The definition of an enhanced recovery pathway for colon and rectal surgery was established by the Consensus Review of Optimal Perioperative Care in Colorectal Surgery Group in 2009. This was a succinct and easily adaptable list which describes the 20 aspects of the enhanced recovery protocol [2]. Our focus was whether adding an enhanced recovery/fast track pathway to patients undergoing laparoscopic techniques add any benefits when compared to those undergoing laparoscopy in the absence of a fast track pathway (Table 42.3).

It is well known that using a laparoscopic approach for colorectal surgery is associated with shorter hospital stays, decreased postoperative complications, and decreased pain when compared to open surgery [9–12]. It is also well established that adding an enhanced recovery protocol to open colorectal surgery results in better patient outcomes. In theory, the addition of an enhanced recovery protocol should produce better outcomes for laparoscopic surgery as well; however, the lack of tier 1 randomized controlled trials makes this presumption difficult to definitively prove. In reality, most studies are retrospective reviews, underpowered, or lack an appropriate number of fast track elements.

However, Zhao et al. attempted to strengthen the literature by combining the data with a meta-analysis in August of 2014 [6].The authors were able to identify and deem eligible five randomized controlled trials and five clinical controlled trials for a total of 1,317 patients. The patients all underwent laparoscopic colorectal surgery, with 696 participating in an enhanced recovery protocol and 621 patients undergoing traditional care. Importantly, all patients underwent a minimally invasive approach. In addition, all studies within the meta-analysis were determined to range in quality from moderate to high. Primary hospital stay (−1.64 days; 95 % CI, −2.25 to−1.03; p < 0.001), time to first flatus (−0.40 day; 95 % CI, −0.77 to−0.04; p = 0.03), time to first bowel movement (−0.98 day; 95 % CI, −1.45 to−0.52; p < 0.001), and complication rate (RR, 0.67; 95 % CI, 0.56–0.80; p < 0.001) were all improved when an enhanced recovery program was applied in addition to the laparoscopic technique. Readmission rate and 30-day mortality were found to be non-significant, which has been consistent with other studies comparing enhanced recovery protocols within colorectal surgery. Another interesting aspect of this meta-analysis was that complication rates were found to be significantly reduced–a finding in which no other meta-analysis had identified before. The authors ultimately concluded that not only can an enhanced recovery protocol be combined with laparoscopic colorectal surgery to decrease primary hospital stay, increase time to first flatus and bowel movements, but also that using laparoscopy within these protocols may actually increase patient safety when compared to traditional perioperative colorectal care.

When looking at some of the existing primary data, a study by Vlug and colleagues provides a closer comparative evaluation. Vlug and associates provided one of the first studies looking specifically at laparoscopy versus open techniques within enhanced recovery protocols in the 2011 entitled LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial) [13]. The authors stratified 400 patients into 4 treatment groups: laparoscopic/fast track, open/fast track, laparoscopic/standard, and open/standard with the primary goal to find a minimum difference of 1 day in hospital stay [13]. They showed a total hospital stay of 5 days in the laparoscopic/fast tract group versus 7 days for the open/fast track group (p < 0.001), concluding that optimal perioperative treatment includes a laparoscopic resection within an enhanced recovery protocol [13]. On regression analysis, laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity [13]. When specifically comparing laparoscopic with fast track, versus laparoscopic with standard perioperative care, the median hospital stay was lower in the fast track cohort at 5 days (interquartile range: 4–8) versus 6 days (range: 4.5–9.5). However, secondary outcomes including postoperative hospital stay, morbidity, reoperation, readmission, in-hospital mortality, and quality of life did not differ significantly amongst the groups.