Fast‐track surgery: the next revolution in surgical care following laparoscopy Laparoscopic-Assisted and Open High Anterior Resection within an ERAS Protocol A systematic review of enhanced recovery protocols in colorectal surgery. ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. EnROL: A multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme Local wound infiltration plus transversus abdominis plane (TAP) block versus local wound infiltration in laparoscopic colorectal surgery and ERAS program Surgical Stress Reduction in Elderly Patients Undergoing Elective Colorectal Laparoscopic Surgery within an ERAS Protocol. Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial. Detailed evaluation of functional recovery following laparoscopic or open surgery for colorectal cancer within an enhanced recovery programme The influence of preoperative nutritional status on the outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery Prospective study of colorectal enhanced recovery after surgery in a community hospital. Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients Influences on length of stay in an enhanced recovery programme after colonic surgery Two-day Hospital Stay After Laparoscopic Colorectal Surgery under an Enhanced Recovery after Surgery (ERAS) Pathway Adherence to Enhanced Recovery after Surgery Protocols across a High-Volume Gastrointestinal Surgical Service Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: EnROL. A prospective cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track multimodal management, for surgical patients with colon carcinomas (TAPAS study) The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Enhanced recovery in colorectal surgery: a multicentre study Enhanced Recovery After Surgery (ERAS) Versus Conventional Postoperative Care in Colorectal Surgery The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer Does enhanced recovery reduce postoperative ileus after colorectal surgery? The effect of formalizing enhanced recovery after esophagectomy with a protocol. Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: Impact of measures to improve adherence. Dexamethasone reduces emesis after major gastrointestinal surgery (DREAMS) Short‐term outcomes from a prospective randomized trial comparing laparoscopic and open surgery for colorectal cancer Hospital Stay and Return to Full Activity Following Laparoscopic Colorectal Surgery Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial Enhanced Recoveryafter Colorectal Surgery. Results from Aprospective Observational Two-Centre Study Laparoscopy within a fast-track program enhances the short-term results after elective surgery for resectable colorectal cancer [Application of the protocol of enhanced recovery after surgery in colorectal surgery]. Safety and efficacy of an “enhanced recovery after surgery” protocol for patients undergoing colon cancer surgery: a multi-institutional controlled study Recovery after open and laparoscopic right hemicolectomy: a comparison. Enhanced recovery in major colorectal surgery: safety and efficacy in an unselected surgical population at a UK district general hospital. Medium-term adoption trends for laparoscopic, robotic and transanal total mesorectal excision (TaTME) techniques
Fast-track surgery , also named enhanced recovery after surgery ( ERAS ) , is in my opinion the most important innovation after the advent of laparoscopy ( in the 1990s ) in the field of  colorectal surgery  ( as in other fields of surgery ) . It is defined as a multimodal pathway aim ing to reduce surgical stress by using pain-free procedures with less organ dysfunction , less morbidity and better recovery . ERAS has been popularized by Henrik Kehlet and his team since the early 2000s [ 1 ] and has rapidly gained popularity around the world because of its remarkable benefits and safety . The concept of ERAS is to make use of the improvement of anaesthetic and analgesic techniques , the development of minimally invasive surgery and evidence -based perioperative care . It involves a number of items , beginning from the first medical visit before surgery to discharge . The items are all evidence based being derived from r and omized controlled trials or meta-analyses . The reader can find the references related to the ERAS items in the valuable consensus review published by the European ERAS group [ 2 ] and the paper of Kehlet and Wilmore [ 3 ] . Through this pathway , the patient can benefit from the best available evidence in anaesthesia , analgesia , perioperative fluid management , surgical procedures , nutrition and ambulation . I will focus in this editorial on the role of ERAS in colorectal surgery , but readers should be aware that ERAS has been applied and vali date d in other abdominal procedures , and in urology , gynaecology , vascular sugery , endocrine surgery , orthopaedic surgery , etc . [ 3 ] . The numerous items or components ( Figure 1 ) involve the preoperative , intra-operative and postoperative periods , necessitating close collaboration between surgeons ( no bowel preparation , no routine nasogastric tube , minimally invasive surgery , no routine abdominal drainage and early postoperative diet ) , anaesthesiologists ( fasting duration of two hours for liquids and six hours for solids , carbohydrate loading , no routine preoperative sedation , avoiding long-acting opioids , epidural analgesia , preventing postoperative nausea and vomiting , preventing intra-operative hypothermia , perioperative fluid restriction and postoperative analgesia ) and nurses and physiotherapists ( early nutrition and mobilisation ) . Several r and omized trials and four meta-analyses [ 4–7 ] have demonstrated the safety and efficacy of ERAS , not only in reducing total length of hospital stay and morbidity , but also in improving patient satisfaction when compared with conventional care . The metaanalyses included both r and omized and non-r and omized studies , the most recent and the largest [ 6 ] showing a reduction of 2.5 days in total hospital stay and significantly less morbidity ( OR 0.54 [ 0.45–0.69 ] ) in favour of the ERAS group , with no difference in readmission rate . A recent meta- analysis focusing on major colorectal surgery demonstrated that the ERAS programme can reduce morbidity by up to 50 % [ 7 ] . ERAS raises three questions . ( i ) What is the respective role of each ERAS item ? ( ii ) Does the ERAS protocol increase the workload of ward nursing staff ? ( iii ) How should this new paradigm be implemented ? Several anaesthesiologists are reluctant to use epidural analgesia in daily practice , mainly when patients are undergoing laparoscopic surgery . Epidural analgesia ( well known to be associated with less pain ) during laparoscopic surgery has been assessed in meta-analyses and r and omized trials but the conclusions are not concordant [ 8,9 ] . In my own daily practice , epidural analgesia is safe and efficacious in relieving pain and allowing early oral intake and mobilization , but it is obvious that its proper role in the ERAS protocol compared with other analgesic regimens such as non-opioid multimodal analgesia , local anaesthesia and continuous wound perfusion , in the era of laparoscopic surgery needs further evaluation . The roleof laparoscopyhas also been debated [ 10 ] . Two small r and omized trials have shown conflicting results [ 11,12 ] , but a recent large r and omized trial [ 13 ] involving four arms ( laparoscopy with ERAS vs laparoscopy with conventional care , vs open surgery with ERAS vs open surgery with conventional care ) has demonstrated a shorter hospital stay after laparoscopic colonic surgery with ERAS , the other outcomes being similar . The conclusion of the authors was that ‘ the most optimal perioperative treatment for patients requiring segmental colectomy for coloncancer is laparoscopic resection embedded in an ERAS program ’ , suggesting that laparoscopic surgery is an important component of ERAS . The same team has performed a futher multivariate linear regression analysis on the same data and showed that the components significantly associated with a successful ERAS programme were laparoscopic surgery , normal diet at postoperative days one , two and three and enforced mobilization at postoperative days one , two and three ( Vlug M , personal communication ) . There is a feeling that the ERAS programme could increase the workload of nursing staff . The nursing Background Due to potentially superior short-term outcomes compared with open colorectal surgery , laparoscopic surgery is currently being implemented in clinical practice worldwide . In parallel , enhanced recovery after surgery ( ERAS ) programs are shown to improve postoperative recovery in open colorectal surgery . This study reports outcomes in laparoscopic versus open surgery in conjunction with compliance to the ERAS protocol . Methods The association between surgical approach ( laparoscopic or open surgery ) , compliance to the ERAS protocol , postoperative symptoms , complications , and length of stay after surgery was studied . Between January 2007 to December 2010 , 114 consecutive patients underwent elective high anterior resection with laparoscopic-assisted ( n = 55 ) or open resection ( n = 59 ) . All clinical data ( 114 variables ) were prospect ively recorded . Results The overall preoperative ERAS- protocol compliance was 77 % for both the laparoscopic and open group . Laparoscopic surgery result ed in shorter total length of stay ( median 4 vs. 6 days , p = 0.04 ) , earlier pain control ( median 2 vs. 3 days , p = 0.008 ) , shorter need for intravenous infusions , improved mobilization on the first postoperative day ( POD1 ) , and lower inflammatory response ( CRP ( POD1 ) 54 ± 24 vs. 67 ± 31 mg/l , p = 0.017 ) compared with open resection . The trends in fewer postoperative complications ( 9.1 vs. 16.9 % ; odds ratio ( OR ) 0.55 ; 95 % confidence interval ( CI ) 0.17–1.81 ) and overall postoperative symptoms delaying recovery ( 20 vs. 30.5 % ; OR 0.63 ; 95 % CI 0.22–1.34 ) in laparoscopic surgery were not statistically significant . Conclusions The use of laparoscopy in colorectal surgery within an ERAS protocol results in faster recovery compared with open resection 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 : Enhanced Recovery After Surgery ( ERAS ) program applied to colorectal laparoscopic surgery is well known to reduce hospitalization improving short-terms outcomes . Its goal is to minimize the surgical stress response in order to maintain the physiological homeostasis altered by surgery . However , there is little knowledge about the involved dynamics in the reduction of the surgical stress that these programs allow . The primary aim of this study was to compare the level of immune and nutritional serum investigators across surgery in patients undergoing elective colorectal laparoscopic surgery within an ERAS protocol or according to a st and ard care program . Material s and Methods : One hundred forty patients undergoing major colorectal laparoscopic surgery  were enrolled and r and omized in 2 groups ( 70 per arm ) . Cortisol , C-reactive protein ( CRP ) , white blood cell count , prolactin , interleukin (IL)-6 levels were collected preoperatively , 1 , 3 , and 5 days after surgery . Transferrin , prealbumin , albumin , and triglyceride level were collected preoperatively , 1 and 5 days after surgery . Short-term outcomes were also prospect ively assessed . Results : IL-6 levels were lower in the ERAS group on 1 , 3 , and 5 days postoperatively ( P<0.05 ) . IL-6 levels in the enhanced group , differently from control group , returned to preoperative level 3 days after surgery . CRP level was lower in the enhanced group on day 1 , 3 , and 5 ( P<0.05 ) . There was no difference in cortisol and prolactin levels between groups . Prealbumin serum level was higher on day 5 ( P<0.05 ) compared to st and ard group . Conclusions : ERAS protocol applied to colorectal laparoscopic surgery affects surgical stress response , decreasing IL-6 and CRP levels postoperatively and improving prealbumin postoperative synthesis INTRODUCTION Laparoscopic surgery is well established in the modern management of colorectal disease . More recently , enhanced recovery after surgery ( ERAS ) protocol s have been introduced to further promote accelerated discharge and faster recovery . However , not all patients are suitable for early discharge . The purpose of this study was to evaluate the early outcomes of patients undergoing such a regime to determine which peri-operative factors may predict safe accelerated discharge . METHODS Data were prospect ively collected on consecutive patients undergoing laparoscopic colorectal surgery .  All patients followed the institution 's ERAS protocol and were discharged once specific criteria were fulfilled . Clinical characteristics and outcomes were compared between patients who were discharged before and after 72 h post-surgery . Thereafter , the peri-operative factors that were associated with delayed discharge were determined using a binary logistic model . RESULTS Three hundred patients were included in the analysis . The most common operation was laparoscopic anterior resection ( n = 123 , 41 % ) . Mean length of stay was 4.8 days ( st and ard deviation 5.9 ) , with 185 ( 62 % ) patients discharged within 72 h. Ten ( 3 % ) patients had a post-operative complication . Three independent predictors of delayed discharge were identified ; BMI ( OR 1.06 , 95%CI 1.01 - 1.11 ) , operation length ( OR 0.99 , 95%CI 0.98 - 0.99 ) and complications ( OR 16.26 , 95%CI 4.88 - 54.08 ) . CONCLUSIONS A combined approach of laparoscopic surgery and ERAS leads to reduced length of stay . This enables more than 60 % of patients to be discharged within 72 h. Increased BMI , duration of operation and complications post-operatively independently predict a longer length of stay BACKGROUND The ERAS ( enhanced recovery after surgery ) care has been shown in r and omized clinical trials to improve outcome after colorectal surgery compared to traditional care . The impact of different levels of compliance and specific elements , particularly out with a trial setting , is poorly understood . OBJECTIVE This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection . METHODS The international , multicenter ERAS registry data , collected between November 2008 and March 2013 , was review ed . Patient demographics , disease characteristics , and perioperative ERAS protocol compliance were assessed . Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication . FINDINGS A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries .  Median length of stay for colorectal resections was 6 days , with readmissions in 216 ( 9.2 % ) , complications in 948 ( 40 % ) , and reoperation in 167 ( 7.1 % ) of 2352 patients . Laparoscopic surgery was associated with reduced complications [ odds ratio ( OR ) = 0.68 ; P < 0.001 ] and length of stay ( OR = 0.83 , P < 0.001 ) . Increasing ERAS compliance was correlated with fewer complications ( OR = 0.69 , P < 0.001 ) and shorter primary hospital admission ( OR = 0.88 , P < 0.001 ) . Shorter hospital stay was associated with preoperative carbohydrate and fluid loading ( OR = 0.89 , P = 0.001 ) , and totally intravenous anesthesia ( OR = 0.86 , P < 0.001 ) ; longer stay was associated with intraoperative epidural analgesia ( OR = 1.07 , P = 0.019 ) . Reduced postoperative complications were associated with restrictive perioperative intravenous fluids ( OR = 0.35 , P < 0.001 ) . CONCLUSIONS This analysis has demonstrated that in a large , international cohort of patients , increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome Background During the last two decades the use of laparoscopic resection and a multimodal approach known as an enhanced recovery programme , have been major changes in colorectal perioperative care . Clinical outcome improves using laparoscopic surgery to resect colorectal cancer but until recently no multicentre trial evidence had been reported regarding whether the benefits of laparoscopy still exist when open surgery is optimized within an enhanced recovery programme . The EnROL trial ( Enhanced Recovery Open versus Laparoscopic ) examines the hypothesis that laparoscopic surgery within an enhanced recovery programme will provide superior postoperative outcomes when compared to conventional open resection of colorectal cancer within the same programme . Methods / design EnROL is a phase III , multicentre , r and omised trial of laparoscopic versus open resection of colon and rectal cancer with blinding of patients and outcome observers to the treatment allocation for the first 7 days post-operatively , or until discharge if earlier . 202 patients will be recruited at approximately 12 UK hospitals and r and omised using minimization at a central computer system in a 1:1 ratio . Recruiting surgeons will previously have performed > 100 laparoscopic colorectal resections  and > 50  open total mesorectal excisions to minimize conversion . Eligible patients are those suitable for elective resection using either technique . Excluded patients include : those with acute intestinal obstruction and patients in whom conversion from laparoscopic to open procedure is likely . The primary outcome is physical fatigue as measured by the physical fatigue domain of the multidimensional fatigue inventory 20 ( MFI-20 ) with secondary outcomes including postoperative hospital stay ; complications ; reoperation and readmission ; quality of life indicators ; cosmetic assessment s ; st and ardized performance indicators ; health economic analysis ; the other four domains of the MFI-20 . Pathological assessment of surgical quality will also be undertaken and compliance with the enhanced recovery programme will be recorded for all patients . Discussion Should this trial demonstrate that laparoscopic surgery confers a significant clinical and /or health economic benefit this will further support the transition to this type of surgery , with implication s for the training of surgeons and re source allocation . Trial registration IS RCT N48516968 Background Few data are available on TAP block in laparoscopic colorectal surgery and ERAS program . The aim of this prospect i ve study was to evaluate local wound infiltration plus TAP block compared to local wound infiltration in the management of postoperative pain , nausea and vomiting , ileus and use of opioids in the context of laparoscopic colorectal surgery and ERAS program . Methods From March 2014 to March 2015 , 48 patients were treated by laparoscopic resection and ERAS program for colorectal cancer and diverticular disease at the Division of General and Hepatobiliary Surgery , University of Verona Hospital Trust . Among these , 24 patients received local wound infiltration plus TAP block ( TAP block group ) and 24 patients received local wound infiltration ( control group ) . Results No differences were observed in baseline patient characteristics , clinical variables and surgical procedures between the two groups . Local wound infiltration plus TAP block allowed to achieve pain control despite a reduced use of opioid analgesics ( P = 0.009 ) . The adoption of TAP block result ed beneficial on the prevention of postoperative nausea ( P = 0.002 ) and improvement of essential outcomes of ERAS program as recovery of bowel function ( P = 0.005 ) , urinary catheter removal ( P = 0.003 ) and capability to tolerate oral diet ( P = 0.027 ) . Conclusions TAP block plus local wound infiltration in the setting of laparoscopic colorectal surgery and ERAS program guarantees a reduced use of opioid analgesics and good pain control allowing the improvement of essential items of enhanced recovery pathways ERAS program applied to colorectal laparoscopic surgery is well known to reduce hospitalization improving short terms outcomes and minimizing the Surgical Stress Response . However its effectiveness in elderly population is yet to be demonstrated . The primary aim of this study is to compare the level of immune and nutritional serum indexes across surgery in patients aged over 70 years old undergoing elective colorectal laparoscopic surgery within an ERAS protocol or according to a St and ard program . 83 patients undergoing colorectal laparoscopic surgery were enrolled and r and omized in two groups ( ERAS Group 40 , St and ard Group 43 ) within a larger r and omized trial on a general population . Surgical stress parameters were collected preoperatively , 1 , 3 and 5 days after surgery . Nutritional parameters were collected preoperatively , 1 and 5 days after surgery . Short Term Outcomes were also prospect ively assessed . IL-6 levels were lower in the EG on 1 , 3 , and 5 days post-operatively ( p 0.05 ) . IL-6 levels in the Enhanced group returned to pre operative level 3 days after surgery . C-reactive protein level was lower in the Enhanced group on day 1 , 3 , and 5 ( p 0.05 ) . There was no difference in Cortisol and Prolactin levels between groups . Prealbumin serum level was higher on day 5 ( p 0.05 ) compared to st and ard group . Postoperative outcomes in terms of normal bowel function and length of hospital stay were significantly improved in the ERAS group . Colorectal laparoscopic surgery within an ERAS prototcol in elderly patients affects Surgical Stress Response , decreasing IL-6 and CRP levels postoperatively and improving Prealbumin post operative synthesis BACKGROUND This study was undertaken to determine the impact of an intrathecal mixture of bupivacaine and morphine , when compared with systemic morphine , on the quality of postoperative analgesia and other outcomes in the context of the enhanced recovery after surgery ( ERAS ) programme for laparoscopic colonic resection . METHODS Fifty patients undergoing general anaesthesia were r and omly allocated  to receive either a spinal mixture of bupivacaine and morphine followed by oral oxycodone ( spinal group ) or patient-controlled analgesia ( PCA group ) . The primary outcome was consumption of opioids during the first three postoperative days . Secondary outcomes were pain scores , return of bowel function and dietary intake , readiness to hospital discharge , and length of hospital stay . RESULTS Postoperative opioid consumption in the spinal group was significantly less over the first three postoperative days ( P<0.001 ) . The quality of analgesia at rest in the first 24 h was better in the spinal group ( P<0.005 ) . Excessive sedation and respiratory depression were reported in two elderly patients with spinal analgesia . There were no differences between the two groups in other outcomes ( return of bowel function and dietary intake , readiness to hospital discharge , and length of hospital stay ) . CONCLUSIONS When ERAS programme is used for laparoscopic colonic resection , an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption , but has no other advantages over systemic opioids Background and aims Evidence demonstrating improved short-term outcomes with laparoscopic surgery compared with open surgery for colorectal cancer is accumulating . In addition , programmes optimising peri-operative care for major abdominal surgery are becoming widespread . Evaluating laparoscopic surgery and enhanced recovery programmes usually focuses on short-term recovery . The aim of this study was to compare recovery after laparoscopic and open surgery for colorectal cancer up to 1 year post-operatively , using a combination of self-report and observer data . Patients / Methods From January 2002 to March 2004 , 62 patients were r and omised ( 2:1 ) to receive laparoscopic ( n = 43 ) or open surgery ( n = 19 ) within an enhanced recovery programme .  Functional outcomes up to 1 year were assessed using interview-administered question naires . Results / Findings Question naire and health-related quality of life data were obtained in over 85 % of patients . Patients undergoing laparoscopic surgery  felt fully recovered and resumed driving more quickly than those having open surgery ( p = 0.016 and p = 0.048 respectively ) . Fifty-eight percent of patients having open surgery felt fully recovered by 12 months versus 88 % of laparoscopic patients .Interpretation/ Conclusion Within an enhanced recovery programme , patients undergoing laparoscopic surgery  recovered more quickly than after open resection . Both approaches however , were associated with slow recovery despite a relatively short hospital stay Background The aim of the present study was to evaluate the effects of preoperative nutritional status on the short-term outcomes of an enhanced recovery after surgery ( ERAS ) programme for colorectal cancer surgery . Methods This prospect i ve observational study included 149 patients who underwent elective resection of colorectal cancer with ERAS from January 2011 to January 2014 in a university hospital .  Subjective global assessment ( SGA ) was used to determine preoperative nutritional status . Primary outcomes included the length of postoperative stay , postoperative morbidity , gastrointestinal recovery , and 30-day readmission . Results The patients were divided into 3 groups according to the SGA classification . There were 96 patients ( 64.4 % ) in SGA-A ( well-nourished ) , 48 ( 32.2 % ) in SGA-B ( mild to moderately malnourished ) , and 5 ( 3.4 % ) in SGA-C ( severely malnourished ) . Patients in SGA-A had the median length of postoperative stay of 4 days ( range 2–23 ) , which was significantly shorter compared to SGA-B ( 5 days ; range 2–16 ; p < 0.01 ) and SGA-C ( 7 days ; range 4–17 ; p < 0.01 ) . The overall complication rates of SGA-A , SGA-B , and SGA-C patients were 11 , 31 % ( adjusted OR 3.76 ; 95 % CI 1.36–10.36 ; p < 0.01 ) and 40 % ( adjusted OR 2.15 ; 95 % CI 0.07–63.64 ; p = 0.66 ) . Mean time to resumption of normal diet and time to first defecation were 1.6 ± 1.3 and 2.2 ± 0.9 days in SGA-A , 2.6 ± 1.7 and 3.1 ± 1.6 days in SGA-B ( p < 0.01 compared to SGA-A ) and 3.2 ± 2.4 days and 2.6 ± 1.5 days in SGA-C ( p = 0.07 and p = 0.1 compared to SGA-A , respectively ) . No 30-day mortality occurred in any group . One patient in SGA-A ( 1 % ) , and 3 patients in SGA-B ( 6 % ) had unplanned 30-day re-admission ; p = 0.11 . Conclusions Within an ERAS programme for colorectal cancer surgery , malnourished patients were at risk for increased postoperative morbidity , delayed recovery of gastrointestinal function , and prolonged length of hospital stay IMPORTANCE Enhanced recovery after surgery ( ERAS ) colorectal programs have shown to be successful at reducing length of stay in many international and academic centers ; however , their efficacy in a community hospital setting remains unclear . OBJECTIVE To determine if favorable results could be reproduced in a community hospital setting using our ERAS program , which was developed using core ERAS guidelines with the goal of accelerated recovery while also addressing other important outcomes affecting patient experience and safety . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve study of ERAS program , a multidisciplinary effort involving anesthesia , preadmission staff , nursing , and surgery staff at a community hospital . The program was initiated in 2010 and was in full practice by 2011 . We assessed practice patterns and patient outcomes for all elective colon and rectal resection cases performed in 2009 ( prior to ERAS implementation ) , 2011 , and 2012 . MAIN OUTCOMES AND MEASURES Laparoscopic approach , narcotic use , length of stay , 30-day readmission , ileus ( defined as reinsertion of nasogastric tube ) , and intra-abdominal infection and association between colorectal cancer ( CRC ) diagnosis and these outcomes . RESULTS From 2009 to 2012 , the use of laparoscopy increased from 57.4 % to 88.8 % ( P < .001 ) . Length of stay decreased significantly ( 6.7 days vs 3.7 days , P < .001 ) , without an increase in 30-day readmission rate ( 17.6 % vs 12.5 % , P = .49 ) . Use of patient-controlled narcotic analgesia and duration of use decreased ( 63.2 % of patients vs 15 % , P < .001 ; 67.8 hours vs 47.1 hours , P = .02 ) . Ileus rate decreased from 13.2 % to 2.5 % ( P = .02 ) . Intra-abdominal infection decreased from 7.4 % to 2.5 % ( P = .24 ) . When comparing laparoscopic cases alone , similar results were observed . Following regression analysis , there were no statistically significant differences between CRC diagnosis and LOS , 30-day readmission rates , ileus , and intra-abdominal infection ( all P 's > .05 ) . Length of stay reductions result ed in an estimated cost savings of $ 3202 per patient ( 2011 ) and $ 4803 per patient ( 2012 ) . CONCLUSIONS AND RELEVANCE Implementation of this patient care-directed enhanced recovery program is feasible in a community hospital setting , and it is associated with decreased LOS without increased readmission or morbidity , as well as significant decreases in narcotic use and cost . Improved outcomes are independent of the laparoscopic approach and CRC diagnosis Aim : Enhanced recovery after surgery ( ERAS ) is a multimodal approach that aims to optimize perioperative treatment . Whether elderly patients receiving colorectal surgery can adhere to and benefit from an ERAS approach is uncertain . The aim of this study was to compare patients in different age groups participating in an ERAS program .  Method : In this sub study of a r and omized controlled trial , we analyzed the interventional ERAS arm of adult patients eligible for laparoscopic or open colorectal resection with regard to the importance of age . Patients were divided into three groups based on age : ≤65 years ( n = 79 ) , 66 - 79 years ( n = 56 ) , and ≥80 years ( n = 19 ) . The primary end point was total postoperative hospital stay ( THS ) . Secondary end points were postoperative hospital stay , postoperative complications , postoperative C-reactive protein levels , readmission rate , mortality , and patient adherence to the different  ERAS elements . All parameters and measuring the adherence to the ERAS protocol were recorded before surgery , on the day of the operation , and daily until discharge . Results : There were no significant differences in length of THS between age groups ( ≤65 years , median 5 [ range 2 - 47 ] days ; 66 - 79 years , median 5.5 [ range 2 - 36 ] days ; ≥80 years , median 7 [ range 3 - 50 ] days ; p = .53 ) . All secondary outcomes were similar between age groups . Patient adherence to the ERAS protocol was as good in the elderly as it was in the younger patients . Conclusion : Elderly patients adhered to and benefited from an ERAS program , similar to their younger counterparts Aim Enhanced recovery after surgery ( ERAS ) programmes have been shown to accelerate and enhance functional recovery after colonic surgery . We analysed prospect ively collected data to investigate potentially modifiable factors that may influence the length of stay ( LOS ) in the ERAS setting at a single institution Background The present study aims to examine the feasibility and safety of a two-day hospital stay after  laparoscopic colorectal resection ( LCR )  under an enhanced recovery after surgery ( ERAS ) pathway . Methods Between 2003 and 2010 , 882 consecutive patients undergoing LCR were analyzed . Patients were grouped and analyzed according to whether their hospital stay was 2 days ( group A ) or longer ( group B ) . Demographic , surgical , and postoperative data were compared . To identify independent predictive factors related to a short hospital stay , a multivariate analysis was also performed . Results Group A represented 10.3 % of this series ( 91 patients ) . There were no differences regarding age , gender , BMI , ASA , and previous abdominal surgeries between groups . Group A had a lower incidence of rectal cancer and anterior resections than group B ( 6.6 vs. 17.7 % [ p = 0.006 ] and 14.3 vs. 23.4 % [ p = 0.048 ] ) , respectively , and a lower mean operative time ( 170 min vs. 192 min ; p = 0.002 ) . Group A had a lower overall morbidity rate than group B ( 5.5 vs. 16.9 % ; p = 0.004 ) and a lower incidence of surgery-related complications ( 5.5 vs. 14.9 % ; p = 0.001 ) . The overall conversion rate was 10 % ( only one patient in group A required conversion ) , and the difference in conversion rate between groups was statistically significant ( 1.2 vs. 10.7 % ; p = 0.003 ) . Group A had a lower readmission rate ( 0 vs. 4.9 % ; p = 0.089 ) . Multivariate analysis showed that conversion , postoperative morbidity , and rectal prolapse were independently associated with the length of hospital stay . Conclusions A two-day hospital stay after LCR is safe and feasible under an ERAS pathway , without compromising the readmission or complication rate Background and Aims : Enhanced recovery after surgery ( ERAS ) has been shown to improve outcomes for patients following gastrointestinal surgery . Data on protocol adherence and how this impacts on outcome are limited . This study examines how protocol adherence changes over time and determines how this impacts on outcome across a large-volume gastrointestinal surgical service . Material s and Methods : A prospect i ve review of patients eligible for colorectal , liver and oesophagogastric ERAS over two 3-month periods in 2010 and 2011 was performed . End points included : length of stay ( LOS ) , overall protocol adherence , individual modality adherence , reason for pathway deviation and patient outcomes . Results : 172 patients ( 110 colorectal , 31 liver and 31 oesophagogastric ) were evaluated . For each sub-speciality , the introduction of ERAS led to significant reductions in LOS that were sustained for the duration of the study . Adherence was achieved across 60 % ( colorectal ) , 75 % ( liver ) and 88 % ( oesophagogastric ) of individual pathway modalities . The major causes of pathway deviation were : post-operative nausea and vomiting ( colorectal ) , pain ( liver ) and pulmonary complications ( oesophagogastric ) . Conclusions : Large-scale implementation of ERAS at a high-volume centre is feasible and offers many of the benefits demonstrated in controlled trials , but adherence may diminish over time PURPOSE Laparoscopic resection and a multimodal approach known as an enhanced recovery program ( ERP ) have been major changes in colorectal perioperative care that have improved clinical outcomes for colorectal cancer resection . EnROL ( Enhanced Recovery Open Versus Laparoscopic ) is a multicenter r and omized controlled trial examining whether the benefits of laparoscopy still exist when open surgery is optimized within an ERP . PATIENTS AND METHODS Adults with colorectal cancer suitable for elective resection were r and omly assigned at a ratio of 1:1 to  laparoscopic or open surgery within an ERP , stratified by center , cancer site ( colon v rectum ) , and age group ( < 66 v 66 - 75 v > 75 years ) using minimization . The primary outcome was physical fatigue at 1 month postsurgery . Secondary outcomes included hospital stay , complications , other patient-reported outcomes ( PROs ) , and physical function . Patients and outcome assessors were blinded until 7 days postsurgery or discharge if earlier . Central independent and blinded pathologic assessment of surgical quality was undertaken . RESULTS A total of 204 patients ( laparoscopy , n=103 ; open surgery , n=101 ) were recruited from 12 UK centers from July 2008 to April 2012 .  One-month physical fatigue scores were similar in both groups ( mean : laparoscopy , 12.28 ; 95 % CI , 11.37 to 13.19 v open surgery , 12.05 ; 95 % CI , 11.14 to 12.96 ; adjusted mean difference , -0.23 ; 95 % CI , -1.52 to 1.07 ) . Median total hospital stay was significantly shorter after laparoscopic surgery ( median : laparoscopy , 5 ; interquartile range [ IQR ] , 4 to 9 v open surgery , 7 ; IQR , 5 to 11 days ; P=.033 ) . There were no differences in other secondary outcomes or in specimen quality after central pathologic review . CONCLUSION In patients treated by experienced surgeons within an ERP , physical fatigue and other PROs were similar in both groups , but laparoscopic surgery significantly reduced length of hospital stay Background The present developments in colon surgery are characterized by two innovations : the introduction of the laparoscopic operation technique and fast recovery programs such as the Enhanced Recovery After Surgery ( ERAS ) recovery program . The Tapas- study was conceived to determine which of the three treatment programs : open conventional surgery , open ' ERAS ' surgery or laparoscopic ' ERAS ' surgery for patients with colon carcinomas is most cost minimizing ? Method / design The Tapas- study is a three-arm multicenter prospect i ve cohort study .All patients with colon carcinoma , eligible for surgical treatment within the study period in four general teaching hospitals and one university hospital will be included . This design produces three cohorts : Conventional open surgery is the control exposure ( cohort 1 ) . Open surgery with ERAS recovery ( cohort 2 ) and laparoscopic surgery with ERAS recovery ( cohort 3 ) are the alternative exposures . Three separate time periods are used in order to prevent attrition bias . Primary outcome parameters are the two main cost factors : direct medical costs ( real cost price calculation ) and the indirect non medical costs ( friction method ) . Secondary outcome parameters are mortality , complications , surgical-oncological resection margins , hospital stay , readmission rates , time back to work/recovery , health status and quality of life . Based on an estimated difference in direct medical costs ( highest cost factor ) of 38 % between open and laparoscopic surgery ( alfa = 0.01 , beta = 0.05 ) , a group size of 3 × 40 = 120 patients is calculated . Discussion The Tapas- study is three-arm multicenter cohort study that will provide a cost evaluation of three treatment programs for patients with colon carcinoma , which may serve as a guideline for choice of treatment and investment strategies in hospitals . Trial registration IS RCT N44649165 Background Enhanced recovery after surgery ( ERAS ) programs can accelerate recovery and shorten the hospital stay after colorectal resections . The RAPID ( remove , ambulate , postoperative analgesia , introduce diet ) protocol is a simplified ERAS program that consists of a simplified , user-friendly single-page pro forma schedule . This study aim ed to evaluate the impact of the RAPID protocol on patients undergoing both laparoscopic and open colorectal resections in two specialized colorectal units . Methods A prospect i ve , two-center study assessed 117 age-matched patients undergoing open or laparoscopic colorectal resection to compare the postoperative course for patients using the RAPID protocol with those treated in a traditional manner . Results Of the 117 patients studied , 70 underwent laparoscopic resection ( 55 with the RAPID protocol ) and 47 underwent open resection ( 25 with the RAPID protocol  ) . Patients undergoing laparoscopic resections with the RAPID protocol had a significantly shorter hospital stay ( p = 0.01 ) and tolerance of a full diet ( p = 0.002 ) . Similarly , patients undergoing open resections with the RAPID protocol also have a significantly shorter hospital stay ( p = 0.04 ) . Conclusion The RAPID protocol is a user-friendly , easy , and effective tool that facilitates earlier tolerance of diet and discharge from the hospital for patients undergoing laparoscopic or open colorectal resections 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 Background Major colorectal surgery usually requires a hospital stay of more than 12 days . Inadequate pain management , intestinal dysfunction and immobilisation are the main factors associated with delay in recovery . The present work assesses the short and medium term results achieved by an enhanced recovery program based on previously published protocol s. Methods This prospect i ve study , performed at 12 Spanish hospitals in 2008 and 2009 , involved 300 patients . All patients underwent elective colorectal resection for cancer following an enhanced recovery program .  The main elements of this program were : preoperative advice , no colon preparation , provision of carbohydrate-rich drinks one day prior and on the morning of surgery , goal directed fluid administration , body temperature control during surgery , avoiding drainages and nasogastric tubes , early mobilisation , and the taking of oral fluids in the early postoperative period . Perioperative morbidity and mortality data were collected and the length of hospital stay and protocol compliance recorded . Results The median age of the patients was 68 years . Fifty-two % of the patients were women . The distribution of patients by ASA class was : I 10 % , II 50 % and III 40 % . Sixty-four % of interventions were laparoscopic ; 15 % required conversion to laparotomy . The majority of patients underwent sigmoidectomy or right hemicolectomy .  The overall compliance to protocol was approximately 65 % , but varied widely in its different components . The median length of postoperative hospital stay was 6 days . Some 3 % of patients were readmitted to hospital after discharge ; some 7 % required repeat surgery during their initial hospitalisation or after readmission . The most common complications were surgical ( 24 % ) , followed by septic ( 11 % ) or other medical complications ( 10 % ) . Three patients ( 1 % ) died during follow-up . Some 31 % of patients suffered symptoms that delayed their discharge , the most common being vomiting or nausea ( 12 % ) , dyspnoea ( 7 % ) and fever ( 5 % ) . Conclusion The following of this enhanced recovery program posed no risk to patients in terms of morbidity , mortality and shortened the length of their hospital stay . Overall compliance to protocol was 65 % . The following of this program was of benefit to patients and reduces costs by shortening the length of hospital stay . The implantation of such programmes is therefore highly recommended 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 Objective To analyze the results after the introduction of enhanced recovery after surgery ( ERAS ) protocol s , a r and omized study was performed to compare the outcomes of laparoscopic hepatectomy under ERAS or traditional care . Methods Patients undergoing laparoscopic hepatectomy from April 2014 to October 2014 were included and r and omly divided into Control group ( CG ) and ERAS . Primary outcome was quality of life ( QoL ) and length of hospital stay ( LOS ) . Secondary endpoints were percentage readmission , mortality , duration to first flatus , complications , hospital costs , conversions and blood loss . Results Thirteen patients withdrew after r and omization . Eighty-six patients completed the study , 48 ERAS and 38 CG . Postoperative LOS was significantly reduced in ERAS [ 6 ( 4–8 ) versus 10 ( 7–15 ) days , P = 0.04 ] . First flatus occurred earlier in ERAS than CG [ 2(1–4 ) versus 3(2–5 ) days , P = 0.02 ] . The average perioperative charges were 9470 ± 1540 in CG and only 7742 ± 1200 in ERAS ( P = 0.03 ) , with no differences in readmission rate , blood loss , conversions to open surgery , mortality or surgical complications . The median AUC ( area under a curve ) of QoL was considerably improved in ERAS ( P = 0.04 ) . Conclusions This study suggests that ERAS is feasible and safe for laparoscopic hepatectomy INTRODUCTION While enhanced recovery after surgery ( ERAS ) has been proven to improve results in colorectal operations with regard to morbidity and duration of hospital stay , its impact on recovery of bowel motility is poorly documented . The aims of this study were to assess the impact of ERAS on bowel motility recovery , and to assess the consequences of the definition of postoperative ileus on its reported incidence in the literature . MATERIAL AND METHODS This is a single-center prospect i ve observational study of consecutive patients who underwent colorectal resection with anastomosis over a period of 17 months .  Global resumption of intestinal transit ( GROT ) was defined as passage of stool combined with alimentary tolerance of solid food . RESULTS One hundred and thirty-one patients were included . A median of 14 items ( range : 13 - 16 ) was complied out of 19 observable items in the protocol . Median time to passage of flatus ( MTPF ) was 2 days and the GROT was 3 days . The time interval to MTPF as well as to GROT decreased as adherence to the ERAS protocol increased ( respectively P<0.001 , r2=0.11 and P=0.04 , r2=0.06 ) . The incidence of postoperative " ileus " varied from 1.5 % to 61.8 % depending on the interval chosen to define ileus ( cut-off from 1 to 7 days ) . Adherence to≥85 % of the items in the ERAS protocol protected patients from " prolonged ileus " , i.e. , lasting≥4 days ( OR=0.35 ; 95 % CI=0.15 to 0.83 ) . CONCLUSION The implementation of and compliance with an ERAS protocol allowed a reduction in the time to GROT . There is a need for a consensual definition of postoperative ileus Enhanced recovery after surgery ( ERAS ) pathways aim to accelerate functional return and discharge from hospital . They have proven effective in many forms of surgery , most notably colorectal . However , experience in esophagectomy has been limited . A recent study reported significant reductions in pulmonary complications , mortality , and length of stay following the introduction of an ERAS protocol alone , without the introduction of any clinical changes . We instituted a similar change 16 months ago , introducing a protocol to provide a formal framework , for our existing postoperative care . This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change . Data were collected from prospect ively maintained secure web-based multidisciplinary data bases . Complication severity was classified using the Clavien-Dindo scale . Operative mortality was defined as death within 30 days of surgery , or at any point during the same hospital admission . Lower respiratory tract infection was defined as clinical evidence of infection , with or without radiological signs . Respiratory complications included lower respiratory tract infection , pleural effusion ( irrespective of drainage ) , pulmonary collapse , and pneumothorax . Statistical analysis was performed using SPSS v21 . One hundred thirty-two patients underwent esophagectomy ( 55 protocol group ; 77 before ) . All were performed open . There were no differences between the two groups in terms of age , gender , operation , use of neoadjuvant therapy , cell type , stage , tumor site , or American Society of Anesthesiologists grade . Median length of stay was 14.0 days ( protocol ) compared with 12.0 before ( interquartile range 9 - 19 and 9.5 - 15.5 , respectively ; P = 0.073 , Mann-Whitney U-test ) . Readmission within 30 days of discharge occurred in five ( 9.26 % ) and six ( 8.19 % ; P = 1.000 , Fisher 's exact test ) . There were four in-hospital deaths ( 3.03 % ) : one ( 1.82 % ) and three ( 3.90 % ) , respectively ( P = 0.641 ) . There were no differences in the severity of complications ( P = non-significant ; Pearson 's chi-squared ) . There were no differences in the type of complications occurring in either group . The protocol was completed successfully by 26 ( 47.3 % ) . No baseline factors were predictive of this . In contrast to previous studies , we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol . Consequently , improvements in short-term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care . Consequently , we would recommend that centers introducing new ( or review ing existing ) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such st and ardized pathways BACKGROUND Perioperative treatment of patients with colorectal cancer according to the Enhanced Recovery After Surgery ( ERAS ) protocol has proven to reduce complications and duration of stay . However , strict adherence remains a challenge and the benefits may decrease with lower adherence . In this study , we report on 8 years of adherence to the ERAS protocol and its effect on postoperative outcome in patients with colon cancer . METHODS In 2006 , the ERAS protocol was introduced for treatment of colon cancer patients in the Medical Center Alkmaar , a large teaching hospital . Patients scheduled for elective colon cancer resection were included in this study . Adherence to ERAS items was monitored and along with clinical data prospect ively gathered in a data base . In 2011 , several measures to improve adherence were implemented . RESULTS In total , 816 patients were included .  Mean adherence rate was 73 % in 2006 and 2007 , 66 % in 2008 and 2009 , 63 % in 2010 and 2011 , and 82 % in 2012 and 2013 . There was a shorter duration of stay in the years with high adherence ( 5.7 days ) compared with the years with low adherence ( 7.3 days ; P < .001 ) . The ERAS items that were the strongest predictors for a shorter duration of stay were no nasogastric tube , early mobilization , early oral nutrition , early removal of epidural , early removal of catheter , and nonopioid oral analgesia . CONCLUSION It is possible to improve adherence to the ERAS protocol and related outcomes with specific measures . Adherence to the ERAS protocol was related inversely to duration of stay . Only postoperative items of the ERAS protocol were predictive for a shorter duration of stay . Keeping adherence optimal remains an ongoing challenge that requires repeated training and dedicated personnel Background Postoperative nausea and vomiting is one of the most common complications affecting patients after surgery and causes significant morbidity and increased length of hospital stay . It is accepted that patients undergoing surgery on the bowel are at a higher risk . In the current era of minimally invasive colorectal surgery combined with enhanced recovery , reducing the incidence and severity of postoperative nausea and vomiting is particularly important . Dexamethasone is widely , but not universally used . It is known to improve appetite and gastric emptying , thus reduce vomiting . However , this benefit is not established in patients undergoing bowel surgery , and dexamethasone has possible side effects such as increased risk of wound infection and anastomotic leak that could adversely affect recovery . Design DREAMS is a phase III , double-blind , multicenter , r and omized controlled trial with the primary objective of determining if preoperative dexamethasone reduces postoperative nausea and vomiting in patients undergoing elective gastrointestinal resections . DREAMS aims to r and omize 1,350 patients over 2.5 years . Patients undergoing laparoscopic or open colorectal resections for malignant or benign pathology are r and omized between 8 mg intravenous dexamethasone and control ( no dexamethasone ) . All patients are given one additional antiemetic at the time of induction , prior to r and omization . Both the patient and their surgeon are blinded as to the treatment arm . Secondary objectives of the DREAMS trial are to determine whether there are other measurable benefits during recovery from surgery with the use of dexamethasone , including quicker return to oral diet and reduced length of stay . Health-related quality of life , fatigue and risks of infections will be investigated . Trial registration IS RCT R and omized trials in low‐risk population s have failed to show any benefit for laparoscopic compared with open colorectal resection in terms of morbidity . Furthermore , it is not known whether laparoscopic colorectal resection would yield advantages if r and omization were revealed during surgery after a diagnostic laparoscopy Background : The short-term benefits of laparoscopic surgery are well established , particularly within an enhanced recovery program . Early return to activity is to be expected but has not been quantified . The aim of this study was to measure the hospital stay and return to full activity following laparoscopic colorectal surgery and compare this with laparoscopic cholecystectomy and laparoscopic inguinal hernia repair . Methods : All totally laparoscopic gallbladder , inguinal hernia , and colorectal operations performed between January 2003 and October 2006 were included . Outcomes were collected from a prospect i ve data base and case notes . Post discharge information was collected by telephone interview . A comparison was made by creating 4 groups : laparoscopic cholecystectomy , laparoscopic inguinal hernia repair ( Transabdominal PrePeritoneal [ TAPP ] ) , laparoscopic colorectal nonresectional , and re-sectional surgery . Results : The median hospital stay following laparoscopic colorectal resection was 7 days , while in the cholecystectomy and hernia group it was 1 day . The median return to full activity after discharge from the hospital was 4 , 5 , 3 , and 7 days in the laparoscopic cholecystectomy , inguinal hernia repair , nonresection , and colorectal resection groups , respectively . Conclusions : Following laparoscopic colorectal surgery , patients can be expected to return to their usual activities within a week after discharge from the hospital and less than 2 weeks from surgery 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 Background and Aims : Enhanced recovery after surgery ( ERAS ) has reduced the median hospital stay from 8–10 days with traditional peri-operative routines to four days . The aim of the present study was to introduce the principles of ERAS in our hospital and measure the effect on hospital stay , complications and quality of life after discharge from hospital . Material and Methods : 94 consecutive patients , 40 males , 54 females , median age 66 years , were included in a prospect i ve non-r and omised observational study at Haukel and University Hospital and Haugesund Hospital from October 2000 until February 2003 . After a three-month preparation period , the principles of ERAS were implemented . The results were evaluated with question naires and by follow-ups 8–10 and 30 days after surgery . The results were compared to the results of colorectal surgery before introduction of accelerated recovery . Results : 45 ( 48 % ) and 73 ( 78 % ) patients were discharged within three and five days after surgery with ERAS , compared to zero and seven ( 5 % ) patients with traditional recovery . The complication rate with ERAS was 31 % , and the readmission rate was 15 % . After one week , 57 % had resumed their daily activities at home . After 30 days , 65 % of the patients had resumed their normal and leisure activities . Conclusion : After a proper preparation period , ERAS principles may be implemented in surgical department , and is followed by a reduced median hospital stay and rapid return to normal daily activities for most patients after colorectal surgery Background Whether laparoscopic colorectal resection improved recovery within an enhanced recovery program was investigated . Methods This study was design ed as a query of a prospect ively maintained colorectal data base to identify 350 patients who underwent elective colorectal resection with primary anastomosis for colorectal cancer between January 1 , 2005 and December 31 , 2009 . Patients were categorized into two groups ( laparoscopic and open resection ) , and demographic , treatment , and outcome variables were independently review ed for accuracy . A detailed fast-track protocol was prepared and distributed to all patients , department doctors , and nurses to st and ardize the treatment . Results A total of 209 patients underwent laparoscopic-assisted colorectal resection , and 141 had open surgery .  There was no difference between the two groups in terms of age , sex , BMI , ASA , comorbidity , previous abdominal surgery , preoperative chemoradiotherapy , cancer site , and AJCC 2002 staging . Twenty-three patients in the laparoscopic group required conversion to an open procedure due to hemorrhage , tumor extension , or technical difficulties . Laparoscopic patients had earlier tolerance of diet , bowel movement , flatus and stool canalization , mobilization , suction drain removal , and interruption of analgesic drug administration . Length of postoperative stay was shorter ( 4 vs. 7 days , p = 0.0004 ) and fewer postoperative nonsurgical complications ( 3 vs. 13 % p = 0.009 ) were registered for the laparoscopic group . Conclusions This study suggests that within an enhanced recovery program , laparoscopic resection may provide the best short-term clinical outcomes for patients with resectable colorectal cancer OBJECTIVE To evaluate  enhanced recovery after surgery(ERAS ) protocol in colorectal surgery . METHODS From september 2006 to February 2007 , 74 patients with colorectal cancer were r and omly assigned to ERAS group and control group . The stress index , nutrition and metabolism index , intraoperative index and postoperative index were evaluated . RESULTS Six patients were excluded , 3 in ERAS group ( 2 cases received hepatectomy concomitantly and 1 case received partial ileum resection ) , and 3 in control group ( 1 case received hepatectomy  and 1 case received colorectomy concomitantly , another presented asthma paroxysm ) . So there were 34 cases in ERAS group and 34 cases in control , with no statistical differences in sex , age , BMI index and operation types . Deviation of HOMA-IR index of ERAS was lower than the control ( P>0.05 ) , the same as plasma cortisol at the 1st day after operation ( P<0.05 ) , but plasma glucagons in the operation of ERAS group was higher than that of control ( P<0.05 ) . Plasma glucose 1st day after operation of ERAS group was lower than control ( P<0.05 ) , while plasma triglyceride intraoperation , at 1st day , 2nd day after operation of ERAS was higher than control ( P<0.05 ) . Nitrogen negative balance of ERAS group was higher than control at 2nd day after surgery , but is lower intraoperation and at 6th day after operation ( P<0.05 ) . The time of exhaust gas and stool , time to eat fluidity and semi-fluidity , out-of-bed time and exercise time per-day , residual time and complication rate in ERAS group were better than those of control ( P<0.05 ) . Post-operative expenses of ERAS was lower than that of control ( P<0.05 ) . CONCLUSION ERAS can decrease surgical stress , increase functional recovery and reduce complication rate Purpose The aim of this multi-institutional study was to prospect ively evaluate the safety and efficacy of an enhanced recovery after surgery ( ERAS ) protocol for colonic surgery . Methods The subjects of this study were 320 patients with an American Society of Anesthesiologists ( ASA ) grade I or II physical status . Patients underwent elective open or laparoscopic colonic resection or high anterior resection between April 2011 and January 2014 at one of six institutions . Three hospitals implemented an ERAS protocol ( n = 159 ) , and three administered conventional care ( n = 161 ) . The primary outcome measure was the surgical complication rate . Results Most operations , irrespective of group , were performed laparoscopically . The incidence of a surgical complication was 17.0 % in the ERAS group vs. 16.1 % in the conventional group ( P = 0.842 ) , in which several non-surgical complications also arose . Oral food intake was implemented earlier for the ERAS group vs. the conventional group , after a median ( range ) of 1 ( 1–31 ) vs. 3 ( 1–9 ) days for the ERAS vs. conventional care groups , respectively ( P < 0.001 ) . The median length of postoperative hospital stay was reduced by 5.5 days for the ERAS group , being 8.5 ( 5–41 ) vs. 14 ( 7–56 ) days for the ERAS vs. conventional care groups , respectively ( P < 0.001 ) . Conclusion This multi-institutional controlled study clearly demonstrated that an ERAS protocol was efficient , without increasing the complication risk BACKGROUND Enhanced Recovery after Surgery ( ERAS ) programs have gained popularity with potential to accelerate recovery and reduce morbidity after colectomy . We were interested in comparing recovery after open right colectomy within an ERAS program compared with laparoscopic right colectomy in a st and ard care perioperative environment . METHODS Between October 2005 and June 2009 , prospect i ve data were collected on consecutive patients undergoing elective open right colectomy within an established ERAS setting ( OpERAS ) . Similarly , between March 2008 and June 2009 , data were collected on consecutive patients undergoing laparoscopic right hemicolectomy with conventional care ( LapCon ) . Exclusion criteria for both groups were : ASA > or= 4 , formation of a stoma , and dementia or mental illness rendering the patient unable to comply with instructions . Perioperative variables were collected . The surgical recovery score ( SRS ) was used as a vali date d means to measure convalescence on d 1 , 3 , 7 , 30 , and 60 postoperatively . RESULTS There were 74 patients in the OpERAS and 39 patients in the LapCon groups . At baseline , there were no significant demographic differences except that more patients had malignancy in OpERAS group .  Mean operating time was longer in the LapCon group . Median day stay was 4 ( 3 - 28 ) in OpERAS and 5 ( 2 - 18 ) in LapCon ( P = 0.032 ) . There was no statistical difference in the incidence of complications or the severity of complications . There were no significant differences in SRS after surgery at any time point . CONCLUSION When perioperative care is optimized , recovery after elective open right hemicolectomy is comparable with laparoscopic resection . Studies looking at the combination of laparoscopy and ERAS are warranted BACKGROUND Enhanced Recovery Programmes ( ERPs ) have been shown to benefit recovery following major surgery in selected centres and patient groups , but their wider applicability requires continued evaluation . The aims of this study were to assess the outcomes of the first 400 consecutive , non-selected patients , undergoing major elective colorectal surgery within an Enhanced Recovery programme at a UK District General hospital and to examine the effects of patient risk factors and operative approach on outcomes . METHODS Since September 2005 all patients undergoing major elective colon and rectal surgery at our hospital have been treated within an ERP and their data recorded prospect ively on a data base . Safety and efficacy outcomes for the first 400 patients were compared using SPSS v14.0 with both a retrospective , pre-ERP group ; and according to patient risk factors and operative approaches . RESULTS Median length of stays ( LOS ) reduced from 9 days ( IQR 7 - 11 ) to 6 days ( IQR 5 - 10 ) after introduction of the ERP ( p < 0.001 ) . No statistically significant differences in LOS were observed between elderly ( ≥80 years ) and younger patients or between different BMI groups . American Society of Anesthesiologists ( ASA ) grade 3 patients demonstrated significantly longer median LOS than those with ASA grade s 1 and 2 . Patients undergoing laparoscopic surgery  had median LOS of 6 days ( IQR 4 - 8 ) compared to 7 days ( IQR 5 - 10 ) for open procedures ( p < 0.001 ) . No differences in morbidity or mortality were observed between the groups . CONCLUSIONS Unselected application of an ERP in our unit has been associated with reductions in post-operative LOS . The ERP was safe and effective when applied to all our study patients independent of age and BMI . Despite LOS being longer in ASA grade 3 patients , application of the ERP to this higher risk group was not associated with significantly increased morbidity or mortality . Laparoscopic surgery result ed in additional modest reductions in LOS compared to open surgery within the ERP Laparoscopic  colorectal surgery ( LCS ) was first described in the 1990s and for the most part has become the st and ard of care for colorectal surgery . Robotic-assisted colorectal surgery ( RACS ) was described around the year 2000 , and advocates argue that it overcomes many issues associated with laparoscopic surgery , particularly in surgery for rectal cancer . More recently , the bottom-up minimally invasive approach , transanal total mesorectal excision ( TaTME ) , for rectal surgery has gained popularity , and it has perceived advantages over laparoscopic rectal surgery . Minimally invasive surgery has been associated with some short-term benefits , including reduced bleeding and postoperative pain , and better cosmetic outcomes . Despite this , the debate on oncologic outcomes when compared with open surgery is still ongoing [ 1–3 ] . The benefits of one minimally invasive approach over the others form the subject of further debate , and as much of this is driven by proponents of an individual technique , choosing the most appropriate technique can be difficult [ 1 , 2 ] . Despite the enthusiasm of the proponents , many other factors play a part in the choice of technique and these can be broadly described as those related to the patient , surgeon and individual hospital or a country . We compared LCS , RACS and TaTME/TAMIS using the following criteria : ( 1 ) number of studies published in three time frames ( I = within the first 2 years after acceptance of the technique ; II = during the subsequent 3 years ; III = 3 years after II , if available ) ; ( 2 ) number of involved patients ; ( 3 ) predicted/actual trends . We search ed PubMed and only included r and omized controlled trials , clinical trials , observational , case – control and cohort studies ( time frames : laparoscopy — I : 1993–1994 , II : 1995–1997 , III : 1997–2000 ; robotically assisted — I : Dec 2004–2006 , II : 2007–2009 , III : 2010–2012 ; transanal proctectomy — I : 2013–2014 , II : 2015–2016 ) . The findings are summarized in Figs. 1 and 2 . In the early years , the USA contributed majority of publications related to LCS , with China contributing at the lower end of the spectrum . By the II time frame , there were more contributions from Western Europe , Japan and Australia . In the III time frame , there was a notable increase in reporting on LCS with more contributions from the USA and Western Europe as well as the UK and Sc and inavian countries , in addition to Japan , Australia and China . For RACS , in the early time period there were a few manuscripts from the USA and Europe . During the subsequent time frame , reports from the USA continued to increase , whereas there was less reporting from European countries with the exception of the UK . There was also more reporting of robotic surgery from South Korea , while the enthusiasm from Europe was not as strong as that for LCS . The USA and South Korea appear to be leading the charge in this regard . This begs the question whether this is mainly related to the cost of the procedure . The concept of TaTME originated in the USA with some individuals promoting the technique within Europe . During the II time frame , adoption of TaTME mushroomed to include many continental European countries , while adoption of the technique was being introduced rapidly in the USA and UK . Figure 2 shows the trends of LCS , RACS and TaTME  in the different time frames . LCS had a gradual but constant increase over time , with an expected further increase probably as experience was disseminated by training a new generation of surgeons . RACS growth was slower during the second time frame , but increased considerably during the third , with an almost threefold increase . TaTME trend sits between these two , in * J. Warusavitarne
Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS , morbidity and readmission .
Conclusion Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection .
Reduced compliance increases LOS , morbidity and readmission to hospital .
The impact of compliance with individual ERAS protocol elements is insufficiently studied , and the lack of a st and ardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection
Objective To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery ( ERAS ) programmes following  laparoscopic colorectal surgery .
Background ERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit .
However , there is a minority of patients that do not benefit from these strategies and their identification is not well characterised .
The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood .