Enhanced recovery after surgery

From Cancer Guidelines Wiki


Enhanced recovery after surgery (ERAS) (fast-track) programs are comprehensive multimodal perioperative pathways, which aim to reduce surgical stress, maintain postoperative physiological function, and enhance mobilisation after surgery.[1][2]

Overview of evidence (non-systematic literature review)

No systematic reviews were undertaken for this topic. Practice points were based on selected published evidence. See Guidelines development process.

ERAS programs have multiple components, which vary between programs. Broadly these include:[1][2]

  • preoperative education and counselling
  • preoperative optimisation
  • perioperative nutritional supplements
  • antimicrobial and prophylaxis
  • venous thromboembolism prophylaxis
  • multimodal antiemetics and analgesia
  • avoidance of bowel preparation, nasogastric tubes and drains.

ERAS has resulted in reduced morbidity, faster recovery and shorter length of stay in series from dedicated centres.[3][4][5][6]

A meta-analysis of six randomised controlled trials (RCTs) on ERAS compared with standard care in patients undergoing open colorectal surgery has demonstrated that length of stay is reduced and postoperative morbidity almost halved.[7][8][9] The benefits of ERAS programs are still demonstrated in laparoscopic surgery as in open surgery, with a recent systematic review and meta-analysis of three RCTs[10][11][12] and six nonrandomised and observational studies and six clinical trials[13][14][15][16][17][18] showing reduced morbidity and particularly reduced length of stay with the addition of ERAS to minimally invasive surgery.[19]

Successful ERAS programs appear to have multiple components, but need to be multidisciplinary, have ongoing education, regular audit, and be adequately resourced.[20]
Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Patients having elective surgery for colorectal cancer should be managed within an appropriately resourced enhanced recovery after surgery (ERAS) program.

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  1. 1.01.1 Gustafsson UO, Tiefenthal M, Thorell A, Ljungqvist O, Nygrens J. Laparoscopic-assisted and open high anterior resection within an ERAS protocol. World J Surg 2012 May;36(5):1154-61 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22395344.
  2. 2.02.1 Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012 Dec;31(6):801-16 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23062720.
  3. Basse L, Hjort Jakobsen D, Billesbølle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000 Jul;232(1):51-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10862195.
  4. Basse L, Raskov HH, Hjort Jakobsen D, Sonne E, Billesbølle P, Hendel HW, et al. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 2002 Apr;89(4):446-53 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/11952586.
  5. Wind J, Hofland J, Preckel B, Hollmann MW, Bossuyt PM, Gouma DJ, et al. Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial). BMC Surg 2006 Nov 29;6:16 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17134506.
  6. 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 Jun;245(6):867-72 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17522511.
  7. Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010 Aug;29(4):434-40 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20116145.
  8. Serclová Z, Dytrych P, Marvan J, Nová K, Hankeová Z, Ryska O, et al. Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Clin Nutr 2009 Dec;28(6):618-24 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19535182.
  9. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N, Zurich Fast Track Study Group.. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009 Mar;136(3):842-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19135997.
  10. Basse L, Jakobsen DH, Bardram L, Billesbølle P, Lund C, Mogensen T, et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg 2005 Mar;241(3):416-23 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15729063.
  11. King PM, Blazeby JM, Ewings P, Franks PJ, Longman RJ, Kendrick AH, et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 2006 Mar;93(3):300-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16363014.
  12. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, et al. 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 Dec;254(6):868-75 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21597360.
  13. Al Chalabi H, Kavanagh DO, Hassan L, Donnell KO, Nugent E, Andrews E, et al. The benefit of an enhanced recovery programme following elective laparoscopic sigmoid colectomy. Int J ColorectalReferring to the large bowel, comprising the colon and rectum. Dis 2010 Jun;25(6):761-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20177688.
  14. Junghans T, Raue W, Haase O, Neudecker J, Schwenk W. [Value of laparoscopic surgery in elective colorectal surgery with "fast-track"-rehabilitation]. Zentralbl Chir 2006 Aug;131(4):298-303 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17004188.
  15. Lloyd GM, Kirby R, Hemingway DM, Keane FB, Miller AS, Neary P. The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections. Surg Endosc 2010 Jun;24(6):1434-9 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20035353.
  16. MacKay G, Ihedioha U, McConnachie A, Serpell M, Molloy RG, O'Dwyer PJ. Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery. ColorectalReferring to the large bowel, comprising the colon and rectum. Dis 2007 May;9(4):368-72 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17432992.
  17. Raue W, Haase O, Junghans T, Scharfenberg M, Müller JM, Schwenk W. 'Fast-track' multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation. Surg Endosc 2004 Oct;18(10):1463-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15791370.
  18. Reurings JC, Spanjersberg WR, Oostvogel HJ, Buskens E, Maring J, Kruijt F, 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 Jun 14;10:18 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20546569.
  19. Spanjersberg WR, van Sambeeck JD, Bremers A, Rosman C, van Laarhoven CJ. Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme. Surg Endosc 2015 Dec;29(12):3443-53 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25801106.
  20. Pearsall EA, Meghji Z, Pitzul KB, Aarts MA, McKenzie M, McLeod RS, et al. A qualitative study to understand the barriers and enablers in implementing an enhanced recovery after surgery program. Ann Surg 2015 Jan;261(1):92-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24646564.
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