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Optimizing Outcomes
withEnhanced Recovery
JulieThacker andNancyMorin
7
Key Concepts
• Enhanced recovery is the process of dening modiable
sources of perioperative stress to the surgical patient and
applying standardized evidence-based interventions
through all phases of care to avoid complications, facilitate faster recovery and discharge (without increasing
readmission rates), and reduce hospital costs.
• Champions from surgery, anesthesia, and nursing are essential to the ERAS team, while other members for protocol creation include pharmacy, IT, nutrition, and administration.
• Key elements of patient care delivery can be broken down
into ve phases, each assigned to and delivered by a different team while certain elements present across phases:
preoperative, perioperative, intraoperative, postoperative,
and post-discharge.
• Implementation of the Enhanced Recovery Program,
ERP, requires order sets, team education, and administrative help as well as databases to facilitate data collection
and ensure optimal compliance and quality control.
• ERAS principles are widely applicable and have been
proven safe and benecial in emergency and IBD patients,
those with diverting ostomies, and elderly patients, realizing that readiness for discharge rather than length of
stay is a more accurate outcome measure.
• Moving forward, technology will assist in gathering
patient recovery-centric outcome measures in addition to
the traditional audit measures to further quality improvement efforts.
Intrinsic to the personality of a surgeon is the drive toward
perfect outcomes. Benchmarking, quality improvement
J. Thacker (*)
Department of Surgery, Duke University School of Medicine,
Durham, NC, USA
e-mail: julie.thacker@duke.edu
N. Morin
SMDB Jewish General Hospital, McGill University, Department of
Surgery, Division of Colorectal Surgery, Montreal, QC, Canada
comparisons, and inherent competitiveness all allow surgeons the means to evaluate their performance. Enhanced
recovery principles, by contrast, focus on intervention elements. Specically, enhanced recovery focuses on the surgical stress imposed on unique patient populations. This
chapter focuses on enhanced recovery efforts, details, challenges, and future directions in the elective colorectal surgery patient.
Enhanced Recovery, Origins, andOverview
Besides a buzz word on hospital webpages for administrators
to publicize adoption of popular care maps for surgical services lines, enhanced recovery has a multi-faceted history
and widely diverse denitions. To some, enhanced recovery
refers to the patient-focused decrease of surgical stress
described in the late 1990s and early 2000s in Scandinavia as
“ERAS, enhanced recovery after surgery.” To others,
“ERAS” is simply an order set or protocolized perioperative
care. Enhanced recovery; enhanced recovery programs,
“ERP”; and enhanced recovery after surgery, “ERAS” will
be used interchangeably in this chapter.
Most clearly, enhanced recovery is the application of
evidence- based, perioperative medicine to the care of the
surgical patient with a goal of best surgical outcomes. In this
chapter we review the thoughtful development of this aspect
of perioperative medicine, and, specically, we discuss the
aspects of perioperative medicine that have been dened as
enhanced recovery for the colorectal surgery patient.
Building on the understanding of nutrition and stress science from the preceding decades, surgeon scientists began
specically addressing the impact of depleted or supported
nutritional reserves at the time of surgical stress on surgical
outcomes. After decades of individual work relating operative outcomes to perioperative metabolism, stress, and nutrition, Douglas Wilmore of Boston and Henrik Kehlet of
Copenhagen reported the importance of considering the
© Springer Nature Switzerland AG 2022
S. R. Steele et al. (eds.), The ASCRS Textbook of Colon and Rectal Surgery, https://doi.org/10.1007/978-3-030-66049-9_7
121
122
J. Thacker and N. Morin
patient’s physiologic reactions, helpful and hurtful, to surgical stress [1–3].
Their work proposed that, with a better understanding of
the physiologic stress impact of operations, surgical teams
could mitigate this stress. From a background of perioperative nutrition science, these early enhanced recovery efforts
began to dene modiable sources of perioperative stress.
Wilmore and Kehlet identied several sources of perioperative stress that were worse with traditional perioperative
care, and they hypothesized that different care plans might
Fig. 7.1 Perioperative stress
and reactions
inflammation
Perioperative
Stress
help patients avoid complications [4]. The complexity of
physiologic interactions is shown diagrammatically in
Fig.7.1 with representative enhanced recovery interventions
to combat these stresses shown in Fig.7.2.
From modifying perioperative stress to fast-track surgery
to enhanced recovery, perioperative care was being revolutionized in Europe in the early 2000s. Simultaneously, in the
USA, a trend toward minimally invasive approaches to
abdominopelvic operations was taking off. Observed shifts
in patient care paradigms followed patient recovery curves
sympathetic
activation
vascular tone
variation
endocrine
activation
insulin
resistance
acute
phase
reaction
inflammation
Perioperative
Stress
thrombosis,
coagulation
NSAID’S
sympathetic
activation
catecholamine
reaction
sympathetic
blockade
vascular tone
variation
neutrophil
leukocytosis
thrombosis,
coagulation
optimization
endocrine
activation
cytokine
production
catecholamine
fluid
reaction
insulin
resistance
acute
phase
reaction
minimize
activators
neutrophil
leukocytosis
preop CHO
early diet
MIS
cytokine
production
ENHANCED
RECOVERY
minimal
drains/tubes
VT proph
mobilization
multimodel
pain mgt
anesth
efforts
minimize
activation
Fig. 7.2 Common ERAS elements to combat perioperative stress
infection
prevention
normalize
activity
Time
7 Optimizing Outcomes withEnhanced Recovery
123
Function
Traditional care
Enhanced Recovery
Fig. 7.3 Kehlet and Wilmore’s representation of lessened perioperative stress resulting in improved recovery curve
and included earlier postoperative oral intake, earlier mobility, and earlier readiness for discharge from the hospital.
Laparoscopic surgeons were responding to patients’
decreased surgical stress and facilitating faster recoveries.
Through critical review of laparoscopic studies and perioperative care standardization, it became obvious that allowing
patients to recover more quickly worked [5]. More directly,
Dr. Kehlet’s parallel efforts began actively addressing perioperative care elements relative to surgical stress. He
reported that an immediate diet and immediate activity, in
combination with multimodal analgesia, led to quicker discharge readiness after open operations [6, 7]. He explained
that the traditional care paradigms worsened surgical stress
and prolonged the amount of recovery below the patient’s
baseline at time of operation. As demonstrated in Fig.7.3,
and as he simply described, patients did not experience the
dip relative to baseline health when they had surgery on his
protocol.
Specic to colorectal surgery, the two paradigm shifts
collided in the early 2000s. Open operations under this new
care paradigm and laparoscopic operations with inherently
faster recovery were resulting in decreased narcotic need,
earlier diet tolerance, and shortened hospital stays. Surgeons
performing predominantly open colorectal operations in
Scandinavia adopted Professor Kehlet’s perioperative principles, and with the explosion of MIS equipment availability
in the USA, more and more surgeons were approaching the
colon laparoscopically. In 2004, the American College of
Surgeons’ Commission on Cancer released the noninferiority COST trial [8], showing that laparoscopic onco-
logic resection for colon cancer did not have worse outcomes
compared to the open approach. This led to increasing numbers of MIS colon resections in North America, particularly
at academic and training centers, where academicians had
been reluctant to adopt the technology without reassurance
of safety in cancer. In 2005, the rst publication of the
“ERAS group” shared their attempt to push surgeon-driven
adoption of Kehlet’s protocols for open colorectal resection
patients on their colorectal surgery wards. Admitting that
their results were not as amazing as the very conned implementation of Kehlet’s single-center and small-sample population, the ERAS group set out to apply implementation
science techniques to the idea of changing the perioperative
management of colorectal surgery at their centers. Subsequent
development and spread of these focused change management strategies has been widely successful [9].
By 2008, worldwide improvement of colorectal surgery
outcomes, predominantly in length of stay and decreased
wound complications, had been reported by many highvolume laparoscopic centers. Perioperative optimization
strategies such as intentional uid management and opioid
stewardship began timely growth from the anesthesia literature. Parallel to the incremental changes happening around
the growth of laparoscopic colorectal surgery was the successful effort of the ERAS Society, so named in 2007 [10].
With westerly drift of ideas, US and Canadian centers
became aware of the principles of enhanced recovery. This
spread was facilitated by the uptake of enhanced recovery in
the UK. The 2008 economic recession drove the National
Health Service to implement many care changes to improve
service and to decrease cost. The implementation of enhanced
recovery for surgery patients was mandated across the country, beginning with colorectal surgery. This effort was to save
money from decreasing length of stay and complications,
and the NICE program was hugely successful at its mission
[11]. Enhanced Recovery Partnership Programme in the
National Health Service, NHS, of the UK was the rst mandated and the rst truly multidisciplinary approach to the
improving perioperative outcomes reported. Since 2010, the
published work of major centers, predominantly shared
anesthesia and surgery efforts, has skyrocketed [12–15].
North American efforts have been stimulated by the 2014
creation of American Society for Enhanced Recovery (ASER
at www.enhancedrecovery.org) and the American chapter of
the ERAS Society, in 2017 (Fig.7.4).
In short and most holistically, enhanced recovery is the
process of considering and implementing the best evidence
for each system-patient touch from diagnosis of surgical disease to complete recovery from operative management of
that disease. Currently, the best outcomes attributed to
enhanced recovery work tend to start with intentional preop-
124
Timeline of Enhanced Recovery Development in North America
Laparoscop
Enhanced Reco
Quality Repor
Health Sciences Research
1980 1990 2000 2010
y
very
ting
Fig. 7.4 Alignment of improvement strategies in colorectal surgery including laparoscopy, ERAS, and quality improvement research
J. Thacker and N. Morin
North America
Fig. 7.5 Models of care for
change management
planning; three phases and
ve phases
erative education regarding surgical planning, followed by
evidence-based management steps via preoperative anesthesia assessment, intraoperative best practices, and intentional
postoperative management schemes to minimize perioperative stress and optimize outcomes. Herein, we will discuss
the evidence of common care variables of enhanced recovery
for colorectal operations, reported implementation schemes,
and examples of improved outcomes. In addition to order
sets and patient-focused care elements, enhanced recovery
efforts frequently lead to continuous improvement platforms.
Such platforms, via change management efforts, are tough to
create and even harder to maintain. Identication of these
barriers and how to break these barriers down is offered.
Enhanced recovery has been attractive to administrators and
payers because of economic impacts which are discussed
toward the end of the chapter. Lastly, next steps and the
future of enhanced recovery for colorectal patients are
covered.
Preop
Preop Periop Intraop
IntraopPostop
Enhanced Recovery Models
There are two ways to consider the care elements of most
enhanced recovery models. One is to dene action in a particular phase of care. Another considers the impact on physiologic stress, allowing for potentially multiple interventions
along the surgical continuum.
Dividing the operative experience into phases is somewhat articial, but it works well when creating an implementation strategy. Care delivery can be divided by time and
shown as preoperative → intraoperative → postoperative.
Care delivery can also be divided by location, which further
denes the team members present in each phase. This vephase care perioperative scheme is consistent with the
Quality Red Book published by the American College of
Surgeons (Fig.7.5) [16].
Preoperatively, the patient is prepared for surgery with
information and testing. Intraoperatively, engagement of the
Postop
Post
Discharge
7 Optimizing Outcomes withEnhanced Recovery
PREOP PERIOP INTRAOP POSTOP POSTDISCHARGE
125
• Education • Risk
• Risk
Assessment
• Surgical
Planning
• Informed
Consent
Fig. 7.6 Common enhanced recovery elements; ve phases of care model
reduction
• Initiation of’
protocol
• Confirmation
of education
and patient driven
elements
• PONV
prophylaxis
• Multimodeal
analgesia
• Confirmation of
protocol
• Time out and
debrief
• Multimodal
analgesia
• Intentional fluid
management
• Minimal surgical
stress
• Minimal drains
tubes/lines
• MIS approaches
• PONV prophylaxis
anesthesia team is key. Important elements in the operating
room include intentional uid management and minimally
stressful surgical techniques. Postoperatively, the patient is
guided back to baseline health, acutely in the hospital and
over the weeks following an operation. Each of these phases
is delivered by a different team. The patient and the surgeon
are the only two players in each phase. A surgeon’s understanding of who does what and when is a key rst step to
enhanced recovery care. Then key elements in each phase are
dened from the evidence. An example of how some elements fall into phases of care is shown (Fig.7.6).
As is obvious by the repetition of items across the phases,
some interventions need to be carried out at multiple time
points. Therefore, when creating a protocol, it is important to
consider the principles of care and the evidence of
interventions.
First Steps toCreating anEnhanced
Recovery Program
To start, the ERAS team needs to dene what outcomes need
to be improved. Seemingly obvious, this initial step is often
skipped with teams jumping into building order sets. The
second step is to create an evidence library. Once outcomes
of interest are dened, and the evidence is collected, the team
assigns the elements of impact to phases of care and team
members. The lift of implementation often includes an order
set, team education, and administrative help. Pearsall etal.
detail the team and facilitators nicely in a chapter on implementation in Surgical Clinics of North America [17].
Champions from surgery, anesthesia, and nursing are
essential. Other team members for protocol creation will be
from the pharmacy, IT, administration, and nutrition.
• Multimodal
analgesia
• Immediate diet
• Immediate
mobilization
• Drains, tubes.
lines out asap
• Only intentional
diagnostics
• Defined d/c
criteria
• Education and
reinforcement
• Established
follow up plan
• Multimodal
analgesia
• Communication
pathways
• Frequent contact,
PRO’s
• Outcomes
analysis, PDSA
Enhanced Recovery Elements inColorectal
Surgery
This section covers elements common to most protocols for
enhanced recovery of the elective colorectal surgery patient.
General groupings into phases of care are used to organize
the information as one would to create a protocol (Table7.1).
Preoperative Elements ofERAS inElective
Colorectal Surgery
Education
Patient education is a key element of enhanced recovery.
Setting expectations for patients at every phase of care helps
to manage stress and encourage participation. Common language and instructions throughout the surgical journey allow
the patient to be more relaxed and receptive to the care plan.
Information needs to be at the simplest appropriate literacy level in written, spoken, and, if possible, video versions
to reach all learners. Important to every phase of enhanced
recovery, the greatest educational effort may be spent at its
introduction in the surgery clinic. The anesthesia assessment
team, the preoperative holding team, and even the recovery
room team– all of these seemingly separate teams– become
part of the patient-focused care in enhanced recovery. When
this philosophy is adopted, variability decreases.
Preoperative Optimization
The explosion of evidence regarding preoperative optimization outreaches this chapter. There is abundant research ongoing to dene readiness for operation. Subjecting patients
to exercise-based challenges, evaluating interleukin levels,
and reading nutritional parameters on CT scans are just a few
of the areas being aggressively studied [18]. This section,
126
J. Thacker and N. Morin
Table 7.1 Common enhanced recovery elements in elective CRS
Phase Element Outcomes of interest
Preoperative Informed consent Shared decision-making and
Education Patient participation and
Optimization Best management of
Perioperative Bowel
Intraoperative VTE prophylaxis Decrease thrombotic
Postoperative Multimodal
Postdischarge
PO Per os, PONV postoperative nausea and vomiting, IVF intravenous
uid, VTE venous thromboembolism, MIS minimally invasive surgery
preparation
Limiting fasting Encourage euvolemia for safe
Carbohydrate
load
Identify/
document
PONV
prophylaxis
Multimodal
analgesia
Antibiotic
prophylaxis
Multimodal
analgesia
Goal-directed
IVF
MIS Decrease surgical stress and
Minimize drains,
tubes, and lines
PONV
prophylaxis
activity
Immediate diet Encourage return of bowel
Immediate
activity
VTE prophylaxis
and teaching
Education Reinforce discharge criteria
Multimodal
analgesia
Continued
activity
VTE prophylaxis Decrease thrombotic
Close contact Decrease stress and recognize
appropriateness
decreased stress
modiable risk factors
Decrease surgical site infection
induction
Decrease insulin resistance and
infection
Increase compliance to
protocol and audit
Optimize early PO tolerance
and patient experience
Decrease opioid-related
complications
complications
Decrease infectious
complications
Minimize opioids during
general anesthesia
Optimize the right uid
relative to needs
optimize recovery
Decrease foreign body reaction
and complication risk without
evidence of benet
Optimize early PO tolerance
and patient experience
Minimize opioids during
general anesthesia
function, minimize catabolism
Minimize complications of
inactivity
Decrease thrombotic
complications and begin
discharge teaching
and goals to minimize
unnecessary length of stay and
stress
Minimize opioid complications
and opioids in the community
Encourage rehabilitation and
muscle preservation
complications
problems early to prevent
readmissions
though, is a brief review of well-established and feasible recommendations that should be routine in all preoperative
preparation programs: smoking cessation, preoperative
nutrition, and anemia and diabetes management recommendations. Since acquiring the “Strong for Surgery” program,
the best guide for this preparation for surgery elements is the
American College of Surgeons webpage, https://www.facs.
org/quality- programs/strong- for- surgery, which includes
resources for clinicians, preoperative programs, and patients.
Smoking Cessation
The association of smoking with worse operative outcomes
is well established [19]. For colorectal surgeons, concerns
include increased risk of anastomotic complications,
impaired microcirculation, increased postoperative pulmonary complications, and special considerations in inammatory bowel disease (IBD). Particular recommendations
include taking advantage of the life-changing moment of a
surgical diagnosis as motivation for patients to quit tobacco
use and encouraging even 2–3weeks of preoperative cessation as benecial. For many patients, smoking is not their
only modiable risk factor; smoking cessation can be one
goal added to increased physical activity, alcohol intake
moderation, and improved blood sugar management during
even a brief elective case delay. Resources available on
Strong for Surgery are thorough. Having a local team with
specic addiction focus and training does result in higher
success of these efforts [20].
Preoperative Nutrition
The evidence that malnutrition is independently associated
with worse colorectal surgery outcomes and increased costs
is abundant. The problem is often underestimated, but it is
substantial. Work by Wischmeyer etal. [21] produced this
infographic dening the impact of inadequate preoperative
nutritional status (Fig.7.7).
However, surgeons’ understanding of this has not easily
translated to universally applicable recommendations for our
patient population. Options to use a diseased gastrointestinal
tract to improve nutrition are limited. Making nutritional
preparation for CRS more challenging is the difculty of
clinically diagnosing malnutrition. A fast screening plan is
proposed by the ASER and PeriOperative Quality Initiative
(www.POQI.org) consensus statement by Wischmeyer etal.
[21] (https://thepoqi.org/POQI- 2- Manuscripts). Detailed
discussion of preoperative supplements and the rare indication for parenteral preoperative repletion is available in the
online resource linked above. Generally, the recommendations include protein calories, regular mineral and vitamin
supplements, and evaluation for nutrient deciencies and
potential directed supplements. Practical implementation is