This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol. A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

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Guidelines for perioperative care in elective colonic surgery: Enhanced recovery after surgery (ERAS®) society recommendations

Background:Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.Objective:To assess, synthesize, and discuss implementation of “fast-track” recovery programs.Data Sources:Medline MBASE (Janua

Evidence-based surgical care and the evolution of fast-track surgery.

Enhanced recovery after surgery

reatment of postoperative pain is provided for humanitarian reasons and to alleviate nocicepT tion-induced responses, such as the endocrine metabolic response to surgery, autonomic reflexes with adverse effects on organ function, reflexes leading to muscle spasm, and other undesirable results (1). During the last decade there has been a virtual explosion in our knowledge of basic pain physiology (2,3), but the implications for clinical practice have been less substantial. The explanation for the discrepancy between the fast progress in basic pain pathophysiology and the rather slow advances in providing optimal postoperative pain treatment may be several, but one important factor may be that more than 95% of the literature on postoperative pain treatment has considered unimodal treatment. We have emphasized previously that total or optimal pain relief allowing normal function can not be achieved by a single drug or method without major strain on equipment and surveillance systems or without significant side effects (4). Therefore, we have recommended combined analgesic regimens (balanced analgesia) or a multimodal approach to the treatment of postoperative pain (4). The rationale for this strategy is achievement of sufficient analgesia due to additive or synergistic effects between different analgesics, with concomitant reduction of side effects, due to resulting lower doses of analgesics and differences in side-effect profiles. We summarize here the existing knowledge concerning the efficacy of analgesic combination therapy from postoperative pain studies. The effects on postoperative outcome are not included, because of lack of sufficient studies. We also exclude obstetric and pediatric pain, which may represent special pain entities and solutions for treatment, although they obviously share many of the problems of general postoperative pain. Primary emphasis will be placed on moderate and severe pain and the use of and need for

The value of "multimodal" or "balanced analgesia" in postoperative pain treatment.

BACKGROUND: The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH). OBJECTIVES: To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS: We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS: At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS: We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies. AUTHORS' CONCLUSIONS: Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.

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Surgical approach to hysterectomy for benign gynaecological disease.

Open colonic resection is usually associated with a hospital stay of about 6 to 11 days and a complication rate of 15% to 20%.1–6 Introduction of laparoscopic-assisted colonic resection has reduced the hospital stay to about 4 to 8 days, with the same or a slightly lower morbidity rate in randomized trials.1–6 Concomitant with these technical developments, an increased body of evidence has been developed to demonstrate that perioperative care regimens, including optimized pain relief, early oral feeding, and mobilization, have profound effects to improve postoperative recovery and outcome.7,8 These so-called multimodal rehabilitation programs or fast-track surgery7,8 have been applied after laparoscopic9,10 and open11 colonic resection, resulting in reduced hospital stay to about 2 to 3 days. Unfortunately, assessment of laparoscopic versus open colonic resection on early postoperative outcome in randomized studies1–6 has not included a revision of postoperative care principles adjusted to recent scientific data,7,8 and therefore the difference between laparoscopic and open colonic resection on early postoperative recovery remains to be determined. Such studies require an optimized regimen and observer-blinded regimen to minimize treatment bias due to expected benefits of minimal invasive surgery or other new surgical techniques.12

The aim of this study was therefore to assess the functional recovery after laparoscopic-assisted versus open colonic resection, where both groups received a multimodal rehabilitation program in a randomized observer and patient-blinded design, and with planned discharge after 48 hours.

Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study.

Background Evidence-based guidelines on optimal perioperative fluid management have not been established, and recent randomized trials in major abdominal surgery suggest that large amounts of fluid may increase morbidity and hospital stay. However, no information is available on detailed functional outcomes or with fast-track surgery. Therefore, we investigated the effects of two regimens of intraoperative fluids with physiological recovery as the primary outcome measure after fast-track colonic surgery. Methods In a double-blind study, 32 ASA I–III patients undergoing elective colonic surgery were randomized to ‘restrictive' (Group 1) or ‘liberal' (Group 2) perioperative fluid administration. Fluid algorithms were based on fixed rates of crystalloid infusions and a standardized volume of colloid. Pulmonary function (spirometry) was the primary outcome measure, with secondary outcomes of exercise capacity (submaximal exercise test), orthostatic tolerance, cardiovascular hormonal responses, postoperative ileus (transit of radio-opaque markers), postoperative nocturnal hypoxaemia, and overall recovery within a well-defined multimodal, fast-track recovery programme. Hospital stay and complications were also noted. Results ‘Restrictive' (median 1640 ml, range 935–2250 ml) compared with ‘liberal' fluid administration (median 5050 ml, range 3563–8050 ml) led to significant improvement in pulmonary function and postoperative hypoxaemia. In contrast, we found significantly reduced concentrations of cardiovascularly active hormones (renin, aldosterone, and angiotensin II) in Group 2. The number of patients with complications was not significantly different between the groups (1 vs 6 patients, P = 0.08). Conclusions A ‘liberal' fluid regimen led to a transient improvement in pulmonary function and postoperative hypoxaemia but no other differences in all-over physiological recovery compared with a ‘restrictive' fluid regimen after fast-track colonic surgery. Since morbidity tended to be increased with the ‘restrictive' fluid regimen, future studies should focus on the effect of individualized ‘goal-directed' fluid administration strategies rather than fixed fluid amounts on postoperative outcome.

Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study†

Limited scientific evidence on optimal intraoperative fluid management has resulted in large variations of administered fluid regimens in daily practice. Currently, there is a tendency toward liberal perioperative fluid administration,1 and in laparoscopic cholecystectomy, administration of 1 to 4 L of crystalloid has been reported.1 The stress response to surgery profoundly alters fluid homeostasis leading to fluid conservation. Primary mediators are aldosterone, antidiuretic hormone, and the renin–angiotensin system. However, the effect of different fluid regimens on these hormonal responses to surgery is largely unknown.1 Although perioperative administration of high volumes may be deleterious in connection with major surgical procedures,1,2 studies in minor (ambulatory) surgery suggest that fluid substitution aiming to correct preoperative dehydration may improve some parameters of recovery (drowsiness and dizziness).3

We therefore investigated the effects of intraoperative fluid administration with 2 different volumes of Ringer’s lactate (LR) (40 mL/kg and 15 mL/kg) for laparoscopic cholecystectomy on pulmonary function, exercise capacity, stress responses (aldosterone, antidiuretic hormone [ADH], angiotensin II, atrial natriuretic peptide [ANP], and renin), and balance function as the primary outcome assessments. Furthermore, pain, nausea, vomiting, hospital stay, and recovery were assessed.

Liberal Versus Restrictive Fluid Administration to Improve Recovery After Laparoscopic Cholecystectomy: A Randomized, Double-Blind Study

BackgroundThe most common side effect of epidural or spinal anesthesia is hypotension with functional hypovolemia prompting fluid infusions or administration of vasopressors. Short-term studies (20 min) in patients undergoing lumbar epidural anesthesia suggest that plasma volume may increase when hy

Epidural anesthesia, hypotension, and changes in intravascular volume.

Twenty patients scheduled for elective major abdominal surgery were matched into two groups with regard to age, sex, height, body weight, and surgical procedure. Both groups received general anesthesia plus lumbar epidural analgesia with similar loading doses of bupivacaine 0.5% (23.1 +/- 1.0 and 23.3 +/- 0.8 ml) (mean +/- SEM) followed by continuous infusion of plain bupivacaine 0.5% (8 ml/hr) plus, in one group, epidural morphine (0.5 mg/hr). Pain score on a 5-point scale and sensory analgesia (pin prick) were assessed hourly for 16 hours after skin incision. If sensory analgesia decreased more than 5 segments from preoperative levels or if pain scores reached 2 (moderate pain), the patients were removed from the study, and pain was treated with other methods. Preoperative mean (+/- SEM) sensory levels of analgesia were similar in the bupivacaine and the bupivacaine-morphine groups (T3.4 +/- 0.5 and T3.3 +/- 0.4, respectively). In the group receiving only bupivacaine, sensory analgesia regressed over time with a simultaneous increase in pain score. Thus, within 10 hr after skin incision, seven patients in this group were discharged from the study, and 16 hr after incision only one patient maintained initial level of sensory analgesia. In contrast, each patient receiving bupivacaine plus morphine had stable sensory analgesia and was completely free of pain as indicated by a mean pain score of zero during the 16-hr observation period. Thus epidural morphine may improve pain relief and maintain analgesia during continuous epidural bupivacaine administration after abdominal surgery.

C. Lund

Papers

Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study.

Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study†

Liberal Versus Restrictive Fluid Administration to Improve Recovery After Laparoscopic Cholecystectomy: A Randomized, Double-Blind Study

Epidural anesthesia, hypotension, and changes in intravascular volume.

Epidural morphine improves pain relief and maintains sensory analgesia during continuous epidural bupivacaine after abdominal surgery.