Enhanced Recovery After Surgery Protocol for Colorectal Surgery

Preoperative Components

The American College of Surgeons recommends patient education and counseling, including detailed information about the surgical procedure, expected recovery course, and active patient participation in the recovery process 1
The ERAS society recommends avoidance of prolonged fasting, with clear fluids allowed up to 2 hours and solid food up to 6 hours before anesthesia 3
The ERAS society recommends carbohydrate loading, with administration of oral carbohydrate-rich drinks (400ml with 50g CHO) 2 hours before surgery to reduce insulin resistance and catabolism 3
The ERAS society recommends no routine mechanical bowel preparation, as it does not improve outcomes and can lead to dehydration and electrolyte disturbances 3
The ERAS society recommends thromboprophylaxis, with use of well-fitting compression stockings and pharmacological prophylaxis with low molecular weight heparin 3
The American College of Surgeons recommends antimicrobial prophylaxis, with single-dose antibiotic prophylaxis administered within 60 minutes before incision 1

The ERAS society recommends a minimally invasive surgical approach, with laparoscopic approach when feasible to reduce the inflammatory response and improve outcomes 3
The ERAS society recommends a standardized anesthesia protocol, with use of short-acting anesthetic agents allowing rapid awakening 3
The ERAS society recommends goal-directed fluid therapy, with use of cardiac output monitoring to optimize hemodynamics and avoid fluid overload 3
The ERAS society recommends maintenance of normothermia, with active warming using warming devices and warmed intravenous fluids to maintain body temperature >36°C 3
The ERAS society recommends prevention of postoperative nausea and vomiting (PONV), with a multimodal approach for patients with ≥2 risk factors 3
The ERAS society recommends no routine use of nasogastric tubes, with nasogastric tubes removed before reversal of anesthesia 3
The ERAS society recommends no routine drainage, with avoidance of routine drainage of the peritoneal cavity after colonic anastomosis 3

The ERAS society recommends multimodal analgesia, with thoracic epidural analgesia (T7-10) for open surgery, combined with acetaminophen and NSAIDs to reduce opioid requirements 3
The American College of Surgeons recommends early mobilization, with patients out of bed within 24 hours after surgery 1
The American College of Surgeons recommends early oral feeding, with oral diet resumed within 24 hours after surgery 1
The ERAS society recommends early removal of urinary catheter, with transurethral bladder drainage removed within 1-2 days postoperatively 3
The American College of Surgeons recommends audit of outcomes and compliance, with regular monitoring of protocol compliance and clinical outcomes 1

The ERAS society reports decreased overall complications and improved recovery with ERAS implementation 1, 2

The ERAS society notes that rectal surgery vs. colonic surgery has higher complication rates and unique challenges, and ERAS protocols should be adapted accordingly 4, 5