Enhanced Recovery in Colorectal Surgery: Are we Going Forward or Backward?_ Crimson Publishers

 Enhanced Recovery in Colorectal Surgery: Are we Going Forward or Backward? by Jayesh Sagar* in Surgical Medicine Open Access Journal_ Surgical Medicine Open Access Journal

 

Abstract
Enhanced Recovery (ERAS) in Colorectal Surgery is a relatively novel concept in patient care. It involves a multidisciplinary team approach (surgeons, anesthetists, ERAS nurse, nutritionist, physiotherapist, pain team, hospital administration and patient motivation) comprising of certain key aspects in the pre, intra and post-operative settings. The whole objective of ERAS pathway is to reduce the physiological trauma to the patient and optimize organ functions, thus leading to reduced pain, post-operative complications, faster patient recovery, improvement in overall outcome, shorter hospital stays and thus, accounting for decreased health-care costs. However, there is still a need for more patient-specific, better designed large-scale, multi-centre randomized trials to study long-term impact of ERAS. A valid primary research question still remains to be answered-whether it is reasonable to apply one standard fixed protocol to everyone or modify the ERAS care to an individual patient considering various other parameters such as patient characteristics and physiology, pre-existing co-morbidities, indication & type of surgery (emergency/ elective) and compliance factors. Our aim is to highlight the importance of formulating a personalized ERAS program for certain high-risk patients, rather than adopting one rigid protocol for everyone.

Introduction
Enhanced recovery After Surgery (ERAS) or “fast track surgery” protocol was first proposed by Henrik [1], Danish Professor of surgery in 1997 and was later developed further by the ERAS working group [2]. Professors Kenneth Fearon and Olle Ljungqvist added postulates to the ERAS protocol, developing the ERAS study group in 2001 and subsequent formation of the ERAS Society in 2010. The intention was to facilitate efficient and safe patient progress from admission to discharge and early rehabilitation. In 2010, ERAS Society was established, with the idea of creating international network of regional and national expert centers that encouraged ERAS protocol utilization. ERAS is based on accelerating early patient recovery following any major surgery, by decreasing the surgical trauma and the inherent body’s stress response, thereby preserving individual’s physiology and organ functions. It consists of 17 key components, ranging from pre-operative education, counselling and nutrition, perioperative measures including fluid optimization, active warming, oxygen administration, to postoperative early enteral nutrition, early ambulation and opioid sparing analgesia. All elements are devised based on high quality evidence.

Two studies analysed the feasibility and relationship between ERAS protocol adherence and clinical outcomes in laparoscopic colorectal surgery and found that, at least 30 patients are required for a period of about 6 months, to achieve a compliance rate of 80% [3,4]. They concluded that complete implementation of ERAS protocol decreases complications, re-admissions, Length of Hospital Stay (LOS) and morbidity rate. Overall, it has a positive impact on specific convalescence parameters, with significant improvement in short term outcomes. One systemic meta-analysis investigated the synergistic effect of ERAS with laparoscopy in colorectal surgery. It reported reduction in major morbidity and hospital stay in group who underwent laparoscopic procedure combined with ERAS compared to open procedure combined with ERAS. However, they concluded that the reduction was due to laparoscopic approach rather than ERAS. There was also no difference in complications between conventional care and ERAS in the laparoscopic group. These findings question the real advantage of ERAS.

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