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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
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allow for strong recommendation even if the data behind the
operative recovery of patients undergoing laparoscopic chole-
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The ERAS SocietyÒ receives an unrestricted
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grant from Nutricia. OL has served as an external advisor to Nutricia
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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
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Source: http://www.acs.ac.nz/upload/resource/2013_ERAS%20Guidelines_Rectum.pdf
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