Download PDF
Clin Colon Rectal Surg 2013; 26(03): 139-145
DOI: 10.1055/s-0033-1351128
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Perioperative Protocols in Colorectal Surgery

Mia DeBarros
1   Department of Surgery, Madigan Healthcare System, Tacoma, Washington
,
Scott R. Steele
1   Department of Surgery, Madigan Healthcare System, Tacoma, Washington
› Author Affiliations
Further Information

Publication History

Publication Date:
19 August 2013 (online)

   Permissions and Reprints

Abstract

The reduction in health-care expenditures and more efficient use of medical resources are now overriding health policy priorities with the two-pronged goal of improving patient outcomes while decreasing overall cost. Current reports show colorectal surgery accounting for 25% of all operative complications and an average length of stay of 8 to 12 days for a standard elective colon resection. To combat this, Kehlet and colleagues introduced a concept of enhanced recovery after surgery (ERAS) or fast-track pathways, with the goal of using current evidence and multimodal therapies to decrease surgical stress, enhance postoperative recovery, and reduce length of stay. The benefits, safety, and cost-effectiveness of fast-track protocols are validated in multiple randomized controlled trials. In this review, the authors focus on the evidence regarding fast-track pathways, use of minimally invasive surgery and its role in fast-track pathways, newer perioperative interventions, and future directions.

Keywords

colorectal surgery - perioperative protocols - fast-track surgery - enhanced recovery after surgery - ERAS
 

  • References

  • 1 Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group. U.S. Department of Commerce, Bureau of Economic Analysis; and U.S. Bureau of the Census. National Healthcare Expenditures Data. Baltimore, MD: U.S. Department of Commerce and U.S. Bureau of the Census; 2012
    Google Scholar
  • 2 The Commonwealth Fund Commission on a High Performance Health System. The path to a high performance health system: a 2020 vision and the policies to pave the way. Available at: http://www.commonwealthfund.org . Accessed October 10, 2012
    PubMedGoogle Scholar
  • 3 Schilling PL, Dimick JB, Birkmeyer JD. Prioritizing quality improvement in general surgery. J Am Coll Surg 2008; 207: 698-704
    CrossrefPubMedGoogle Scholar
  • 4 Longo WE, Virgo KS, Johnson FE , et al. Risk factors for morbidity and mortality after colectomy for colon cancer. Dis Colon Rectum 2000; 43 (1) 83-91
    CrossrefPubMedGoogle Scholar
  • 5 Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011; 149 (6) 830-840
    CrossrefPubMedGoogle Scholar
  • 6 Kehlet H. Fast-track colorectal surgery. Lancet 2008; 371: 791-793
    CrossrefPubMedGoogle Scholar
  • 7 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78 (5) 606-617
    CrossrefPubMedGoogle Scholar
  • 8 Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 2008; 248 (2) 189-198
    CrossrefPubMedGoogle Scholar
  • 9 Lassen K, Soop M, Nygren J , et al; Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 2009; 144 (10) 961-969
    CrossrefPubMedGoogle Scholar
  • 10 Wind J, Polle SW, Fung Kon Jin PH , et al; Laparoscopy and/or Fast Track Multimodal Management Versus Standard Care (LAFA) Study Group; Enhanced Recovery after Surgery (ERAS) Group. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006; 93 (7) 800-809
    CrossrefPubMedGoogle Scholar
  • 11 Walter CJ, Collin J, Dumville JC, Drew PJ, Monson JR. Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Dis 2009; 11 (4) 344-353
    CrossrefPubMedGoogle Scholar
  • 12 Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2011; (2) CD007635
    PubMedGoogle Scholar
  • 13 Lv L, Shao YF, Zhou YB. The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Colorectal Dis 2012; 27 (12) 1549-1554
    CrossrefPubMedGoogle Scholar
  • 14 Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 2007; 245 (6) 867-872
    CrossrefPubMedGoogle Scholar
  • 15 Hjort Jakobsen D, Sonne E, Basse L, Bisgaard T, Kehlet H. Convalescence after colonic resection with fast-track versus conventional care. Scand J Surg 2004; 93 (1) 24-28
    PubMedGoogle Scholar
  • 16 Delaney CP, Kiran RP, Senagore AJ, Brady K, Fazio VW. Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery. Ann Surg 2003; 238 (1) 67-72
    CrossrefPubMedGoogle Scholar
  • 17 Basse L, Hjort Jakobsen D, Billesbølle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000; 232 (1) 51-57
    CrossrefPubMedGoogle Scholar
  • 18 Wind J, Hofland J, Preckel B, Hollmann MW, Bossuyt PM, Gouma DJ. Perioperative strategy in colonic surgery: LAparoscopy and or FAst Track Multimodal Management versus Standard Care (LAFA Trial). BMC Surg 2006; 6: 6
    CrossrefPubMedGoogle Scholar
  • 19 Keller D, Delaney CP. The role of enhanced recovery pathways in the setting of minimally invasive colorectal surgery. Seminars in Colorectal Surgery 2012; ; In press
    PubMedGoogle Scholar
  • 20 Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J 2010; 123 (1319) 61-70
    PubMedGoogle Scholar
  • 21 Stein SL, Delaney CP. Standardized fast track protocols or enhanced recovery pathways. In: Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD, , eds. The ASCRS Textbook of Colon and Rectal Surgery. 2nd ed. Heidelberg, Germany: Springer; 2011
    CrossrefGoogle Scholar
  • 22 Kehlet H, Büchler MW, Beart Jr RWJ, Billingham RP, Williamson R. Care after colonic operation—is it evidence-based? Results from a multinational survey in Europe and the United States. J Am Coll Surg 2006; 202 (1) 45-54
    CrossrefPubMedGoogle Scholar
  • 23 Slim K, Panis Y, Chipponi J ; Société Française de Chirurgie Digestive. Half of the current practice of gastrointestinal surgery is against the evidence: a survey of the French Society of Digestive Surgery. J Gastrointest Surg 2004; 8 (8) 1079-1082
    CrossrefPubMedGoogle Scholar
  • 24 Walter CJ, Smith A, Guillou P. Perceptions of the application of fast-track surgical principles by general surgeons. Ann R Coll Surg Engl 2006; 88 (2) 191-195
    CrossrefPubMedGoogle Scholar
  • 25 Lassen K, Hannemann P, Ljungqvist O , et al; Enhanced Recovery After Surgery Group. Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 2005; 330 (7505) 1420-1421
    CrossrefPubMedGoogle Scholar
  • 26 Delaney CP, Senagore AJ, Gerkin TM , et al. Association of surgical care practices with length of stay and use of clinical protocols after elective bowel resection: results of a national survey. Am J Surg 2010; 199 (3) 299-304 , discussion 304
    CrossrefPubMedGoogle Scholar
  • 27 Cabana MD, Rand CS, Powe NR , et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 (15) 1458-1465
    CrossrefPubMedGoogle Scholar
  • 28 Andersen J, Hjort-Jakobsen D, Christiansen PS, Kehlet H. Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery. Br J Surg 2007; 94 (7) 890-893
    CrossrefPubMedGoogle Scholar
  • 29 Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ 2001; 322 (7284) 473-476
    CrossrefPubMedGoogle Scholar
  • 30 Chestovich PJ, Lin AY, Yoo J. Fast-track pathways in colorectal surgery. Surg Clin North Am 2013; 93 (1) 21-32
    CrossrefPubMedGoogle Scholar
  • 31 Tonnesen H, Rosenberg J, Nielsen HJ , et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ 1999; 318 (7194) 1311-1316
    CrossrefPubMedGoogle Scholar
  • 32 Tønnesen H. Alcohol abuse and postoperative morbidity. Dan Med Bull 2003; 50 (2) 139-160
    PubMedGoogle Scholar
  • 33 Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011; 124 (2) 144-154 , e8
    CrossrefPubMedGoogle Scholar
  • 34 Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth 2012; 59 (3) 268-279
    CrossrefPubMedGoogle Scholar
  • 35 Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg 2012; 255 (6) 1069-1079
    CrossrefPubMedGoogle Scholar
  • 36 Fleisher LA, Beckman JA, Brown KA , et al; American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines; American Society of Echocardiography; American Society of Nuclear Cardiology; Heart Rhythm Society; Society of Cardiovascular Anesthesiologists; Society for Cardiovascular Angiography and Interventions; Society for Vascular Medicine; Society for Vascular Surgery. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009; 54 (22) e13-e118
    CrossrefPubMedGoogle Scholar
  • 37 Chopra V, Eagle KA. Perioperative mischief: the price of academic misconduct. Am J Med 2012; 125 (10) 953-955
    CrossrefPubMedGoogle Scholar
  • 38 Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. (Review) Cochrane Database Syst Rev 2011; (9) CD001544
    PubMedGoogle Scholar
  • 39 Zerey M, Hawver LM, Awad Z, Stefanidis D, Richardson W, Fanelli RD. Members of the SAGES Guidelines Committee. SAGES evidence-based guidelines for the laparoscopic resection of curable colon and rectal cancer. Surg Endosc 2013; 27 (1) 1-10
    PubMedGoogle Scholar
  • 40 Bessey PQ. Metabolic Response to Critical Illness. New York, NY: Scientific American Inc; 1995
    Google Scholar
  • 41 Minowada G, Welch WJ. Clinical implications of the stress response. J Clin Invest 1995; 95: 3-12
    CrossrefPubMedGoogle Scholar
  • 42 Desborough JP. The stress response to trauma and surgery. Br J Anaesth 2000; 85 (1) 109-117
    CrossrefPubMedGoogle Scholar
  • 43 Blackburn GL. Metabolic considerations in management of surgical patients. Surg Clin North Am 2011; 91 (3) 467-480
    CrossrefPubMedGoogle Scholar
  • 44 Kehlet H. Fast-track surgery-an update on physiological care principles to enhance recovery. Langenbecks Arch Surg 2011; 396 (5) 585-590
    CrossrefPubMedGoogle Scholar
  • 45 Kleinman W, Mikhail MS, Murray MJ. Spinal, epidural and caudal blocks. In: Clinical Anesthesiology. 4th ed. New York, NY: McGraw-Hill; 2005
    Google Scholar
  • 46 Wilmore DW. From Cuthbertson to fast-track surgery: 70 years of progress in reducing stress in surgical patients. Ann Surg 2002; 236 (5) 643-648
    CrossrefPubMedGoogle Scholar
  • 47 Senagore AJ, Delaney CP, Mekhail N, Dugan A, Fazio VW. Randomized clinical trial comparing epidural anaesthesia and patient-controlled analgesia after laparoscopic segmental colectomy. Br J Surg 2003; 90 (10) 1195-1199
    CrossrefPubMedGoogle Scholar
  • 48 Jørgensen H, Wetterslev J, Møiniche S, Dahl JB. Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev 2000; (4) CD001893
    PubMedGoogle Scholar
  • 49 Herroeder S, Pecher S, Schonherr ME , et al. Systemic lidocaine shortens length of hospital stay after colorectal surgery: a double-blinded, randomized, placebo-controlled trial. Ann Surg 2007; 246 (2) 192-200
    CrossrefPubMedGoogle Scholar
  • 50 Rafi AN. Abdominal field block: a new approach via the lumbar triangle. Anesthesia 2001; 56 (10) 1024-1026
    PubMedGoogle Scholar
  • 51 McDonnell JG, O'Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominus plane block after abdominal surgery: a prospective randomized controlled trial. Anesth Anal 2007; 104 (1) 193-197
    CrossrefPubMedGoogle Scholar
  • 52 Delaney CP, Marcello PW, Sonoda T, Wise P, Bauer J, Techner L. Gastrointestinal recovery after laparoscopic colectomy: results of a prospective, observational, multicenter study. Surg Endosc 2010; 24 (3) 653-661
    CrossrefPubMedGoogle Scholar
  • 53 Delaney CP, Chang E, Senagore AJ, Broder M. Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database. Ann Surg 2008; 247 (5) 819-824
    CrossrefPubMedGoogle Scholar
  • 54 Kuhry E, Schwenk WF, Gaupset R, Romild U, Bonjer HJ. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database Syst Rev 2008; (2) CD003432
    PubMedGoogle Scholar
  • 55 Schwenk WF, Haase O, Neudecker J, Müller JM. Short term benefits for laparoscopic colorectal resection. Cochrane Database Syst Rev 2005; (3) CD003145
    PubMedGoogle Scholar
  • 56 Senagore AJ, Delaney CP. A critical analysis of laparoscopic colectomy at a single institution: lessons learned after 1000 cases. Am J Surg 2006; 191 (3) 377-380
    CrossrefPubMedGoogle Scholar
  • 57 Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ. Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways. Am J Surg 2012; 203 (3) 353-355 , discussion 355–356
    CrossrefPubMedGoogle Scholar
  • 58 Delaney CP. Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery. Dis Colon Rectum 2008; 51 (2) 181-185
    CrossrefPubMedGoogle Scholar
  • 59 Poon JT, Fan JK, Lo OS, Law WL. Enhanced recovery program in laparoscopic colectomy for cancer. Int J Colorectal Dis 2011; 26 (1) 71-77
    CrossrefPubMedGoogle Scholar
  • 60 King PM, Blazeby JM, Ewings P , et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery program. Br J Surg 2006; 2006 (93) 300-308
    PubMedGoogle Scholar
  • 61 Reurings JC, Spanjersberg WR, Oostvogel HJ , et al. 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). BMC Surg 2010; 10: 18
    CrossrefPubMedGoogle Scholar
  • 62 Vlug MS, Wind J, Hollmann MW , et al; LAFA study group. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 2011; 254 (6) 868-875
    CrossrefPubMedGoogle Scholar
  • 63 Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA. Collaborative LAFA Study Group. Which fast track elements predict early recovery after colon cancer surgery?. Colorectal Dis 2012; 14 (8) 1001-1008
    CrossrefPubMedGoogle Scholar
  • 64 Kennedy RH, Francis A, Dutton S , et al. EnROL: a multicentre randomised trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme. BMC Cancer 2012; 12: 181
    CrossrefPubMedGoogle Scholar
  • 65 Trastulli S, Cirocchi R, Lisorti C , et al. Laparoscopic vs open resection for rectal cancer: a meta-analysis of randomized clinical trials. Colorectal Dis 2012; 14 (6) e297-e296
    CrossrefPubMedGoogle Scholar
  • 66 Nygren J, Thacker J, Carli F , et al. Guidelines for perioperative care in rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 2013; 37 (2) 285-305
    CrossrefPubMedGoogle Scholar
  • 67 Senagore AJ. Pathogenesis and clinical and economic consequences of postoperative ileus. Am J Health Syst Pharm 2007; 64 (20) (Suppl. 13) S3-S7
    PubMedGoogle Scholar
  • 68 Livingston EH, Passaro Jr EPJ. Postoperative ileus. Dig Dis Sci 1990; 35 (1) 121-132
    CrossrefPubMedGoogle Scholar
  • 69 Council PIM . Available at: www.clinicalwebcasts.com/PIMC.htm . Accessed October 10, 2012.
    PubMed
  • 70 Goldstein JL, Matuszewski KA, Delaney CP , et al. Inpatient economic burden of postoperative ileus associated with abdominal surgery in the United States. Pharmacy Therapeutics J 2007; 32 (2) 82-90
    PubMedGoogle Scholar
  • 71 Sinatra RS, Larach S, Ramamoorthy S. Surgeon's Guide to Postsurgical Pain Management: Colorectal and Abdominal Surgery. West Islip, NY: Professional Communications; 2012
    Google Scholar
  • 72 Kehlet H, Slim K. The future of fast-track surgery. Br J Surg 2012; 99 (8) 1025-1026
    CrossrefPubMedGoogle Scholar
  • 73 Bardram L, Funch-Jensen P, Kehlet H. Rapid rehabilitation in elderly patients after laparoscopic colonic resection. Br J Surg 2000; 81 (11) 1540-1545
    PubMedGoogle Scholar
  • 74 Basse L, Jakobsen DH, Bardram L , et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg 2005; 241 (3) 416-423
    CrossrefPubMedGoogle Scholar