title: Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. A systematic review of enhanced recovery protocols in colorectal surgery. Impact of fast-track postoperative care on intestinal function, pain, and length of hospital stay after laparoscopic radical prostatectomy. Fast-track surgery for bilateral total knee replacement. Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial A clinical pathway to accelerate recovery after colonic resection. Fast-track hysterectomy: a randomised, controlled study.
abstract: OBJECTIVES To study the impact of different adherence levels to the enhanced recovery after surgery ( ERAS ) protocol and the effect of various ERAS elements on outcomes following major surgery . DESIGN Single-center prospect i ve cohort study before and after reinforcement of an ERAS protocol . Comparisons were made both between and across periods using multivariate logistic regression . All clinical data ( 114 variables ) were prospect ively recorded . SETTING Ersta Hospital , Stockholm , Sweden . PATIENTS Nine hundred fifty-three consecutive patients with colorectal cancer : 464 patients treated in 2002 to 2004 and 489 in 2005 to 2007 . MAIN OUTCOME MEASURES The association between improved adherence to the ERAS protocol and the incidence of postoperative symptoms , complications , and length of stay following major colorectal cancer surgery was analyzed . RESULTS Following an overall increase in preoperative and perioperative adherence to the ERAS protocol from 43.3 % in 2002 to 2004 to 70.6 % in 2005 to 2007 , both postoperative complications ( odds ratio , 0.73 ; 95 % confidence interval , 0.55 - 0.98 ) and symptoms ( odds ratio , 0.53 ; 95 % confidence interval , 0.40 - 0.70 ) declined significantly . Restriction of intravenous fluid and use of a preoperative carbohydrate drink were major independent predictors . Across periods , the proportion of adverse postoperative outcomes ( 30-day morbidity , symptoms , and readmissions ) was significantly reduced with increasing adherence to the ERAS protocol ( > 70 % , > 80 % , and > 90 % ) compared with low ERAS adherence ( < 50 % ) . CONCLUSION Improved adherence to the st and ardized multimodal ERAS protocol is significantly associated with improved clinical outcomes following major colorectal cancer surgery , indicating a dose-response relationship 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 . METHODS Systematic search es of the PubMed and Embase ™ data bases and the Cochrane library were conducted . A h and search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy . RESULTS A total of 59 relevant studies were identified . These included six r and omised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria . 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 . CONCLUSIONS 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 . These findings help to confirm that ERAS protocol s should now be implemented as the st and ard approach for peri-operative care in colorectal surgery BACKGROUND AND PURPOSE Postoperative recovery of intestinal function , ability to ambulate , and effective pain management are main features to establish an effective fast-track surgery model . We investigated pain scores , ambulation rate , and recovery of intestinal function in a cohort of patients who were undergoing laparoscopic radical prostatectomy ( LRP ) .  PATIENTS AND METHODS Fifty patients who underwent LRP in our institution were r and omized to receive either  conventional  or  fast-track postoperative care . Postoperative intestinal function was quantified by clinical signs of intestinal motility . Ambulation data were collected by means of step-count devices . Pain scores were measured by a visual analog scale . Overall satisfaction and additional measures to describe patient satisfaction with the clinical course were used as quality -of-life variables . RESULTS Fast-track patients had significantly earlier propulsive intestinal motility without increased intestinal complications . Enforced mobilization led to a significantly shorter period to first deflation/defecation . Despite significantly increased ambulation rates in the fast-track group , these patients reported significantly less pain sentience during a significantly shorter hospital stay . Overall satisfaction was significantly higher in the fast-track cohort during the hospital stay . CONCLUSION With the implementation of fast-track concepts for LRP , patients can be discharged to home earlier with fewer complications , lower pain scores , and an overall higher satisfaction with life Bilateral  simultaneous total knee replacement ( TKR )  has been considered by some to be associated with increased morbidity and mortality . Our study analysed the outcome of 150 consecutive , but selected , bilateral simultaneous TKRs  and compared them with that of 271 unilateral TKRs in a st and ardised fast-track setting . The procedures were performed between 2003 and 2009 . Apart from staying longer in hospital ( mean 4.7 days ( 2 to 16 ) versus 3.3 days ( 1 to 25 ) ) and requiring more blood transfusions , the outcome at three months and two years was similar or better in the bilateral  simultaneous TKR  group in regard to morbidity , mortality , satisfaction , the range of movement , pain , the use of a walking aid and the ability to return to work and to perform activities of daily living .  Bilateral simultaneous TKR can therefore be performed as a fast-track procedure with excellent results Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety 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 OBJECTIVE To investigate if intrathecally administered morphine combined with a low-dose mode of total intravenous anaesthesia ( TIVA ) accelerates recovery after abdominal surgery as compared , to patient-controlled analgesia ( PCA ) combined with anaesthesia , based on volatile anaesthetics . STUDY DESIGN Fifty-three patients who were hysterectomised abdominally were r and omised to TIVA or PCA .  Their per- and post-operative course was strictly monitored and their pain score was evaluated with a visual analogue scale at repeated time intervals . RESULTS Patients with TIVA had a significantly shorter stay on the post-operative ward , 180 (105 - 330)min , compared with the PCA group , 237 (120 - 1140)min ( p<0.01 ) . The start of peroral fluid also differed significantly between groups , 4h ( 2 - 6 ) for TIVA versus 5h ( 2 - 24 ) for the PCA group ( p<0.01 ) . The removal of the indwelling catheter took place significantly earlier in the TIVA group , 9h ( 5 - 23 ) versus 22h ( 17 - 24 ) in the PCA group ( p<0.0001 ) . There was significantly less post-operative nausea in the TIVA group compared with the PCA group on the first post-operative day ( p<0.01 ) . The length of stay was shorter , 2 days ( 1 - 3 ) compared with 3 days ( 1 - 6 ) for the TIVA group versus PCA ( p<0.001 ) . There was no difference in complications between groups . One patient in each group was re-admitted to hospital because of a vaginal cuff infection . CONCLUSION The TIVA per- and post-operative care was an advantage over PCA in most respects
target: The majority of this literature derives from the study of patients undergoing colorectal surgery , but increasingly enhanced recovery is spreading to other surgical specialties .
  The combination of reduced length of hospital stay ( a surrogate for morbidity ) with no increase in readmissions to hospital suggests that morbidity is reduced with enhanced recovery .
  Inconsistency in morbidity reporting limits the value of pooling data between studies , but within study comparisons in general support this conclusion .
  Patients adhering to an  enhanced recovery programme  return to normal function faster than those following traditional care pathways .
background: PURPOSE OF REVIEW The aim of this review is to summarize important publications in  enhanced recovery during 2010 - 2011 and to highlight key themes .