Enhanced Recovery After Colon and Rectal Surgery

Publication Date: January 31, 2023
Last Updated: January 31, 2023

Summary of Recommendations

  • A preoperative discussion regarding clinical milestones and discharge criteria should typically be performed prior to surgery.
    • Grade of recommendation: strong recommendation based on low-quality evidence, 1C
  • Patients undergoing ileostomy creation should receive stoma teaching and counseling regarding how to avoid dehydration.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Clear liquids may be continued up to 2 h prior to general anesthesia.
    • Grade of recommendation: strong recommendation based on high-quality evidence, 1A
  • Carbohydrate loading should be encouraged prior to surgery in non-diabetic patients.
    • Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B
  • Oral nutritional supplementation is recommended in malnourished patients prior to elective colorectal surgery.
    • Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B
  • Mechanical bowel preparation combined with preoperative oral antibiotics is typically recommended prior to elective colorectal resection.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Multimodal prehabilitation prior to elective colorectal surgery may be considered for patients with multiple co-morbidities or significant deconditioning.
    • Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B
  • Standardized order sets should be utilized in enhanced recovery pathways.
    • Grade of recommendation: weak recommendation based on low-quality evidence, 2C
  • A bundle of measures should be in place to reduce surgical site infection.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • A multimodal, opioid-sparing, pain management plan should be implemented before the induction of anesthesia.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • 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.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Pre-emptive, multimodal anti-emetic prophylaxis reduces perioperative nausea and vomiting.
    • Grade of recommendation: strong recommendation based on high-quality evidence, 1A
  • Fluid administration should be tailored to avoid excessive fluid administration and volume overload or undue fluid restriction and hypovolemia.
    • Grade of recommendation: strong recommendation based on high-quality evidence, 1A
  • 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.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Intraoperative hypotension should be avoided as even short durations of MAP < 65 are associated with adverse outcomes, in particular myocardial injury and acute kidney injury.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • In high-risk patients and in patients undergoing colorectal surgery with anticipated significant intravascular losses, the use of goal-directed hemodynamic therapy is recommended.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • In the absence of surgical complications or hemodynamic instability, intravenous fluids should be routinely discontinued in the early postoperative period.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • A minimally invasive surgical approach should be employed when the expertise is available and when appropriate.
    • Grade of recommendation: strong recommendation based on high-quality evidence, 1A.
  • The routine use of nasogastric tubes and intra-abdominal drains for colorectal surgery should be avoided.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Early and progressive patient mobilization are associated with shorter length of stay.
    • Grade of recommendation: strong recommendation based on low-quality evidence, 1C
  • Patients should be offered a regular diet within 24 h after elective colorectal surgery.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Sham feeding (i.e., chewing gum for ≥ 10 min 3–4 times daily) after colorectal surgery is safe, results in small improvements in GI recovery, and may be associated with a reduction in length of hospital stay.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Alvimopan is recommended to hasten recovery after open colorectal surgery.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Urinary catheters should typically be removed within 24 h of elective colonic or upper rectal resection irrespective of thoracic epidural analgesia use.
    • Grade of recommendation: strong recommendation, based on moderate-quality evidence, 1B
  • Urinary catheters should typically be removed within 24–48 h after mid/lower rectal resection.
    • Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B
  • Hospital discharge prior to return of bowel function may be offered for selected patients.
    • Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B

Overview

Title

Enhanced Recovery After Colon and Rectal Surgery

Authoring Organizations