By Tina DiMarcantonio Brown

A multi-institutional controlled study has shown the efficacy of an enhanced recovery after surgery (ERAS) protocol for patients undergoing colon cancer surgery, without an increase in complication risk (Surg Today 2016 Sep 29. [Epub ahead of print], PMID: 27688031).

ERAS or “fast-track” surgical pathways have been developed to accelerate postoperative recovery. These pathways involve perioperative care interventions focused on anesthesia, analgesia, reduction of surgical stress, goal-directed fluid therapy, prevention of nausea and ileus, thromboembolic prophylaxis, minimally invasive techniques, nutrition and early mobilization. Researchers believe that implementing as many of these ERAS elements as possible shortens hospital length of stay without increasing the postoperative complication rate or mortality; however, this belief has been based on a small amount of data.

In the current study, investigators prospectively evaluated the safety and efficacy of an ERAS protocol among 320 patients with an American Society of Anesthesiologists physical status of grade I or II. The patients underwent elective colon resection or high anterior resection from April 2011 to January 2014 at six institutions. Most operations were done laparoscopically. Three hospitals implemented an ERAS protocol (159 patients), and three administered conventional care (161 patients).

Results revealed less blood loss in the ERAS patients, at 10 mL compared with 35.5 mL in the conventional care patients. Operative time was shorter with ERAS than conventional care (196 vs. 230 minutes), and intraoperative fluid administration was also less in the ERAS group (950 vs. 1,700 mL).

Researchers found a 17% incidence of surgical complications, including ileus, surgical site infection, anastomotic leaks, and anastomotic or intraperitoneal bleeding, in the ERAS group compared with 16.1% in the conventional care group. Nonsurgical complications were also similar between the two groups.

Patients receiving the ERAS protocol consumed food orally at a median of one day postoperatively compared with three days in patients receiving conventional care. Hospital length of stay was a median of 5.5 days shorter with ERAS than conventional care.

Discharge criteria were also met sooner in the ERAS group, after a median of three days compared with 10 days in the conventional-care group. Discharge criteria for both groups included adequate pain relief using nonopioid oral analgesia, normal food intake without parenteral nutrition, a bowel movement and ability to resume activities of daily living at the preoperative level.

“The present series of 320 patients represents one of the largest ERAS trials,” the investigators wrote. “Our results suggest that the ERAS protocol is superior to conventional postoperative management after elective colonic resection for colon cancer. … These results may encourage medical staff, surgeons and anesthetists to implement and support adherence to an ERAS protocol.”