Advertisement

Overview: Key Elements and the Impact of Enhanced Recovery Care

  • Kenneth C. H. Fearon
Chapter
Part of the Enhanced Recovery book series (ER)

Abstract

Surgeons have had a long-standing interest in the immune and metabolic response to injury. Such interest has been spurred on by the recognition that modulation of these pathways might provide a route to reduce postoperative morbidity and mortality. Claude Bernard (France) first developed the concept of the milieu intérieur and Walter Cannon (USA) described the complex homeostatic responses involving the brain, nerves, heart, lungs, kidneys and spleen that work to maintain body constancy. Subsequently, Sir David Cuthbertson (UK) divided the metabolic response to injury into ebb, flow and recovery phases and quantified the amount and likely sources of protein breakdown following long bone fracture. Thereafter, individuals such as Francis Moore (USA) and Douglas Wilmore (USA) described in detail the response to injury in humans and methods of optimal nutritional and metabolic support. However, by the time of the second millennium the average length of hospital stay after colorectal abdominal surgery was still 10–15 days.

Keywords

Epidural Analgesia Postoperative Ileus Oral Nutritional Supplement Enhance Recovery Programme Open Colorectal Surgery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Basse L, Raskov HH, Hjort Jakobsen D, Sonne E, Billesbolle P, Hendel HW, et al. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg. 2002;89(4):446–53.PubMedCrossRefGoogle Scholar
  2. 2.
    Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg. 2000;232:51–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Basse L, Thorbol JE, Lossl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum. 2004;47(3):271–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg. 2003;90(12):1497–504.PubMedCrossRefGoogle Scholar
  5. 5.
    Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson AL, Remzi FH. ‘Fast track’ postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001;88(11):1533–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Fearon KC, Ljungqvist O, von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr. 2005;24(3):466–77.PubMedCrossRefGoogle Scholar
  7. 7.
    Hendry PO, Hausel J, Nygren J, Lassen K, Dejong CH, Ljungqvist O, et al. Enhanced Recovery After Surgery Study Group. Determinants of outcome after colorectal resection within an enhanced recovery programme. Br J Surg. 2009;96:197–205.PubMedCrossRefGoogle Scholar
  8. 8.
    Lassen K, Soop M, Nygren J, Cox BW, Hendry PO, Spies C, et al. Consensus review of ­optimal peri-operative care in colorectal surgery. Arch Surg. 2009;144(10):961–9.PubMedCrossRefGoogle Scholar
  9. 9.
    van Dam RM, Hendry PO, Coolsen MM, Bemelmans MH, Lassen K, Revhaug A, et al. Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection. Br J Surg. 2008;95:969–75.PubMedCrossRefGoogle Scholar
  10. 10.
    Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R. Psychological ­ influences on surgical recovery. Perspectives from psychoneuroimmunology. Am Psychol. 1998;53:1209–18.PubMedCrossRefGoogle Scholar
  11. 11.
    Egbert LD, Battit G, Welch C, Bartlett M. Reduction of postoperative pain by encouragement and instruction of patients. A study of doctor-patient rapport. N Engl J Med. 1964;270:825–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Halaszynski TM, Juda R, Silverman DG. Optimizing postoperative outcomes with efficient preoperative assessment and management. Crit Care Med. 2004;32:S76–86.PubMedCrossRefGoogle Scholar
  13. 13.
    Forster AJ, Clark HD, Menard A, Dupuis N, Chernish R, Chandok N, et al. Effect of a nurse team coordinator on outcomes for hospitalized medicine patients. Am J Med. 2005;118:1148–53.PubMedCrossRefGoogle Scholar
  14. 14.
    Disbrow EA, Bennett HL, Owings JT. Effect of preoperative suggestion on postoperative ­gastrointestinal motility. West J Med. 1993;158:488–92.PubMedGoogle Scholar
  15. 15.
    Blay N, Donoghue J. The effect of pre-admission education on domiciliary recovery following laparoscopic cholecystectomy. Aust J Adv Nurs. 2005;22:14–9.PubMedGoogle Scholar
  16. 16.
    Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg. 2003;90:400–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;4:CD004423.PubMedGoogle Scholar
  18. 18.
    Brady M, Kinn S, O’Rourke K, Randhawa N, Stuart P. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst Rev. 2005;(2):CD005285.Google Scholar
  19. 19.
    Eriksson LI, Sandin R. Fasting guidelines in different countries. Acta Anaesthesiol Scand. 1996;40:971–4.PubMedGoogle Scholar
  20. 20.
    Soreide E, Eriksson LI, Hirlekar G, Eriksson H, Henneberg SW, Sandin R, et al. Pre-operative fasting guidelines: an update. Acta Anaesthesiol Scand. 2005;49:1041–7.PubMedCrossRefGoogle Scholar
  21. 21.
    Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology. 2001;90:1344–50.Google Scholar
  22. 22.
    Hausel J, Nygren J, Lagerkranser M, Hellstrom PM, Hammarqvist F, Almstrom C, et al. A carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients. Anesth Analg. 2001;93:1344–50.PubMedCrossRefGoogle Scholar
  23. 23.
    Nygren J. The metabolic effects of fasting and surgery. Best Pract Res Clin Anaesthesiol. 2006;20:429–38.PubMedCrossRefGoogle Scholar
  24. 24.
    Crowe PJ, Dennison A, Royle GT. The effect of pre-operative glucose loading on postoperative nitrogen metabolism. Br J Surg. 1984;71:635–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Svanfeldt M, Thorell A, Hausel J, Soop M, Rooyackers O, Nygren J, et al. Randomized ­clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg. 2007;94:1342–50.PubMedCrossRefGoogle Scholar
  26. 26.
    Yuill KA, Richardson RA, Davidson HIM, Garden OJ, Parks RW. The administration of an oral carbohydrate-containing fluid prior to major elective upper-gastrointestinal surgery ­preserves skeletal muscle mass postoperatively – a randomised clinical trial. Clin Nutr. 2005;24:32–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Henriksen MG, Hessov I, Dela F, Hansen HV, Haraldsted V, Rodt SA. Effects of preoperative oral carbohydrates and peptides on postoperative endocrine response, mobilization, nutrition and muscle function in abdominal surgery. Acta Anaesthesiol Scand. 2003;47:191–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Nygren J, Thorell A, Ljungqvist O. Preoperative oral carbohydrate nutrition: an update. Curr Opin Clin Nutr Metab Care. 2001;4:255–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069–76.PubMedCrossRefGoogle Scholar
  30. 30.
    British national formulary 55. London: BMJ Group and RPS Publishing; 2008.Google Scholar
  31. 31.
    Uchida I, Asoh T, Shirasaka C, Tsuji H. Effect of epidural analgesia on postoperative insulin resistance as evaluated by insulin clamp technique. Br J Surg. 1988;75:557–62.PubMedCrossRefGoogle Scholar
  32. 32.
    Miedema BW, Johnson JO. Methods for decreasing postoperative gut dysmotility. Lancet Oncol. 2003;4:365–72.PubMedCrossRefGoogle Scholar
  33. 33.
    Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology. 1995;82:1474–506.PubMedCrossRefGoogle Scholar
  34. 34.
    Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan Jr JA, Wu CL. Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA. 2003;290:2455–63.PubMedCrossRefGoogle Scholar
  35. 35.
    Jorgensen H, Wetterslev J, Moiniche S, Dahl JB. Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev. 2000;(4):CD001893.Google Scholar
  36. 36.
    Niemi G, Breivik H. The minimally effective concentration of adrenaline in a low-­concentration thoracic epidural analgesic infusion of bupivacaine, fentanyl and adrenaline after major surgery. A randomized, double-blind, dose-finding study. Acta Anaesthesiol Scand. 2003;47:439–50.PubMedCrossRefGoogle Scholar
  37. 37.
    Tjandra JJ, Chan MK. Systematic review on the short-term outcome of laparoscopic resection for colon and rectosigmoid cancer. Colorectal Dis. 2006;8:375–88.PubMedCrossRefGoogle Scholar
  38. 38.
    Basse L, Jakobsen DH, Bardram L, Billesbolle P, Lund C, Mogensen T, et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg. 2005;241:416–23.PubMedCrossRefGoogle Scholar
  39. 39.
    King PM, Blazeby JM, Ewings P, Franks PJ, Longman RJ, Kendrick AH, et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg. 2006;93:300–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Wind J, Hofland J, Preckel B, Hollmann MW, Bossuyt PM, Gouma DJ, et al. Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial). BMC Surg. 2006;6:16.PubMedCrossRefGoogle Scholar
  41. 41.
    Grantcharov TP, Rosenberg J. Vertical compared with transverse incisions in abdominal ­surgery. Eur J Surg. 2001;167:260–7.PubMedCrossRefGoogle Scholar
  42. 42.
    Lindgren PG, Nordgren SR, Oresland T, Hulten L. Midline or transverse abdominal incision for right-sided colon cancer-a randomized trial. Colorectal Dis. 2001;3:46–50.PubMedCrossRefGoogle Scholar
  43. 43.
    Brown SR, Goodfellow PJ, Adam IJ, Shorthouse AJ. A randomised controlled trial of transverse skin crease vs. vertical midline incision for right hemicolectomy. Tech Coloproctol. 2004;8:15–8.PubMedCrossRefGoogle Scholar
  44. 44.
    Greenall MJ, Evans M, Pollock AV. Midline or transverse laparotomy? A random controlled clinical trial. Part II: Influence on postoperative pulmonary complications. Br J Surg. 1980;67:191–4.PubMedCrossRefGoogle Scholar
  45. 45.
    Kam HM, Seow-Choen F, Peng XH, Eu KW, Tang CL, Heah SM, et al. Minilaparotomy left iliacfossa skin crease incision vs. midline incision for left-sided colorectal cancer. Tech Coloproctol. 2004;8:85–8.PubMedCrossRefGoogle Scholar
  46. 46.
    Brown SR, Goodfellow PB. Transverse verses midline incisions for abdominal surgery. Cochrane Database Syst Rev. 2005;(4):CD005199.Google Scholar
  47. 47.
    O’Dwyer PJ, McGregor JR, McDermott EW, Murphy JJ, O’Higgins NJ. Patient recovery following cholecystectomy through a 6 cm or 15 cm transverse subcostal incision: a prospective randomized clinical trial. Postgrad Med J. 1992;68:817–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Marret E, Remy C, Bonnet F. Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg. 2007;94:665–73.PubMedCrossRefGoogle Scholar
  49. 49.
    Zutshi M, Delaney CP, Senagore AJ, Mekhail N, Lewis B, Connor JT, et al. Randomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway versus the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection. Am J Surg. 2005;189:268–72.PubMedCrossRefGoogle Scholar
  50. 50.
    Rigg JR, Jamrozik K, Myles PS, Silbert BS, Peyton PJ, Parsons RW, et al. Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet. 2002;359:1276–82.PubMedCrossRefGoogle Scholar
  51. 51.
    Low J, Johnston N, Morris C. Epidural analgesia: first do no harm. Anaesthesia. 2008;63:1–3.PubMedCrossRefGoogle Scholar
  52. 52.
    Fedder A, Dall R, Laurberg S, Rodt SA. Epidural anaesthesia with bupivacaine does not cause increased oedema in small gut anatomoses in pigs. Eur J Anaesthesiol. 2004;21:864–70.PubMedGoogle Scholar
  53. 53.
    Gould TH, Grace K, Thorne G, Thomas M. Effect of thoracic epidural anaesthesia on colonic blood flow. Br J Anaesth. 2002;89:446–51.PubMedGoogle Scholar
  54. 54.
    Woolsey CA, Coopersmith CM. Vasoactive drugs and the gut: is there anything new? Curr Opin Crit Care. 2006;12:155–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Thoren A, Elam M, Ricksten SE. Differential effects of dopamine, dopexamine, and dobutamine on jejunal mucosal perfusion early after cardiac surgery. Crit Care Med. 2000;28:2338–43.PubMedCrossRefGoogle Scholar
  56. 56.
    Seguin P, Laviolle B, Guinet P, Morel I, Malledant Y, Bellissant E. Dopexamine and norepinephrine versus epinephrine on gastric perfusion in patients with septic shock: a randomized study [NCT00134212]. Crit Care. 2006;10:R32.PubMedCrossRefGoogle Scholar
  57. 57.
    Meier-Hellmann A, Sakka SG, Reinhart K. Catecholamines and splanchnic perfusion. Schweiz Med Wochenschr. 2000;130:1942–7.PubMedGoogle Scholar
  58. 58.
    Meier-Hellmann A, Reinhart K, Bredle DL, Sakka SG. Therapeutic options for the treatment of impaired gut function. J Am Soc Nephrol. 2001;12 Suppl 17:S65–9.PubMedGoogle Scholar
  59. 59.
    Cepeda MS, Carr DB, Miranda N, Diaz A, Silva C, Morales O. Comparison of morphine, ketorolac, and their combination for postoperative pain: results from a large, randomized, double-blind trial. Anesthesiology. 2005;103:1225–32.PubMedCrossRefGoogle Scholar
  60. 60.
    Andersen J, Hjort-Jakobsen D, Christiansen PS, Kehlet H. Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery. Br J Surg. 2007;94:890–3.PubMedCrossRefGoogle Scholar
  61. 61.
    Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology. 2005;103:25–32.PubMedCrossRefGoogle Scholar
  62. 62.
    Lobo DN, Bostock KA, Neal KR, Perkins AC, Rowlands BJ, Allison SP. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a ­randomised controlled trial. Lancet. 2002;359:1812–8.PubMedCrossRefGoogle Scholar
  63. 63.
    Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF. Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Dis. 2006;8:563–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Hendry PO, van Dam RM, Bukkens SF, McKeown DW, Parks RW, Preston T, et al on behalf of ERAS Group. RCT to determine effect of post-operative laxation and its interaction into oral nutritional supplements within an ERAS protocol. Br J Surg. 2010;97:1198-1206Google Scholar
  65. 65.
    Delaney CP, Wolff BG, Viscusi ER, Senagore AJ, Fort JG, Du W, et al. Alvimopan, for postoperative ileus following bowel resection: a pooled analysis of phase III studies. Ann Surg. 2007;245:355–63.PubMedCrossRefGoogle Scholar
  66. 66.
    Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev. 2007;(3):CD004929.Google Scholar
  67. 67.
    Soop M, Carlson GL, Hopkinson J, Clarke S, Thorell A, Nygren J, et al. Randomized clinical trial of the effects of immediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Br J Surg. 2004;91:1138–45.PubMedCrossRefGoogle Scholar
  68. 68.
    Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183:630–41.PubMedCrossRefGoogle Scholar
  69. 69.
    Houborg KB, Jensen MB, Hessov IB, Laurberg S. Little effect of physical training on body composition and nutritional intake following colorectal surgery – a randomised placebo-­controlled trial. Eur J Clin Nutr. 2005;59:969–77.PubMedCrossRefGoogle Scholar
  70. 70.
    Houborg KB, Jensen MB, Rasmussen P, Gandrup P, Schroll M, Laurberg S. Postoperative physical training following colorectal surgery: a randomised, placebo controlled study. Scand J Surg. 2006;95:17–22.PubMedGoogle Scholar
  71. 71.
    Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;94(2):224–31.PubMedCrossRefGoogle Scholar
  72. 72.
    Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr. 2010;29:434–40.PubMedCrossRefGoogle Scholar
  73. 73.
    Kariv Y, Delaney CP, Senagore AJ, Manilich EA, Hammel JP, Church JM, et al. Clinical ­outcomes and cost analysis of a ‘fast track’ postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon Rectum. 2007;50:137–46.PubMedCrossRefGoogle Scholar
  74. 74.
    Kehlet H. Fast-track colonic surgery: status and perspectives. Recent Results Cancer Res. 2005;165:8–13.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2012

Authors and Affiliations

  • Kenneth C. H. Fearon
    • 1
  1. 1.Department of Surgical OncologyUniversity of Edinburgh/Royal InfirmaryEdinburghUK

Personalised recommendations