Guidelines for Perioperative Care in Elective Rectal/Pelvic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Improved Recovery Experience Achieved for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model Substitution of Usual Perioperative Care by eHealth to Enhance Postoperative Recovery in Patients Undergoing General Surgical or Gynecological Procedures: Study Protocol of a Randomized Controlled Trial Effects of goal-directed fluid therapy on enhanced postoperative recovery: An interventional comparative observational study with a historical control group on oesophagectomy combined with ERAS program. Enhanced Recovery After Surgery Versus Conventional Perioperative Care in Rectal Surgery Evidence-Based Protocol for Infection Control in Immediate Implant-Based Breast Reconstruction A systematic review of enhanced recovery protocols in colorectal surgery. Optimal Timing of Acustimulation for Antiemetic Prophylaxis as an Adjunct to Ondansetron in Patients Undergoing Plastic Surgery Observation of clinical efficacy of application of enhanced recovery after surgery in perioperative period on esophageal carcinoma patients. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. A Prospective Randomized Controlled Trial of Multimodal Perioperative Management Protocol in Patients Undergoing Elective Colorectal Resection for Cancer Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection Improving recovery after elective degenerative spine surgery: 5-year experience with an enhanced recovery after surgery (ERAS) protocol. Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial
Background This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery , and to provide grade d recommendations for items for an evidence d-based enhanced recovery protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omized controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( evidence grade : high or moderate ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , European Society for Clinical Nutrition and Metabolism ( ESPEN ) and International Association for Surgical Metabolism and Nutrition ( IASMEN ) present a comprehensive evidence -based consensus review of perioperative care for rectal surgery Background Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . Methods An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated “ high ” , “ moderate ” , “ low ” or “ very low ” . Recommendations were grade d as “ strong ” or “ weak ” . Results Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . Conclusions The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials Background This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery BACKGROUND & AIMS Protocol s for enhanced recovery provide comprehensive and evidence -based guidelines for best perioperative care . Protocol implementation may reduce complication rates and enhance functional recovery and , as a result of this , also reduce length-of-stay in hospital . There is no comprehensive framework available for pancreaticoduodenectomy . METHODS An international working group constructed within the Enhanced Recovery After Surgery ( ERAS ® ) Society constructed a comprehensive and evidence -based framework for best perioperative care for pancreaticoduodenectomy patients . Data were retrieved from st and ard data bases and personal archives . Evidence and recommendations were classified according to the GRADE system and reached through consensus in the group . The quality of evidence was rated " high " , " moderate " , " low " or " very low " . Recommendations were grade d as " strong " or " weak " . RESULTS Comprehensive guidelines are presented . Available evidence is summarised and recommendations given for 27 care items . The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations . CONCLUSIONS The present evidence -based guidelines provide the necessary platform upon which to base a unified protocol for perioperative care for pancreaticoduodenectomy . A unified protocol allows for comparison between centres and across national borders . It facilitates multi-institutional prospect i ve cohort registries and adequately powered r and omised trials Background : Enhanced recovery after surgery was compared with traditional recovery after surgery for postmastectomy alloplastic breast reconstruction . Methods : Length of stay , emergency room visits , and complications within 30 days of surgery were compared among three groups : traditional recovery after surgery , transition ( some elements of enhanced recovery protocol , not transitioned to outpatient care ) , and enhanced recovery after surgery ( day surgery , provided with st and ardized perioperative education and multimodal analgesia ) . Prospect i ve data collection allowed quality -of-recovery assessment using a vali date d question naire for enhanced recovery/transition groups . Results were statistically analyzed ( analysis of variance/chi-square ) . Results : The traditional recovery , transition , and enhanced recovery cohorts comprised 29 , 11 , and 29 patients , respectively . No significant differences were present regarding age , smoking status , preoperative radiation , single stage direct-to-implant versus tissue exp and er , bilateral versus unilateral surgery , or immediate versus delayed reconstruction among groups . Average length of stay was 1.6 nights in both the traditional recovery and transition groups , compared with 0 nights in the enhanced recovery group ( p < 0.001 ) . Enhanced recovery patients had less severe pain ( p = 0.02 ) and nausea ( p = 0.01 ) , and better enjoyed their food ( p = 0.0002 ) and felt more rested ( p = 0.02 ) than their transition counterparts . There were no differences in the number of emergency room visits among the three groups ( p = 0.88 ) . There was no difference in the rate of hematoma ( p = 0.36 ) , infection requiring intravenous antibiotics ( p = 0.36 ) , or infection requiring explantation ( p = 0.36 ) among the three groups . Conclusion : An enhanced recovery protocol for alloplastic breast reconstruction treated patients safely , with improved patient satisfaction and same-day discharge and with no increase in complications . CLINICAL QUESTION /LEVEL OF EVIDENCE : Therapeutic , III Background Due to the strong reduction in the length of hospital stays in the last decade , the period of in-hospital postoperative care is limited . After discharge from the hospital , guidance and monitoring on recovery and resumption of ( work ) activities are usually not provided . As a consequence , return to normal activities and work after surgery is hampered , leading to a lower quality of life and higher costs due to productivity loss and increased health care consumption . Objective With this study we aim to evaluate whether an eHealth care program can improve perioperative health care in patients undergoing commonly applied abdominal surgical procedures , leading to accelerated recovery and to a reduction in costs in comparison to usual care . Methods This is a multicenter r and omized , single-blinded , controlled trial . At least 308 patients between 18 and 75 years old who are on the waiting list for a laparoscopic cholecystectomy , inguinal hernia surgery , or laparoscopic adnexal surgery for a benign indication will be included . Patients will be r and omized to an intervention or control group . The intervention group will have access to an innovative , perioperative eHealth care program . This intervention program consists of a website , mobile phone app , and activity tracker . It aims to improve patient self-management and empowerment by providing guidance to patients in the weeks before and after surgery . The control group will receive usual care and will have access to a nonintervention ( st and ard ) website consisting of the digital information brochure about the surgical procedure being performed . Patients are asked to complete question naires at 5 moments during the first 6 months after surgery . The primary outcome measure is time to return to normal activities based on a patient-specific set of 8 activities selected from the Patient-Reported Outcomes Measurement Information System ( PROMIS ) physical functioning item bank version 1.2 . Secondary outcomes include social participation , self-rated health , duration of return to work , physical activity , length of recovery , pain intensity , and patient satisfaction . In addition , an economic evaluation alongside this r and omized controlled trial will be performed from the societal and health care perspective . All statistical analyses will be conducted according to the intention-to-treat principle . Results The enrollment of patients started in September 2015 . The follow-up period will be completed in February 2017 . Data cleaning and analyses have not begun as of the time this article was su bmi tted . Conclusions We hypothesize that patients receiving the intervention program will resume their normal activities sooner than patients in the control group and costs will be lower . Clinical Trial Netherl and s Trial Registry NTC4699 ; http://www.trialregister.nl/trialreg/admin/ rct view.asp?TC=4699 ( Archived by WebCite at http://www.webcitation.org/6mcCBZmwy BACKGROUND AND AIMS The Enhanced Recovery after Surgery ( ERAS ) program has been proposed as a postoperative recovery-enhancing strategy . We frequently apply the Modified-ERAS program following oesophagectomy . This study aims to eluci date the impact of goal -directed fluid therapy ( GDT ) for the perioperative management of oesophageal cancer on the postoperative recovery of patients undergoing oesophagectomy . METHODS This is an interventional before-after comparative observational study conducted at Kanagawa Cancer Centre , Japan . Patients who underwent elective oesophagectomy for oesophageal cancer were recruited . Group H ( retrospectively collected ) received intraoperative and postoperative management consisting of fluid administration without haemodynamic monitoring and the M-ERAS program , while Group S prospect ively received management consisting of GDT and the M-ERAS program . The primary endpoint was the speed of gastrointestinal functional recovery , while secondary endpoints were the level of postoperative mobilisation , incidence of complications , postoperative length of hospital stay ( LOS ) , and nutritional status after discharge . RESULTS The proportion of patients who completely egested Gastrografin by postoperative day 4 , the level of postoperative mobilisation , and achievement ratio for a 100-m walk on the first postoperative attempt were significantly higher in Group S than in Group H ( P = 0.034 , P = 0.0197 , and P < 0.0001 , respectively ) . No significant differences were observed in the postoperative LOS and incidence of complications within 30 days between the groups . The serum albumin levels at 6 months after discharge was higher in Group S than in Group H ( P = 0.0002 ) . CONCLUSIONS The GDT-ERAS program enhanced postoperative gastrointestinal recovery and mobilisation , as well as postoperative nutritional status and protein synthesis . The program did not affect either postoperative LOS or the incidence of complications . TRIAL REGISTRATION UMIN registration number : UMIN000013705 , https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000015999 BACKGROUND : Enhanced recovery after surgery programs have been developed to improve recovery , shorten hospital stays , and reduce morbidity . OBJECTIVE : The aim of the current study was to examine the effects of the enhanced recovery program on the outcome of rectal surgery . DESIGN : A cohort of patients who underwent open rectal surgery after an enhanced recovery program was compared with a historic case-matched control group receiving conventional perioperative care . Patients were matched for type of surgery , disease , comorbidity , and demographic characteristics . Data regarding fast-track targets , length of hospital stay , mortality , complications , relaparotomies , and readmissions were collected . RESULTS : Forty-one patients in the enhanced recovery group were compared with 82 case-matched patients receiving conventional care .  The length of hospital stay ( median : 8 days vs 12 days , P < .005 ) was reduced in the enhanced recovery after surgery group . There were no significant differences in epidural use , mortality , morbidity , and readmission rates between groups . LIMITATIONS : This study performed an intention-to-treat analysis for the multimodal enhanced recovery program in rectal surgery . Specific elements of the program were not analyzed separately . The study used nonr and omly assigned historic controls for comparison . CONCLUSION : Enhanced recovery after surgery programs help to reduce the length of hospital stay after rectal surgery Abstract Immediate breast implant reconstruction has among the highest incidence of infections in plastic surgery . A literature search returned key articles that showed a significant decrease in surgical-site infections by performing nasal swab evaluation to treat methicillin-sensitive and methicillin-resistant Staphylococcus aureus before surgery with mupirocin nasal ointment and 5 days of chlorhexidine scrub to the surgical area . Additional Level 1 data supported the use of chlorhexidine-alcohol over povidone-iodine solutions for skin preparation . Intraoperative data on breast pocket irrigation showed the benefits of povidone-iodine as well as a triple antibiotic solution . Nasal swabs from 120 patients showed no methicillin-resistant S. aureus but did identify 10 patients with methicillin-sensitive S. aureus , 1 with streptococcus , and 3 with gram-negative rods , which changed perioperative antibiotic management . On the basis of the previously mentioned data , an evidence -based protocol for infection control was developed to potentially decrease infection rates . Further cost and efficacy data are warranted INTRODUCTION Colorectal surgery has been associated with a complication rate of 15 - 20 % and mean post-operative inpatient stays of 6 - 11 days . The principles of enhanced recovery after surgery ( ERAS ) are well established and have been developed to optimise peri-operative care and facilitate discharge . The purpose of this systematic review is to present an up date d review of peri-operative care in colorectal surgery from the available evidence and ERAS group recommendations . METHODS Systematic search es of the PubMed and Embase ™ data bases and the Cochrane library were conducted . A h and search of bibliographies of identified studies was conducted to identify any additional articles missed by the initial search strategy . RESULTS A total of 59 relevant studies were identified . These included six r and omised controlled trials and seven clinical controlled trials that fulfilled the inclusion criteria . These studies showed reductions in duration of inpatient stays in the ERAS groups compared with more traditional care as well as reductions in morbidity and mortality rates . CONCLUSIONS Review ing the data reveals that ERAS protocol s have a role in reducing post-operative morbidity and result in an accelerated recovery following colorectal surgery . Similarly , both primary and overall hospital stays are reduced significantly . However , the available evidence suggests that ERAS protocol s do not reduce hospital readmissions or mortality . These findings help to confirm that ERAS protocol s should now be implemented as the st and ard approach for peri-operative care in colorectal surgery We design ed this study to evaluate the antiemetic efficacy of transcutaneous electrical acupoint stimulation in combination with ondansetron when applied before , after , or both before and after plastic surgery . A r and omized , double-blind , sham-controlled study design was used to compare three prophylactic acustimulation treatment schedules : preoperative — an active device was applied for 30 min before and a sham device for 72 h after surgery ; postoperative — a sham device was applied for 30 min before and an active device for 72 h after surgery ; and perioperative — an active device was applied for 30 min before and 72 h after surgery ( n = 35 per group ) . All patients received a  st and ardized general anesthetic  , and ondansetron 4 mg IV was administered at the end of surgery . The incidence of vomiting/retching and the need for rescue antiemetics were determined at specific time intervals for up to 72 h after surgery . Nausea scores were recorded with an 11-point verbal rating scale . Other outcome variables assessed included discharge times ( for out patients ) , resumption of normal activities of daily living , complete antiemetic response rate , and patient satisfaction with antiemetic therapy and quality of recovery . Perioperative use of the ReliefB and ® significantly increased complete responses ( 68 % ) compared with use of the device before surgery only ( 43 % ) . Median postoperative nausea scores were significantly reduced in the peri- and postoperative ( versus preoperative ) treatment groups . Finally , patient satisfaction with the quality of recovery ( 83 ± 16 and 85 ± 13 vs 72 ± 18 ) and antiemetic management ( 96 ± 9 and 94 ± 10 vs 86 ± 13 ) on an arbitrary scale from 0 = worst to 100 = best was significantly higher in the groups receiving peri- or postoperative ( versus preoperative ) acustimulation therapy . For patients discharged on the day of surgery , the time to home readiness was significantly reduced ( 114 ± 41 min versus 164 ± 50 min ; P < 0.05 ) when acustimulation was administered perioperatively ( versus preoperatively ) . In conclusion , acustimulation with the ReliefB and ® was most effective in reducing postoperative nausea and vomiting and improving patients ’ satisfaction with their antiemetic therapy when it was administered after surgery PURPOSE To observe the clinical efficacy of the application of enhanced recovery after surgery ( ERAS ) in the perioperative period of esophageal carcinoma patients . METHODS A total of 114 patients who were admitted to Affiliated Hospital of Jining Medical University for surgical treatment of esophageal carcinoma between June 2012 and June 2016 were enrolled and r and omly divided into the intervention group and the regular group according to the difference of management procedures during the perioperative period . ERAS was carried out in 57 patients in the intervention group , while conventional management procedures were applied in 57 patients in the regular group . Thereafter , compared were the fluctuations in nutritional indicators and immunological indicators , postoperative complications , time to recovery of gastrointestinal function , length of stay ( LOS ) in hospital and cost of patients between the two groups . RESULTS Seven days post-operation in the intervention group , the evaluation indexes of nutrition status , including total protein ( TP ) , albumin ( ALB ) , prealbumin ( PA ) and transferrin ( TF ) , and of immunological functions , including immunoglobulin G ( IgG ) , immunoglobulin A ( IgA ) , immunoglobulin M ( IgM ) and total blood lymphocyte count ( TLC ) , were significantly higher than those in the regular group . As for postoperative complications , the incidence rate of the intervention group was remarkably lower than that of the regular group ; the recovery time of gastrointestinal function in the intervention group was shorter than that in the regular group ; the LOS in the intervention group was also shorter than that in the regular group ; the in-hospital cost in the intervention group was also lower than that in the regular group . All differences above were statistically significant ( p<0.05 ) . CONCLUSION During the perioperative period of esophageal carcinoma patients , ERAS should be fully applied to sustain the good status , and promote the recovery of immunological functions and gastrointestinal functions ; at the same time , ERAS also reduces the incidence rate of postoperative complications , LOS and in-hospital cost , and we maintain that ERAS should be performed in clinical practice BACKGROUND The ERAS ( enhanced recovery after surgery ) care has been shown in r and omized clinical trials to improve outcome after colorectal surgery compared to traditional care . The impact of different levels of compliance and specific elements , particularly out with a trial setting , is poorly understood . OBJECTIVE This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection . METHODS The international , multicenter ERAS registry data , collected between November 2008 and March 2013 , was review ed . Patient demographics , disease characteristics , and perioperative ERAS protocol compliance were assessed . Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication . FINDINGS A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries .  Median length of stay for colorectal resections was 6 days , with readmissions in 216 ( 9.2 % ) , complications in 948 ( 40 % ) , and reoperation in 167 ( 7.1 % ) of 2352 patients . Laparoscopic surgery was associated with reduced complications [ odds ratio ( OR ) = 0.68 ; P < 0.001 ] and length of stay ( OR = 0.83 , P < 0.001 ) . Increasing ERAS compliance was correlated with fewer complications ( OR = 0.69 , P < 0.001 ) and shorter primary hospital admission ( OR = 0.88 , P < 0.001 ) . Shorter hospital stay was associated with preoperative carbohydrate and fluid loading ( OR = 0.89 , P = 0.001 ) , and totally intravenous anesthesia ( OR = 0.86 , P < 0.001 ) ; longer stay was associated with intraoperative epidural analgesia ( OR = 1.07 , P = 0.019 ) . Reduced postoperative complications were associated with restrictive perioperative intravenous fluids ( OR = 0.35 , P < 0.001 ) . CONCLUSIONS This analysis has demonstrated that in a large , international cohort of patients , increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome Objective : A prospect i ve r and omized controlled trial ( RCT ) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer . Aims : This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT . Methods : Patients for elective resection for colorectal cancer were offered trial entry . Participants were stratified by sex and requirement for a total mesorectal excision and central ly r and omized .  Multimodal patients received intravenous fluid restriction , unrestricted oral intake with prokinetic agents , early ambulation , and fixed regimen epidural analgesia . Control patients received intravenous fluids to prevent oliguria , restricted oral intake until return of bowel motility , and weaning regimen epidural analgesia . Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets . Discharge decision was made using preagreed criteria . The primary endpoint was postoperative stay , and achievement of independence milestones . Secondary endpoints were postoperative complications , readmission rates , and mortality . Analysis was by intention to treat . Results : Seventy patients were recruited . Approximately one fourth underwent TME . Median ages were similar ( 69.3 vs. 73.0 years ) . The median stay was significantly reduced in the multimodal group ( 5 vs. 7 days ; P < 0.001 , Mann-Whitney U test ) . Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days . Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions . There were 2 deaths , both controls . Conclusions : This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery . Morbidity and mortality are not increased Enhanced recovery after surgery ( ERAS ) pathways have been associated with improved perioperative outcomes following several surgical procedures . Less is known , however , regarding their use following hepatic surgery OBJECTIVE Enhanced recovery after surgery ( ERAS ) has led to a paradigm shift in various surgical specialties . Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process . Still , ERAS remains relatively new to spine surgery . The authors report their 5-year experience , focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures , including anterior lumbar interbody fusion ( ALIF ) . METHODS A multimodal ERAS protocol was applied between November 2013 and October 2018 . The authors analyze hospital stay , perioperative outcomes , readmissions , and adverse events obtained from a prospect i ve institutional registry .  Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive ( MI ) anterior or posterior fusion cases were included . Their institutional ERAS protocol contains 22 pre- , intra- , and postoperative elements , including preoperative patient counseling , MI techniques , early mobilization and oral intake , minimal postoperative restrictions , and regular audits . RESULTS A total of 2592 consecutive patients were included , with 199 ( 8 % ) undergoing fusion . The mean hospital stay was 1.1 ± 1.2 days , with 20 ( 0.8 % ) 30-day and 36 ( 1.4 % ) 60-day readmissions . Ninety-four percent of patients were discharged after a maximum 1-night hospital stay . Over the 5-year period , a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed ( p < 0.001 ) , with a concomitant decrease in adverse events in the overall cohort ( p = 0.025 ) and without increase in readmissions . For fusion procedures , the rate of 1-night hospital stays increased from 26 % to 85 % ( p < 0.001 ) . Similarly , the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days ( p < 0.001 ) , with a notable concomitant decrease in variance , result ing in an estimated reduction in nursing costs of 46.8 % . CONCLUSIONS Application of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures , including ALIF , for treatment of degenerative spine conditions was safe and effective , without increase in readmissions . The data from this large case series stress the importance of the multidisciplinary , iterative improvement process to overcome the learning curve associated with ERAS implementation , and the importance of a dedicated perioperative care team . Prospect i ve trials are needed to evaluate spinal ERAS on a higher level of evidence Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety
Key recommendations support use of  opioid-sparing perioperative medications  , minimal preoperative fasting and early feeding , use of anesthetic techniques that decrease postoperative nausea and vomiting and pain , use of measures to prevent intraoperative hypothermia , and support of early mobilization after surgery .
Background : Enhanced recovery following surgery can be achieved through the introduction of evidence -based perioperative maneuvers .
This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery  and to provide evidence -based recommendations for an enhanced perioperative protocol .