Enhanced recovery for colorectal surgery: Practical hints, results and future challenges

Table 1 Types of enhanced recovery after surgery protocols adopted

Ref.	Preoperative	Intraoperative	Postop (first 24 h)	Day 1	Day 2	Day 3	Day 4	Additional comments
Kahokehr et al[8,9]	Nutritional supplementation	Thoracic epidural	All IV fluid stopped	Removal of urinary catheter	Removal of epidural			Early mobilization and physiotherapy
	NBM two hours preinduction	Short acting anaesthetics	Prophylactic antiemetics
	Carbohydrate loading	Intraoperative fluids: 1000 mL of crystalloid and 500 mL of colloid	Early oral feeding
	No bowel preparation	Prophylactic antiemetics at induction (Dexamethasone)	Nutritional supplementation
	Functional assessment and goal setting	No drains or NG tubes	No opioids
King et al[12-14]	Nutrition supplementation	Thoracic epidural	Free fluid	All IV fluid stopped	Removal of epidural Regular NSAIDS	Removal of urinary catheter for rectal resections		Aim for discharge on day 3 for colonic or day 5 for rectal resection
Blazeby et al[15]	Optimised pre-morbid health status	Intraoperative fluids: 2000 mL of crystalloid	Nutritional supplementation	Regular paracetamol	Morphine for breakthrough			Provision of hospital contact numbers, review on ward if problems within 2 wk
Faiz et al[16]	Functional assessment and goal setting	Minimal-access surgery	Patient sat out in chair	3 high-protein/high-calorie drink				Review in outpatient clinic on day 12
	Stoma nurse	Local anaesthetic infiltration to the largest wound		Normal diet offered
	Bowel preparation in left-sided resections	No drains or NG tubes		Patient sat out in chair
				Start walking
				Removal of urinary catheter for colonic resections
				Laxatives
Jottard et al[7]	Nutrition supplementation	Thoracic epidural	Free fluid	All IV fluid stopped				Use of anti-emetics
	Functional assessment and goal setting	Standard anesthetic protocol		Normal diet offered				Early mobilization
	No bowel preparation	Prevention of intraoperative hypothermia						Postoperative nutritional care
		No drains or NG tubes
Maessen et al[20,21]	Nutrition supplementation1	Thoracic epidural	Oral analgesia	All IV fluid stopped	Removal of epidural Removal of urinary catheter
Nygren et al[22]	Functional assessment and goal setting	Prevention of intraoperative hypothermia	Patient sat out in chair	Nutritional supplements > 400 mL
Hendry et al[23]	No bowel preparation	Transverse/curved incision	Nutritional supplements	Normal diet offered
			Free fluid > 800 mL	Patient sat out in chair
Soop et al[26]	Nutrition supplementation	Thoracic epidural	Prophylactic antiemetics	Regular paracetamol and NSAIDS	Patient sat out in chair	Patient sat out in chair	Epidural removed (at least)
				Patient sat out in chair
Raymond et al[28]	Nutrition supplementation Functional assessment and goal setting	Thoracic epidural						Early mobilization/resumption of diet
		Intra-operative targeted fluid management
		No NG tube
Turunen et al[10]	Functional assessment and goal setting	Thoracic epidural		Removal of urinary catheter				Early mobilization/resumption of diet
	Preoperative feeding	High-oxygen P						No routine opioids, regular paracetamol and NSAIDS
	Bowel preparation	Prevention of hypothermia						Fluid restriction
		No drains or NG tubes
Senagore et al[35]		No NG tube	PCA	Removal of urinary catheter
			Free fluids	Normal diet offered
				regular NSAIDs, gabapentin, hydroxycodone if needed
				No drains
Wennstrom et al[11]	Functional assessment and goal setting	Thoracic epidural	Free fluid		Epidural removed
	No bowel preparation	Short acting anaesthetics	Patient sat out in chair		Urinary catheter removal
	Preoperative oral hydration	No opioids
Mohn et al[18]	Nutrition supplementation	Thoracic epidural	Patient sat out in chair	Removal of urinary catheter Patient sat out in chair	Epidural removed			Regular laxatives twice daily
	Functional assessment and goal setting	Total intravenous anaesthesia		Normal diet offered
	Bowel preparation	Intra-operative targeted fluid management		Regular paracetamol and NSAIDs, opioids for breakthrough				Restricted postoperative intravenous fluids
		Prophylactic antiemetics
		Short midline incisions
		No drains or NG tubes
Teeuwen et al[17]	Nutrition supplementation	Thoracic epidural	Free fluids	Normal diet offered	Epidural removed
	Bowel preparation in left-sided resections	Transverse incisions except in Crohn's disease and rectal surgery	Nutritional supplements	Intravenous fluid administration	Urinary catheter removal
		Intra-operative targeted fluid management (hypotension treated with vasopressors)	Patient sat out in chair	Start walking	Regular Paracetamol NSAIDs, opioids for breakthrough
		Prophylactic antiemetics
		No drains or NG tubes
Ahmed et al[24,25]	Nutrition supplementation	High inspired oxygen	Free fluids	Start walking				Regular paracetamol NSAIDs, opioids for breakthrough
	Functional assessment and goal setting	Concentration	Soft diet offered
	No bowel preparation	Transverse incisions	Patient sat out in chair
		No drains or NG tubes
Kirdak et al[19]	Nutrition supplementation	Thoracic epidural	Start walking	NG tubes and urinary catheters removed (except pelvic dissection)	Removal urinary catheter (low pelvic operations) and drains	Epidural removed
	Bowel preparation	Pelvic drains with rectal dissections		Soft diet offered		Regular paracetamol
		Urinary, central venous, and nasogastric catheters were routinely used		Patient sat out in chair		Central venous catheters removed
				Start walking		Normal diet

¹These authors followed Kearon for the nutritional supplementation. NBM: Nihil by mouth; NG: Nasogastric; IV: Intravenous; NSAIDs: Non-steroidal antinflammatory drugs; PCA: Patient-controlled analgesia.