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World J Surg (2013) 37:285–305 Guidelines for Perioperative Care in Elective Rectal/PelvicSurgery: Enhanced Recovery After Surgery (ERASÒ) SocietyRecommendations J. Nygren • J. Thacker • F. Carli • K. C. H. Fearon •S. Norderval • D. N. Lobo • O. Ljungqvist •M. Soop • J. Ramirez Ó Enhanced Recovery After Surgery, The European Society for Clinical Nutrition and Metabolism, and International Association for SurgicalMetabolism and Nutrition 2012 perioperative treatment pathway, available English-lan- This review aims to present a consensus for guage literature was examined, reviewed and graded. A optimal perioperative care in rectal/pelvic surgery, and to consensus recommendation was reached after critical provide graded recommendations for items for an evi- appraisal of the literature by the group.
denced-based enhanced recovery protocol.
For most of the protocol items, recommendations Studies were selected with particular attention are based on good-quality trials or meta-analyses of good- paid to meta-analyses, randomized controlled trials and quality trials (evidence grade: high or moderate).
Based on the evidence available for each item of the multimodal perioperative care pathway, the EnhancedRecovery After Surgery (ERAS) Society, European Society This study was conducted on behalf of the ERASÒ Society, the for Clinical Nutrition and Metabolism (ESPEN) and Inter- European Society for Clinical Nutrition and Metabolism and the national Association for Surgical Metabolism and Nutrition International Association for Surgical Nutrition and Metabolism.
(IASMEN) present a comprehensive evidence-based con-sensus review of perioperative care for rectal surgery.
The guidelines are published as a joint effort between the EnhancedRecovery After Surgery (ERAS) Society, for Perioperative Care, TheEuropean Society for Clinical Nutrition and Metabolism (ESPEN)and The International Association for Surgical Metabolism and Nutrition (IASMEN) and copyrights for this publication is sharedbetween the three societies. The guidelines are published jointly inWorld Journal of Surgery (IASMEN) and Clinical Nutrition Until quite recently, patients undergoing colorectal resec- (ESPEN), and will also be available on the ESPEN tion were counselled to accept a 20–25 % risk of compli- (and ERAS Society website cations and a 7–10-day postoperative stay in hospital. As Department of Surgery, Ersta Hospital, Karolinska Institutet, Department of Clinical Surgery, School of Clinical Sciences and Stockholm, Sweden Community Health, University of Edinburgh, Royal Infirmary, Department of Clinical Sciences, Danderyd Hospital, Karolinska Department of Gastroenterological Surgery, University Hospital Institutet, Stockholm, Sweden of North Norway, Tromsø, Norway Department of Surgery, Duke University, Durham, NC, USA Division of Gastrointestinal Surgery, Nottingham DigestiveDiseases Centre National Institute for Health Research, Biomedical Research Unit, Nottingham University Hospitals, Department of Anesthesia, McGill University, Montreal, QC, Queen's Medical Centre, Nottingham, UK World J Surg (2013) 37:285–305 studies throughout the 1980s to 1990s showed, length of laparoscopic resection for pelvic inflammatory bowel stay in hospital (LOSH) and complication rates improved even if a single component of care was changed . With With recognition of the aspects of pelvic bowel surgery this, the idea of incorporating many of these elements into that are known to be more difficult and moribund than a comprehensive perioperative care pathway developed.
abdominal surgery, we critically reviewed and graded the Enhanced Recovery After Surgery (ERASÒ) is a evidence. These guidelines are a literature review with dynamic culmination of upon perioperative care elements.
summary expert opinion regarding the application of The strongest evidence for ERAS implementation is in the ERAS principles to rectal resection. Many (but not all) care of patients undergoing open colonic resection. Many ERAS protocol elements, as defined in colonic resection, interventions previously shown to benefit outcomes in this have been applied successfully to rectal resection. Table population have now been successfully applied to laparo- is an overview of the individual components of ERAS for scopic colon resections, as well as to other surgical spe- colonic resection with explanations as to the applicability cialties such as urology, orthopedics, and gynecology .
in rectal resection. While practical, a discussion of appli- Investigators studying the application of ERAS princi- cation of the individual elements may not be as important ples to colonic resections have acknowledged the differ- as the consideration of a paradigm shift. The true focus of ence between intra-abdominal large-bowel resections and ERAS, whether the application of interventions is to rectal pelvic surgery. Pelvic intestinal resections are fraught with resection or orthopedics, is the understanding and preven- higher complication rates, longer LOSH, and unique tion of the causative factors of perioperative stress and loss complications not seen in abdominal surgery. Because of of homeostasis. By considering the specific stress factors this and a need to address the more common lower-bowel associated with rectal resection during our review of the resections, the authors of ERAS studies have excluded literature, we have created guidelines to shift the paradigm patients undergoing rectal resection or treated pelvic of care of rectal resection patients and stimulate more resections as a subgroup. In several studies, rectal resec- studies to further this effort.
tions are included in the overall analysis of an ERASprotocol or component implementation, only to be exclu-ded or discounted as a ‘special consideration' group.
In the present work, the authors have specifically con- sidered the application of ERAS principles to a special Literature search population of rectal resection patients. We define pelvicbowel procedures to include resections of the last 12–15 cm The authors met in April 2011, and the topics for inclusion of the large bowel as measured from the anus, and/or those were agreed and allocated. The principal literature search resections defined intraoperatively to be below the pelvic utilised MEDLINE, Embase and Cochrane databases to reflection. Through the application of these definitions, we identify relevant articles published between January 1966 have included resections that encompass the increased: and January 2012. Medical Subject Headings terms difficulty of pelvic surgery compared with segmental were used, as well as the accompanying entry terms for colonic resections; operative times and use of retraction the patient group, interventions and outcomes. The known to increase perioperative morbidity; risk to the pelvic selected key words were ‘‘rectum'', ‘‘perioperative care'', structures (e.g., hypogastric nerves, ureters). Although all ‘‘enhanced recovery'' and ‘‘fast track''. There was no lan- indications for pelvic resections were included in the liter- guage restriction. Reference lists of all eligible articles were ature search, mention of specific recommendations relative checked for other relevant studies. Conference proceedings to the diagnosis is made if appropriate. For example, the use were not searched. Expert contributions came from within of laparoscopy for pelvic bowel malignancy is not as readily the ERAS Society Working Party on Systematic Reviews.
applied outside of a trial as opposed to commonly accepted Department of Surgery, Orebro University Hospital, Orebro,Sweden Titles and abstracts were screened by individual reviewers toidentify potentially relevant articles. Discrepancies in M. SoopDepartment of Surgery, Middlemore Hospital, South Auckland judgement were resolved by the senior author and during Clinical School University of Auckland, Auckland, New Zealand committee meetings of the ERAS Society Working Party onSystematic Reviews. Reviews, case series, non-randomised and randomised control studies, meta-analyses and sys- Department of Colorectal Surgery, Hospital Clı´nicoUniversitario Lozano Blesa, Zaragoza, Spain tematic reviews were considered for each individual topic.
World J Surg (2013) 37:285–305 Table 1 Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERASÒ) Society recommen-dations and difference to protocol in colonic resection As recommended in colon resection As recommended in rectal resection Difference in protocol Essential discussion between surgeon and Identical but with the addition of specific Increased (stoma) patient regarding activity, drains/tubes/ education for the marking and lines, and expectations regarding hospital management of stomas Addressing anaemia, malnutrition, and Identical with consideration of possibly Increased evaluation, though no higher blood loss, longer operative time, specific optimisation open surgery more often that Smoking cessation and moderation of laparoscopy, and more aggressive preoperative therapy in the case ofpreoperative pelvic radiation andchemotherapy Should be avoided Some cleansing of diverted bowel Specific indications with diversion of stomas Avoidance of long-acting sedation Avoidance of long-acting sedation Encouraged to minimise postoperative ileus Avoid with creation of an end ileostomy Specific indications with stoma or diverting ileostomy Treatment as indicated.
Treatment as indicated nausea andvomiting General anaesthesia plus use of epidural in Identical, may be lower epidural insertion None, though recommended cases of longer operative time and open in APR or additional narcotics mid-thoracic epidural may not cover perineal wound pain Consider adjuvant multimodal for Recommended in benign disease.
Specific to disease Laparoscopic resection of rectal cancercurrently only in selected cases orwithin a trial Not sufficient evidence if considering Specific to procedure without pelvic drainage after rectal resection Expert opinion is avoidance except with specific indications, such as excessiveintraoperative blood loss or tenuousanastomosis Recommended removal on first Recommended in selected patients and in Specific consideration of postoperative day procedure and expected urinaryretention risks Higher re-insertion rates due to direct retraction on the bladder and close Recognized increased catheter- proximity to/occasional en bloc associated infection risk in resection of the lateral pelvic nerves cases requiring prolongedcatheterisation May be indication for supra-pubic catheter if planned postoperativedrainage is [4 days.
World J Surg (2013) 37:285–305 Table 1 continued As recommended in colon resection As recommended in rectal resection Difference in protocol Recommended, though possible need for Specific consideration of specific guidelines for patients with procedure without guiding perineal flap closure after APR may be evidence, except general guidelines for plastic-surgerycare Quality assessment and data analyses regarding enterostomal therapy to better prepare them forthe procedure and to reduce postoperative LOSH [ The methodological quality of the included studies was Patients should receive routine assessed using the Cochrane checklist . The strength of dedicated preoperative counsel- evidence and conclusions were assessed and agreed by all authors in May 2012. Quality of evidence and recom- mendations were evaluated according to the Grading of Recommendation grade Recommendations, Assessment, Development and Evalu-ation (GRADE) system [–]. Quoting from the GRADEguidelines the recommendations are given as follows: ‘‘Strong recommendations indicate that the panel is confi-dent that the desirable effects of adherence to a recom- Preoperative optimisation is a crucial step in major abdom- mendation outweigh the undesirable effects''. ‘‘Weak inal surgery and physiological preparation for surgery is recommendations indicate that the desirable effects of important. Preoperative evaluation should be used to identify adherence to a recommendation probably outweigh the medical conditions and risk factors for postoperative mor- undesirable effects, but the panel is less confident''. Rec- bidity and mortality. Optimisation of anaemia, diabetes ommendations were based on quality of evidence (‘‘high'', mellitus (DM) and hypertension improves outcomes (Pre- ‘‘moderate'', ‘‘low'', ‘‘very low'') but also on the balance operative Assessment and Patient Preparation, AAGBI between desirable and undesirable effects; and on values Guidelines, January 2010. Available at: and preferences . The latter implies that, in some cases, strong recommendations could be reached from low-qual- nourished patients have limited nutritional stores, and benefit ity data and vice versa.
from preoperative nutritional supplementation with fewerinfectious complications and anastomotic leaks [ Before surgery, patients should be advised to stop smoking or drinking excessive amounts of alcohol. A Evidence base and recommendations recent review over 11 randomised controlled trials (RCTs)involving 1,194 patients concluded that smoking cessation in the perioperative period (initiated 4 weeks before sur-gery) appeared to be beneficial in improving surgical out- Preoperative counselling comes ]. Several studies have described the associationbetween hazardous intake of alcohol and an increase in Preoperative counselling targeting expectations about sur- postoperative morbidity with a higher risk of postoperative gical and anaesthetic procedures may diminish fear and infections, cardiopulmonary complications and bleeding anxiety and enhance postoperative recovery and discharge [–]. Personal counselling, leaflets or multimedia infor- A recent RCT [showed that ‘pre-habilitation' (a mation containing explanations of the procedure along with programme designed to increase functional capacity in tasks that the patient should be encouraged to fulfil may anticipation of an upcoming stressor) addresses the impact improve perioperative feeding, early postoperative mobi- that physical exercise might have on postoperative func- lisation, pain control, and respiratory physiotherapy; and tional exercise capacity. The effect of such programmes hence reduce the prevalence of complications [– regarding outcome remains to be evaluated [ Ideally, the patient should meet with the surgeon, anaes-thetist and nurse. Patients destined for a diverting or per- Preoperative optimisation of medical manent stoma should have a preadmission nursing visit conditions (e.g., anaemia), cessation of World J Surg (2013) 37:285–305 smoking and alcohol intake 4 weeks anterior resection. It is necessary to conduct further trials before rectal surgery is recommended.
comparing MBP with no preparation/enema in patients Increasing exercise preoperatively may undergoing laparoscopic surgery (especially in pelvic be of benefit. Preoperative specialised nutritional support should be considered In general, MBP should not be used for malnourished patients.
in pelvic surgery. However, when a Medical optimisation: Moderate; Pre- diverting ileostomy is planned, MBP habilitation: Very low; Cessation of may be necessary (although this needs smoking: Moderate; Cessation of excess to be studied further.
consumption of alcohol: Low Anterior resection: (do not use MBP) High; Total mesorectal excision (TME) habilitation: No; Cessation of smoking: with diverting stoma: (use MBP) Low Strong; Cessation of excess consumption Anterior resection: (do not use MBP) of alcohol: Strong Strong; TME with diverting stoma:(use MBP) Weak Preoperative bowel preparation Preoperative fasting Mechanical bowel preparation (MBP) is associated with Fasting from midnight has been standard practice in the dehydration and changes in electrolyte balance (particu- belief that this reduces the risk of pulmonary aspiration in larly in the elderly) [A meta-analysis from studies elective surgery. However, a Cochrane review of 22 RCTs focusing on colonic surgery show no clinical benefit from showed that fasting from midnight did not reduce gastric content, increase the pH of gastric fluid, or affect the A recent update of the Cochrane review on MBP in prevalence of complications compared with patients colorectal surgery included 18 studies (n = 5,805) allowed free intake of clear fluids up until 2 h before Comparisons were made between MBP versus no prepa- anesthesia for surgery [Thus, most national anesthesia ration and MBP versus rectal enema only. Anastomotic societies now recommend intake of clear fluids up until 2 h leakage was assessed in patients undergoing restoration of before the induction of anesthesia as well as a 6-h fast for bowel continuity, and showed no difference between MBP solid food ]. Although diabetic patients with neuropathy and no preparation/enema. Patients undergoing low ante- may have delayed gastric emptying (thereby possibly rior resection were also analysed separately (7 studies, increasing the risk of regurgitation and aspiration), patients n = 846). In this group of patients, bowel preparation was with uncomplicated type-2 DM have been reported to have not associated with a changed prevalence of anastomotic normal gastric emptying [ leakage (7.4 vs. 7.9 %). The authors concluded (as wasshown before) that routine bowel preparation before colo- Intake of clear fluids up until 2 h nic surgery was of no value, and should not be recom- before the induction of anaesthesia is mended. However, if intraoperative colonoscopy might be allowed. Intake of solids should be carried out due to a small lesion or for any other reason, withheld at C6 h before anaesthesia.
MBP should be initiated.
Patients undergoing pelvic surgery with restoration of bowel continuity frequently receive a proximal diversion.
Although this has not been studied in detail, this group ofpatients will probably need oral MBP. A recent multicentre,single-blind, RCT included 178 patients undergoing low Preoperative treatment with carbohydrates anterior resection for rectal cancer. Patients were random-ised to preoperative MBP versus no preparation ]. In this By providing a clear fluid containing a defined (12 %) study (in which [80 % of subjects had a diverting stoma), concentration of complex carbohydrates up until 2 h before overall and infectious morbidity were higher in the no MBP anesthesia, patients can undergo surgery in a metabolically group. A non-significant trend to a twofold higher risk for fed state . This treatment reduces the prevalence of overall and clinical anastomotic leak (19 vs. 11 %) and preoperative thirst, hunger, and anxiety ]. In addition, peritonitis (7 vs. 2 %) was also found in the no MBP group.
postoperative insulin resistance is reduced by &50 % as In the latter study, [80 % underwent laparoscopic low shown in several placebo-controlled randomised studies in World J Surg (2013) 37:285–305 various surgical procedures (e.g., major abdominal sur- No advantages in using long-acting gery, orthopedic surgery) ]. The treatment (avoiding benzodiazepines. Short-acting benzodi- preoperative fasting) also results in less postoperative azepines can be used in young patients nitrogen and protein losses , as well as better- before potentially painful interventions maintained lean body mass [and muscle strength (insertion of spinal or epidural, arterial Data from RCTs indicated accelerated recovery, and pre- catheter), but they should not be used in liminary data from a meta-analysis showed 1-day shorter the elderly (age[60 years).
LOSH in patients receiving preoperative carbohydrate loading in major abdominal surgery [Studies have indicated that the relative reduction in insulin sensitivity after a specific surgical procedure is related to the degreeof surgery, and that more pronounced surgical stress resultsin a more advanced insulin resistance ]. Thus, patients Prophylaxis against thromboembolism undergoing pelvic surgery suffer from significant andsevere insulin resistance, and will benefit from avoiding It has been shown that pharmacological prophylaxis preoperative fasting using this metabolic preparation. In against venous thrombosis (VT) reduces the prevalence of addition, in a large prospective cohort of patients under- symptomatic venous thromboembolism (VTE) without going colorectal surgery (n = 953), including 419 patients increasing side effects such as bleeding [In addition, undergoing pelvic surgery, preoperative carbohydrate use of compression stockings reduces the incidence of VTE loading was an independent predictor of postoperative ]. Patients with extensive comorbidity, malignant dis- clinical outcome, including postoperative nausea and ease, who are taking corticosteroids preoperatively, who vomiting (PONV) [ have undergone previous pelvic surgery, and those inhypercoagulable states have an increased risk of VTE [ Preoperative oral carbohydrate load- In a recent Cochrane report based on 4 RCTs (n = 1,021), ing should be administered to all non- it was concluded that prolonged (4 weeks postoperatively) diabetic patients.
VTE prophylaxis as compared with in-hospital prophylaxis Reduced postoperative insulin resis- was associated with a significantly reduced prevalence of VTE (14.3 vs. 6.1 %, p 0.0005), as well as symptomatic Improved clinical VTE (1.7 vs. 0.2 %), without an increase in postoperative bleeding complications or other side effects . It is also demonstrated that compliance with prolonged treatment with low-molecular-weight heparin (LMWH) was high([97 %). It is not known if early recovery, with the use oflaparoscopic surgery and/or enhanced recovery protocols, reduces the risk of VTE. In addition, there are no controlleddata available in patients undergoing major abdominal or Patients undergoing rectal surgery are anxious about the pelvic surgery within enhanced recovery protocols. Until surgery and outcome. Education and reassurance can allay such data are available it is recommended that patients anxiety, but pharmacological interventions to reduce anx- undergoing major abdominal or pelvic surgery with iety can be indicated, particularly in younger patients increased risk for VTE receive a prolonged treatment with before procedures such as insertion of an epidural or LMWH up to 4 weeks postoperatively even if early recovery arterial catheter. Anxiolytics such as clonidine, have been and early discharge from hospital is achieved.
shown to have opioid-sparing capacity but clonidine isassociated with hypotension and sedation [ Patients should wear well-fitting com- Short-acting benzodiazepines can be given to facilitate pression stockings, and receive phar- patient positioning and insertion of an epidural catheter.
macological prophylaxis with LMWH.
Long-acting benzodiazepines are discouraged because they cause psychomotor impairment during the postoper- should be considered in patients with ative period, which can impair mobilisation and direct colorectal cancer or other patients with participation ]. These medications are not indicated in increased risk of VTE.
the elderly (age [60 years) because they have been associated with cognitive dysfunction and delirium after surgery , ].
World J Surg (2013) 37:285–305 Antimicrobial prophylaxis and skin preparation Standard anaesthetic protocol Laparotomy with resection of the rectum requires a longer effective against aerobes and anaerobes; they have been abdominal incision and more extensive dissection in the shown to reduce the prevalence of infectious complications pelvic area. A laparoscopic approach to rectal dissection in colorectal surgery [A single dose is as effective requires longer periods of time but is less invasive. A as multidose regimens [but further doses should be 5–7-cm surgical incision (horizontal or vertical) is used to given in prolonged cases ([3 h) depending on the phar- facilitate extraction of the specimen. Mobilization of the macokinetics of the antibiotics used ]. The first intra- viscera and excision of the colon and rectum requires the venous dose should be administered before skin incision Trendelenburg position for better access. There are no but B1 h before surgery ]. A Cochrane meta-analysis randomized controlled trials comparing the impact of concluded that a combination of intravenous and oral intravenous versus inhalational anaesthesia on postopera- administration is more effective than intravenous alone or tive outcome in rectal surgery. The considerations men- oral alone [However, none of the included studies tioned below should be taken into account if surgical stress compared a similar combination of antibiotics adminis- needs to be attenuated.
tered orally and intravenously versus orally alone or Induction and maintenance of anesthesia can be guided intravenously alone. Hence, the revealed effect may just be by the bispectral index (BIS) monitor, thereby avoiding the effect of adding another antimicrobial drug in the oral/ deep levels of anesthesia (BIS 30), particularly in the intravenous groups and not an effect of the route of administration. The optimal combination of antibiotics has Insertion of a thoracic epidural catheter is recommended not been established, but a combination of metronidazole for open and assisted laparoscopic procedures to attenuate the and a relevant aerobic antibiotic is often suggested. New stress response and provide better postoperative pain relief.
generations of antibiotics have been reserved for infectious Long-acting local anesthetics can be administered as a bolus complications. However, in a 2006 multicentre prospective or by continuous infusion throughout the procedure. If an study in the USA, Itani et al. [showed an absolute epidural is not feasible or contraindicated, intravenous lido- difference in infection rate of nearly 15 % lower in a group caine can be administered due to its anti-inflammatory and randomised to single preoperative dose of ertepenem ver- opioid-sparing properties. It can be given at induction sus a cephalosporin. The greatest difference was seen in (1.5 mg/kg) followed by a continuous infusion of 2 mg/kg/h the subgroup of rectal resections. Whether improved during surgery Spinal local anesthetics and opioids have effectiveness is sufficient reason to change the ‘‘dogma'' of been used successfully for colonic and colorectal resection not using new antibiotics for prophylaxis remains to be Attention should be paid to the opioid doses because postoperative respiratory depression in the elderly can occur.
A reduced dose of opioid is advised in those aged[70 years.
Patients should receive antimicrobial Short-acting potent opioids such as remifentanil can also prophylaxis before skin incision in a be used to attenuate the stress response [There is no single dose. Repeated doses may be evidence that induction of acute hyperalgesia associated necessary depending on the half-life of with high doses of remifentanil can be reduced by keta- drug and duration of surgery.
mine, magnesium or other N-methyl D-aspartate (NMDA) antagonists [Adequate relaxation of muscle is indi- cated to facilitate extensive resection in the pelvic area, especially during laparoscopic surgery. However, reversalof profound muscle relaxation can leave incomplete reversal. The use of sugammadex to counteract the actionof large doses of muscle relaxants has proven to facilitate A recent randomized trial has shown recovery ]. But no data are available with the ERAS that skin preparation with a scrub of programme. Adequate lung ventilation with low tidal vol- chlorhexidine-alcohol is superior to umes to limit peak airway pressure is suggested to reduce povidone-iodine in preventing surgical- the risk of barotraumas . However, if patients are in the Trendelenburg position, the risk of atelectasis is greater and therefore lung recruitment is required. Inspired oxygen For skin preparation in general: Strong; concentration [80 % has been shown to decrease the Specific choice of preparation: Weak World J Surg (2013) 37:285–305 prevalence of surgical-site infection ]. There is insuffi- higher doses of perioperative glucocorticoids may further cient evidence for the use of positive-end expiratory pres- reduce the incidence of PONV. Without any clear evidence from RCTs, it seems reasonable to include in any ERAS complications and the impact on mortality ]. Increased protocol a multimodal anti-emetic prophylaxis regimen to insulin resistance as a result of surgery causes hypergly- eliminate (or substantially reduce) the incidence of PONV.
cemia ], and this should be avoided because it can lead Prevention of PONV should be included to postoperative complications . The optimal level as standard in ERAS protocols. More of blood glucose is not known, so effort should be made to specifically, a multimodal approach to measure blood sugar during surgery and to keep it PONV prophylaxis should be adopted in 10 mmol/l using intravenous insulin when needed.
all patients with C2 risk factors Maintenance of adequate gut perfusion is of paramount undergoing major colorectal surgery. If importance for the integrity of the anastomosis. Because of PONV is present, treatment should be the lack of vascular autoregulation in the splanchnic area, via a multimodal approach.
gut perfusion is dependent upon mean arterial pressure and High-risk patients: (use multimodal cardiac output [Satisfactory gut perfusion can be prophylaxis) High; In all patients: Low achieved by providing adequate amounts of intravascular fluids and more specifically goal-directed fluid therapy using minimally invasive cardiac output monitoring Intraoperative hypotension should be avoided because itcan impact negatively on perfusion of the gut and anasto- Surgical techniques mosis. Appropriate use of vasopressors such as neosy-nephrine or low doses of norepinephrine is strongly Laparoscopic rectal resection Though not yet supported with strong evidence from RCTs, the laparoscopicapproach to pelvic surgery has been shown to decrease the inflammatory response to surgery relative to open approa- response, intraoperative maintenance ches. It therefore merits mention in this review of multi- of adequate hemodynamic control, modal interventions for enhanced recovery.
central and peripheral oxygenation, Minimally invasive surgery has become the standard muscle relaxation, depth of anesthesia, against which other surgical approaches are now compared.
and appropriate analgesia is strongly The impetus for this worldwide change in surgical approach to procedures such as cholecystectomy and Epidural: Moderate; IV Lidocaine: nephrectomy reflect impressively better short-term recov- Low; Remifentanil: Low; High oxygen ery. The improvement in short-term recovery in colon concentration: High resection relative to open is less dramatic, but it is certainly Epidural: Strong; IV Lidocaine: Weak; ‘physiologically rational and definitely will be an important Remifentanil: Strong; High oxygen component in future accelerated recovery programs' concentration: Strong according to Kehlet and Wilmore in their review in 2008Three diagnoses eligible for minimally invasive approaches are familial adenomatous polyposis (FAP),inflammatory bowel disease (IBD) and neoplasms.
PONV is a major cause of delay in recommencement oforal food intake and can be more stressful than pain – Laparoscopic rectal resection for benign disease Risk factors include being female and a non-smoker, roscopic proctocolectomy for FAP or IBD has been defined history of motion sickness (or PONV), and postoperative as ‘safe' and ‘feasible' at specialist centers, though some administration of opioids. PONV is a well-known side reports have raised concerns of under-studied functional effect of some routine perioperative drugs, such as opioids outcomes and increased costs. Nevertheless, retrospective or neostigmine, which should be avoided if possible. In reviews, prospectively collected cohort studies, and the one fact, the prevalence of PONV after a standard anesthetic RCT have consistently shown a decreased LOSH as well as procedure of inhalational anesthetics and opioids and no the same or decreased: time to bowel function; time to oral PONV prophylaxis is B30 %. PONV can be minimised nutrition tolerance; and wound complications , with the use of effective anti-emetic regimens. Multimodal Additionally, the Washington University review showed prevention may represent a more simple approach and a that the laparoscopic ileal pouch group came to ileostomy more reliable strategy. The addition to these regimens of closure sooner than the open group, presumptively because World J Surg (2013) 37:285–305 of fewer complications and more expedient return to nor- supports a laparoscopic approach for rectal cancer but mal activities and recovery ]. Given that these proce- included a high conversion rate and unexpected higher rate dures are often undertaken in young patients, a study of TME in the laparoscopic group. This was in combination documenting better female fecundity after laparoscopic with a slightly higher positive circumferential resection versus open proctocolectomy is an important addition to margin in the laparoscopic group. This brings into question the evidence of safety and applicability of laparoscopy for the pathological standardization and the surgeon experi- the resection of benign tumours [The only meta- ence in both groups. At 3-year follow-up, however, no analysis in this area involves one RCT and 15 studies; all higher cancer recurrence than the open group was noted included studies had mixed populations relative to the , ]. Poon and Huang reviewed the topic separately, preoperative risk factors of immunosuppression and and concluded the greatest concern was the quality of the immunomodulator use, as well as medically refractory or TME. Both concluded that, if proven to be oncologically complicated IBD. Laparoscopic resection in the included equivalent, laparoscopic proctectomy offers benefits of studies was ‘‘at least as safe'' and seemed to confer improved short-term outcomes similar to laparoscopic decreased postoperative ileus and LOSH in combination colon resection as well as better visualization of the pelvic with a decreased overall complication rate [Necessary nerves and easier dissection between the visceral and RCTs are unlikely to follow because the use of laparoscopy parietal fascia with pneumoperitoneum [ in IBD is strongly driven by the surgeon and patient.
Laparoscopic resection of rectal cancer With proven safety and at least equivocal is currently not generally recommended disease-specific outcomes, laparoscopic outside of a trial setting (or specialized proctectomy and proctocolectomy for centre with ongoing audit) until equivalent benign disease can be carried out by an oncologic outcomes are proven.
experienced surgeon within an ERAS protocol with the goals of reduced decreased postoperative ileus), decreasedLOSH, and fewer overall complications.
Nasogastric intubation A meta-analysis ] in 1995 showed that routine naso- gastric decompression should be avoided after colorectalsurgery because fever, atelectasis, and pneumonia are Laparoscopic resection of rectal cancer reduced in patients without a nasogastric tube. A Cochrane laparoscopic-assisted, and robotic rectal resection for meta-analysis [of 33 trials with [5,000 patients neoplastic disease is controversial. A recent meta-analysis undergoing abdominal surgery confirmed this finding, and identified 9 RCTs addressing this topic, but a consensus is also found earlier return of bowel function in patients if pending after reporting of the European-based Randomized nasogastric decompression was avoided. Gastroesophageal Clinical Trial Comparing Laparoscopic and Open Surgery reflux is increased during laparotomy if nasogastric tubes for Rectal Cancer (COLOR II) and the American College are inserted ]. A recent meta-analysis of randomised of Surgeons Oncology Group (ACOSOG Z6051) studies is trials including 1,416 patients undergoing colorectal sur- complete [This international debate regarding the gery showed that pharyngolaryngitis and respiratory adequacy of oncologic resection of rectal cancer by lapa- infection occurred less frequently if postoperative naso- roscopy has led to brilliant discussions in the literature and gastric decompression was avoided but that vomiting was at surgical meeting forums regarding the definition of more common if a nasogastric tube was inserted in 15 % of resection, the risks of inadequate resection, the expected subjects ] In a Dutch study with [2,000 patients found short-term and long-term oncologic outcomes and, to a that the use of nasogastric decompression after elective lesser extent, the possible physiological benefits of lapa- colonic surgery declined from 88 to 10 % without increa- roscopy. In relation to this review, there is little doubt ses in patient morbidity or mortality ]. There is no about the physiological benefits of laparoscopic rectal rationale for routine insertion of a nasogastric tube during resection over open resection , This discussion elective colorectal surgery except to evacuate air that may though, will be null, should the evidence prove inferiority have entered the stomach during ventilation by the facial with respect to oncology.
mask prior to endotracheal intubation. Nasogastric tubes The UK-based Conventional Versus Laparoscopic- placed during surgery should be removed before the Assisted Surgery In Colorectal Cancer (CLASICC) trial reversal of anesthesia.
World J Surg (2013) 37:285–305 Postoperative nasogastric tubes should oxygen delivery and haemodynamic status than systolic not be used routinely.
blood pressure and pulse). Other minimally invasive car- diac output monitors that use arterial waveform analysis can provide useful information not only during but also after surgery.
Fluid requirement is decreased in laparoscopic surgery, and no difference has been shown between colloids and Preventing intraoperative hypothermia crystalloids ]. It appears that balanced crystalloid going rectal surgery can become hypothermic as a result of solutions are more physiological than 0.9 % sodium chlo- prolonged exposure of the body and the abdominal cavity to cold ambient air and anesthesia-induced impaired ther-moregulation. There is sufficient evidence that mild Fluid balance should be optimised by hypothermia is associated with postoperative complications targeting cardiac output and avoiding such as wound infections, cardiac ischemia and bleeding, overhydration. Judicious use of vaso- and increased pain sensitivity. Warming patients before pressors is recommended with arterial surgery keeps the high core temperature [but might not hypotension. Targeted fluid therapy be practical. Monitoring core temperature during surgery is using the oesophageal Doppler system is recommended.
Patients undergoing rectal surgery need to have their body temperature monitored during and after surgery.
Attempts should be made to avoidhyothermia because it increases the Drainage of the peritoneal cavity or pelvis risk of perioperative complications.
The use of a suction drain in the pelvic cavity after rectal surgery has been traditionally advocated to evacuate potential blood or serous collections and prevent anasto-motic leakage.
In 2004, a Cochrane systematic review was published Perioperative fluid management with the aim to compare the safety and effectiveness ofroutine drainage and no-drainage regimens after elective Most of the literature on fluid management in colorectal colorectal surgery. The primary outcome was clinical anas- surgery does not separate the colon from the rectum.
tomotic leakage ]. This study included 6 RCTs enrolling Compared with the colon, rectal surgery leads to more fluid 1,140 patients, but only 2 RCTs (191 patients) separated low shift as a result of bowel preparation, bowel handling and rectal anastomoses. The authors could not find a significant blood loss from the pelvic area. In addition, the use of difference in outcomes (odds ration (OR) = 0.85).
epidural local anesthetics, pneumoperitoneum, hypother- In 2005, Bretagnol and coworkers undertook a meta- mia and vasodilatation-induced by anesthetic drugs can analyses concerning only rectal surgery (pelvic anastomo- cause changes in vascular tone. Whether a restrictive fluid ses). They included 3 RCTs, and they found that the use of regimen is better to a liberal one is controversial, but a a drain after rectal surgery did not seem to affect the recent review [concluded that fluid excess was asso- leakage rate or overall outcome [ ciated with worse outcome.
Pelvic drains should not be used Goal-directed fluid therapy using the oesophageal Doppler system has been shown to reduce the LOSH and the rate of postoperative complications [, Minimising intravas- Recommendation grade cular fluid shift is achieved by avoiding bowel preparation,adequate oral preload up until 2 h prior to surgery, and min-imising blood loss. However, goal-directed fluid therapy has never been compared with restrictive fluid management.
The same results were not confirmed when the ERAS Patients risk for urinary retention should be assessed pre- protocol was applied in laparoscopic surgery [The operatively. Major risk factors can include male sex, pre- rationale of using this device is that the intravenous fluids existing prostatism, open surgery, neoadjuvant therapy, are titrated to optimize cardiac output (a better indicator of large pelvic tumours, and APR.
World J Surg (2013) 37:285–305 Transurethral catheter Urinary drainage used to be stan- beneficial in reducing time to first bowel movement by dard in rectal resections because urinary function may be 1 day after gastrointestinal surgery ]. There was no impaired. However, catheter-associated urinary tract infec- effect on LOSH.
tions are the most common hospital-acquired infection, accounting for almost 40 % of all nosocomial infections.
optimising gut function after In fast-track surgery, urinary drainage should be as short rectal resection should involve as possible (ideally B24 h). A recent prospective study chewing gum.
indicated that routine urinary bladder catheterisation after pelvic surgery may be safely removed on postoperative day Recommendation grade 1 ], as indicated in a previous study ]. If epiduralanalgesia is used, there is a potential risk for urinaryretention but, after 24 h of urinary bladder catheterisation, Postoperative laxatives and prokinetics In a report from a this risk is low. A recent randomised study (215 patients) well-established ERAS programme, the use of oral laxatives advocated early removal (the morning after surgery) of the such as oral magnesium has been associated with normali- bladder catheter. Leaving the bladder catheter as long as sation of gastrointestinal transit after colonic resection [ the epidural leads to a higher incidence of urinary tract Administration of magnesium hydroxide in combination infections and prolongs LOSH [ with bisacodyl suppositories has been described in a cohortstudy of patients undergoing radical hysterectomy [A After pelvic surgery with a low estimated randomised trial of bisacodyl alone in 200 patients under- risk of postoperative urinary retention, going colorectal resection (outwith a defined ERAS proto- the transurethral bladder catheter may be col) demonstrated a 1-day reduction in time to defaecation, safely removed on postoperative day 1, with no alteration in tolerance of oral food or LOSH. Mor- even if epidural analgesia is used.
bidity and mortality were unaltered [A randomised trial (n = 74) of postoperative administration of oral magnesium to patients undergoing elective hepatic resection within an enhanced recovery protocol demonstrated a 1-day reductionin time to defaecation but again with no influence on other Suprapubic catheter Several randomised trials have outcomes [When oral magnesium oxide was combined reported that suprapubic bladder drainage compared with with disodium phosphate in fast-track hysterectomy, a ran- urethral catheterisation is associated with lower rates of domised trial (n = 53) demonstrated a 1-day reduction in urinary tract infection and/or less discomfort in patients time to defaecation ], but with no change in other out- undergoing abdominal surgery, whereas another study comes. Although one study (n = 49) recently failed to show showed no such benefits ]. However, the duration of a difference of oral magnesium within a well-established catheterisation in these studies was C4 days.
ERAS setting in colonic surgery, no randomised trial hasinvestigated the use of oral laxatives specifically in rectal n patients with an increased risk of surgery with/without ERAS, so further studies are necessary.
prolonged postoperative urinary reten- The overall question of whether stimulant laxatives are tion, placement of a suprapubic catheter associated with anastomotic dehiscence has not been is recommended.
addressed in a randomised trial of sufficient size.
Prolonged catheterisation: Low A multimodal approach to optimising gut function after rectal resectionshould involve oral laxatives.
Prevention of ileus Prevention of postoperative ileus is a key objective in therecovery. Optimal prevention care involves balancing flu-ids, using analgesics that allow optimal gut function and Postoperative analgesia avoiding PONV as outlined elsewhere, but also specifictreatments as outlined below Although most of the studies have not distinguished anal-gesia for colon surgery from that of rectal surgery, some Gum chewing has been shown in a sys- distinction between the two types of surgery must be made tematic review and meta-analysis (n = 272) to be safe and in view of the extensive tissue dissection with the latter World J Surg (2013) 37:285–305 procedure. Furthermore, there is limited knowledge of the analgesic techniques and using the ERAS protocol, but not impact of postoperative analgesic techniques when ERAS in all studies.
is used. For rectal procedures, the considerations shown Multimodal analgesia with paracetamol (acetamino- below must be taken into account: phen) and non-steroidal anti-inflammatory drugs (NSAIDs) The surgical approach for laparotomy can be achieved has been shown to spare opioid use and side effects by with a vertical incision from the umbilicus down or a 30 %. Cyclo-oxygenase (Cox)-2 inhibitors can be used horizontal incision. Epidural analgesia is indicated for open safely in conjunction with epidural anaesthesia. Recently, procedures because it provides superior analgesia to sys- two reviews of mainly retrospective studies and work on temic opioids [Continuous intravenous infusion of animals and humans highlighted a possible association lidocaine has been shown to spare postoperative use of between ibuprofen, diclofenac and celecoxib and a higher opioids . However, no data are available for com- incidence of anastomotic dehiscence [, ]. No studies paring continuous intravenous lidocaine versus epidural for have established whether administration of ketamine, postoperative analgesia within an ERAS programme. For gabapentin or tramadol in the postoperative period impact laparoscopy or assisted laparoscopy in which a small hor- positively on postoperative outcome after rectal surgery.
izontal incision is used and in the context of the ERAS Patients need to be monitored daily by the Acute Pain programme, epidural analgesia or continuous intravenous Team (whose role is to optimize analgesia to facilitate infusion of lidocaine provided good pain relief in the first mobilisation) to limit the incidence of side effects such as 24 h with a similar time to return of bowel function or hypotension, nausea and vomiting.
TEA is recommended for open rectal Abdominoperineal resection includes excision of the surgery for 48–72 h in view of the rectal stump, which requires further consideration. These superior quality of pain relief compared patients might have preoperative pain partially induced by with systemic opioids. Intravenous neoadjuvant radiotherapy and which might be neuropathic administration of lidocaine has also in nature, thereby requiring a multi-pharmacological been shown to provide satisfactory approach. Thoracic epidural anaesthesia (TEA, inserted at analgesia, but the evidence in rectal the T10 level) might not be sufficient to cover the perineal surgery is lacking. If a laparoscopic and sacral incisions, so some arrangements are needed. In approach is used, epidural or intravenous the first instance, addition of morphine to bupivacaine lidocaine, in the context of ERAS, might increase the spread of anaesthesia and be effective. If provides adequate pain relief and no this is not sufficient, another epidural can be inserted at the difference in the duration of LOSH and lumbar level (L3–4), even if this approach might cause return of bowel function. Rectal pain can some motor block in the lower limbs (and therefore might be of neuropathic origin, and needs to be delay mobilization) and also significantly increase the risk of urinary retention.
methods. There is limited evidence for Alternatives are a combination of thoracic epidural the routine use of wound catheters and analgesia, infusing only local anesthetic, and systemic continuous TAP blocks in rectal surgery.
(patient-controlled anaesthesia (PCA)) or oral opioids as Epidural for open surgery: High; Epi- rescue analgesia to control perineal pain. No studies are dural for laparoscopy: Low; Intravenous available. Continuous infusion of local anesthetics via pre- lidocaine: Moderate; Wound infiltration peritoneal wound catheters has been shown to provide and TAP blocks: Low satisfactory pain relief and fewer side effects [How- Epidural for open surgery: Strong ever, no studies using the ERAS programme are available.
Epidural for laparoscopy: Weak Transversus abdominis plane (TAP) blocks can be used Intravenous lidocaine: Weak [, There is only limited evidence suggesting the Wound infiltration and TAP blocks: use of perioperative TAP blocks to reduce opioid con- sumption and pain scores after abdominal surgery whencompared with systemic opioids or placebo. The sideeffects of opioids are not reduced by the use of TAP blocks.
The efficacy of bilateral local anesthetic boluses through a Perioperative nutritional care subcostal TAP block catheter has been compared withepidural analgesia in only 66 patients undergoing upper Early oral intake (within 24 h) In the well-nourished abdominal surgery, without showing major analgesic ben- patient with preserved gastrointestinal function in the days efits. However, a comparison has been made with other after surgery, high-quality hospital food introduced within World J Surg (2013) 37:285–305 24 h will fulfil most nutritional requirements, and little from treatment of hyperglycaemia with insulin in mainly artificial nutritional support is required. It has been well- postoperative patients with planned admission to an Inten- established that any delay in the resumption of normal oral sive Care Unit (ICU) . Subsequent multivariable diet after major surgery is associated with increased rates regression analyses revealed that lower glucose concentra- of infectious complications and delayed recovery tions were the important factor A recent multicentre Importantly, early oral diet has been shown to be safe in trial confirmed these findings in the subgroup of patients patients with a new non-diverted colorectal anastomosis with trauma No subsequent trials of intensive insulin . Meta-analyses highlight an increased risk of vom- therapy in surgical patients have been published.
iting; considerable efforts must be made to prevent post- However, there is little doubt that hyperglycaemia is operative ileus and a risk of aspiration.
harmful also in routine perioperative care outside the ICUThere is no high-level evidence on what gly- An oral ad libitum diet is recommended caemic target is appropriate in this setting; expert opinion 4 h after rectal surgery.
only is available. The US Endocrine Society has recom- mended a pre-meal blood glucose target of 7.8 mmol/l and a random glucose value of 10.0 mmol/l .
Strategies for achieving such targets are evolving.
Intensive insulin treatment is not advised due to the intake Oral nutritional supplements There are no randomised of discrete meals in most patients . The traditional and trials showing whether oral nutritional supplements (ONS) still widely used sliding-scale subcutaneous insulin regi- act to supplement total food intake in patients undergoing men is a reactive rather than preventive strategy, and is not rectal surgery within an ERAS protocol.
supported by available clinical evidence Basal-bolus A large prospective series confirmed that an oral diet subcutaneous insulin therapy was shown to result in better after colorectal resection within an ERAS protocol can be glycaemic control and lower overall complication rates in substantial (&1,200 kcal daily from the first day after diabetic, non-critically ill surgical patients in a recent surgery) but in itself cannot prevent postoperative randomised trial ].
weight loss (by &3 kg on postoperative day 28). There In elective major surgery, there is an opportunity to may, therefore, be a role for extended routine use of pro- prevent or attenuate metabolic responses to surgery, rather tein-rich supplements in ERAS protocols. Two trials of than having to treat them with insulin. Several stress- perioperative nutritional supplements in the outpatient reducing interventions in ERAS attenuate insulin resistance phase lasting 4–16 weeks demonstrated significant effects as single interventions, including preoperative oral carbo- on postoperative morbidity [, ] in general surgical hydrate treatment [, epidural blockade ] patients, but another trial did not .
and minimally invasive surgery . If such interventionsare combined in an ERAS protocol, hyperglycaemia can be In addition to normal food intake, patients avoided even during full enteral feeding starting immedi- should be offered ONS to maintain ately after major colorectal surgery [ adequate intake of protein and energy.
Maintenance of perioperative blood sugar levels within an expert-defined range results in better outcomes. Therefore,insulin resistance and hyperglycemiashould be avoided using stress-reducing Perioperative glycaemic control measures or if already established byactive treatment. The level of glycaemia Insulin resistance is a physiological response to surgical to target for intervention at the ward level injury characterised by impaired uptake of peripheral glu- remains uncertain, and is dependent upon cose and accelerated hepatic glucose release, resulting in local safety aspects.
hyperglycaemia . Hyperglycaemia is common in non- Use of stress-reducing measures: Mod- critically ill postoperative patients with and without a pre- erate; Level of glycaemia for insulin operative diagnosis of DM The risk of complications associated with hyperglycaemia in the surgical patient first Use of stress-reducing treatments: Strong; became widely appreciated with publication of an inter- Insulin treatment (non-diabetics) at the ventional trial of intensive insulin treatment. This demon- strated appreciable reductions in morbidity and mortality World J Surg (2013) 37:285–305 Early mobilisation single elements into a background of traditional care. Forexample, allowing patients to eat on the first postoperative Extended bed rest is associated not only with an increase risk day was found to be safe . Once an ERAS programme of thromboembolism but also with several unwanted effects is in place, however, it is impossible to ‘dissect out' the use such as insulin resistance, muscle loss, loss of muscle strength, of immediate ad libitum oral nutrition to determine its pulmonary depression, and reduced tissue oxygenation.
impact on the outcomes observed with the entire protocol Encouraging postoperative early mobilisation is impor- Quite similar is the finding that compliance with tant to avoid patient discomfort (pain and ileus) because NSQIP and SCIP interventions resulted in general patients must be adequately nursed, keeping their inde- improvements in outcomes, but individual elements did not pendence as much as possible. Patients should be out of result in improvements in the outcomes of interest.
bed 2 h on the day of surgery, and 6 h per day until hos- Improved compliance with recommended perioperative pital discharge .
antibiotic use did not reduce further the prevalence ofsurgical-site infections Whether or not the individual Patients should be nursed in an components of greatest impact can be defined, auditing is environment that encourages indepen- essential to maintain compliance and to provide a back- dence and mobilisation. A care plan ground from which future studies are shaped. Adherence to that facilitates patients being out of an established protocol is proven to be in linear relationship bed for 2 h on the day of surgery and to improved outcomes ]. Also, all improvements in the 6 h thereafter is recommended.
ERAS programme and ERAS Society protocols have arisen from database review and compliance auditing Auditing is necessary. The question is which components should be strictly recorded and followed, as well as, howthe data are retrieved, stored, shared, and analysed.
As with any intervention, variability exists between Audit and outcome measures healthcare systems. Many outcomes most easily retrievedfrom the medical records are linked to use of health system The evidence of improved outcomes with the implemen- resources. Thus, LOSH, overall cost, complications requiring tation of individual elements of ERAS protocols is pre- readmission to hospital, longer operations, need for blood sented in this paper. We have included more recent studies transfusions, and similar outcomes are often reported. Each of undertaken within an ERAS protocol and evaluated the these may be important or may only be a marker for improved impact of specific interventions with an ERAS control care. For example, a patient is not actually ‘‘healthier'' cohort. All surgeons in ‘developed countries' are func- because he/she leaves the hospital 14 h sooner than another, tioning in an era of: reform of healthcare management; but he may be recovering with lesser difficulty as witnessed by reduced cost initiatives concomitant with increased patient meeting discharge criteria sooner. As discussed above, rectal safety and providers for improved outcomes mandates; and resections are different from colon resections with respect to pay-for-performance programmes. Incumbent upon peri- indication, preoperative optimisation of patients, intraopera- operative care is the implementation and auditing of care tive challenges, and postoperative needs. This is particularly improvement strategies. During the early reporting of true if considering preoperative chemoradiation for malig- ERAS, critics of fast-track protocols questioned whether nancy, immunosuppression for inflammatory bowel disease, reported improvement could be due only to increased previous pelvic surgery, ostomy creation, and flap closures.
Considering these factors, which are not specifically addres- (improved performance due to known observation) also sed in ERAS studies of colon resection, will create a relative brought into question the validity of early reports of stratification of perioperative risk factors for a clearer improved outcomes from the US-based Surgical Compli- assessment of the same outcome analysis.
cations Improvement Program (SCIP) In many In short, auditing of any change in perioperative care is ways, the SCIP and ERAS protocols as well as the US- prudent and, in some healthcare settings, essential. Occa- based National Surgical Quality Improvement Program sionally the outcome variable defined by a healthcare (NSQIP) share the difficult blessing of improved observed system does not directly define better or worse outcomes, outcomes without clarity as to which variable of care and care providers need to be involved in these analyses resulted in the improvement. By implementing the stress- and care management plans to ensure fair evaluations of reducing elements of perioperative care that have con- outcomes and the best possible auditing of their work.
vincing supporting studies, the ERAS programme has The outcomes of interest in rectal resection are essen- shown outcome improvements over implementation of tially the same as those in colon resection. However, there World J Surg (2013) 37:285–305 is significant difference in risks for worse outcomes in There are no prospective randomised trials that have rectal resection. Hence, preoperative assessment and defi- specifically focused on the role of ERAS in rectal surgery nition of risks specific to rectal resection is required.
alone. All randomised trials that have included rectal sur- The best studies of ERAS in rectal resection will be gery have also included an admixture of colonic resections.
specific to this population in accrual and auditing. Given The numbers of patients in such studies are relatively small the number of rectal resections compared with colon and even in the context of meta-analyses it has not been resections, few centres have adequate numbers of patients possible to separate the rectal patients . Thus, it is not to independently undertake the rigorous evaluation already possible to be definitive about the influence of traditional accomplished in ERAS for colon resection. The ongoing versus ERAS care upon recovery, morbidity or mortality.
multinational efforts of the ERAS Society Research However, published case series with retrospective controls Committee, in conjunction with the ERAS Interactive have suggested a consistent reduction in LOSH by Audit System, will result in adequate subject numbers to 3–5 days whether the resection is undertaken by open or provide strong outcomes analyses for the pelvic bowel laparoscopic means [–There has been no reported resection patient group. This system will also act as a increase in postoperative complications or mortality, sug- background upon which new interventions may be intro- gesting that managing rectal cancer patients within an duced in randomised or large cohort study design.
ERAS protocol is safe.
All patients should be audited for Rectal surgery undertaken within an protocol compliance and outcomes enhanced recovery programme is safe and improves recovery as reflected by a 3–5 day reduction in LOSH.
Quality of evidence Overall traditional versus ERAS care The principles of ERAS have largely been established on the Health economics and quality of life (QoL) basis of elective segmental colonic resection . Initially,the focus was on open surgery and latterly on laparoscopic Although implementation of an ERAS protocol is a resection. Rectal surgery, however, represents a different complex and time-consuming multidisciplinary project, challenge. The magnitude and duration of surgery is longer, available data demonstrate that such costs are offset by blood loss is greater, the patients may have received pre- subsequent savings in reduced LOSH [, ] and operative chemoradiation, and the frequent use of a stoma reduced complication rates . Furthermore, signifi- requires significant educational input. Moreover, the rate of cant long-term cost savings are possible in ERAS pro- anastamotic leaks is higher and overall morbidity and mor- tocols: an average calculated cost saving of NZD 6,900 tality greater. On the one hand, this suggests that there may per patient was reported for 50 consecutive ERAS be even greater gains to be had by adopting optimal nutri- patients compared with 50 patients who underwent tra- tional and metabolic care in patients undergoing more major surgery. On the other hand, traditionalists worry about any Few significant differences have been reported in terms of adverse influence of altered practice, especially with respect QoL perhaps because health-specific QoL to anastamotic integrity. In particular, concerns have been instruments for perioperative care have been unavailable expressed about the use or lack of use of MBP [epidu- and investigators have instead used generic QoL instruments rals, vasopressors, NSAIDs, and laxatives.
or instruments developed for certain diagnoses rather than Within an enhanced recovery programme for open perioperative care. This is currently being addressed with the colorectal surgery, male sex, preoperative comorbidity and development of well-validated, health-specific abdominal age [80 years have been shown to be independent deter- surgery perioperative QoL scores . Better data are minants of prolonged LOSH and postoperative morbidity available on the important phenomenon of postoperative . Such data suggest that, even with enhanced recovery, fatigue, which has been reported to be decreased within rectal surgery represents a greater challenge than colonic ERAS care in observational studies [, surgery. An international survey of surgeons (123 surgeonsin 28 countries) reported recently that 63 % use enhanced ERAS protocols are cost-neutral or recovery for rectal cancer Thus, despite the greater cost-effective and result in reduced challenges for ERAS in rectal surgery, the trend seems fatigue. They are recommended as the towards widespread adoption of ERAS for such patients.
current standard of care.
World J Surg (2013) 37:285–305 Table 2 Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERASÒ) Societyrecommendations Recommendation grade Patients should routinely receive dedicated preoperative education and counseling Preoperative optimisation of medical conditions (e.g., Medical optimisation: Moderate Medical optimisation: Strong anaemia), cessation of smoking and alcohol intake Pre-habilitation: Very low Pre-habilitation: No 4 weeks before rectal surgery is recommended.
Cessation of smoking: Moderate Cessation of smoking: Strong Increasing exercise preoperatively may be of benefit.
Preoperative specialised nutritional support should be Cessation of excess consumption of Cessation of excess considered for malnourished patients consumption of alcohol:Strong Preoperative bowel In general, MBP should not be used in pelvic surgery.
Anterior resection: (No MBP) High Anterior resection: Strong However, when a diverting ileostomy is planned, MBP Total mesorectal excision (TME) TME with diverting stoma: may be necessary (although this needs to be studied with diverting stoma: (use MBP) Preoperative fasting Intake of clear fluids up to 2 h and solids up to 6 h prior to induction of anaesthesia Preoperative treatment with Preoperative oral carbohydrate loading should be Reduced postop insulin resistance: administered to all non-diabetic patients Improved clinical outcomes: low Preanesthetic medication No advantages in using long-acting benzodiazepines Short-acting benzodiazepines can be used in young patients before potentially painful interventions (insertion ofspinal or epidural, arterial catheter), but they should notbe used in the elderly (age [60 years) Prophylaxis against Patients should wear well-fitting compression stockings, and receive pharmacological prophylaxis with LMWH.
Extended prophylaxis for 28 days should be consideredin patients with colorectal cancer or other patients withincreased risk of VTE Patients should receive antimicrobial prophylaxis before skin incision in a single dose. Repeated doses may benecessary depending on the half-life of drug and durationof surgery A recent RCT has shown that skin preparation with a scrub For skin preparation in of chlorhexidine-alcohol is superior to povidone-iodine in preventing surgical-site infections Specific choice of preparation: Weak Standard anesthetic To attenuate the surgical stress response, intraoperative Epidural: Moderate maintenance of adequate hemodynamic control, central IV Lidocaine: Weak and peripheral oxygenation, muscle relaxation, depth ofanesthesia, and appropriate analgesia is strongly IV Lidocaine: Low Remifentanil: Strong Remifentanil: Low High oxygen concentration: High oxygen concentration: High Prevention of PONV should be included as standard in High-risk patients: High ERAS protocols. More specifically, a multimodal In all patients: Low approach to PONV prophylaxis should be adopted in allpatients with C2 risk factors undergoing major colorectalsurgery. If PONV is present, treatment should be via amultimodal approach Laparoscopic resection of With proven safety and at least equivocal disease-specific outcomes, laparoscopic proctectomy andproctocolectomy for benign disease can be carried out byan experienced surgeon within an ERAS protocol with thegoals of reduced perioperative stress (manifested bydecreased postoperative ileus), decreased LOSH, andfewer overall complications Laparoscopic resection of Laparoscopic resection of rectal cancer is currently not generally recommended outside of a trial setting (orspecialized centre with ongoing audit) until equivalentoncologic outcomes are proven Nasogastric intubation Postoperative nasogastric tubes should not be used World J Surg (2013) 37:285–305 Table 2 continued Recommendation grade Patients undergoing rectal surgery need to have their body temperature monitored during and after surgery.
Attempts should be made to avoid hyothermia because itincreases the risk of perioperative complications Perioperative fluid Fluid balance should be optimised by targeting cardiac output and avoiding overhydration. Judicious use ofvasopressors is recommended with arterial hypotension.
Targeted fluid therapy using the oesophageal Dopplersystem is recommended Drainage of peritoneal Pelvic drains should not be used routinely Transurethral catheter After pelvic surgery with a low estimated risk of postoperative urinary retention, the transurethralbladder catheter may be safely removed on postoperativeday 1, even if epidural analgesia is used Suprapubic catheter In patients with an increased risk of prolonged Prolonged catheterisation: Low postoperative urinary retention, placement of asuprapubic catheter is recommended A multimodal approach to optimising gut function after rectal resection should involve chewing gum Postoperative laxatives and A multimodal approach to optimising gut function after rectal resection should involve oral laxatives Postoperative analgesia TEA is recommended for open rectal surgery for 48–72 h in Epidural for open surgery: High Epidural for open surgery: view of the superior quality of pain relief compared with systemic opioids. Intravenous administration of lidocaine Epidural for laparoscopy: Low Epidural for laparoscopy: has also been shown to provide satisfactory analgesia, but the evidence in rectal surgery is lacking. If a Intravenous lidocaine: Moderate Intraveous lidocaine: Weak laparoscopic approach is used, epidural or intravenouslidocaine, in the context of ERAS, provides adequate pain Wound infiltration and TAP blocks: Wound infiltration and TAP relief and no difference in the duration of LOSH and return of bowel function. Rectal pain can be ofneuropathic origin, and needs to be treated withmultimodal analgesic methods. There is limited evidencefor the routine use of wound catheters and continuousTAP blocks in rectal surgery Early oral intake An oral ad libitum diet is recommended 4 h after rectal In addition to normal food intake, patients should be offered ONS to maintain adequate intake of protein andenergy.
Postoperative glucose Maintenance of perioperative blood sugar levels within an Use of stress-reducing measures: Use of stress-reducing expert-defined range results in better outcomes.
treatments: Strong Therefore, insulin resistance and hyperglycemia should Level of glycemia for insulin Insulin treatment (non- be avoided using stress-reducing measures or if already diabetics) at the ward level: established by active treatment. The level of glycaemia to target for intervention at the ward level remainsuncertain, and is dependent upon local safety aspects Early mobilisation Patients should be nursed in an environment that encourages independence and mobilisation. A care planthat facilitates patients being out of bed for 2 h on theday of surgery and 6 h thereafter is recommended aim to help surgeons and anaesthetists to employ current best practice to enhance the recovery of patients undergoing major rectal surgery. The ERAS Society is involved in updatingguidance to support the use of best perioperative care. Thecurrent guidelines are in development from two consensus papers [, ]. We decided to produce separate guidelines forcolonic and rectal resections because there are differences These guidelines in perioperative care for rectal surgery are developing in best practice. The present guidelines were based on the current literature (summarised in Table They produced using the GRADE system  using strict criteria to World J Surg (2013) 37:285–305 determine the levels of evidence. As explained in the methods 9. Halaszynski TM, Juda R, Silverman DG (2004) Optimizing section, the reviewers take into consideration the potential postoperative outcomes with efficient preoperative assessmentand management. Crit Care Med 32:S76–S86 good versus potential harm argument that the treatment may 10. Stergiopoulou A, Birbas K, Katostaras T et al (2007) The effect have when setting the level of the recommendation. This may of interactive multimedia on preoperative knowledge and post- allow for strong recommendation even if the data behind the operative recovery of patients undergoing laparoscopic chole- evidence are of moderate, or even low, quality, but the harm is cystectomy. Methods Inf Med 46:406–409 11. Clarke HD, Timm VL, Goldberg BR et al (2011) Preoperative patient education reduces in-hospital falls after total knee Since the practice of surgery and anesthesia is contin- arthroplasty. Clin Orthop Relat Res 470:244–249 uously changing, there is a need for regular updates of the 12. Edward GM, Naald NV, Oort FJ et al (2010) Information gain in knowledge base and for continuous training of those patients using a multimedia website with tailored information onanaesthesia. Br J Anaesth 106:319–324 involved in the treatment of surgical patients. The ERAS 13. Haines TP, Hill AM, Hill KD et al (2010) Patient education to Society for Perioperative Care () was prevent falls among older hospital inpatients: a randomized initiated by the former ERAS Study Group and was formed controlled trial. Arch Intern Med 171(516–52):4 in 2010 to support these processes. The Society participates 14. Younis J, Salerno G, Fanto D et al (2011) Focused preoperative patient stoma education, prior to ileostomy formation after in the improvement of perioperative care by developing anterior resection, contributes to a reduction in delayed discharge new knowledge through research, education and also by within the enhanced recovery programme. Int J Colorectal Dis being involved in the implementation of best practice.
15. AAGBI (2010) Pre-operative assessment and patient preparation Supported by the ERASÒ Society, International 16. Gustafsson UO, Ljungqvist O (2011) Perioperative nutritional Association for Surgical Metabolism and Nutrition (IASMEN) and management in digestive tract surgery. Curr Opin Clin Nutr the European Society for Clinical Nutrition and Metabolism Metab Care 14:504–509 (ESPEN). The ERAS Society have received an unrestricted devel- 17. Mastracci TM, Carli F, Finley RJ et al (2011) Effect of preop- opment grant from Nutricia Research.
erative smoking cessation interventions on postoperative com-plications. J Am Coll Surg 212:1094–1096 Conflict of interest The ERAS SocietyÒ receives an unrestricted 18. Tonnesen H, Nielsen PR, Lauritzen JB et al (2009) Smoking and grant from Nutricia. OL has served as an external advisor to Nutricia alcohol intervention before surgery: evidence for best practice.
and has occasionally received travel and lecture honoraria from Nu- Br J Anaesth 102:297–306 tricia, Fresenius-Kabi, BBraun, Baxter and Nestle. OL also previously 19. Carli F, Charlebois P, Stein B et al (2010) Randomized clinical held a patent for a preoperative carbohydrate drink formerly licensed trial of prehabilitation in colorectal surgery. Br J Surg 97: to Nutricia. All other authors declare no conflicts of interests.
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Volume 101, Number 3, May–June 1996 Journal of Research of the National Institute of Standards and Technology [J. Res. Natl. Inst. Stand. Technol. 101, 295 (1996)] Using NIST Crystal Data Within Siemens Software for Four-Circle and SMART CCD Diffractometers Susan K. Byram, Charles NIST Crystal Data developed at The Ideas for future access to this and other