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.

Background
In recent years the Enhanced Recovery after Surgery (ERAS) postoperative pathway in (ileo-)colorectal surgery, aiming at improving perioperative care and decreasing postoperative complications, has become more common.

Objectives
We investigated the effectiveness and safety of the ERAS multimodal strategy, compared to conventional care after (ileo-)colorectal surgery. The primary research question was whether ERAS protocols lead to less morbidity and secondary whether length of stay was reduced.

Search methods
To answer the research question we entered search strings containing keywords like "fast track", "colorectal and surgery" and "enhanced recovery" into major databases. We also hand searched references in identified reviews concerning ERAS.

Selection criteria
We included published randomised clinical trials, in any language, comparing ERAS to conventional treatment in patients with (ileo-) colorectal disease requiring a resection. RCT's including at least 7 ERAS items in the ERAS group and no more than 2 in the conventional arm were included.

Data collection and analysis
Data of included trials were independently extracted by the reviewers. Analyses were performed using "REVMAN 5.0.22". Data were pooled and rate differences as well as weighted mean differences with their 95% confidence intervals were calculated using either fixed or random effects models, depending on heterogeneity (I2).

Main results
4 RCTs were included and analysed. Methodological quality of included studies was considered low, when scored according to GRADE methodology. Total numbers of inclusion were limited. The trials included in primary analysis reported 237 patients, (119 ERAS vs 118 conventional). Baseline characteristics were comparable. The primary outcome measure, complications, showed a significant risk reduction for all complications (RR 0.50; 95% CI 0.35 to 0.72). This difference was not due to reduction in major complications. Length of hospital stay was significantly reduced in the ERAS group (MD -2.94 days; 95% CI -3.69 to -2.19), and readmission rates were equal in both groups. Other outcome parameters were unsuitable for meta-analysis, but seemed to favour ERAS.

Authors' conclusions
The quantity and especially quality of data are low. Analysis shows a reduction in overall complications, but major complications were not reduced. Length of stay was reduced significantly. We state that ERAS seems safe, but the quality of trials and lack of sufficient other outcome parameters do not justify implementation of ERAS as the standard of care. Within ERAS protocols included, no answer regarding the role for minimally invasive surgery (i.e. laparoscopy) was found. Furthermore, protocol compliance within ERAS programs has not been investigated, while this seems a known problem in the field. Therefore, more specific and large RCT's are needed.

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Fast track surgery versus conventional recovery strategies for colorectal surgery

Meta-analyses in the literature show that enhanced recovery after surgery (ERAS) is associated with lower morbidity rate and shorter hospital stay after elective colorectal surgery. However, a recent Cochrane review did not indicate the ERAS pathway as being the new standard of care due to the limited number of published trials, together with their poor quality. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the impact of the ERAS pathway on overall morbidity, single postoperative complications, length of hospital stay, and readmission rate following colorectal surgery.
 We searched BioMedCentral, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) for RCTs comparing the ERAS pathway to conventional perioperative care. No language restrictions were considered. A quality score was calculated for each trial included.
 A total of 2,376 patients in 16 RCTs were included in the analysis. The ERAS pathway was associated with a reduction of overall morbidity [relative ratio (RR) = 0.60, (95 % CI 0.46–0.76)], particularly with respect to nonsurgical complications [RR = 0.40, (95 % CI 0.27–0.61)]. The reduction of surgical complications was not significant [RR = 0.76, (95 % CI 0.54–1.08)]. The ERAS pathway shortened hospital stay (WMD = −2.28 days [95 % CI –3.09 to –1.47]), without increasing readmission rate. The ERAS pathway reduced overall morbidity rates and shortened the length of hospital stay, without increasing readmission rates. A significant reduction in nonsurgical complications was evident, while no significant reduction was found for surgical complications.

Enhanced Recovery Program in Colorectal Surgery: A Meta-analysis of Randomized Controlled Trials

Background
Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1–19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs.

Methods
A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment.

Results
Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3–5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented.

Conclusion
Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.

Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks.

The World Health Organization (WHO) has released new guidelines [1] for reducing health care associated infections related to surgery. The new guidelines include 29 concrete recommendations distilled by 20 of the world’s leading experts from 26 reviews of the latest evidence. The recommendations are designed to address the increasing burden of health care associated infections on both patients and health care systems globally. The guidelines include 13 recommendations for the period before surgery, and 16 for preventing infections during and after surgery. They range from simple precautions such as ensuring that patients bathe or shower before surgery and the best way for surgical teams to clean their hands, to guidance on when to use antibiotics to prevent infections, what disinfectants to use before incision, and which sutures to use.

Global Guidelines for the Prevention of Surgical Site Infection

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.

L. Valentiner

Papers

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