Major surgery is usually followed by pain, stress-induced organ dysfunction, and catabolism. These sequelae increase the risk of cardiopulmonary, infectious, thromboembolic, and cognitive complications and functional impairment, prolong hospitalization, and require rehabilitation and readmission. The concept of “fast-track surgery” or “enhanced recovery programs” has evolved in response to the adverse effects of surgery and is based on a multimodal intervention encompassing all perioperative care principles. This concept has been tested across surgical specialties with major success; it has reduced organ dysfunction, medical morbidity, and the need for hospitalization and has achieved faster recovery.
Components of Evidence-Based Care
In the original colorectal fast-track studies, the components included thoracic epidural analgesia in open surgery, avoidance of nasogastric tubes, early feeding, avoidance of fluid overload, and early mobilization. Since then, the Enhanced Recovery After Surgery (ERAS) group has suggested 19 fast-track elements. Unfortunately, most of the available studies with the multicomponent program have not been able to repeat the early studies because of lack of sufficient compliance with the program. When discussing components of evidence-based care that are relevant to enhanced recovery, the focus should be on implementing the programs as originally described. However, many of the components from past ERAS programs obviously should be updated and optimized in future research.
Evidence for Improved Outcome
The benefits of ERAS have been consistently shown in colonic surgery, although much of the literature has failed to separate out colon from rectum surgery. Benefits have been fewer complications, less patient fatigue, shorter length of stay, and decreased costs. In fact, the magnitude of these benefits far surpasses any other intervention, including laparoscopic surgery. It is likely that the maximum benefit from ERAS will be seen when when laparoscopy and ERAS are combined. Some research has suggested that many of the benefits attributed to laparoscopic technique are in fact due to optimization and standardization of perioperative care.
A number of systematic reviews and meta-analyses have demonstrated the aforementioned benefits. However, the number of patients in randomized clinical trials has been relatively small because of the difficulties of blinding patients and staff. Thus much of the data has come from prospective case series and retrospective studies.
Nonetheless, complication rates of colonic surgery have been halved in some studies, and the length of stay has been decreased consistently by 2 days or more compared with conventional care. As would be expected, these results have been associated with decreased costs, although costs have been evaluated in only a few studies.
Criticism of ERAS programs suggests that early discharge might be associated with increased mortality and readmissions and that the burden of care has merely been shifted to the community. If anything, however, readmissions appear to be decreased, as are complications, especially cardiopulmonary complications. The issue of shifting of care into the community has not been answered definitively but has not been apparent in the literature.
Postoperative fatigue is an important part of the patient experience after colorectal surgery. Previous research has shown that this debilitating problem is an issue for up to 3 months after even uncomplicated colorectal surgery. When postoperative fatigue has been measured in ERAS programs, its duration appears to be decreased to 4 to 6 weeks, and in studies in which this has been measured directly against traditional care, these improvements have been confirmed.
The proposed ERAS programs for rectal surgery share some of the same problems as those discussed for colonic surgery. A recent meta-analysis examined the effect of ERAS care in 16 randomized trials, and within the component trials, 657 of the 2367 patients included (28%) had undergone resection for rectal disease. The overall conclusions were that an ERAS pathway reduced overall morbidity by about 40% and shortened hospital stay by about 2 days, without increasing the readmission rate. Although the patients with colonic and rectal disease were not analyzed separately, it seems extremely likely that the benefits are equally applicable.
Evidence also comes from “before and after” studies, which show a reduction of about 4 days in hospitalization and trends to decreased complications, as documented in larger trials. ERAS facilitates recovery to such an extent that failure to achieve milestones prompts an investigation. For instance, if patients who have undergone laparoscopic colonic or rectal resection with anastomosis to the rectum are not independently mobilizing and close to discharge at day 3 or 4, investigations to assess anastomotic integrity may be indicated.
Other Colorectal Procedures
Similar benefits to those seen in colorectal resection have been observed in patients who have undergone transabdominal rectopexy, ileostomy closure, and reversal of Hartmann and ileal pouch–anal anastomosis surgery. Most studies have been case series, however, and interest has focused on length of stay rather than on reduction of complications.