Enhanced recovery after surgery vs conventional care in emergency colorectal surgery

Table 1 Summary of enhanced recovery after surgery programme and comparison with conventional care pathway

Primary component	ERAS programme	Conventional care pathway
Before surgery	Detailed information and education, including breathing exercise, mobilisation, dietary goal, and estimated length of hospital stay	Advice given by an on-call consultant surgeon
During surgery	Standard anaesthetic protocol (balanced general anaesthesia) and surgical management	Standard anaesthetic protocol (balanced general anaesthesia) and surgical management
	Transverse abdominal incision for right-sided colon cancer surgery	Midline incision with the application of Balfour self-retaining retractor
	Manual colonic decompression prior to primary anastomosis in obstructing left-sided colorectal cancer	Intra-abdominal or pelvic drainage at the surgeon’s discretion
	No intra-abdominal or pelvic drainage	No standard protocol for prophylaxis of PONV
	Application of O-ring wound retractor (Alexis® Retractor)
	Active warming (warm intravenous fluid, Bair Hugger®, warm saline-soaked swab around the intestine)
	Infiltration of 0.5% bupivacaine into fascial layer and skin before wound closure
	Prophylaxis of PONV based on risk factors
After surgery	Fluid therapy to keep a urine output of 0.5-1 mL/kg per hour, with deliberate administration of colloid solution if needed	Care decided by consultant surgeon
	Early removal of NGT at 24-48 h postoperatively unless there was > 400 mL drainage in a 24-h period	Crystalloid fluid replacement
	Early ingestion of oral intake after NGT removal	NPO until patients passed flatus, had an active bowel sound and NGT content < 400 mL/d
	Multimodal analgesia with the preferential use of selective cyclo-oxygenese 2 inhibitors	Intravenous opioids as a primary modality for postoperative analgesia
	Scheduled removal of urinary catheter at 48-72 h postoperatively in a stable patient
	Regular mobilisation with daily physiotherapy
	Aim to discharge on postoperative d5
After discharge	Telephone call 3 d and 1 wk after discharge	2 wk and 30 d follow-up in clinic
	2 wk and 30 d follow-up in clinic

ERAS: Enhanced recovery after surgery; NGT: Nasogastric tube; NPO: Nil per os; PONV: Postoperative nausea and vomiting.

Table 2 Patient characteristics and operative details n (%)

	ERAS group (n = 20)	Non-ERAS group (n = 40)	P value
Age (yr)	57.6 ± 13.2	62.0 ± 13.2	0.22
Male	14 (70)	24 (60)	0.45
BMI (kg/m2)	21.7 ± 3.3	22.8 ± 3.4	0.22
ASA grade ≥ 3	4 (20)	4 (10)	0.42
CR-POSSUM predicted mortality rate	3.34 ± 2.83	3.56 ± 2.47	0.76
Preoperative haematocrit (%)	36.1 ± 6.4	36.1 ± 5.8	0.98
Preoperative serum albumin (g/dL)	3.6 ± 0.6	3.7 ± 0.6	0.63
Duration of obstruction (d)	3.5 ± 1.6	3.3 ± 1.6	0.69
Left-sided colonic obstruction1	10 (50)	21 (53)	0.71
Obstructing rectal cancer2	2 (10)	5 (13)	1.00
Detailed procedure type			0.93
(Extended) right hemicolectomy	10 (50)	19 (48)
Left hemicolectomy/sigmoidectomy	3 (15)	5 (13)
Hartmann’s procedure	4 (20)	7 (18)
Anterior resection	2 (10)	4 (10)
Subtotal colectomy	1 (5)	5 (13)
Tumor removal with primary anastomosis	16 (80)	33 (83)	1.00
Multi-visceral organ resection	3 (15)	5 (13)	1.00
Operative time (min)	216 ± 85	190 ± 59	0.17
Estimated blood loss (mL)	233 ± 200	192 ± 166	0.42
Maximal tumour size (cm)	6.3 ± 2.5	5.6 ± 2.2	0.34
Pathological staging 3 or 4	14 (70)	26 (65)	0.70

¹Left-sided colonic obstruction is defined as an obstruction caused by tumor distal to the splenic flexure (including rectal cancer);

²Rectal cancer is defined as a cancer located within 12 cm of the anal verge. ASA: American Society of Anesthesiologists; BMI: Body mass index; CR-POSSUM: ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity; ERAS: Enhanced recovery after surgery.

Table 3 Surgical outcomes n (%)

	ERAS group(n = 20)	Non-ERAS group(n = 40)	P value
Median length of hospital stay (d)	5.5 (3-16)	7.5 (5-25)	0.009
Average length of hospital stay (d)	6.0 ± 2.9	9.4 ± 5.1	0.002
Overall complications	5 (25)	19 (48)	0.090
Complications excluding Grade I1	2 (10)	8 (20)	0.470
Time to first flatus (d)	1.6 ± 0.7	2.8 ± 1.3	< 0.001
Time to first defaecation (d)	3.4 ± 1.2	3.7 ± 1.4	0.430
Time to resumption of normal diet (d)	3.4 ± 1.7	5.5 ± 2.4	0.002
Unplanned 30-d readmission	0	0	NA
Patients receiving adjuvant chemotherapy	16 (80)	27 (68)	0.380
Interval between operation and initiation of adjuvant chemotherapy (d)	37.0 ± 8.9	49.4 ± 20.4	0.009

¹According to the Clavien-Dindo classification of surgical complication. ERAS: Enhanced recovery after surgery; NA: Not applicable.