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GI surgeon societies release guidelines for enhanced recovery after colon, rectal surgery
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The American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons have jointly issued clinical practice guidelines for enhanced recovery after colon and rectal surgery.
Also known as fast-track protocols, enhanced recovery after surgery (ERAS) protocols have been used for years in Europe and more recently in the U.S. It “is the principle whereby the patient is actually ‘in the driver’s seat,’ so to speak, and participates and improves the quality of their own care,” Scott R. Steele, MD, FACS, FASCRS, coeditor of Diseases of the Colon and Rectum, chair of the ASCRS Clinical Practice Guidelines Committee, chair of the department of colorectal surgery at the Cleveland Clinic, and professor of surgery at Case Western Reserve University School of Medicine, said in a statement to the media. “This ‘pathway’ involves everyone from doctors and nurses to physical therapists and dieticians,” and spans the preoperative period through aftercare, he added. “There are now numerous studies showing that this type of care results in a more rapid recovery, shorter hospital stay, fewer side effects due to drugs, and fewer postoperative complications for the patient.”
In contrast, standard colorectal surgery can be associated with long hospital stays (open surgery, 8 days; laparoscopic surgery, 5 days), high costs, a nearly 20% rate of surgical site infection, up to an 80% incidence of perioperative nausea and vomiting, and up to a 35.4% readmission rate, the committee wrote.
To develop the guideline, members from the two societies reviewed available literature on ERAS published up to 2016, and ultimately reviewed 764 studies to inform their recommendations on preoperative, perioperative and postoperative interventions.
Preoperative recommendations
The committee made strong recommendations about preoperative patient education, including preadmission counseling to discuss “milestones and discharge criteria” with patients before surgery, and preoperative ileostomy education, marking, and counseling on avoiding dehydration.
They also included statements on preadmission nutrition and bowel preparation, including a strong recommendation that it is safe and beneficial for patients to continue a clear liquid diet for at least 2 hours before general anesthesia. Further, they noted that moderate-quality evidence supports preoperative carbohydrate loading in nondiabetic patients for “attenuate[ing] insulin resistance induced by surgery and starvation,” and that mechanical bowel preparation plus oral antibiotic bowel preparation may reduce complication rates.
Finally, they noted that moderate-quality evidence supports “prehabilitation,” or “enhancement of the preoperative condition” for patients with multiple comorbidities or significant deconditioning.
Perioperative recommendations
Guidelines for the perioperative period included recommendations for preventing surgical site infections, managing pain, nausea and vomiting, and intraoperative fluids, and the approach to surgery.
For reducing surgical site infections, the committee strongly recommended the use of preventive care bundles that include preoperative, intraoperative and postoperative measures.
For pain management, they strongly recommended implementing a multimodal pain management plan using alternatives to opioids before anesthesia. Additionally, they strongly recommended thoracic epidural analgesia for open but not laparoscopic colorectal surgery, citing evidence that its “modest analgesic benefits ... do not support a faster recovery” in the latter.
For preventing perioperative nausea and vomiting, they strongly recommended that patients be screened for risk factors to guide the use of prophylactic antiemetics, and that all at-risk patients should preemptively receive multimodal antiemetics.
They made several strong recommendations for intraoperative fluid management, including the use of tailored crystalloid infusion maintenance for avoiding excess fluid administration and volume overload; the use of balanced chloride-restricted crystalloid solutions as maintenance infusion in colorectal surgery; and the use of goal-directed fluid therapy in high-risk patients and those undergoing major colorectal surgery.
They also made two strong recommendations regarding surgical approach: that a minimally invasive approach be used in appropriate cases whenever a properly trained expert is available, and that intra-abdominal drains and nasogastric tubes should not be routinely used in colorectal surgery.
Postoperative recommendations
Finally, the committee made several strong recommendations for improving postoperative outcomes, including patient mobilization, preventing postoperative ileus, managing fluids after surgery and the use of urinary catheters.
They wrote that early and progressive patient mobilization is linked to shorter hospital stays, and that patients in enhanced recovery programs achieve mobilization targets sooner.
For ileus prevention, they recommended patients undergoing elective colorectal surgery should be offered a regular diet immediately after surgery; that sham feeding (with chewing gum, for example) is safe and beneficial after colorectal surgery; and that alvimopan can reduce recovery time after open colorectal surgery.
They also recommended early discontinuation of IV fluids, and early removal of urinary catheters (within 24 hours for elective colonic or upper rectal resection without vesicular fistula, and within 48 hours for midrectal or lower rectal resections.
In his statement to the media, Steele summarized the principle behind ERAS as the “avoidance of large amounts of narcotic pain medication after surgery, which paralyzes the bowel and delays recovery, minimizing the use of intravenous fluids in the postoperative period, early and frequent activity out of bed for the patient starting very soon after surgery, and early resumption of an oral diet.” He added that he and his fellow committee members “are excited to share this combined effort ... in an opportunity to help accomplish what we all desire — better outcomes for our patients.” – by Adam Leitenberger
Disclosures: The researchers report that the ASCRS and SAGES, which funded the development of the guidelines, did not influence their content. Steele reports no relevant financial disclosures. Please see the full guideline for a list of all committee members’ relevant financial disclosures.
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