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Results
The definition of an enhanced recovery pathway for colon and rectal surgery was
established by the Consensus Review of Optimal Perioperative Care in Colorectal
Surgery Group in 2009. This was a succinct and easily adaptable list which describes
the 20 aspects of the enhanced recovery protocol [2]. Our focus was whether adding
an enhanced recovery/fast track pathway to patients undergoing laparoscopic tech-
niques add any benefits when compared to those undergoing laparoscopy in the
absence of a fast track pathway (Table 42.3).
It is well known that using a laparoscopic approach for colorectal surgery is
associated with shorter hospital stays, decreased postoperative complications, and
decreased pain when compared to open surgery [9–12]. It is also well established
that adding an enhanced recovery protocol to open colorectal surgery results in bet-
ter patient outcomes. In theory, the addition of an enhanced recovery protocol
should produce better outcomes for laparoscopic surgery as well; however, the lack
of tier 1 randomized controlled trials makes this presumption difficult to definitively
prove. In reality, most studies are retrospective reviews, underpowered, or lack an
appropriate number of fast track elements.
However, Zhao et al. attempted to strengthen the literature by combining the
data with a meta-analysis in August of 2014 [6].The authors were able to identify
and deem eligible five randomized controlled trials and five clinical controlled tri-
als for a total of 1,317 patients. The patients all underwent laparoscopic colorectal
surgery, with 696 participating in an enhanced recovery protocol and 621 patients
undergoing traditional care. Importantly, all patients underwent a minimally inva-
sive approach. In addition, all studies within the meta-analysis were determined to
range in quality from moderate to high. Primary hospital stay (−1.64 days; 95 % CI,
−2.25 to−1.03; p < 0.001), time to first flatus (−0.40 day; 95 % CI, −0.77 to−0.04;
p = 0.03), time to first bowel movement (−0.98 day; 95 % CI, −1.45 to−0.52;
p < 0.001), and complication rate (RR, 0.67; 95 % CI, 0.56–0.80; p < 0.001) were all
improved when an enhanced recovery program was applied in addition to the lapa-
roscopic technique. Readmission rate and 30-day mortality were found to be non-
significant, which has been consistent with other studies comparing enhanced
recovery protocols within colorectal surgery. Another interesting aspect of this
meta-analysis was that complication rates were found to be significantly reduced--a
finding in which no other meta-analysis had identified before. The authors ulti-
mately concluded that not only can an enhanced recovery protocol be combined
with laparoscopic colorectal surgery to decrease primary hospital stay, increase
time to first flatus and bowel movements, but also that using laparoscopy within
these protocols may actually increase patient safety when compared to traditional
perioperative colorectal care.
When looking at some of the existing primary data, a study by Vlug and col-
leagues provides a closer comparative evaluation. Vlug and associates provided one
of the first studies looking specifically at laparoscopy versus open techniques within
enhanced recovery protocols in the 2011 entitled LAparoscopy and/or FAst track
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multimodal management versus standard care (LAFA trial) [13]. The authors
stratified 400 patients into 4 treatment groups: laparoscopic/fast track, open/fast
track, laparoscopic/standard, and open/standard with the primary goal to find a min-
imum difference of 1 day in hospital stay [13]. They showed a total hospital stay of
5 days in the laparoscopic/fast tract group versus 7 days for the open/fast track
group (p < 0.001), concluding that optimal perioperative treatment includes a lapa-
roscopic resection within an enhanced recovery protocol [13]. On regression analy-
sis, laparoscopy was the only independent predictive factor to reduce hospital stay
and morbidity [13]. When specifically comparing laparoscopic with fast track, ver-
sus laparoscopic with standard perioperative care, the median hospital stay was
lower in the fast track cohort at 5 days (interquartile range: 4–8) versus 6 days
(range: 4.5–9.5). However, secondary outcomes including postoperative hospital
stay, morbidity, reoperation, readmission, in-hospital mortality, and quality of life
did not differ significantly amongst the groups.
Table 42.3 GRADE profile for laparoscopic colorectal surgery in enhanced recovery protocols
Study year Study type Patients numbers Outcomes
Quality of
evidence
Zhuang et al.
(2015) [3]
Meta-analysis 598 patients
Lap vs. Open in
ERAS program
Laparoscopic surgery
↓Total hospital stay
↓# of complications
Moderate
Lei et al.
(2015) [4]
Meta-analysis 714 Patients
373 FT Lap
341 FT Open
Lap surgery – shorter
post op stay and shorter
overall hospital stay
Moderate
Tiefenthal
et al. (2015)
[5]
Prospective
Clinical Trial
292 Patients
Lap within ERAS
program
↓Pain control
↓Hospital stay
Moderate
Zhao et al.
(2014) [6]
Meta-analysis 1,317 Patients
696 Lap/ERAS
621 LAP/
traditional care
↓Primary hospital stay
↓Time to first flatus
↓Time to first bowel
movement
↓Complications
Moderate-
High
Vlug et al.
(2012) [7]
RCT 400 Patients
193 Lap/Open FT
207 Lap/Open
standard
Factors ↓ total hospital
stay
Female Sex
Laparoscopic
resection
Normal diet on POD 1,
2, 3 Enforced
Mobilization
Low-moderate
Vlug et al.
(2011) [8]
RCT 400 Patients
Lap FT
Lap standard
Open FT
Open standard
Laparoscopy within
ERAS protocol
↓hospital stay to 5 days
vs. 7 days in the Open
and ERAS protocol
Moderate
RCT randomized controlled trial, ERAS enhanced recovery after surgery pathway, Lap laparo-
scopic, FT fast track pathway
42 Quality Improvement: Are Fast Track Pathways for Laparoscopic Surgery Needed?
480
In 2012, Vlug and colleagues followed up with a more specific question given the
potentially confounding elements of the enhanced recovery recommendations and
attempted to ferret out which aspects of the enhanced recovery protocol predicted
early recovery after colon cancer surgery [7]. Using patients from the LAFA trial,
all patients who were randomized to fast track care (n = 193) and standard care
(n = 207) were analyzed to determine whether one single item or a set of items inde-
pendently predicted “enhanced recovery” as defined by total postoperative hospital
stay as the primary outcome [7]. Six baseline characteristics (female gender, age,
ASA, BMI, laparoscopic operation, and right-sided resections) along with the
achieved fast-track elements were entered in a univariate linear regression analysis.
Those with a p < 0.100 were subsequently entered in a multivariate linear regression
analysis, which identified female gender, laparoscopic resection, normal diet at
postoperative days 1, 2, and 3, and enforced mobilization at postoperative days 1, 2,
and 3, as independent predictors of total postoperative hospital stay [7]. They con-
cluded that a laparoscopic resection was an independent predictor of decreased
length of stay, in accordance with the results of the earlier LAFA Trial, thus further
validating the improvement in early recovery with the use of laparoscopy within an
enhanced recovery protocol.
Zhuang et al., published an update to their prior meta-analysis regarding ERAS
protocols within colorectal surgery versus traditional care with a more focused
meta-analysis in 2015,evaluating laparoscopic versus open colorectal surgery within
an enhanced recovery program [3, 14].Five randomized clinical trials encompassing
598 patients were included in the final analysis. The nature of their inclusion/exclu-
sion criteria increased the strength of this meta-analysis. They included only RCTs
and all studies must have had at least 7 enhanced recovery interventions.
Laparoscopic colorectal surgery significantly reduced total hospital stay by
1.92 days (95 % confidence interval (CI): 2.61± 1.23 days; p < 0.00001) and number
of complications (RR 0.78; 95 % CI 0.66–0.94; p = 0.007) compared with open sur-
gery in the setting of enhanced recovery programs [3]. Unfortunately, the benefits of
laparoscopic colorectal resection within optimal ERAS programs was not able to be
determined. In part, this was due to the lack of high-quality primary studies. In addi-
tion, there were too few laparoscopic/standard versus laparoscopic/fast track
comparisons.
The effect of the skill level of surgeons performing laparoscopy on final out-
comes within an enhanced recovery protocol has also surfaced amongst these stud-
ies, as many of the prior studies proclaimed that the participating surgeons were
well versed in the technique of laparoscopic colorectal surgery [13, 15]. Tiefenthal
published a study in the summer of 2015 looking at laparoscopic versus open right-
sided colonic resection within an ERAS protocol [5]. They attempted to avoid the
bias introduced in previous laparoscopic research where laparoscopic specialists
performed the surgery. They included surgery performed by low-volume surgeons
and trainees. Their primary outcomes included postoperative recovery and morbid-
ity, with secondary outcomes including preoperative variables that influenced the
selection of patients for laparoscopic or open surgery [5]. The compliance with the
enhanced recovery elements was very high compared to most studies at 87 %, and
on multivariate analysis the authors reported earlier pain control and shorter hospi-
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tal stay in the laparoscopic group (2.4 ± 3.2 days vs. 4.2 ± 5.9 p = 0.016; and 4 vs. 6
days (p = 0.002), respectively). The authors concluded that trainees and low-volume
surgeons within a well-performed enhanced recovery protocol program might still
produce the similar results as reported in prior studies.
The most recent evidence supporting laparoscopic colonic resection within an
enhanced recovery protocol was a meta-analysis performed by Lei and colleagues
in 2015, which supports the use of laparoscopic-assisted techniques [4]. This meta-
analysis encompassed seven RCTs and a total of 714 patients: 373 undergoing lapa-
roscopic colonic resections and 341 undergoing an open operation--all within an
enhanced recovery program. The authors found the laparoscopic group demon-
strated a significant decrease in postoperative hospital stay, total hospital stay, and
overall complications when compared to the open operation [4]. The strengths of
this meta-analysis include their inclusion of only RCTs, large number of patients,
and studies only comparing laparoscopic with open colorectal resection within the
setting of an established enhanced recovery program. The downside includes the
lack of comparison evaluating the benefit of laparoscopic plus enhanced recovery
versus simply laparoscopy alone. Despite this drawback, this analysis strongly sup-
ports our recommendation concerning the use of laparoscopic techniques within an
enhanced recovery system in order to reduce the postoperative stay, total hospital
stay, and overall complications without jeopardizing patient’s safety.
Song and colleagues looked at randomized and clinical controlled trials from
2000–2012, and focused this analysis on laparoscopic cases only—identifying 13
trials and 1795 patients. Overall, time to time to passage of flatus (WMD = −1.37, 95
% CI: -1.55 ~ −1.19, P < 0.05), time to resumption of diet/drink (WMD = −2.62, 95
% CI: -2.69 ~ −2.55, P < 0.05), postoperative length of postoperative hospital stay
(WMD = −1.63, 95 % CI: −1.92 ~ −1.34, P < 0.05) and the incidence of postopera-
tive complications (OR = 0.52, 95 % CI: 0.41 ~ 0.67, P < 0.05) were all improved in
the fast track cohort. The authors concluded that enhanced recovery does make a
difference in improving outcomes, even for those patients undergoing a laparoscopic
approach [16]. Taupyk and colleagues followed this in a small blinded controlled
trial of 70 patients with colorectal cancer, all of who munder went conventional
laparoscopic surgery and were then randomized to fast track versus conventional
recovery [17]. The fast track protocol consisted of avoidance of bowel preparation,
early postoperative feeding, and early ambulation. Total length of stay (5.9 vs.
10.9 days), post-operative stay (4.3 vs. 8.0 days), first flatus (1.6 vs. 2.5 days), def-
ecation time (2.2 vs. 4.5 days), and time to resumption of solid diet (1.1 vs. 3.6
days) were all improved in the fast track cohort, as well as lower CRP levels.
Although this was a “bare-bones” fast track system, it does highlight that even sim-
ple things can improve outcomes--even in patients undergoing laparoscopic
surgery.
Improved length of stay with the addition of an enhanced recovery pathway for
all patients undergoing laparoscopic colorectal surgery has also been shown by
Haverkamp and associates. This retrospective chart review looked at those prior to
(n = 77) and after (n = 109) implementation of a fast track program. Whereas they
were unable to show any improvement in postoperative procedure-related compli-
cations, morbidity, readmission, reoperation, or mortality, length of stay was
42 Quality Improvement: Are Fast Track Pathways for Laparoscopic Surgery Needed?
482
improved in those with a fast track program (4 vs. 6 days) [18]. These same benefits
with regards to hospital length of stay have been demonstrated in the setting of
minimally invasive approaches for rectal cancer as well [19, 20].
Recommendations Based on the Data
A 2005 Cochrane review confirmed that laparoscopic colorectal resection resulted
in better safety, decreased the postoperative pain, and lessened the duration of post-
operative ileus than open surgery [21]. Around this time, enhanced care protocols
came into the forefront of colorectal surgery, initially making their mark in open
surgery [2]. We feel strongly that this same improvement can be witnessed when
applied to laparoscopic colorectal surgery as well. This improvement in clinical out-
comes seen when combing laparoscopic surgery with the enhanced recovery proto-
col may be due to simply combining the two modalities, which ultimately decreases
postoperative stress, inflammatory response, and leads to a faster recovery. The lit-
erature discussed above only strengthens the recommendation stated in the Cochrane
review: the implementation of an enhanced recovery protocol to a minimally
invasive approach for colorectal surgery should be performed in every possible
instance. This STRONG recommendation would be expected to result primarily in
faster recovery times and decreased length of stay. The effect on decreasing compli-
cations, improving patient satisfaction, and cultivating overall patient safety remains
to be determined, but the majority of the literature suggests (at a minimum) equiva-
lent, and likely better outcomes with adding a fast track program.
Recommendations Based on the Data
1. Adding an enhanced recovery/fast track pathway to laparoscopic-assisted
colorectal surgery is the preferred approach whenever feasible. (Strong recom-
mendation based on moderate-high quality evidence)
2. Patients deemed at high-risk (i.e., elderly, multiple comorbidities, high frailty
index) may still benefit from individual components of an enhanced recovery/
fast track pathway when undergoing laparoscopic colorectal surgery. (Weak rec-
ommendation based on low-quality evidence)
A Personal View of the Data
Our review of the data regarding the addition of an enhanced recovery/fast track
pathway even in those well versed in laparoscopic-assisted techniques for colorec-
tal surgery is that it will result in an improvement in outcomes. Anecdotally, this
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has definitely been the senior author’s experience. The data seems clear that add-
ing a fast track pathway will result in shorter hospital stays. Although outcomes
such as complications, readmission, quality of life, and reoperations are lower
with fast track pathways when comparing open with laparoscopic approaches, the
majority of data shows equivalent or more modest benefits when limited to lapa-
roscopic cohorts alone. Part of this is obvious--the benefits of a minimally inva-
sive technique (i.e., laparoscopy) for emergent and elective colon and rectal
procedures has been clearly evident based on relatively longstanding literature.
Several meta-analyses have demonstrated not only the impact on decreased length
of stay, morbidity and quality of life, but also improved pain control, earlier return
of bowel function, and lower mortality with the laparoscopic approach. With such
vast improvements in outcomes, the question remains that in the face of a techni-
cally sound laparoscopic approach, what is the impact of an enhanced recovery
program to improve outcomes even further? On one hand, laparoscopic techniques
are increasingly becoming a new “standard of care” within colorectal surgery, and
many institutions have already implemented a majority of fast track tenets within
their “traditional” care pathways. Therefore, many comparisons are “apples to
apples”. However, especially for those without a fast track pathway in place, lapa-
roscopy with the addition of an enhanced recovery program will improve out-
comes. We do need more and higher level data to solidify this recommendation.
As such, we need to gear our future investigations to augment the paucity of lit-
erature evaluating outcomes following laparoscopic colorectal surgery in tradi-
tional postoperative recovery pathway versus outcomes following laparoscopic
colorectal surgery in an enhanced recovery pathway. It seems likely that there is a
symbiotic relationship that results in a meaningful improvement inpatient
outcomes.
References
1. Guyatt G, Gutermen D, Baumann MH, et al. Grading strength of recommendations and quality
of evidence in clinical guidelines: report from an American College of Chest Physicians Task
Force. Chest. 2006;129:174–81.
2. Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorec-
tal surgery: enhanced recovery after surgery (eras) group recommendations. Arch Surg.
2009;144(10):961–9.
3. Zhuang CL, Huang DD, Chen FF, et al. Laparoscopic versus open colorectal surgery within
enhanced recovery after surgery programs: a systematic review and meta-analysis of random-
ized controlled trials. Surg Endosc. 2015;29(8):2091–100.
4. Lei QC, Wang XY, Zheng HZ, et al. Laparoscopic versus open colorectal resection within fast
track programs: an update meta-analysis based on randomized controlled trials. J Clin Med
Res. 2015;7(8):594–601.
5. Tiefenthal M, Asklid D, Hjern F, Matthiessen P, Gustafsson UO. Laparoscopic and open right-
sided colonic resection in daily routine practice. A prospective multicentre study within an
ERAS protocol. Colorectal Dis. 2016;18(2):187–94.
6. Zhao JH, Sun JX, Gao P, et al. Fast-track surgery versus traditional perioperative care in lapa-
roscopic colorectal cancer surgery: a meta-analysis. BMC Cancer. 2014;14:607.
42 Quality Improvement: Are Fast Track Pathways for Laparoscopic Surgery Needed?
484
7. Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA. Which fast track
elements predict early recovery after colon cancer surgery? Colorectal Dis Off J Assoc
Coloproctol of Great Brit Irel. 2012;14(8):1001–8.
8. Vlug MS, Wind J, van der Zaag E, Ubbink DT, Cense HA, Bemelman WA. Systematic review
of laparoscopic vs open colonic surgery within an enhanced recovery programme. Colorectal
Dis Off J Assoc Coloproctology Great Brit Irel. 2009;11(4):335–43.
9. Braga M, Vignali A, Gianotti L, et al. Laparoscopic versus open colorectal surgery: a random-
ized trial on short-term outcome. Ann Surg. 2002;236(6):759–66; discussion 767.
10. Jun L. Systematic review of laparoscopic versus open surgery for colorectal cancer (Br J Surg.
2006;93;921–8). Br J Surg. 2007;94(2):250; author reply 250.
11. Kehlet H. Systematic review of laparoscopic versus open surgery for colorectal cancer (Br
J Surg. 2006;93:921–8). Br J Surg. 2006;93(11):1434–5.
12. Reza MM, Blasco JA, Andradas E, Cantero R, Mayol J. Systematic review of laparoscopic
versus open surgery for colorectal cancer. Br J Surg. 2006;93(8):921–8.
13. Vlug MS, Wind J, Hollmann MW, et al. Laparoscopy in combination with fast track multi-
modal management is the best perioperative strategy in patients undergoing colonic surgery: a
randomized clinical trial (LAFA-study). Ann Surg. 2011;254(6):868–75.
14. Zhuang C-L, Ye X-Z, Zhang X-D, Chen B-C, Yu Z. Enhanced recovery after surgery programs
versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials.
Dis Colon Rectum. 2013;56(5):667–78.
15. Kennedy RH, Francis EA, Wharton R, et al. Multicenter randomized controlled trial of con-
ventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery pro-
gramme: EnROL. J Clin Oncol. 2014;32(17):1804–U1884.
16. Song KC, Wang YH, Li T, Zhang WB, Xu XC. Systemic review of fast-track surgery in
patients undergoing laparoscopic colorectal resection. [Article in Chinese]. Zhonghua Wei
Chang Wai Ke Za Zhi. 2012;15(10):1048–52.
17. Taupyk Y, Cao X, Zhao Y, Wang C, Wang Q. Fast-track laparoscopic surgery: a better option
for treating colorectal cancer than conventional laparoscopic surgery. Oncol Lett.
2015;10(1):443–8.
18. Haverkamp MP, de Roos MA, Ong KH. The ERAS protocol reduces the length of stay after
laparoscopic colectomies. Surg Endosc. 2012;26(2):361–7.
19. Huibers CJ, de Roos MA, Ong KH. The effect of the introduction of the ERAS protocol in lap-
aroscopic total mesorectal excision for rectal cancer. Int J Colorectal Dis. 2012;27(6):751–7.
20. Khreiss W, Huebner M, Cima RR, et al. Improving conventional recovery with enhanced recov-
ery in minimally invasive surgery for rectal cancer. Dis Colon Rectum. 2014;57(5):557–63.
21. Schwenk W, Haase O, Neudecker J, Muller JM. Short term benefits for laparoscopic colorectal
resection. Cochrane Database Syst Rev. 2005;(3):CD003145.
A.S. Walker et al.
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485© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_43
Chapter 43
Quality Improvement: Enhanced Recovery
Pathways for Open Surgery
W. Conan Mustain and Conor P. Delaney
Introduction
Patients undergoing open colectomy are frequently subjected to severe metabolic
stress and dramatic alterations of their normal physiology during the perioperative
period. These changes contribute to prolonged pain, immobility, and gut dysfunc-
tion which require extended hospitalization. In recent years efforts have been made
to accelerate recovery, by minimizing stress, optimizing pain control, and shorten-
ing the time to resumption of normal activities, with the goal of returning patients to
their normal lives and avoiding perioperative complications. The logical secondary
benefit of decreasing length of stay and complications is a reduction in health care
costs. The combination of multiple modalities to achieve this goal has been referred
to as fast-track surgery, multimodal recovery, enhanced recovery pathways (ERP),
or enhanced recovery after surgery (ERAS).
The general concept of ERP involves a protocol designed to avoid unnecessary
stress, preserve organ function, and promote patient autonomy. This requires a series
of targeted interventions in the preoperative, intraoperative, and immediate postopera-
tive period. The principle areas of an effective ERP and the outlined in Table 43.1. The
specific interventions within each realm that are required for an effective ERP are still
open to debate. Over 20 different possible interventions have been described, with
great variation in their use between institutions. A detailed analysis of the evidence
behind each potential component of an ERP is beyond the scope of this review. For a
W.C. Mustain, MD
Division of Colon and Rectal Surgery, University of Arkansas for Medical Sciences,
Little Rock, AR, USA
C.P. Delaney, MD, PhD (
*)
Digestive Disease Institute, Cleveland Clinic,
9500 Euclid Avenue, Cleveland, OH 44195, USA
e-mail: delanec@ccf.org
486
comprehensive analysis of the evidence supporting specific pathway components the
reader is referred to the Guidelines for Perioperative Care in Elective Surgery:
Enhanced Recovery After Surgery (ERAS®) Society Recommendations [1].
While the theoretical benefits of ERP are clear, it is necessary to ensure that the
benefits outweigh any undesirable consequences caused by deviations from conven-
tional management. Simply achieving an earlier discharge from the hospital is
insufficient if there are resultant increases in complications from feeding patients
too early, readmissions from sending them out too soon, or dissatisfaction from
patients’ feeling rushed out of the hospital. In this chapter we review the literature
supporting ERP for open colectomy and provide an evidence-based endorsement
for their routine application.
Methods
Following the GRADE approach we began by formulating an appropriate clinical
question, defining the four critical components of patient population, intervention,
comparison, and outcomes of interest, illustrated in a standard PICO table
Table 43.1 Components of an enhanced recovery pathway
Patient information
1. Preoperative information and counseling
2. Preset discharge criteria
3. Stoma marking and education if indicated
4. Optimization (home incentive spirometer, smoking cessation, prehab)
Preservation of bowel function
5. Clear liquids until 2 h before surgery
6. High-carbohydrate beverage morning of surgery
7. Alvimopan, chewing gum, laxatives
8. Early feeding post-operatively
Avoiding organ dysfunction
9. Selective use of bowel prep
10. Antimicrobial and thromboembolic prophylaxis
11. Avoid hypothermia
12. Balanced use of crystalloids to optimize cardiac output and avoid excess fluid
Optimizing pain control
13. Preemptive analgesia started before surgery
14. Local anesthetic, regional blocks, or epidurals
15. Laparoscopy or minimal access incisions
16. Scheduled use of non-opioid analgesics
Promotion of patient autonomy
17. Avoid long-acting sedative premedication
18. Avoid nasogastric tubes and drains
19. Enforced early mobilization
20. Early removal of urinary catheter and IV fluids
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(Table 43.2) [2]. The patient group of interest was those undergoing open colec-
tomy, with the intervention of treatment by ERP as compared to traditional care
(TC), with the intent to answer, “Should patients undergoing open colectomy be
managed by ERP rather than TC?” The outcomes considered critical in this search
were morbidity, mortality, and readmission rates, recognizing the principle of non-
maleficence (do no harm) as paramount over any effects on hospital stay or costs.
However, because beneficence (acting for the benefit of others), rather than simply
avoidance of harm, should form the foundation of any clinical recommendation
we also considered hospital length of stay (LOS), costs, and patient satisfaction or
quality of life (QoL) as important outcomes. The quality of the evidence was
graded for each outcome and the evidence was used to formulate a recommenda-
tion on the question of interest. The strength of our recommendation is based on
our degree of confidence that the desirable effects outweigh the undesirable
effects, as influenced by the magnitude of the differences between benefit and
harm, the quality of the evidence, and the value placed on the outcomes of
interest.
Search Strategy
A systematic search of the literature was conducted using MEDLINE, PubMed,
Web of Science, and the Cochrane Collaborative to identify articles related to the
topic of interest. The initial search included Medical Subject Headings terms, as
well as entry terms for relevant interventions and outcomes. Key words included
[“colectomy” OR “colon surgery” OR “colorectal surgery”] AND [“perioperative”
OR “post-operative” OR “post-surgical” OR “rehabilitation”] AND [“enhanced
recovery” OR “ERAS” OR “ERP” OR “fast-track” OR “multimodal”]. The search
was conducted for all dates up to November 2015 and restricted to English language
titles. No age limits were applied. Titles and abstracts were screened for inclusion
based on relevance. In addition, reference lists of retrieved articles were screened
for additional relevant studies. Randomized controlled trials, case control trials, ret-
rospective cohorts, systematic reviews, meta-analyses, reviews, letters, and editori-
als were considered. Emphasis was placed on studies comparing ERP to TC after
open colectomy, with priority given to randomized controlled trials and meta-
analyses where data was available for specific outcomes. For less well-studied out-
comes all sources were considered.
Table 43.2 PICO table
P (patient population) I (intervention) C (comparator) O (outcomes of interest)
Patients undergoing
open colectomy
Enhanced recovery
pathways (ERP)
Traditional care
(TC)
Complications
Readmissions
Length of Stay
Cost
Quality of Life/
Satisfaction
43 Quality Improvement: Enhanced Recovery Pathways for Open Surgery