscopic surgery (NOTES) pro-
cedures have been attempted with some success, but there is
currently little evidence towarrant theiruseoutsideof a trial setting.
Where open surgery is performed, a recent systematic review
suggests that transverse incisions appear to be associated with
less pain and postoperative opiate use compared to midline
laparotomy incisions.6 However, the same study showed no
difference in length of inpatient stay and rate of pulmonary
complications between both groups.
Maintenance of normothermia
Intraoperative hypothermia is a common phenomenon that oc-
curs secondary to anaesthesia and heat loss from the abdominal
cavity. Hypothermia interferes with homoeostasis and is associ-
ated with multiple adverse outcomes including wound infection,
cardiac events, bleeding and coagulopathy. Close monitoring of
core temperature and prevention of hypothermia using active
warming devices is strongly recommended at present.
Inspired oxygen concentration
The use of high inspired oxygen concentration (HIOC) is a sub-
ject open to debate. It has been proposed that HIOC minimizes
the risk of surgical site infection, particularly in patients under-
going colorectal surgery.7 However current literature on the
subject contains significant heterogeneity and it is recommended
that the FiO2 be titrated to produce normal blood gas levels to
protect against the potential risks of hyperoxia.
Perioperative fluid management
Optimal fluid balance is a crucial component of the ERAS pathway.
Preoperatively this is minimized by selective use of bowel prep-
aration, curtailed fasting allowing intake of clear fluids up to 2
hours before surgery and administration of an oral carbohydrate
preload. Both fluid depletion and overload have been shown to
increase postoperative morbidity. Fluid overload and electrolyte
imbalance have been shown to increase bowel oedema and affect
anastomotic integrity. Intraoperative fluid administration should
SURGERY 35:2 99
be guided by real-time cardiac output monitoring with oesopha-
geal Doppler studies. This is termed goal-directed fluid therapy
and has been shown to reduce postoperative morbidity and
duration of hospital stay.8 There is no consensus on the type of
fluid that should be administered and there appears to be little
difference in outcomes between colloids and crystalloids. Where
hypotension occurs secondary to epidural analgesia in the nor-
movolaemic patient, judicious use of vasoconstrictor drugs is
recommended rather than liberal fluid administration.
Tubes, catheters and drains
The presence of tubes and drains is a significant impediment to
early mobilization and themselves are associated with various
complications. Routine use of prophylactic nasogastric tubes is
not recommended following elective colorectal surgery as there
is strong evidence linking it to respiratory morbidity and delayed
gut motility.9 Placement of pelvic drains has not been shown to
decrease rates of anastomotic leaks and confer no additional
benefit; as such, routine use of these is also discouraged. Urinary
catheters are associated with urinary tract infections and their
early removal (ideally on postoperative day 1) is recommended,
unless there is a specific clinical indication for the contrary.
Prolonged postoperative bed rest has now been linked to
increased incidence of venous thromboembolism (VTE), pro-
longed insulin resistance, muscle loss from catabolism and res-
piratory complications such as atelectasis and pneumonia.
Current ERAS protocols typically encourage mobilization as
soon as 4 hours postoperatively. Typically, patients are encour-
aged to spend 2 hours out of bed on the day of surgery and 6
hours daily thereafter until discharge.
Systemic analgesia: effective pain relief remains a cornerstone
of every ERAS programme. It enables early mobilization and
prevents complications such as respiratory infections and venous
thromboembolism. Opiate analgesia is associated with significant
morbidity (respiratory depression, drowsiness, decreased
mobility, PONV and delayed gut function) and should be avoided
where possible. A multimodal analgesic regime typically
comprising paracetamol and non-steroidal anti-inflammatory
drugs (NSAIDs) is extremely effective at achieving sufficient pain
relief especially in combination with the regional/local analgesia
described below. There have been some weak associations be-
tween the use of NSAIDs and COX-2 inhibitors with increased
risk of anastomotic leak, but a subsequent meta-analysis showed
no significant increase in leak rates in patients receiving post-
operative NSAIDs in the first 48 hours after surgery.10
Recently, systemic administration of intravenous magnesium,
or local anaesthetic (such as lidocaine) has increasingly been
used and is shown to decrease systemic opiate requirements.
Currently, the precise details of administration that achieves the
best analgesic effect remains undefined.
Regional/local analgesia: thoracic epidural analgesia (TEA) re-
mains the gold standard in patients undergoing open colorectal
� 2016 Published by Elsevier Ltd.
resection. Neuraxial blockade has been shown to mitigate the
surgical stress response and postoperative insulin resistance.
TEA has also been linked to earlier return of gut function, lower
incidence or cardiorespiratory complications and decreased
mortality. These benefits were not observed in patients under-
going laparoscopic resections and TEA has also been linked with
postoperative hypotension and urinary retention.
Laparoscopic-assisted resections are associated with signifi-
cantly less pain and there has been a shift towards the use of
intrathecal opiates in conjunction with transverses abdominis
plane (TAP) blocks over the lower abdominal incision in these
patients. There is good evidence demonstrating the efficacy of a
single-shot TAP block in the first 24 hours of surgery11 but cur-
rent evidence surrounding the use of continuous TAP infusion of
local anaesthetic is ambiguous.12
Early postoperative feeding does not increase the risk of post-
operative anastomotic leak and is associated with decreased
incidence of postoperative infections and length of hospital stay.13
Most of the evidence surrounding early postoperative oral feeding
has been obtained from traditional postoperative care pathways
rather than in a dedicated ERAS setting. However, early oral/
enteral nutrition should be attemptedwherever possible following
colorectal surgery as it decreases postoperative insulin resistance
by limiting the surgical stress response and preserves gut barrier
function, both of which improve tissue healing. Most ERAS
guidelines typically recommend drinking in the immediate post-
operative period and intake of solids approximately 4 hours post-
surgery. Meta-analyses have indicated an increased risk of post-
operative vomiting with early oral feeding e therefore, it is
important that the patient receives adequate anti-emetic cover in
the early postoperative period.
There is weak evidence in support of the use of oral nutri-
tional supplements (ONS), including immunonutrition, which
contains specific combinations of amino acids, nucleotides and
omega-3 fatty acids that help boost immune function. However
the effect of these supplements is most marked in malnourished
patients and there is currently no ERAS-specific evidence in
support of ONS. A 2016 meta-analysis on immunonutrition in
upper gastrointestinal surgery showed a decreased risk of wound
infection and length of hospital stay in the intervention group,
but no difference in other infective complications.14
Patients undergoing bowel surgery are at increased risk of devel-
oping postoperative ileus. It is a major impeding factor of early
mobilization, predisposes to aspiration and is associated with
extended hospital stay and increased hospital costs. Risk factors
for developing postoperative ileus include old age, long duration
of surgery, fluid and electrolyte imbalance, intra-abdominal sepsis
and postoperative placement of nasogastric tubes.
Current practices associated with a lower incidence of post-
operative ileus include the use of minimally invasive surgical
techniques, mid-thoracic epidural analgesia, early oral/enteral
nutrition and goal-directed fluid therapy. There is weak evidence
to suggest that the use of laxatives and chewing gum may play a
role in prevention of ileus. However, a Cochrane review found
that the use of prokinetic agents had no significant effect in
SURGERY 35:2 100
stimulating gut motility.15 Interestingly, recent evidence has also
shown that early postoperative mobilization does not directly
stimulate gastrointestinal motility; although it does confer an
overall beneficial effect on postoperative recovery.
Enhanced recovery after colorectal surgery is a cost-effective,
evidence-based means of optimizing the whole of the perioper-
ative pathway of patient care. Individual elements are each
important but are ineffective without the involvement of the
patient and the whole team that will be caring for the patient,
including, where possible, primary care. The addition of an
‘enhanced recovery facilitator’ to the team is highly desirable,
particularly when starting such a programme as a means of
provision of information, bringing together the patient and the
whole of the care team, and auditing such pathways to inform
the team on a regular basis so that changes can be made where
necessary to provide the optimum patient experience and surgi-
cal outcome. A
REFERENCES 1 Awad S, Varadhan KK, Ljungqvist O, Lobo DN. A meta-analysis of
randomised controlled trials on preoperative oral carbohydrate treatment in elective surgery. Clin Nutr 2013; 32: 34e44.
2 Guenaga KF, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2011. Issue 9. Art. No.:CD001544.
3 Bretagnol F, Panis Y, Rullier E, et al. Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multi- center single-blinded randomized trial. Ann Surg 2010; 252: 863e8.
4 Green BL, Marshall HC, Collinson F, et al. Long-term follow-up of the Medical Research Council CLASICC trial of conventional versus laparoscopically assisted resection in colorectal cancer. Br J Surg 2013; 100: 75e82.
5 Abraham NS, Byrne CM, Young JM, Solomon MJ. Meta-analysis of non-randomised comparative studies of the short-term out- comes of laparoscopic resection for colorectal cancer. ANZ J Surg 2007; 508e16.
6 Brown SR, Goodfellow PB. Transverse versus midline incisions for abdominal surgery. Cochrane Database Syst Rev 2011. Issue 4. Art. No.:CD005199.
7 Togioka B, Galvagno S, Sumida S, Murphy J, Ouanes JP, Wu C. The role of perioperative high inspired oxygen therapy in reducing surgical site infection: a meta-analysis. Anesth Analg 2012; 114: 334e42.
8 Pearse RM, Harrison DA, MacDonald N, et al. Effect of a periop- erative cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. J Am Med Assoc 2014; 311: 2181e90.
9 Rao W, Zhang X, Zhang J, Yan R, Hu Z, Wang Q. The role of nasogastric tube in decompression after elective colon and rectum surgery: a meta-analysis. Int J Colorectal Dis 2011; 26: 423e9.
10 Burton TP, Mittal A, Soop M. Nonsteroidal anti-inflammatory drugs and anastomotic dehiscence in bowel surgery: systematic
� 2016 Published by Elsevier Ltd.
review and meta-analysis of randomized, controlled trial. Dis Colon Rectum 2013; 56: 126e34.
11 Johns N, O’Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Colorectal Dis 2012; 14: e635e642.
12 Feldheiser A, Aziz O, Baldini G, et al. Enhanced recovery after surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60: 289e334.
SURGERY 35:2 101
13 Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24 h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 2006; 18. Issue 4. Art. No.:CD004080.
14 Wong CS, Aly EH. The effects of enteral immunonutrition in upper gastrointestinal surgery: a systematic review and meta-analysis. Int J Surg 2016; 29: 137e50.
15 TrautU,Br€ugger L,KunzR, et al. Systemicprokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery inadults.JAmMedAssoc2008. Issue1.Art.No.:CD004930.
� 2016 Published by Elsevier Ltd.
- Enhanced recovery after colorectal surgery: an update on current practice
- Preoperative practice
- Patient education
- Assessment and optimization of comorbidities
- Curtailed fasting and carbohydrate loading
- Selective bowel preparation
- Intraoperative practice
- Surgical technique
- Maintenance of normothermia
- Inspired oxygen concentration
- Perioperative fluid management
- Tubes, catheters and drains
- Postoperative practice
- Early mobilization
- Postoperative analgesia
- Postoperative nutrition
- Postoperative ileus