Elsevier

Clinical Nutrition

Volume 24, Issue 3, June 2005, Pages 466-477
Clinical Nutrition

SPECIAL ARTICLE
Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection

https://doi.org/10.1016/j.clnu.2005.02.002Get rights and content

Summary

Background & Aims

Clinical care of patients undergoing colonic surgery differs between hospitals and countries. In addition, there is considerable variation in rates of recovery and length of hospital stay following major abdominal surgery. There is a need to develop a consensus on key elements of perioperative care for inclusion in enhanced recovery programmes so that these can be widely adopted and refined further in future clinical trials.

Methods

Medline database was searched for all clinical studies/trials relating to enhanced recovery after colorectal resection. Relevant papers from the reference lists of these articles and from the authors’ personal collections were also reviewed. A combination of evidence-based and consensus methodology was used to develop the resulting enhanced recovery after surgery (ERAS) clinical care protocol.

Results and Conclusions

Within traditional perioperative practice there is considerable evidence supporting a range of manoeuvres which, in isolation, may improve individual aspects of recovery after colonic surgery. The present manuscript reviews these issues in detail. There is also growing evidence that an integrated multimodal approach to perioperative care can result in an overall enhancement of recovery. However, effects on major morbidity and mortality remain to be determined. A protocol is presented which is in current use by the ERAS Group and may provide a standard of care against which either current or future novel elements of an enhanced recovery approach can be tested for their effect on outcome.

Introduction

The key factors that keep a patient in hospital after uncomplicated major abdominal surgery include the need for parenteral analgesia (persistent pain), intravenous fluids (persistent gut dysfunction), and bed rest (persistent lack of mobility). These factors often overlap and interact to delay return of function. Obviously, postoperative complications will also prolong the time until recovery and ultimately length of stay. Interestingly, recent findings suggest that the rate of complications can be unaltered or even reduced when actions are taken that support faster return of normal function.1 A clinical pathway to accelerate recovery after colonic resection based on a multimodal programme with optimal pain relief, stress reduction with regional anaesthesia, early enteral nutrition and early mobilisation has demonstrated improvements in physical performance, pulmonary function, body composition and a marked reduction of length of stay.2, 3, 4 A subsequent randomised trial using a similar protocol has demonstrated a significant reduction in median length of stay from 7 to 3 days.5 However, different surgical groups proclaim wide variation in the nature of their optimal ‘fast-track’ or enhanced recovery programmes. For example, apparently similar outcomes can be achieved with3, 4, 5 or without epidural anaesthesia/analgesia.6 This suggests that it is the combination of each of the different elements of an enhanced recovery programme that goes to make an effective regimen rather than any single element on its own. At present, the evidence on which to base a multimodal programme is taken in isolation from traditional care pathways and little evidence is available concerning the importance of each element when considered within the context of an enhanced recovery pathway. The aim of this review is to consider the evidence-base for individual components of enhanced recovery programmes and to present the consensus of the The European Society of Clinical Nutrition and Metabolism (ESPEN) special interest group on management of patients undergoing such a programme (Fig. 1). The content of the consensus protocol refers to colonic surgery, but similar protocols have and can be developed for other surgical procedures.

Section snippets

Methods

The ERAS group was established in 2001 as a collaborative of five university or specialised Departments of Surgery from five Northern European Countries (Scotland, Sweden, Denmark, Norway and The Netherlands). Using the Medline database, an electronic search on ‘fast-track’ or ‘multimodal’ recovery was undertaken. Relevant papers from the reference lists of these articles and from group members’ personal collections were also reviewed. The committee met on several occasions to reach a consensus

Principles of the ERAS protocol

Conventional perioperative metabolic care has accepted that a stress response to major surgery is inevitable. This concept has recently been challenged with the view that a substantial element of the stress response can be avoided with the appropriate application of modern anaesthetic, analgesic and metabolic support techniques. Conventional postoperative care has also emphasised prolonged rest for both the patient and their gastrointestinal tract. Similarly, this concept has recently been

Acknowledgement

The ERAS group would like to thank Nutricia Healthcare for their generous financial support via an unrestricted grant.

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