Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices

Table 1 Enhanced recovery after surgery elements used in 4 published trials comparing enhanced recovery after surgery vs non-enhanced recovery after surgery in emergency colorectal surgery

ERAS elements	Lohsiriwat[8]	Wisely et al[10]	Shida et al[11]	Shang et al[12]
Preoperative phase
Education and detailed counseling	Y	Y	Y	Y
Medical optimization		Y
No bowel preparation	Y	Y	Y	Y
No pre-anesthetic medication	Y	Y	Y	Y
Intraoperative phase
Use of epidural analgesia		Y	Y
Active warming	Y		Y	Y
Avoid sodium/fluid overload	Y	Y	Y	Y
Prophylaxis of nausea and vomiting	Y	Y		Y
No intraabdominal drainage	Y			Y
Postoperative phase
Opioid-sparing multimodal analgesia	Y	Y	Y	Y
Early removal of nasogastric tube	Y	Y	Y	Y
Early feeding	Y	Y	Y	Y
Early removal of urinary catheter	Y	Y	Y	Y
Use of laxatives		Y	Y	Y
Early mobilization	Y	Y	Y	Y

Y: Yes or applicable; ERAS: Enhanced recovery after surgery.

Table 2 Summary of study characteristics and clinical outcomes of three published studies comparing enhanced recovery after surgery vs non-enhanced recovery after surgery in emergency colorectal surgery

	Lohsiriwat[8]	Wisely et al[10]	Shida et al[11]	Shang et al[12]
Characteristics
Country, year	Thailand, 2014	Australia, 2016	Japan, 2017	China, 2018
Study design	Match case-control	Pre-Post ERAS	Pre-Post ERAS	Match case-control
ERAS/non-ERAS	20/40	80/97	42/80	318/318
Inclusion criteria	Obstructing colorectal cancer	Benign diseases and malignancy	Obstructing colorectal cancer	Obstructing colorectal cancer
Exclusion criteria	No bowel resection, concomitant bowel perforation	Laparoscopic surgery	No bowel resection, concomitant bowel perforation	Recurrent tumor, no bowel resection, concomitant bowel perforation
Clinical outcomes
GI recovery time	Sig. decreased	NA	NA	Sig. decreased
Complication	Decreased	Sig. decreased	Decreased	Sig. decreased
Hospital stay	Sig. decreased	Same	Sig. decreased	Sig. decreased
30-d mortality	Same	Same	Same	Same
30-d readmission	Same	Same	Same	Same
30-d reoperation	NA	Same	Same	Same
Interval between surgery and chemotherapy	sig. decreased	NA	NA	sig. decreased

GI: Gastrointestinal; NA: Not available; Sig.: Significantly; ERAS: Enhanced recovery after surgery.

Table 3 Evidence-based enhanced recovery after surgery protocol in emergency colorectal surgery

ERAS item	Recommendation
Preoperative phase
Education and detailed counseling	Patients should routinely receive concise and practical preoperative education including stoma counseling
Medical optimization	Preoperative risk stratification and “targeted” optimization of general conditions are recommended
Glycemic control	Perioperative blood glucose should be maintained between 140 and 180 mg/dL
Intraoperative phase
Use of epidural analgesia	Thoracic epidural analgesia may be used in patients with stable hemodynamic and no bleeding tendency
GDFT	GDFT may be beneficial in patients with high-predicted postoperative mortality
Prevention of hypothermia	All measures should be done to prevent or reverse intraoperative hypothermia
PONV	A multimodal prophylaxis of PONV should be used in all patients based on their risk factors for PONV
Minimally invasive surgery	Laparoscopy may be performed in selected patients by experienced surgeons
Avoidance of intraperitoneal drains	Intraabdominal and pelvic drains should not be used routinely
Postoperative phase
Multimodal analgesia	Opioid-sparing multimodal analgesia should be tailored to the individual and the operation involved
Early removal of NGT	NGT can be removed safely on postoperative day 1-2 unless paralytic ileus is evident
Early feeding	Oral intake can resume in stabilized patients and should progress moderately if patients can tolerate
Early removal of urinary catheter	Urinary catheter can be removed safely on postoperative day 1-2
Breathing and coughing exercise	Patients are encouraged to have sessions of deep breathing and coughing exercise postoperatively
Early mobilization	Patients are encouraged to have early independent mobilization as a part of physiotherapy and rehabilitation program

ERAS: Enhanced recovery after surgery; GDFT: Goal-directed fluid therapy; PONV: Postoperative nausea and vomiting; NGT: Nasogastric tube.