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Invited Critique
May 2011May 16, 2011

Enhanced Recovery Programs: Major Benefits Demonstrated Again: Comment on “Adherence to the Enhanced Recovery After Surgery Protocol and Outcomes After Colorectal Cancer Surgery”

Author Affiliations

Author Affiliations: Division of Colon and Rectal Surgery (Dr Kwaan), Department of Surgery (Dr Vickers), University of Minnesota, Minneapolis.

Arch Surg. 2011;146(5):577-578. doi:10.1001/archsurg.2011.118

On its face, the ERAS program is a combination of simple, low-risk interventions that, when used in an integrated approach, can reduce LOS and major complications. The benefits have been proven in multiple studies, mostly from Europe, on colorectal surgery patients, not limited to patients with cancer. Gustafsson et al contribute additional information on a large number of patients who underwent resection of colorectal cancers. The data compare an earlier phase (2002-2005) during which ERAS was poorly implemented with a more recent phase (2005-2007) during which more substantial efforts achieved significantly higher compliance with the protocol. Fewer major complications, fewer debilitating postoperative symptoms, and more frequent discharges within LOS targets were seen during the more recent phase of practice and in patients with better compliance with ERAS components. Causality can be questioned since patients who have major complications are ill and less likely to participate in various postoperative ERAS activities such as ambulation and early refeeding. However, multivariable analysis showed 2 early interventions in the process of surgery and recovery to be independent predictors of postoperative outcomes: preoperative carbohydrate loading and perioperative fluid restriction.