Initial Experiences of an Enhanced Recovery Protocol in Esophageal Surgery The effect of formalizing enhanced recovery after esophagectomy with a protocol. A systematic review of enhanced recovery protocols in 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 A prospective study on the influence of a fast-track program on postoperative fatigue and functional recovery after major colonic 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 Fast‐track surgery: the next revolution in surgical care following laparoscopy 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 influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. Adherence to Enhanced Recovery after Surgery Protocols across a High-Volume Gastrointestinal Surgical Service Enhanced Recoveryafter Colorectal Surgery. Results from Aprospective Observational Two-Centre Study Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Enhanced Recovery After Surgery (ERAS) Versus Conventional Postoperative Care in Colorectal Surgery Laparoscopic-Assisted and Open High Anterior Resection within an ERAS Protocol The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations An enhanced recovery pathway decreases duration of stay after esophagectomy. Local wound infiltration plus transversus abdominis plane (TAP) block versus local wound infiltration in laparoscopic colorectal surgery and ERAS program Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. ERAS Protocol Reduces IL-6 Secretion in Colorectal Laparoscopic Surgery: Results From a Randomized Clinical Trial [Application of the protocol of enhanced recovery after surgery in colorectal surgery]. Recovery after open and laparoscopic right hemicolectomy: a comparison. Surgical Stress Reduction in Elderly Patients Undergoing Elective Colorectal Laparoscopic Surgery within an ERAS Protocol. Short-term quality of life in patients undergoing colonic surgery using enhanced recovery after surgery program versus conventional perioperative management Safety, feasibility, and tolerance of early oral feeding after colorectal resection outside an enhanced recovery after surgery (ERAS) program Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: Impact of measures to improve adherence. The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer Effects of goal-directed fluid therapy on enhanced postoperative recovery: An interventional comparative observational study with a historical control group on oesophagectomy combined with ERAS program. Compliance with enhanced recovery after surgery criteria and preoperative and postoperative counselling reduces length of hospital stay in colorectal surgery: results of a randomized controlled trial Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Safety and efficacy of an “enhanced recovery after surgery” protocol for patients undergoing colon cancer surgery: a multi-institutional controlled study Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. Effect of an enhanced recovery after surgery protocol in patients undergoing pancreaticoduodenectomy: A randomized controlled trial. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Influences on length of stay in an enhanced recovery programme after colonic surgery Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial) Does enhanced recovery reduce postoperative ileus after colorectal surgery? Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections The influence of preoperative nutritional status on the outcomes of an enhanced recovery after surgery (ERAS) programme for colorectal cancer surgery Initial clinical outcomes after completion of training in a Canadian Royal College thoracic surgery program. Combined endoscopic mucosal resection and photodynamic therapy versus esophagectomy for management of early adenocarcinoma in Barrett's esophagus. Two-day Hospital Stay After Laparoscopic Colorectal Surgery under an Enhanced Recovery after Surgery (ERAS) Pathway Transhiatal versus transthoracic esophagectomy for adenocarcinoma of the distal esophagus and cardia. Transhiatal esophagectomy: clinical experience and refinements. Use of activity tracking in major visceral surgery—the Enhanced Perioperative Mobilization (EPM) trial: study protocol for a randomized controlled trial Observation of clinical efficacy of application of enhanced recovery after surgery in perioperative period on esophageal carcinoma patients. Hospital Volume and Operative Mortality in the Modern Era Intravenous hydration versus naso-jejunal enteral feeding after esophagectomy: a randomised study. Association of Angiotensin-Converting Enzyme Insertion/Deletion Polymorphism With Serum Level and Development of Pulmonary Complications Following Esophagectomy Preoperative Nutrition and Postoperative Discomfort in an ERAS Setting: A Randomized Study in Gastric Bypass Surgery Dexamethasone reduces emesis after major gastrointestinal surgery (DREAMS) Enteral Nutrition Enriched With Eicosapentaenoic Acid (EPA) Preserves Lean Body Mass Following Esophageal Cancer Surgery: Results of a Double-Blinded Randomized Controlled Trial Prospective comparison of transthoracic versus transhiatal esophagectomy following neoadjuvant therapy for esophageal cancer. Tubular stomach or whole stomach for esophagectomy through cervico-thoraco-abdominal approach: a comparative clinical study on anastomotic leakage Enhanced recovery after liver surgery. A randomized comparative study of topical versus intravenous tranexamic acid administration in enhanced recovery after surgery (ERAS) total knee replacement. Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial Fast-track surgery improves postoperative clinical recovery and reduces postoperative insulin resistance after esophagectomy for esophageal cancer Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients. Fiberoptic endoscopic evaluation of swallowing in assessing aspiration after transhiatal esophagectomy. Two Thousand Transhiatal Esophagectomies: Changing Trends, Lessons Learned
Background A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery ( ERAS ) programs . Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce . We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease . Methods The ERAS program was initiated in 2009 . Patients who underwent esophagectomy and were treated according to the ERAS program were included . Items of ERAS included preoperative nutrition , early extubation , early removal of nasogastric tube , and early mobilization . Primary outcome parameters were hospital stay and the incidence of postoperative complications . Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol . A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient . Results Between 2008 and August 2010 , 181 patients in our department underwent esophagectomy .  Of these , 103 patients were included in the ERAS program ( ERAS+ group ) and were compared to 78 patients who had undergone an esophagectomy in 2008 ( ERAS– group ) .  Overall hospital stay was 14 days versus 15 days ( ERAS+ and ERAS– , respectively ; p = 0.013 ) . There were no significant differences in the incidence of postoperative complications in either group . The percentage of achieved items varied between 42 and 93 % per item . Conclusions The implementation of an ERAS program in esophageal surgery was feasible and result ed in a small but significant reduction in overall hospital stay , whereas overall morbidity was not affected 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 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 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 INTRODUCTION Enhanced Recovery After Surgery ( ERAS ) programs have demonstrated significant reduction in hospital stay for patients undergoing colonic surgery ;  however , their impact on long-term outcomes , such as postoperative fatigue ( POF ) , has not been fully established . AIM To assess the impact of an ERAS program on POF and recovery following elective open colonic surgery . METHOD In a prospect i ve study , 26 consecutive patients undergoing open colonic surgery under a conventional care plan were compared with 26 consecutive patients in an ERAS program .  RESULTS Demographic and clinical characteristics were comparable at baseline . The median duration of total hospital stay ( 4 versus 7 d , P < 0.001 ) , rates of urinary tract infections ( P = 0.028 ) and ileus ( P = 0.042 ) were significantly smaller in the ERAS group . Postoperatively , POF significantly increased in both groups . However , peak POF score was significantly lower in the ERAS group ( P = 0.001 ) . In the first 30 d after surgery , Fatigue Consequence scores were also significantly smaller in the ERAS group . Overall , the total fatigue experience ( P = 0.035 ) and the total fatigue impact ( P = 0.005 ) were significantly smaller in the ERAS group . CONCLUSION The impact of ERAS programs may extend beyond the commonly reported short-term outcomes , and ERAS may accelerate overall recovery and return to normal function 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 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 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 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 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 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 This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery , and to provide grade d recommendations for items for an evidence d-based enhanced recovery protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omized controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( evidence grade : high or moderate ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , European Society for Clinical Nutrition and Metabolism ( ESPEN ) and International Association for Surgical Metabolism and Nutrition ( IASMEN ) present a comprehensive evidence -based consensus review of perioperative care for rectal surgery 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 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 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 This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery PURPOSE Enhanced recovery pathways ( ERP ) decrease morbidity and duration of stay after colorectal surgery . There is little information about their role in complex procedures , such as esophagectomy . The purpose of this study was to determine the impact of an ERP on duration of stay , complications , and readmissions after esophagectomy . METHODS Patients undergoing esophagectomy for cancer or high- grade dysplasia from June 2009 to December 2011 were identified from a prospect ively maintained data base . Beginning in June 2010 , all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan , indications for intensive care admission , early structured mobilization , and diet and drain management . Short-term ( 30-day ) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway . Data are expressed as median values [ interquartile range ] . RESULTS We identified 106 patients ; 47 underwent esophagectomy before ERP implementation and 59 after . Patients were similar with respect to age , gender , diagnosis , and operative time .  Hospital stay was shorter in the ERP group ( 8 [ 7 - 17 ] vs 10 [ 9 - 17 ] days ; P = .01 ) . There were no differences in rates of complications ( 59 % vs 62 % ) or readmissions ( 6 % vs 5 % ) . CONCLUSION Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay , without an increase in complications or readmissions 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 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 : 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 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 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 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 Objective Enhanced recovery after surgery ( ERAS ) integrates evidence -based interventions to reduce surgical stress and accelerate rehabilitation . Our study was to compare the short-term quality of life ( QOL ) in patients undergoing open colonic surgery using ERAS program or conventional management .  Methods A prospect i ve study of 57 patients using ERAS program and 60 patients using conventional management was conducted . The clinical characteristics of all patients were recorded . QOL was evaluated longitudinally using the question naires ( EORTC QLQ-C30 and QLQ-CR29 ) pre- and postoperatively . Generalized estimating equation was used to do the analysis in order to determine the effective impact of correlative factors on the postoperative QOL , including age , sex , BMI , ASA grade , tumor location , tumor size , pTNM stage , recovery program and length of time after surgery . Results The morbidity in ERAS and control group was 17.5 versus 26.7 % ( p = 0.235 ) . The patients in ERAS group had much faster rehabilitation and less hospital stay . In the primary statistical analysis , the scores of global QOL ( on POD3 , POD6 , POD10 , POD14 , POD21 ) , physical functioning ( on POD3 , POD6 , POD10 , POD14 , POD21 ) , role functioning ( on POD6 , POD10 , POD14 , POD21 ) , emotional functioning ( on POD3 , POD6 , POD10 , POD14 , POD21 ) , cognitive functioning ( on POD3 , POD6 ) and social functioning ( on POD3 , POD6 , POD10 , POD14 , POD21 , POD28 ) were higher in ERAS group than in control group , which suggested that the patients in ERAS group had a better life status . However , the scores of pain ( on POD10 , POD14 , POD21 ) , appetite loss ( on POD3 , POD6 ) , constipation ( on POD3 , POD6 , POD10 ) , diarrhea ( on POD3 , POD10 ) , financial difficulties ( on POD10 , POD14 , POD21 ) , perspective of future health ( on POD6 , POD10 , POD14 ) , gastrointestinal tract problems ( on POD3 , POD6 , POD10 ) and defecation problems ( on POD6 , POD10 , POD14 ) were lower in ERAS group than in control group , which revealed that the patients in ERAS group suffered less symptoms . In the further generalized estimating equation analysis , the result showed that recovery program and length of time after surgery had independently positive impact on the patient ’s postoperative QOL . ConclusionS hort-term QOL in patients undergoing colonic cancer using ERAS program was better than that using conventional management Introduction It is generally believed that resumption of feeding after colorectal resection is indicated only after recovery of bowel function . This study was design ed to verify safety , feasibility , and tolerance of early oral postoperative feeding ( EOF ) outside an enhanced recovery after surgery ( ERAS ) program . Material s and methods One hundred patient c and i date s to elective colorectal resection were prospect ively enrolled in an EOF program . Feeding was started on postoperative day ( POD ) 1 with oral nutritional supplement ( ONS ) . On POD 2 , patients had normal food plus ONS to reach 1,000–1,200 kcal/day with progressive increase until 1,800–2,000 kcal/day . Results were compared with historical controls ( n = 100 ) in whom oral feeding was allowed only after full bowel function recovery . The ERAS program was not applied in both groups . Results The EOF group had a better recovery of short half-life protein synthesis compared with the control group ( P < 0.001 ) . Stool canalization occurred after a median of 3 days ( range , 1–6 days ) in the EOF group versus 5 days ( range , 2–8 days ) in the control group ( P = 0.001 ) . The feeding protocol was completed in 89 patients within POD 5 . Tolerance to resumption of feeding was similar in the two groups . The overall rate of postoperative complication was 22 % in the EOF group vs. 27 % in the control group ( P = 0.51 ) . The median length of hospitalization was 9 days ( range , 6–25 days ) in the EOF group vs. 12 days ( range , 6–31 days ) in controls ( P = 0.01 ) . Conclusions EOF after colorectal operations is feasible and safe outside an ERAS program 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 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 BACKGROUND AND AIMS The Enhanced Recovery after Surgery ( ERAS ) program has been proposed as a postoperative recovery-enhancing strategy . We frequently apply the Modified-ERAS program following oesophagectomy . This study aims to eluci date the impact of goal -directed fluid therapy ( GDT ) for the perioperative management of oesophageal cancer on the postoperative recovery of patients undergoing oesophagectomy . METHODS This is an interventional before-after comparative observational study conducted at Kanagawa Cancer Centre , Japan . Patients who underwent elective oesophagectomy for oesophageal cancer were recruited . Group H ( retrospectively collected ) received intraoperative and postoperative management consisting of fluid administration without haemodynamic monitoring and the M-ERAS program , while Group S prospect ively received management consisting of GDT and the M-ERAS program . The primary endpoint was the speed of gastrointestinal functional recovery , while secondary endpoints were the level of postoperative mobilisation , incidence of complications , postoperative length of hospital stay ( LOS ) , and nutritional status after discharge . RESULTS The proportion of patients who completely egested Gastrografin by postoperative day 4 , the level of postoperative mobilisation , and achievement ratio for a 100-m walk on the first postoperative attempt were significantly higher in Group S than in Group H ( P = 0.034 , P = 0.0197 , and P < 0.0001 , respectively ) . No significant differences were observed in the postoperative LOS and incidence of complications within 30 days between the groups . The serum albumin levels at 6 months after discharge was higher in Group S than in Group H ( P = 0.0002 ) . CONCLUSIONS The GDT-ERAS program enhanced postoperative gastrointestinal recovery and mobilisation , as well as postoperative nutritional status and protein synthesis . The program did not affect either postoperative LOS or the incidence of complications . TRIAL REGISTRATION UMIN registration number : UMIN000013705 , https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000015999 The aim of this r and omized clinical trial was to compare patients treated using a multimodal approach [ enhanced recovery after surgery ( ERAS ) ]  , with a special focus on counselling , to patients treated in a st and ard conventional care pathway , who underwent elective colorectal resection BACKGROUND & AIMS Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . METHODS An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated " high " , " moderate " , " low " or " very low " . Recommendations were grade d as " strong " or " weak " . RESULTS Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . CONCLUSIONS The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials 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 OBJECTIVE Enhanced recovery after surgery ( ERAS ) has led to a paradigm shift in various surgical specialties . Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process . Still , ERAS remains relatively new to spine surgery . The authors report their 5-year experience , focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures , including anterior lumbar interbody fusion ( ALIF ) . METHODS A multimodal ERAS protocol was applied between November 2013 and October 2018 . The authors analyze hospital stay , perioperative outcomes , readmissions , and adverse events obtained from a prospect i ve institutional registry .  Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive ( MI ) anterior or posterior fusion cases were included . Their institutional ERAS protocol contains 22 pre- , intra- , and postoperative elements , including preoperative patient counseling , MI techniques , early mobilization and oral intake , minimal postoperative restrictions , and regular audits . RESULTS A total of 2592 consecutive patients were included , with 199 ( 8 % ) undergoing fusion . The mean hospital stay was 1.1 ± 1.2 days , with 20 ( 0.8 % ) 30-day and 36 ( 1.4 % ) 60-day readmissions . Ninety-four percent of patients were discharged after a maximum 1-night hospital stay . Over the 5-year period , a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed ( p < 0.001 ) , with a concomitant decrease in adverse events in the overall cohort ( p = 0.025 ) and without increase in readmissions . For fusion procedures , the rate of 1-night hospital stays increased from 26 % to 85 % ( p < 0.001 ) . Similarly , the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days ( p < 0.001 ) , with a notable concomitant decrease in variance , result ing in an estimated reduction in nursing costs of 46.8 % . CONCLUSIONS Application of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures , including ALIF , for treatment of degenerative spine conditions was safe and effective , without increase in readmissions . The data from this large case series stress the importance of the multidisciplinary , iterative improvement process to overcome the learning curve associated with ERAS implementation , and the importance of a dedicated perioperative care team . Prospect i ve trials are needed to evaluate spinal ERAS on a higher level of evidence BACKGROUND & AIMS Evidence of the advantages of enhanced recovery after surgery ( ERAS ) protocol s following pancreaticoduodenectomy ( PD ) is limited . The aim of this study was to examine the efficiency of ERAS protocol s in patients following PD . METHODS Between June 2014 and October 2016 , patients undergoing PD were r and omly assigned to receive ERAS protocol s or st and ard care . The primary endpoint was the postoperative length of stay . Secondary endpoints included postoperative complications , postoperative quality -of-life ( QoR-40J ) , readmission , and medical cost . RESULTS Of 80 eligible patients , 74 were analyzed in intention-to-treat principles : 37 in the control group and 37 in the ERAS group . The mean length of stay in the ERAS group was significantly shorter than that in the control group ( 20.1 ± 5.4 vs 26.9 ± 13.5 days , P < 0.001 ) . The ERAS group had a significantly lower percentage of postoperative complications ( 32.4 % vs 56.8 % , P = 0.034 ) and readmissions ( 0 % vs 8.1 % , P = 0.038 ) . Quality -of-life was also significantly better in the ERAS group ( 184 ± 12.4 vs 177 ± 14.5 , P = 0.022 ) . The total medical cost was lower in the ERAS group , but not significantly ( $ 25,445 ± 5065 vs $ 28,384 ± 9999 , P = 0.085 ) . CONCLUSIONS The optimization of ERAS protocol s in patients undergoing PD  is safe and accelerates perioperative recovery and quality -of-life , thereby reducing the length of stay . Morbidity was significantly decreased in the ERAS group without compromising surgical outcome . REGISTRATION NUMBER UMIN000014068 Background Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . Methods An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated “ high ” , “ moderate ” , “ low ” or “ very low ” . Recommendations were grade d as “ strong ” or “ weak ” . Results Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . Conclusions The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials 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 For esophageal cancer patients , radical esophagolymphadenectomy is the cornerstone of multimodality treatment with curative intent . Transthoracic esophagectomy is the preferred surgical approach worldwide allowing for en-bloc resection of the tumor with the surrounding lymph nodes . However , the percentage of cardiopulmonary complications associated with the transthoracic approach is high ( 50 to 70%).Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy ( RATE ) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes . RATE was accompanied with reduced blood loss , shorter ICU stay and improved lymph node retrieval compared with open esophagectomy , and the pulmonary complication rate , hospital stay and perioperative mortality were comparable . The objective is to evaluate the efficacy , risks , quality of life and cost-effectiveness of RATE as an alternative to open transthoracic esophagectomy for treatment of esophageal cancer . Methods / design This is an investigator-initiated and investigator-driven monocenter r and omized controlled parallel-group , superiority trial . All adult patients ( age ≥18 and ≤80 years ) with histologically proven , surgically resectable ( cT1 - 4a , N0 - 3 , M0 ) esophageal carcinoma of the intrathoracic esophagus and with European Clinical Oncology Group performance status 0 , 1 or 2 will be assessed for eligibility and included after obtaining informed consent . Patients ( n = 112 ) with resectable esophageal cancer are r and omized in the outpatient department to either RATE ( n = 56 ) or open three-stage transthoracic esophageal resection ( n = 56 ) . The primary outcome of this study is the percentage of overall complications ( grade 2 and higher ) as stated by the modified Clavien – Dindo classification of surgical complications . Discussion This is the first r and omized controlled trial design ed to compare RATE with open transthoracic esophagectomy as surgical treatment for resectable esophageal cancer . If our hypothesis is proven correct , RATE will result in a lower percentage of postoperative complications , lower blood loss , and shorter hospital stay , but with at least similar oncologic outcomes and better postoperative quality of life compared with open transthoracic esophagectomy . The study started in January 2012 . Follow-up will be 5 years . Short-term results will be analyzed and published after discharge of the last r and omized patient . Trial registration Dutch trial register : NTR3291 Clinical Trial.gov : 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 Background Colorectal cancer ( CRC ) is the second most prevalent type of cancer in the world . Surgery is the only curative option . However , postoperative complications occur in up to 50 % of patients and are associated with higher morbidity and mortality rates , lower health related quality of life ( HRQoL ) and increased expenditure in health care . The number and severity of complications are closely related to preoperative functional capacity , nutritional state , psychological state , and smoking behavior . Traditional approaches have targeted the postoperative period for rehabilitation and lifestyle changes . However , recent evidence shows that the preoperative period might be the optimal moment for intervention . This study will determine the impact of multimodal prehabilitation on patients ’ functional capacity and postoperative complications . Methods / design This international multicenter , prospect i ve , r and omized controlled trial will include 714 patients undergoing colorectal surgery for cancer . Patients will be allocated to the intervention group , which will receive 4 weeks of prehabilitation ( group 1 , prehab ) , or the control group , which will receive no prehabilitation ( group 2 , no prehab ) . Both groups will receive perioperative care in accordance with the enhanced recovery after surgery ( ERAS ) guidelines . The primary outcomes for measurement will be functional capacity ( as assessed using the six-minute walk test ( 6MWT ) ) and postoperative status determined with the Comprehensive Complication Index ( CCI ) . Secondary outcomes will include HRQoL , length of hospital stay ( LOS ) and a cost-effectiveness analysis . Discussion Multimodal prehabilitation is expected to enhance patients ’ functional capacity and to reduce postoperative complications . It may therefore result in increased survival and improved HRQoL. This is the first international multicenter study investigating multimodal prehabilitation for patients undergoing colorectal surgery for cancer . Trial registration Trial Registry : NTR5947 – date of registration : 1 August 2016 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 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 BACKGROUND Thoracic procedures are currently performed by general and thoracic surgeons . Initial clinical outcome after training is a good measure of the quality of the surgical training received . METHODS We examined the morbidity and mortality for  pneumonectomy , lobectomy and esophagectomy  during one surgeon 's first 2 years of practice ; we collected data prospect ively . The results were based on the experience of the only dedicated thoracic surgeon ( 5 years of general surgery and 3 years of thoracic surgery training with certification from the Royal College of Physicians and Surgeons of Canada ) at the largest tertiary care hospital of Brown University School of Medicine . RESULTS During the 2-year period , 154 major pulmonary resections ( 20 pneumonectomies , 134 lobectomies ) and 25 esophagectomies ( 18 transhiatal , 4 Ivor-Lewis , 2 thoracoabdominal , one 3-incision ) were performed . Mortality for major lung resection was 1.9 % ( pneumonectomy 5 % , lobectomy 1.5 % ) , and morbidity was 27 % ( pneumonectomy 35 % , lobectomy 26 % ) . Mortality for esophagectomy was 4 % , and morbidity was 36 % ( anastamotic leak 12 % ) . CONCLUSIONS These results compare favourably with clinical outcomes published from several large series . Thoracic surgical training in Canada is adequate and prepares surgeons well to perform major thoracic procedures . A data base of the initial results from all graduates of thoracic surgery training in Canada is needed . Such a data base could be used to compare the initial results of thoracic procedures performed by general and thoracic surgery graduates from Canada and the United States BACKGROUND & AIMS Although esophagectomy is the st and ard of care for treating early adenocarcinoma in Barrett 's esophagus , the procedure is associated with significant morbidity and mortality . For these patients , the multimodal approach of endoscopic mucosal resection and photodynamic therapy ( EMR/PDT ) may be a viable , less invasive option . METHODS A retrospective review ( 1996 - 2001 ) of all patients undergoing either combined EMR/PDT group or esophagectomy ( SURG ) for early-stage Barrett 's adenocarcinoma was performed . Data were collected on patient demographics , tumor staging , procedure-related morbidity and mortality , persistence or recurrence of cancer , and cancer-related deaths after therapy . Differences in outcomes between the 2 groups were assessed . RESULTS Twenty-four patients were identified in the EMR/PDT group and 64 in the SURG group . The SURG group was found to have a significantly higher procedure-related complication rate compared with the EMR/PDT group ( 31 vs. 4 ; P < 0.01 ) . There were no procedure-related deaths in the EMR/PDT group , whereas one death occurred in the SURG group as a result of complications . Eighty-three percent of patients ( 20 of 24 ) in the EMR/PDT group and all patients in the SURG group remained free of cancer over a follow-up of 12 + /- 2 and 19 + /- 3 months , respectively . Four patients in the EMR/PDT group failed to respond to therapy ; 2 of them underwent alternate therapies and are free of disease , whereas the other 2 died of unrelated causes . CONCLUSIONS The combination of EMR/PDT seems to be a viable and less morbid alternative to st and ard esophagectomy in patients presenting with early Barrett 's esophageal adenocarcinoma . A prospect i ve r and omized , controlled trial of EMR/PDT compared with esophagectomy for managing early adenocarcinoma in Barrett 's esophagus may be warranted 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 Transhiatal esophagectomy is a popular method of resection because of its reported lower morbidity and mortality and similar survival rates compared to transthoracic esophagectomy . A review of recent experience with these two procedures for resection of distal esophageal and cardia adenocarcinoma is reported . METHODS From 1988 to 1994 , 48 patients with adenocarcinoma of the distal esophagus and gastric cardia were resected with intent to cure , 32 by transhiatal esophagectomy ( group 1 ) and 16 by transthoracic esophagectomy ( group II ) . The two groups were comparable in terms of patient demographics , preoperative risk factors , tumor stage , tumor differentiation , and involvement of resection margins ( all not significant [ NS ] ) . RESULTS There was no significant difference in median intensive care unit stay , median hospital stay , incidence of postoperative anastomotic leak , and stricture . Respiratory complications were higher in group I ( 41 % versus 6 % , P = 0.01 ) . Hospital mortality was not significantly different for the two groups ( group I 3.1 % versus group II 0 % , NS ) . Actuarial 5-year survival rates ( Kaplan-Meier ) were 12 % for group I and 39 % for group II ( NS ) . CONCLUSIONS These results suggest that when compared with transhiatal esophagectomy , the transthoracic approach is at least as safe , has comparable complication and survival rates , and remains an acceptable procedure for resection of adenocarcinomas of the distal esophagus and gastric cardia OBJECTIVE To review the authors ' clinical experience with  transhiatal esophagectomy ( THE )  and the refinements in this procedure that have evolved . BACKGROUND Increased use of THE during the past two decades has generated controversy about the merits and safety of this approach compared with transthoracic esophageal resection . The authors ' large THE experience provides a valuable basis for benchmarking data regarding the procedure . METHODS The results of THE were analyzed retrospectively using the authors ' prospect ively established esophageal resection data base and follow-up information on these patients . RESULTS From 1976 to 1998 , THE was performed in 1085 patients , 26 % with benign disease and 74 % with cancer . The procedure was possible in 98.6 % of cases . Stomach was the esophageal substitute in 96 % . The hospital mortality rate was 4 % . Blood loss averaged 689 cc . Major complications were anastomotic leak ( 13 % ) , atelectasis/pneumonia ( 2 % ) , intrathoracic hemorrhage , recurrent laryngeal nerve paralysis , chylothorax , and tracheal laceration ( < 1 % each ) . Actuarial survival of patients with carcinoma equaled or exceeded that reported after transthoracic esophagectomy .  Late functional results were good or excellent in 70 % . With preoperative pulmonary and physical conditioning , a side-to-side stapled cervical esophagogastric anastomosis ( <3 % incidence of leak ) , and postoperative epidural anesthesia , the need for an intensive care unit stay has been eliminated and the length of stay reduced to 7 days . CONCLUSION THE is possible in most patients requiring esophageal resection and can be performed with greater safety and fewer complications than the traditional transthoracic approaches Background Enhanced recovery after surgery ( ERAS ) programs are aim ed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles . “ Early mobilization ” is one such principle , but the quality of assessment and monitoring is poor , and evidence of improved outcome is lacking . Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization . The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristb and s. Methods / design Patients undergoing elective open and laparoscopic surgery of the colon , rectum , stomach , pancreas , and liver for any indication will be included . Further inclusion criteria are age between 18 and 75 years , American Society of Anesthesiologists Physical Status class less than IV , and a signed informed consent form . Patients will be stratified into two subgroups , laparoscopic and open surgery , and will be r and omized 1:1 for automatic feedback of their step count using an activity tracker wristb and . The control group will have no automatic feedback . The sample size ( n = 30 patients in each of the four groups , overall n = 120 ) is calculated on the basis of an assumed difference in step count of 250 steps daily ( intervention group versus control group ) . The primary study endpoint is the average step count during the first 5 postoperative days ; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization ( step count ) targets , assessment of additional activity data obtained from the devices , assessment of preoperative mobility , length of hospital and intensive care unit stays , number of patients who receive physiotherapy , 30-day mortality , and overall 30-day morbidity . Discussion Early mobilization is a key element of ERAS . However , enhanced early mobilization is difficult to define , to assess objective ly , and to implement in clinical practice . Consequently , there is a discrepancy between ERAS targets and actual practice , especially in patients undergoing major visceral surgery . This study is the first r and omized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization . Trial registration Clinical Trials.gov identifier : NCT02834338 . Registered on 15 June 2016 PURPOSE To observe the clinical efficacy of the application of enhanced recovery after surgery ( ERAS ) in the perioperative period of esophageal carcinoma patients . METHODS A total of 114 patients who were admitted to Affiliated Hospital of Jining Medical University for surgical treatment of esophageal carcinoma between June 2012 and June 2016 were enrolled and r and omly divided into the intervention group and the regular group according to the difference of management procedures during the perioperative period . ERAS was carried out in 57 patients in the intervention group , while conventional management procedures were applied in 57 patients in the regular group . Thereafter , compared were the fluctuations in nutritional indicators and immunological indicators , postoperative complications , time to recovery of gastrointestinal function , length of stay ( LOS ) in hospital and cost of patients between the two groups . RESULTS Seven days post-operation in the intervention group , the evaluation indexes of nutrition status , including total protein ( TP ) , albumin ( ALB ) , prealbumin ( PA ) and transferrin ( TF ) , and of immunological functions , including immunoglobulin G ( IgG ) , immunoglobulin A ( IgA ) , immunoglobulin M ( IgM ) and total blood lymphocyte count ( TLC ) , were significantly higher than those in the regular group . As for postoperative complications , the incidence rate of the intervention group was remarkably lower than that of the regular group ; the recovery time of gastrointestinal function in the intervention group was shorter than that in the regular group ; the LOS in the intervention group was also shorter than that in the regular group ; the in-hospital cost in the intervention group was also lower than that in the regular group . All differences above were statistically significant ( p<0.05 ) . CONCLUSION During the perioperative period of esophageal carcinoma patients , ERAS should be fully applied to sustain the good status , and promote the recovery of immunological functions and gastrointestinal functions ; at the same time , ERAS also reduces the incidence rate of postoperative complications , LOS and in-hospital cost , and we maintain that ERAS should be performed in clinical practice Objective : To determine whether the relationship between  hospital volume  and mortality has changed over time . Background : It is generally accepted that hospital volume is associated with mortality in high-risk procedures . However , as surgical safety has improved over the last decade , recent evidence has suggested that the inverse relationship has diminished or been eliminated . Methods : Using national Medicare cl aims data from 2000 through 2009 , we examined mortality among 3,282,127 patients who underwent 1 of 8 gastrointestinal , cardiac , or vascular procedures .  Hospitals were stratified into quintiles of operative volume . Using multivariable logistic regression models to adjust for patient characteristics , we examined the relationship between hospital volume and mortality , and assessed for changes over time . We performed sensitivity analyses using hierarchical logistic regression modeling with hospital-level r and om effects to confirm our results . Results : Throughout the 10-year period , a significant inverse relationship was observed in all procedures . In 5 of the 8 procedures studied , the strength of the volume- outcome relationship increased over time . In esophagectomy , for example , the adjusted odds ratio of mortality in very low volume hospitals compared to very high volume hospitals increased from 2.25 [ 95 % confidence interval ( CI ) : 1.57–3.23 ] in 2000–2001 to 3.68 ( 95 % CI : 2.66–5.11 ) in 2008–2009 . Only pancreatectomy showed a notable decrease in strength of the relationship over time , from 5.83 ( 95 % CI : 3.64–9.36 ) in 2000–2001 , to 3.08 ( 95 % CI : 2.07–4.57 ) in 2008–2009 . Conclusions : For all procedures examined , higher volume hospitals had significantly lower mortality rates than lower volume hospitals . Despite recent improvements in surgical safety , the strong inverse relationship between hospital volume and mortality persists in the modern era OBJECTIVE Patients undergoing esophagectomy are typically nutritionally depleted and can not establish oral feeding for up to a week after surgery . We have investigated the routine use of enteral feeding via a naso-jejunal tube . METHODS Forty consecutive patients undergoing a transthoracic esophagectomy for cancer were r and omised to receive enteral feeding or intravenous crystalloid fluids after surgery . Nutritional indices were obtained prior to surgery and on the 7th post-operative day . RESULTS There were no post-operative deaths . Non-fatal complications occurred in 10 patients , without difference in morbidity between the two groups . Lean body mass did not change in either group over the study period . No differences in any other parameters were identified between the two groups . CONCLUSION Enteral feeding via a naso-jejunal tube is safe and well tolerated after esophagectomy . It is a simple method of providing nutritional support prior to the re- introduction of oral feeding . However it provides no measurable benefit over intravenous hydration only for patients undergoing routine esophagectomy Background : Pulmonary complications remain the major cause of postoperative mortality in patients with esophageal cancer undergoing esophagectomy . It was unclear whether this dismal complication has a genetic predisposition . We therefore investigated the role of an angiotensin-converting enzyme ( ACE ) insertion/deletion polymorphism in developing these complications . Methods : We conducted a prospect i ve study including 152 patients with esophageal cancer who underwent esophagectomy in National Taiwan University Hospital between 1996 and 2002 . The ACE genotype was determined by polymerase chain reaction amplification of leukocyte DNA obtained before surgery . The serum ACE concentration was determined by enzyme-linked immunosorbent assay . Results : Thirty-five patients ( 23 % ) developed pulmonary complications following esophagectomy . As compared with patients with the I/I and I/D genotypes , those with the D/D genotype had a higher risk for pulmonary complications ( adjusted odds ratio [ OR ] , 3.12 ; 95 % confidence interval [ CI ] , 1.01–9.65 ) . The risk was additively enhanced by combination of the ACE D/D genotype with other clinical risk factors ( old age , hypoalbuminemia , and poor pulmonary function ) . The circulating ACE level was also dose-dependently with the presence of ACE D allele . As compared with the patients with circulating ACE less than 200 ng/mL , the patients with circulating ACE of 200 to 400 ng/mL and over 400 ng/mL had ORs ( 95 % CI ) of 2.75 ( 1.12–6.67 ) and 15.00 ( 4.3–52.34 ) to present with ACE D allele , respectively . Conclusions : An ACE insertion/deletion polymorphism might modulate the function of ACE gene and play a role in affecting individual susceptibility to pulmonary injury following esophagectomy in patients of esophageal cancer Background Many patients experience postoperative nausea and vomiting ( PONV ) . Preoperative treatment with carbohydrate solutions seems to improve the course after different types of surgery . This study was undertaken to investigate the potential value of different models for preoperative hydration/nutrition , in addition to our ERAS ( enhanced recovery after surgery ) protocol . Methods Ninety non-diabetic women planned for elective laparoscopic gastric bypass and aged 18–65 years were included . All were on preoperative low-calorie diet ( LCD ) . They were r and omized into three arms , either a carbohydrate-rich drink , a protein-enriched drink , or tap water and instructed to drink 800 and 200 mL 16 and 2 h , respectively , prior to operation . Risk factors for PONV were recorded preoperatively . All patients were operated before lunch and received 1500–2000 mL of Ringer-Acetate solution during the 24–30-h postoperative hospital time . Four variables ( nausea , pain , tiredness , and headache ) were registered on 100-mm visual analog scales six times over 22 h. The need for additional medication was registered . Results Out of 90 patients , 73 complete data sets were obtained . Nausea peaked at 7 p.m. but with no statistically significant differences between groups for any of the variables . Pain peaked the first 2 h postoperatively , remained longer , and had not returned to baseline values at 6 a.m. the morning after surgery but with no difference between groups . Conclusions Inside our ERAS protocol , additional preoperative carbohydrate- or protein-enriched fluid treatment did not further reduce immediate patient discomfort in laparoscopic gastric bypass surgery 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 Background : Esophagectomy represents an exemplar of controlled major trauma , with marked metabolic , immunologic , and physiologic changes as well as an associated high incidence of complications . Eicosapentaenoic acid ( EPA ) enriched enteral nutrition ( EN ) modulates immune function and limits catabolism in patients with advanced cancer , but its impact in the peri-operative period is unclear . Objectives : To examine the effects of perioperative EPA enriched EN on the metabolic , nutritional , and immuno-inflammatory response to esophagectomy , and on postoperative complications . Methods : In a double-blind design , patients were r and omized to a st and ard EN formula or a formula enriched with 2.2 g EPA/d for 5 days preoperatively ( orally ) and 21 days postoperatively ( jejunostomy ) . Segmental bioelectrical impedance analysis was performed preoperatively and on POD 21 . Postoperative complications were monitored , as well as the acute phase response , coagulation markers , and serum cytokines . Results : Fifty-three patients ( 28 EPA , 25 st and ard ) completed the study , and both groups were well matched . Serum and peripheral blood mononuclear cell ( P BMC ) membrane EPA levels were significantly increased in the EPA group . There was no difference in the incidence of major complications . The EPA group maintained all aspects of body composition postoperatively , whereas patients in the st and ard EN group lost significant amounts of fat-free mass ( 1.9 kg , P = 0.030 ) compared with the EPA group [ leg ( 0.3 kg , P = 0.05 ) , arm ( 0.17 kg , P = 0.01 ) , and trunk ( 1.44 kg , P = 0.03 ) ] . The EPA group had a significantly ( P < 0.05 ) attenuated stress response for TNFα , IL-10 , and IL-8 compared with the st and ard group . Conclusions : EPA supplemented early EN is associated with preservation of lean body mass post esophagectomy compared with a st and ard EN . These properties may merit longer-term study to address its impact on recovery of function and quality of life in models of complex surgery or multimodal cancer treatment regimens Transthoracic esophagectomy ( TT ) has been championed as a better cancer operation than transhiatal esophagectomy ( TH ) because the approach facilitates meticulous wide tumor excision and lymphadenectomy . However , neoadjuvant chemoradiotherapy ( CRTS ) and chemotherapy ( CS ) have been reported to improve outcomes , and we aim ed to compare outcomes after multimodal therapy related to the operative approach . One hundred and fifty-one consecutive patients were studied prospect ively . All patients were staged with computed tomography and endoluminal ultrasound , and treatment decisions were related to stage and performance status . One hundred and nineteen TT ( median age 58 years , 92 male , 54 CRTS , 65 CS ) were performed compared to 32 TH ( median age 57 year , 27 male , 14 CRTS , 18 CS ) . Primary outcome measure was survival . Post-operative morbidity and mortality were 54 % and 4 % , respectively , after TT compared with 59 % and 6 % after TH ( chi2 0.239 df 1 , P=0.625 ) . Recurrent cancer was no less frequent after TT ( 52 % ) than after TH ( 37.5 % , chi2 2.151 df=1 , P=0.142 ) . Cumulative uncorrected 5-year survival was 34 % after TT compared with 53 % after TH ( log rank 1.44 , df=1 , P=0.2298 ) . Median survival was also similar in lymph node positive patients ( TT vs. TH , 23 months vs. 22 months , respectively , log rank 0.25 , df=1 , P=0.6199 ) . Despite the fact that patients receiving multimodal therapy and a TH esophagectomy were less fit , operative morbidity , mortality and recurrence were similar , and survival did not differ significantly when compared with multimodal TT esophagectomy Background Esophagectomy through cervico-thoraco-abdominal approach is a useful surgical technique in treating patients with esophageal cancer . However , the cervical reconstruction is also known to have a high rate of anastomotic leakage , as well as anastomotic stricture , intrathoracic stomach syndrome , reflux esophagitis and other complications , thereby influencing postoperative recovery and quality of life . Aims The objective of this study was to investigate whether tubular stomach is superior to whole stomach in reducing anastomotic leakage for esophageal reconstruction through the cervico-thoraco-abdominal ( 3-field ) approach . Methods A total of 850 patients undergoing the 3-field esophagectomy  were retrospectively included in this study and divided into a tubular stomach reconstruction group ( Group A , n = 453 ) and a whole stomach reconstruction group ( Group B , n = 397 ) . All patients underwent esophagectomy through right thorax , left cervical part , abdominal triple incisions and done in esophageal reconstruction by h and -sewn two-layer anastomosis . Results Results revealed that in comparison with whole stomach , esophageal reconstruction with tubular stomach had a lower incidence of anastomotic leakage ( 5.5 vs. 9.3 % , P < 0.05 ) , less manifestation of intrathoracic syndrome ( 3.3 vs. 9.8 % , P < 0.001 ) and less occurence of reflux esophagitis ( 5.1 vs. 11.1 % , P < 0.01 ) . However , for the incidence of anastomotic stricture , there was no significant difference between the two groups ( 9.3 vs. 9.8 % ) . Conclusions This observation study suggests that for esophageal cancer patients undergoing the 3-field esophagectomy tubular stomach is better than whole stomach for esophageal reconstruction as reflected by a reduced postoperative anastomotic leakage , intrathoracic syndrome and reflux esophagitis INTRODUCTION In a majority of cases , enhanced recovery after surgery program ( ERP ) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery . The program 's preoperative , perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team . Having shown its merits in digestive surgery , ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail . The objective of this review was to evaluate the efficacy of ERP  in liver surgery . METHOD This is a systematic narrative review of the literature on the efficacy of ERP  in liver surgery by laparotomy or laparoscopy . RESULTS Notwithst and ing a number of studies ( n=30 : 5 r and omized trials , 14 cohort studies and 11 meta-analyses ) less sizable than with regard to digestive surgery in general and colorectal surgery in particular , analysis of the literature confirms that in liver surgery , ERP is associated with an overall decrease in complications by 30 to 60 % , but without improvement in the rates of hospital readmission and postoperative mortality . All of the studies report a reduction in average length of stay ( ALOS ) by 2.3 days and in functional recovery , a more objective indicator than ALOS , by 2.5 days . As of now , the economic impact of the ERP programs in liver surgery is neither positive nor negative , the above-mentioned savings being counterbalanced by heightened costs for material and equipment . Laparoscopic surgery is independently associated with better outcomes in terms of complications , functional recovery and ALOS ; that is why it is important to incorporate this surgical approach in ERP as often as possible . Given a lack of robust evidence , Prehabilitation , which is a preoperative optimization process leading to improved functional reserve , has yet to be assigned a place in ERP programs pertaining to liver surgery . Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader , a motivated multidisciplinary team , training courses and dedicated teaching sessions . CONCLUSION ERP is a care improvement process that has a major play to play in organization of liver surgery , and its large-scale application is to be recommended BACKGROUND The aim of this study was to compare the topical to IV tranexamic acid ( TXA ) administration of the same dose , given at the same time in patients who underwent TKR using an enhanced recovery after surgery ( ERAS ) regime . METHODS Ninety patients were r and omized in control group , and IV and topical application groups received 1 g TXA . RESULTS Blood loss and transfusion requirements in control group were statistically higher compared to both TXA groups ( p < 0.05 ) . Length of stay was the same in all groups . CONCLUSIONS TXA reduced significantly the blood loss and the need for transfusion in ERAS primary unilateral TKR Abstract Background : Prehabilitation has been previously shown to be more effective in enhancing postoperative functional capacity than rehabilitation alone . The purpose of this study was to determine whether a weekly supervised exercise session could provide further benefit to our current prehabilition program , when comparing to st and ard post-surgical rehabilitation . Methods : A parallel-arm single-blind r and omized control trial was conducted in patients scheduled for non-metastatic colorectal cancer resection . Patients were assigned to either a once weekly supervised prehabilitation ( PREHAB+ , n = 41 ) or st and ard rehabilitation ( REHAB , n = 39 ) program . Both multimodal programs were home-based program and consisted of moderate intensity aerobic and resistance exercise , nutrition counseling with daily whey protein supplementation and anxiety-reduction strategies . Perioperative care was st and ardized for both groups as per enhanced recovery after surgery ( ERAS ® ) guidelines . Functional exercise capacity , as determined by the 6-minute walk test distance ( 6MWD ) , was the primary outcome . Exercise quantity , intensity and energy expenditure was determined by the CHAMPS question naire . Results : Both groups were comparable for baseline walking capacity ( PREHAB+ : 448 m [ IQR 375–525 ] vs. REHAB : 461 m [ 419–556 ] , p=.775 ) and included a similar proportion of patients who improved walking capacity ( > 20 m ) during the preoperative period ( PREHAB+ : 54 % vs. REHAB : 38 % , p = .222 ) . After surgery , changes in 6MWD were also similar in both groups . In PREHAB+ , however , there was a significant association between physical activity energy expenditure and 6MWD ( p < .01 ) . Previously inactive patients were more likely to improve functional capacity due to PREHAB+ ( OR 7.07 [ 95 % CI 1.10–45.51 ] ) . Conclusions : The addition of a weekly supervised exercise session to our current prehabilitation program did not further enhance postoperative walking capacity when compared to st and ard REHAB care . Sedentary patients , however , seemed more likely to benefit from PREHAB+ . An association was found between energy spent in physical activity and 6MWD . This information is important to consider when design ing cost-effective prehabilitation programs Purpose This study aims to investigate the influence of fast-track surgery ( FTS ) on insulin resistance indicators in a prospect i ve r and omized , controlled clinical trial in esophageal cancer patients . Methods Between November 2009 and March 2011 , 34 patients underwent the FTS pathway , and 34 patients underwent the conventional pathway after esophagectomy in our department . The times to postoperative flatus and defecation , duration of postoperative hospital stay , hospitalization expenditures , and postoperative complications were recorded . Insulin resistance indicators were measured before operation as well as on the 1st , 3rd , and 7th postoperative days ( PODs ) , including serum levels of fasting blood glucose ( FBG ) , fasting insulin ( FINS ) , interleukin-6 ( IL-6 ) , and C-reactive protein ( CRP ) in patients of both groups . The insulin resistance index ( homeostasis model assessment of insulin resistance ( HOMA-IR ) ) was calculated at each time point . Results We found a significantly shorter postoperative hospital stay and faster return of gastrointestinal function in patients who underwent  FTS  ( P < 0.01 ) . In addition , the total hospitalization expenditure was significantly lower in the FTS group ( P < 0.01 ) . The preoperative insulin resistance indicators showed no significant differences between the two groups . On PODs 1 and 3 , the levels of log-HOMA-IR , FINS , IL-6 , and CRP in the FTS group were significantly lower than those in the control group ( all P < 0.05 ) . On POD 7 , the CRP level in the FTS group was significantly lower than that in the control group ( P < 0.05 ) . Conclusions FTS promotes early recovery of gastrointestinal function and reduces stress reaction and postoperative insulin resistance after esophagectomy for esophageal cancer OBJECTIVE Debate continues as to whether transhiatal esophagectomy results in lower morbidity and mortality than transthoracic esophagectomy . Most data addressing this issue are derived from single-institution studies . To investigate this question from a nationwide multicenter perspective , we used the Veterans Administration National Surgical Quality Improvement Program to prospect ively analyze risk factors for morbidity and mortality in patients undergoing transthoracic esophagectomy or transhiatal esophagectomy from 1991 to 2000 . METHODS Univariate and multivariate analyses were performed on 945 patients ( mean age , 63 + /- 10 years ) . There were 562 transthoracic esophagectomies and 383 transhiatal esophagectomies in 105 hospitals , with complete 30-day outcomes recorded . RESULTS There were no differences in recorded preoperative variables between the groups that might bias any comparisons . Overall mortality was 10.0 % ( 56/562 ) for transthoracic esophagectomy and 9.9 % ( 38/383 ) for transhiatal esophagectomy ( P = .983 ) . Morbidity occurred in 47 % ( 266/562 ) of patients after transthoracic esophagectomy and in 49 % ( 188/383 ) of patients after transhiatal esophagectomy ( P = .596 ) . Risk factors for mortality common to both groups included a serum albumin value of less than 3.5 g/dL , age greater than 65 years , and blood transfusion of greater than 4 units ( P < .05 ) . When comparing transthoracic esophagectomy with transhiatal esophagectomy , there was no difference in the incidence of respiratory failure , renal failure , bleeding , infection , sepsis , anastomotic complications , or mediastinitis . Wound dehiscence occurred in 5 % ( 18/383 ) of patients undergoing transhiatal esophagectomy and only 2 % ( 12/562 ) of patients undergoing transthoracic esophagectomy ( P = .036 ) . CONCLUSIONS These data demonstrate no significant differences in preoperative variables and postoperative mortality or morbidity between transthoracic esophagectomy and transhiatal esophagectomy on the basis of a 10-year , prospect i ve , multi-institutional , nationwide study BACKGROUND Pulmonary complications after transhiatal esophagectomy occur commonly and frequently cause severe morbidity and possible mortality . Aspiration , both overt and silent , can also be present with some regularity after this procedure , and it appears intuitive that identification of aspiration with the appropriate measures of avoidance of oral intake and avoidance of oral contrast studies may help reduce the consequences of aspiration pneumonia . STUDY DESIGN In an attempt to help identify patients at risk for aspiration , we prospect ively studied 73 patients who had recently undergone transhiatal esophagectomy using fiberoptic endoscopic evaluation of swallowing ( FEES ) .  Evaluation of premature spillage , pharyngeal residue , pooling , penetration , and aspiration was carried out . RESULTS Twenty-one percent of patients showed evidence of aspiration and were kept npo , with deferral of oral contrast studies . Of all the potential predictors of aspiration studied , only vocal fold immobility was a notable predictor of aspiration . But 40 % of patients who aspirated had normal vocal fold function . Vocal fold immobility was also identified in several patients thought to have completely normal voice quality . There were no complications of FEES . All patients who demonstrated aspiration and all those with vocal fold immobility eventually demonstrated swallowing without aspiration and recovery of cord function . CONCLUSIONS This study demonstrated the safety and efficacy of FEES in evaluation of laryngeal function in the postoperative setting after transhiatal esophagectomy . A FEES is recommended before the contrast study or oral feeding challenge for objective determination of aspiration risk from pharyngeal or laryngeal pathology . Early determination of aspiration status may reduce or eliminate pulmonary complications Objective : “ Rediscovered ” in 1976 , transhiatal esophagectomy ( THE ) has been applicable in most situations requiring esophageal resection and reconstruction . The objective of this study was to review the authors ’ 30-year experience with THE and changing trends in its use . Methods : Using the authors ’ prospect i ve Esophagectomy Data base , this single institution experience with THE was analyzed retrospectively . Results : Two thous and and seven THEs were performed—1063 ( previously reported ) between 1976 and 1998 ( group I ) and 944 from 1998 to 2006 ( group II ) , 24 % for benign disease , 76 % , cancer . THE was possible in 98 % . Stomach was the esophageal substitute in 97 % . Comparing outcomes between group I and group II , statistically significant differences ( P < 0.001 ) were observed in hospital mortality ( 4 % vs. 1 % ) ; adenocarcinoma histology ( 69 % vs. 86 % ) ; use of neoadjuvant chemoradiation ( 28 % vs. 52 % ) ; mean blood loss ( 677 vs. 368 mL ) ; anastomotic leak ( 14 % vs. 9 % ) ; and discharge within 10 days ( 52 % vs. 78 % ) . Major complications remain infrequent : wound infection/dehiscence , 3 % , atelectasis/pneumonia , 2 % , intrathoracic hemorrhage , recurrent laryngeal nerve paralysis , chylothorax , and tracheal laceration , < 1 % each . Late functional results have been good or excellent in 73 % . Aggressive preoperative conditioning , avoiding the ICU , improved pain management , and early ambulation reduce length of stay , with 50 % in group II discharged within 1 week . Conclusion : THE refinements have reduced the historic morbidity and mortality of esophageal resection . This largest reported THE experience reinforces the value of consistent technique and a clinical pathway in managing these high acuity esophageal patients
Overall , there is little direct evidence for components of ERAS , with much derived from nonesophageal thoracoabdominal surgery .
ERAS in principle seems logical and safe for esophagectomy .
OBJECTIVE This article aims to provide the first systematic review of enhanced recovery after surgery ( ERAS ) programs for  esophagectomy  and generate guidelines .
BACKGROUND ERAS programs use multimodal approaches to reduce complications and accelerate recovery .
Although ERAS is well established in colorectal surgery , experience after esophagectomy has been minimal .
However , esophagectomy remains an extremely high-risk operation , commonly performed in patients with significant comorbidities .
Consequently , ERAS may have a significant role to play in improving outcomes .
No guidelines or review s have been published in esophagectomy .