Updated Guidelines: Enhanced Recovery Protocols for Colon and Rectal Surgery

Patient in hospital bed with doctor holding their hand, recovery after surgery

Enhanced recovery protocols (ERPs), also known as “fast track” or “enhanced recovery after surgery” protocols, are standardized perioperative procedures designed to be applied to all patients undergoing certain elective surgeries.

The content of ERPs varies substantially between institutions, but in the case of colorectal surgery, all are intended to improve outcomes such as rates of nausea, pain, and wound infection; time to return of bowel function; and length of hospital stay.

In Surgical Endoscopy, the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons published revised joint guidelines for developing ERPs related to elective colon and rectal resection. Jennifer L. Irani, MD, a surgeon in the Division of Colorectal Surgery at Brigham and Women’s Hospital, served as co–first author.

New Recommendations

Using the 2017 version of the guidelines as a platform, representatives of the two societies evaluated the evidence supporting common components of ERPs for colorectal surgery. They added three new recommendations:

  • Oral nutritional supplementation is recommended in malnourished patients before elective colorectal surgery (graded by the authors as a weak recommendation based on moderate-quality evidence)

  • Hypotension should be avoided as even short durations of MBP (mean blood pressure) <65 are associated with adverse outcomes, particularly myocardial injury and acute kidney injury (strong recommendation based on moderate-quality evidence)

  • Early discharge before the return of bowel function may be feasible in low-risk patients undergoing minimally invasive colectomy when coupled with close outpatient communication and follow-up (weak recommendation based on moderate-quality evidence)

New Evidence

For six statements, the authors updated the level of evidence as follows:

  • Mechanical bowel preparation combined with preoperative oral antibiotics is typically recommended before elective colorectal resection (strong recommendation based on moderate-quality evidence)

  • Thoracic epidural analgesia, while not recommended for routine use in laparoscopic colorectal surgery, is an option for open colorectal surgery if a dedicated acute pain team is available for postoperative management (strong recommendation based on moderate-quality evidence)

  • Fluid administration should be tailored to avoid excessive fluid administration and volume overload or undue fluid restriction and hypovolemia (strong recommendation based on high-quality evidence)

  • Balanced chloride-restricted crystalloid solutions should be used for maintenance infusions and fluid boluses in patients undergoing colorectal surgery; there is no benefit to the routine use of colloid solutions for fluid boluses (strong recommendation based on moderate-quality evidence)

  • In high-risk patients and patients undergoing colorectal surgery with significant intravascular losses, the use of goal-directed hemodynamic therapy may be considered (weak recommendation based on moderate-quality evidence)

  • Urinary catheters should typically be removed within 24–48 hours after mid/lower rectal resection (strong recommendation based on moderate-quality evidence)

The guidelines retain 18 other recommendations. Separate guidelines of the ASCRS discuss frailty, prevention of deep vein thrombosis, bowel preparation, and ostomy surgery in detail.

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