title: Enhanced Recovery After Surgery (ERAS) Versus Conventional Postoperative Care in Colorectal Surgery Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection Implementation of a Fast-Track Perioperative Care Program: What Are the Difficulties? Randomized clinical trial of multimodal optimization and standard perioperative surgical care ‘Fast-track’ multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation A clinical pathway to accelerate recovery after colonic resection. Prospective, Randomized, Controlled Trial Between a Pathway of Controlled Rehabilitation With Early Ambulation and Diet and Traditional Postoperative Care After Laparotomy and Intestinal Resection A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer Is mechanical bowel preparation mandatory for elective colon surgery? A prospective randomized study. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection Physiologic Effects of Bowel Preparation Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition
abstract: Background Enhanced Recovery After Surgery ( ERAS ) programs are associated with reduced hospital morbidity and mortality . The aim of the present study was to evaluate whether the introduction of ERAS care improved the adverse events in colorectal surgery . In a cohort study , mortality , morbidity , and length of stay were compared between ERAS patients and carefully matched historical controls . Methods Patients were matched for their type of disease , the type of surgery , P-Possum ( Portsmouth-Possum ) , CR-Possum ( Colorectal-Possum ) Physiological and Operative Score for Enumeration of Mortality and Morbidity ( POSSUM ) , gender , and American Society of Anesthesiologists ( ASA ) grade . The primary outcome measures of this study were mortality and morbidity . Secondary outcome measures were fluid intake , length of hospital stay , the number of relaparotomies , and the number of readmissions within 30 days . Data on the ERAS patients were collected prospect ively . Results Sixty-one patients treated according to the ERAS program were compared with 122 patients who received conventional postoperative care .  The two groups were comparable with respect to age , ASA grade , P-Possum ( Portsmouth-Possum ) , CR-Possum ( Colorectal-Possum ) score , type of surgery , stoma formation , type of disease , and gender . Morbidity was lower in the ERAS group compared to the control group ( 14.8 % versus 33.6 % respectively ; P = < 0.01 ) . Patients in the ERAS group received significantly less fluid and spent fewer days in the hospital ( median 6 days , range 3–50 vs. median 9 days , range 3–138 ; P = 0.032 ) . There was no difference between the ERAS and the control group for mortality ( 0 % vs. 1.6 % ; P = 0.55 ) and readmission rate ( 3.3 % vs. 1.6 % ; P = 0.60 ) . Conclusion Enhanced Recovery After Surgery program  reduces morbidity and the length of hospital stay for patients undergoing elective colonic or rectal surgery BACKGROUND Studies have shown the value of using fast-track postoperative recovery . St and ard procedures ( non-fast-track strategies ) remain in common use for perioperative care . Few prospect i ve reports exist on the outcome of fast-tracking in Central Europe . The aim of our study was to assess the effect and safety of our own fast-track protocol with regard to the postoperative period after open bowel resection . PATIENTS AND METHODS One hundred and five patients with ASA score I-II scheduled for open intestinal resection in the period April 2005-December 2007 were r and omly selected for the fast-track group ( FT ) and non-fast-track group ( non-FT ) . A design ed protocol was used in the FT group with the emphasis on an interdisciplinary approach . The control group ( non-FT ) was treated by st and ard established procedures .  Postoperative pain , rehabilitation , gastrointestinal functions , postoperative complications , and post-op length of stay were recorded . RESULTS Of 105 patients , 103 were statistically analyzed . Patients in the FT group ( n=51 ) and non-FT group ( n=52 ) did not differ in age , surgical diagnosis , or procedure . The fast-track procedure led to significantly better control of postoperative pain and faster restoration of GI functions ( bowel movement after 1.3 days vs. 3.1 , p<0.001 ) . Food tolerance was significantly better in the FT group and rehabilitation was also faster . Hospital stay was shorter in the FT group - median seven days ( 95 % CI 7.0 - 7.7 ) versus ten days ( 95 % CI 9.5 - 11.3 ) in non-FT ( p<0.001 ) . Postoperative complications within 30 postoperative days were also significantly lower in the FT group ( 21.6 vs. 48.1 % , p=0.003 ) . There were no deaths and no patients were readmitted within 30 days . CONCLUSIONS Following the FT protocol helped to reduce frequency of postoperative complications and reduced hospital stay . We conclude that the FT strategy is safe and effective in improving postoperative outcomes The aim of this trial was to compare  multimodal optimization  with  conventional perioperative management  in a consecutive series of patients undergoing a wide range of colorectal procedures Background : To evaluate the feasibility of a fast-track ( FT ) program and it ’s effect on postoperative recovery . Methods : All patients , scheduled for elective segmental colorectal resection were treated in a FT program ( FT group ) . Data were compared to a control group operated for elective colorectal resections and treated in a traditional care program ( TC group ) . Data from the FT group were collected prospect ively , data from the TC group retrospectively . Outcome parameters included the number of successfully applied FT modalities , patient satisfaction , morbidity rate , re-operation rate , primary ( PHS ) and total hospital stay ( THS ) , and readmission rate . Results : One-hundred and seven patients were included ( 55 FT group vs. 52 TC group ) . The groups were comparable for patient characteristics such as age and cr-POSSUM score ( p = 0.22 and p = 0.40 ) . An average of 7.4 of 13 predefined FT modalities were successfully achieved per patient . Patient satisfaction was comparable ( p = 0.84 ) . Seven versus 5 patients required a re-operation in the FT and TC groups , respectively ( p = 0.52 ) . Morbidity rate was comparable ( n = 16 vs. 15 , p = 0.83 ) . Median PHS was 4.0 vs. 6.0 days and median THS was 4.0 vs. 6.5 days in the FT and TC groups ( p < 0.01 and p < 0.03 , respectively ) . Six vs. 3 patients were re-admitted in the FT and TC groups , respectively ( p = 0.49 ) . Conclusion : Implementation of all FT modalities was difficult since a rather low number of pre-defined FT modalities was effectively realized . Despite incomplete implementation , PHS and THS were shorter in the FT group without affecting patient satisfaction Multimodal optimization of surgical care has been associated with reduced hospital stay and improved physical function . The aim of this r and omized trial was to compare multimodal optimization with st and ard care in patients undergoing colonic resection Background  Laparoscopic colorectal resection improves patient outcome by reducing pain , postoperative pulmonary dysfunction , gastrointestinal paralysis , and fatigue . A multimodal rehabilitation program ( “ fast-track ” ) with epidural analgesia , early oral feeding , and enforced mobilization may further improve the excellent results of laparoscopic colorectal resection , enabling early ambulation of these patients . Methods Fifty two consecutive patients underwent laparoscopic sigmoidectomy with st and ardized regular perioperative treatment ( st and ard ) or multimodal rehabilitation program ( “ fast-track ” ) .  Outcome measures included pulmonary function , duration of postoperative ileus , pain perception , fatigue , morbidity , and mortality . Results Twenty nine st and ard-care patients ( 19 men and 10 women ) and 23 fast-track patients ( 15 men and eight women ) were evaluated . Demographic and operative data were similar for the two groups . On the 1st postoperative day , pulmonary function was improved ( p = 0.01 ) in fast-track patients . Oral feeding was achieved earlier ( p < 0.01 ) and defecation occurred earlier ( p < 0.01 ) in the fast-track group . Visual analogue scale scores for pain were similar for the two groups ( p > 0.05 ) , but fatigue was increased in the st and ard-care group on the 1st ( p = 0.06 ) and 2nd ( p < 0.05 ) postoperative days . Morbidity was not different for the two groups . Fast-track patients were discharged on day 4 ( range , 3–6 ) and st and ard-care patients on day 7 ( range , 4–14 ) ( p < 0.001 ) . Conclusion Multimodal rehabiliation can improve further on the excellent results of laparoscopic sigmoidectomy and decrease the postoperative hospital stay OBJECTIVE To investigate the feasibility of a 48-hour postoperative stay program after colonic resection . SUMMARY BACKGROUND DATA Postoperative hospital stay after colonic resection is usually 6 to 12 days , with a complication rate of 10 % to 20 % . Limiting factors for early recovery include stress-induced organ dysfunction , paralytic ileus , pain , and fatigue . It has been hypothesized that an accelerated multimodal rehabilitation program with optimal pain relief , stress reduction with regional anesthesia , early enteral nutrition , and early mobilization may enhance recovery and reduce the complication rate . METHODS Sixty consecutive patients undergoing elective colonic resection  were prospect ively studied using a well-defined postoperative care program including continuous thoracic epidural analgesia and enforced early mobilization and enteral nutrition , and a planned 48-hour postoperative hospital stay . Postoperative follow-up was scheduled at 8 and 30 days . RESULTS Median age was 74 years , with 20 patients in ASA group III-IV . Normal gastrointestinal function ( defecation ) occurred within 48 hours in 57 patients , and the median hospital stay was 2 days , with 32 patients staying 2 days after surgery . There were no cardiopulmonary complications . The readmission rate was 15 % , including two patients with anastomotic dehiscence ( one treated conservatively , one with colostomy ) ; other readmissions required only short-term observation . CONCLUSION A multimodal rehabilitation program may significantly reduce the postoperative hospital stay in high-risk patients undergoing colonic resection . Such a program may also reduce postoperative ileus and cardiopulmonary complications . These results may have important implication s for the care of patients after colonic surgery and in the future assessment of open versus laparoscopic colonic resection Abstract INTRODUCTION : In an era of dwindling hospital re sources and increasing medical costs , safe reduction in postoperative stay has become a major focus to optimize utilization of healthcare re sources . Although several protocol s have been reported to reduce postoperative stay , no Level I evidence exists for their use in routine clinical practice . METHODS : Sixty-four patients undergoing laparotomy and intestinal or rectal resection  were r and omly assigned to a pathway of controlled rehabilitation with early ambulation and diet or to traditional postoperative care .  Time to discharge from hospital , complication and readmission rates , pain level , quality of life , and patient satisfaction scores were determined at the time of discharge and at 10 and 30 days after surgery . Subgroups were defined to evaluate those who derived the optimal benefit from the protocol . RESULTS : Pathway patients spent less total time in the hospital after surgery ( 5.4 vs. 7.1 days ; P = 0.02 ) and less time in the hospital during the primary admission than traditional patients . Patients younger than 70 years old had greater benefits than the overall study group ( 5 vs. 7.1 days ; P = 0.01 ) . Patients treated by surgeons with the most experience with the pathway spent significantly less time in the hospital than did those whose surgeons were less experienced with the pathway ( P = 0.01 ) . There was no difference between pathway and traditional patients for readmission or complication rates , pain score , quality of life after surgery , or overall satisfaction with the hospital stay . CONCLUSIONS : Patients scheduled for a laparotomy and major intestinal or rectal resection  are suitable for management by a pathway of controlled rehabilitation with early ambulation and diet . Pathway patients have a shorter hospital stay , with no adverse effect on patient satisfaction , pain scores , or complication rates . Patients younger than 70 years of age derive the optimal benefit , and increased surgeon experience improves outcome Objective : A prospect i ve r and omized controlled trial ( RCT ) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer . Aims : This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT . Methods : Patients for elective resection for colorectal cancer were offered trial entry . Participants were stratified by sex and requirement for a total mesorectal excision and central ly r and omized .  Multimodal patients received intravenous fluid restriction , unrestricted oral intake with prokinetic agents , early ambulation , and fixed regimen epidural analgesia . Control patients received intravenous fluids to prevent oliguria , restricted oral intake until return of bowel motility , and weaning regimen epidural analgesia . Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets . Discharge decision was made using preagreed criteria . The primary endpoint was postoperative stay , and achievement of independence milestones . Secondary endpoints were postoperative complications , readmission rates , and mortality . Analysis was by intention to treat . Results : Seventy patients were recruited . Approximately one fourth underwent TME . Median ages were similar ( 69.3 vs. 73.0 years ) . The median stay was significantly reduced in the multimodal group ( 5 vs. 7 days ; P < 0.001 , Mann-Whitney U test ) . Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days . Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions . There were 2 deaths , both controls . Conclusions : This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery . Morbidity and mortality are not increased BACKGROUND Bowel preparation prior to colonic surgery usually includes antibiotic therapy together with mechanical bowel preparation ( MBP ) . Mechanical bowel preparation may cause discomfort to the patient , prolonged hospitalization , and water and electrolyte imbalance . It was assumed that with the improvement in surgical technique together with the use of more effective prophylactic antibiotics , it was possible that MBP would no longer be necessary . HYPOTHESIS There is no statistical difference in the postoperative results of patients who undergo elective colon resection with MBP  as compared with those who have no MBP . DESIGN AND PATIENTS The study includes all patients who had elective large bowel resection at Campus Golda between April 1 , 1999 , and March 31 , 2002 . Emergency operations were not included . The patients were r and omly assigned to the 2 study groups ( with or without MBP ) according to identification numbers . All patients were treated with intravenous and oral antibiotics prior to surgery . The patients in the MBP group received Soffodex for bowel preparation . RESULTS A total of 329 patients participated in the study , 165 without MBP and 164 with MBP . The 2 groups were similar in age , sex , and type of surgical procedure . Two hundred sixty-eight patients ( 81.5 % ) underwent surgery owing to colorectal cancer and 61 patients ( 18.5 % ) owing to benign disease . The hospitalization period was longer in the bowel-prepared group ( mean + /- SD , 8.2 + /- 5.1 days ) as compared with the nonprepared group ( mean + /- SD , 8.0 + /- 2.7 days ) . However , this difference was not statistically significant . The time until the first bowel movement was similar between the 2 groups : a mean + /- SD of 4.2 + /- 1.3 days in the nonprepared group as compared with a mean + /- SD of 4.3 + /- 1.1 days in the prepared group ( P = NS ) . Four patients ( 1.2 % ) died in the postoperative course owing to acute myocardial infa rct ion and pulmonary embolism . Sixty-two patients ( 37.6 % ) of the non-MBP group suffered from postoperative complications as compared with 77 patients ( 46.9 % ) of the MBP group . CONCLUSION Our results suggest that no advantage is gained by preoperative MBP in elective colorectal surgery Recent studies have suggested that MBP does not lower the risk of postoperative septic complications after elective colorectal surgery . This r and omized clinical trial assessed whether preoperative MBP is beneficial in elective colonic surgery PURPOSE : Despite the universal use of bowel preparation before colonoscopy and colorectal surgery , the physiologic effects have not been described in a st and ardized setting . This study was design ed to investigate the physiologic effects of bowel preparation . METHODS : In a prospect i ve study , 12 healthy volunteers ( median age , 63 years ) underwent bowel preparation with bisacodyl and sodium phosphate . Fluid and food intake were st and ardized according to weight , providing adequate calorie and oral fluid intake . Before and after bowel preparation , weight , exercise capacity , orthostatic tolerance , plasma and extracellular volume , balance function , and biochemical parameters were measured . RESULTS : Bowel preparation led to a significant decrease in exercise capacity ( median , 9 percent ) and weight ( median , 1.2 kg ) . Plasma osmolality was significantly increased from 287 to 290 mmol kg−1 , as well as increased phosphate and urea concentrations , whereas calcium and potassium concentrations decreased significantly after bowel preparation . No differences in plasma or extracellular volumes were seen . Orthostatic tolerance and balance function did not change after bowel preparation . CONCLUSIONS : Bowel preparation has significant adverse physiologic effects , which may be attributed to dehydration . The majority of these findings is small and may not be of clinical relevance in otherwise healthy patients undergoing bowel preparation  and following recommendations for oral fluid intake Postoperative organ dysfunction contributes to morbidity , hospital stay and convalescence . Multimodal rehabilitation with epidural analgesia , early oral feeding , mobilization and laxative use after colonic resection has reduced ileus and hospital stay
target: These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates .
  Review ing the data reveals that ERAS protocol s have a role in reducing post-operative morbidity and result in an accelerated recovery following colorectal surgery .
  Similarly , both primary and overall hospital stays are reduced significantly .
  However , the available evidence suggests that ERAS protocol s do not reduce hospital readmissions or mortality .
background: INTRODUCTION Colorectal surgery has been associated with a complication rate of 15 - 20 % and mean post-operative inpatient stays of 6 - 11 days .
  The principles of enhanced recovery after surgery ( ERAS ) are well established and have been developed to optimise peri-operative care and facilitate discharge .
  The purpose of this systematic review is to present an up date d review of peri-operative care in colorectal surgery from the available evidence and ERAS group recommendations .