Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as advancing minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information based on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for use by all practitioners, health care workers, and patients who desire information on the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the ASCRS and the SAGES and was approved by both societies. STATEMENT OF THE PROBLEM Colorectal surgery has historically been associated with long postoperative hospital stays, high costs, and surgical-site infection (SSI) rates approaching 20%.1,2 In addition, the incidence rates of in-hospital perioperative nausea and vomiting (PONV) may be as high as 80%3 and readmission rates as high as 35%.4 Enhanced recovery protocols (ERPs) are a set of standardized perioperative processes, the content of which may vary significantly, that are applied to patients undergoing elective surgery. In general, these protocols are not intended for nonelective cases, but components of ERPs could certainly be applied to the emergent/urgent patient.5,6 Also known as "fast track" or "enhanced recovery after surgery" (ERAS) protocols, ERPs are designed to improve patient outcomes.7 Outcomes of interest include alleviating nausea and pain, achieving early return of bowel function, and decreasing rates of wound infection and length of hospital stay.8 Although numerous perioperative protocols exist, this clinical practice guideline will evaluate the evidence in support of individual measures to improve patient outcomes after elective colon and rectal resections. Implementation of ERPs in colorectal surgery has been shown to reduce morbidity rates and decrease length of stay (LOS) without increasing readmission rates.9–13 A 2011 Cochrane review found that ERPs were associated with reduced overall complication rates and LOS compared to conventional perioperative patient management.14 Subsequent studies have shown that ERPs are associated with reduced health care costs, improved patient satisfaction, lower rates of complications, and reduced mortality.2,10,15–20 ERPs are also associated with improved outcomes regardless of whether patients undergo laparoscopic or open surgery.21 In addition, multiple studies have shown that ERPs are safe and efficacious in elderly patient populations.22–30 Studies also support that ERPs should not be implemented and maintained dogmatically but rather require ongoing compliance evaluation and continual quality improvement.31–34 Greater adherence to ERPs is associated with decreased complications and shorter LOS.35–38 There are many different preoperative, intraoperative, and postoperative components of a typical ERP' and it is difficult to identify which are most beneficial within the "bundle" of simultaneously implemented measures. This clinical practice guideline evaluates the evidence pertaining to different components of ERPs for colorectal surgery. Although ostomy surgery, deep vein thrombosis prevention, bowel preparation, and frailty are discussed in this clinical practice guideline, a detailed review of these topics is beyond the scope of this clinical practice guideline; these topics are addressed in depth in other ASCRS Clinical Practice Guidelines.39–42 MATERIALS AND METHODS The original clinical practice guidelines for enhanced recovery after colon and rectal surgery from the ASCRS and the SAGES was published in 2017.43 The present guideline was constructed using the 2017 guidelines as a platform. Compared with 2017, this guideline has 3 new recommendations and 5 statements with updated levels of evidence. All other statements have been reviewed and updated with current evidence (Table 1). A systematic search was conducted under the guidance of a librarian. In brief, a systematic search was conducted from January 1, 2016, to May 1, 2022, using the Cochrane Library, Embase, and the MEDLINE databases using a variety of key word combinations. A supplemental search was conducted using related articles and bibliographies of previously identified articles. Directed searches of the embedded references from the primary articles were also performed in certain circumstances. Prospective, randomized controlled trials (RCTs) and meta-analyses were given preference. A total of 7712 abstracts were identified; 6962 articles were excluded, and a total of 750 full-text articles were evaluated. Of those, 547 were excluded, and along with 212 articles from the 2017 guidelines, a total of 415 articles were included in the final document (Fig. 1). The final grade of recommendation was performed using the Grading of Recommendation, Assessment, Development, and Evaluation system (Table 2).44 When the agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. Members of the ASCRS Clinical Practice Guidelines Committee worked together with members of the SAGES Colorectal Committee from inception to publication. The entire Clinical Practice Guidelines Committee of ASCRS and the Colorectal Committee of SAGES reviewed recommendations formulated by the subcommittee. The submission was approved by both the ASCRS and SAGES executive councils and then peer-reviewed by the Diseases of the Colon & Rectum and Surgical Endoscopy. In general, each ASCRS Clinical Practice Guideline (including joint guidelines) is updated every 5 years. No funding was received for preparing this guideline, and the authors have declared no competing interests related to this material. This guideline conforms to the Appraisal of Guidelines for Research and Evaluation checklist. Table 1. - What is New in the 2022 ASCRS Enhanced Recovery After Colon and Rectal Surgery Clinical Practice Guidelines New Recommendations Preoperative Interventions Preadmission Nutrition and Bowel Preparation5. Oral nutritional supplementation is recommended in malnourished patients prior to elective colorectal surgery. Grade of recommendation: weak recommendation based on moderate quality evidence, 2B. Perioperative Interventions Intraoperative Fluid Management15. Hypotension should be avoided as even short durations of mechanical bowel preparation < 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. Postoperative Interventions Discharge Criteria26. Early discharge prior to return of bowel function may be feasible in low-risk patients undergoing minimally invasive colectomy when coupled with close outpatient communication and follow-up. Grade of recommendation: weak recommendation based on moderate quality evidence, 2B. Updated Recommendations Preadmission 6. 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. Pain Control 11. 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. Fluid Management 13. 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. Fluid Management 14. 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. Fluid Management 16. In high-risk patients and in patients undergoing colorectal surgery with significant intravascular losses, the use of goal-directed hemodynamic therapy may be considered. Grade of recommendation: weak recommendation, based on moderate-quality evidence, 2B Postoperative Management 25. Urinary catheters should typically be removed within 24-48 hours after mid/lower rectal resection. Grade of recommendation: strong recommendation based on moderate quality evidence, 1B. FIGURE 1.: PRISMA literature search flow sheet. CPG = clinical practice guideline; PRISMA = preferred reporting items for systematic reviews and meta-analysis. TABLE 2. - The GRADE System: Grading Recommendations Grade Description Benefit versus risk and burdens Methodologic quality of supporting evidence Implications 1A Strong recommendation, High quality evidence Benefits clearly outweigh risk and burdens or vice versa RCTs without important limitations or overwhelming evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1B Strong recommendation, Moderate quality evidence Benefits clearly outweigh risk and burdens or vice versa RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Strong recommendation, can apply to most patients in most circumstances without reservation 1C Strong recommendation, Low or very low quality evidence Benefits clearly outweigh risk and burdens or vice versa Observational studies or case series Strong recommendation but may change when higher quality evidence becomes available 2A Weak recommendation, High quality evidence Benefits closely balanced with risks and burdens RCTs without important limitations or overwhelming evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients' or societal values 2B Weak recommendations, Moderate quality evidence Benefits closely balanced with risks and burdens RCTs with important limitations (inconsistent results, methodologic flaws, indirect or imprecise) or exceptionally strong evidence from observational studies Weak recommendation, best action may differ depending on circumstances or patients' or societal values 2C Weak recommendation, Low or very low quality evidence Uncertainty in the estimates of benefits, risks and burden; benefits, risk and burden may be closely balanced Observational studies or case series Very weak recommendations; other alternatives may be equally reasonable PREOPERATIVE INTERVENTIONS Preadmission Counseling 1. A preoperative discussion regarding clinical milestones and discharge criteria should typically be performed before surgery. Grade of recommendation: strong recommendation based on low-quality evidence, 1C. Preadmission counseling regarding milestones and discharge criteria are a well-established cornerstone of ERPs.7,45–50 Single-center case series, prospective cohort studies, systematic reviews, and RCTs have reported the benefits of using an ERP that includes preoperative education describing milestones and discharge criteria.2,51–72 Furthermore, compliance with an ERP that includes preoperative patient education is associated with decreased LOS and decreased complication rates.31,73–79 Despite the benefit, in-person preoperative counseling can be resource intensive, which may limit its widespread use; prescripted phone calls may provide sufficient counseling while saving resources.78,79 2. 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. The creation of an ostomy is an independent risk factor for prolonged LOS after colorectal surgery.50,80–83 Several single-center and multicenter studies as well as a systematic review have shown that structured patient stoma education significantly improves quality of life, facilitates psychosocial adjustment, and reduces hospital LOS and hospital costs.84–94 Ostomy education can also impact readmission rates.80,95–97 As dehydration is the most common cause of readmission after ileostomy creation,98,99 counseling patients regarding dehydration avoidance is an important element of ERP.98,99 In a prospective study of 42 patients versus 168 historical controls, implementation of an ileostomy pathway in which patients were directly engaged in ostomy management, discharged with supplies for measuring input/output, and set up with visiting nurse services reduced the readmission rate for dehydration from 15.5% to 0% (p = 0.02).4 Others have reported similar reductions in readmission rates for dehydration when using an ERP focused on ostomy education.100–102 Gonella et al, in a retrospective study of 296 patients, showed that the hospital readmission rate within 30 days postdischarge for dehydration dropped from 9% to 3.9% after protocol application.101 Preadmission Nutrition and Bowel Preparation 3. Clear liquids may be continued up to 2 hours before general anesthesia. Grade of recommendation: strong recommendation based on high-quality evidence, 1A. Drinking clear fluids up to 2 hours before induction of anesthesia, according to data from multiple RCTs, is safe and improves patients' sense of well-being.103–111 The same RCTs have also reported that ingesting clear liquids within 2 to 4 hours of surgery versus >4 hours is associated with smaller gastric volumes and higher gastric pH at the time of surgery. The current practice guidelines of both the ASA and the European Society of Anesthesiology support this recommendation.111–113 4. Carbohydrate loading should be encouraged before surgery in patients without diabetese. Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B. The use of carbohydrate-rich beverages should be encouraged to attenuate insulin resistance induced by surgery and starvation.114–116 The focus is not on avoiding glycogen depletion but rather on converting the patient from a fasting state to a fed state to impact insulin resistance. A 2014 Cochrane review of 27 international trials, including 1976 patients undergoing elective operations, concluded that carbohydrate loading was associated with a 0.3-day reduction in length of hospital stay compared with placebo or fasting (95% CI, 0.56–0.0) but no difference was found in overall perioperative complications.114 Of note, most beverages consumed in these studies contained complex carbohydrates (eg, maltodextrin) as opposed to the monosaccharides (eg, fructose) or disaccharides (eg, sucrose) found in fruit juice or sports drinks. Another meta-analysis of 21 randomized studies including 1685 patients showed no overall difference in LOS; however, the subgroup of patients undergoing major abdominal surgery had a shorter LOS associated with carbohydrate loading (mean difference –1.08 d; 95% CI, –1.87 to –0.29; p = 0.007).117 Another meta-analysis including 43 RCTs with 3110 elective surgery patients found that high-dose carbohydrate loading (≥45 g) was associated with a reduced length of hospital stay compared to fasting (–1.7 d; 95% CI, –3.2 to –0.1) or placebo/water (–1.4 d; 95% CI, –2.7 to –0.1; p < 0.05), but there were no differences in complication rates or other secondary end points.118 This recommendation applies to patients without diabetes because patients with diabetes were not included in the trials. 5. Oral nutritional supplementation is recommended in malnourished patients before elective colorectal surgery. Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B. In malnourished patients planning elective GI surgery, oral nutritional supplementation targeting a protein intake of 1.2 to 1.5 g/kg/d for a period of 1 to 2 weeks has been associated with reduced postoperative complications and is endorsed by several national and international guidelines.119–122 Meanwhile, the efficacy of immunonutrition, supplementation containing immune-modulating nutrients such as arginine, fish oil (ω-3 fatty acids), nucleotides, and glutamine, over standard high protein oral nutritional supplements remains controversial. Meta-analyses have demonstrated reduced complications and infectious complications and shortened LOS associated with preoperative immunonutrition.123,124 However, other studies have reported conflicting results depending on whether patients were malnourished, the degree of industry support (more positive results reported in industry-sponsored trials), and the type of control used for comparison (standard isonitrogenous, isocaloric nonenhancing nutritional supplement versus normal diet without any supplementation).123–126 6. Mechanical bowel preparation combined with preoperative oral antibiotics is typically recommended before elective colorectal resection. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B. A 2011 Cochrane review of RCTs showed no benefit to mechanical bowel preparation (MBP) alone in colorectal surgery in reducing anastomotic leak or complications.127 Meanwhile, a meta-analysis of 7 RCTs, including 1769 patients comparing MBP with oral antibiotics to MBP alone, showed a reduction in total SSI (7.2% versus 16.0%; p < 0.001) and incisional site infection (4.6% versus 12.1%; p < 0.001), with no difference in the rate of organ/space infection after elective colorectal surgery.128 These trial findings are consistent with population-level data. In a retrospective analysis of a nationwide database from the United States, MBP plus oral antibiotic preparation in left colon resection was associated with decreased overall morbidity, superficial SSI, anastomotic leakage, and intra-abdominal infections.129 Similar retrospective studies in different populations (Veterans Administration database130 and a Polish hospital database131) have also shown a reduction in SSI with the addition of oral bowel preparation to MBP. The Michigan Surgical Quality Collaborative database showed reductions in SSI and in postoperative Clostridium difficile colitis in patients who received MBP and oral bowel preparation versus patients who received no bowel preparation.132 These kinds of data supported the ASCRS 2019 Clinical Practice Guideline on Bowel Preparation, recommending the use of a MBP combined with preoperative oral antibiotics in elective colorectal surgery.40 Preadmission Optimization 7. Multimodal prehabilitation before elective colorectal surgery may be considered for patients with multiple comorbidities or significant deconditioning. Grade of recommendation: weak recommendation based on moderate-quality evidence, 2B. Prehabilitation, defined as enhancement of the patient's preoperative condition, has been proposed as a possible strategy for improving postoperative outcomes.133–135 Several recent RCTs136–143 and systematic reviews have demonstrated that prehabilitation improves physical function before colorectal or major abdominal surgery.135,144–148 However, whether better physical function translates into improved postoperative outcomes remains debatable.135–139,147,149 A meta-analysis of 35 studies evaluating 3402 patients undergoing major abdominal surgery found that patients who received prehabilitation experienced significantly lower rates of overall complications (p = 0.005), pulmonary complications (p < 0.001), and cardiac complications (p = 0.044).150 Another meta-analysis of 8 trials with 442 patients undergoing major liver, colorectal, gastroesophageal, and general abdominal surgery demonstrated significant reductions in postoperative pulmonary complications and overall postoperative morbidity in the prehabilitation group versus the control group and no differences in LOS.151 Although the available data remain limited because of many underpowered studies, patients with lower baseline functional capacity undergoing open surgery may achieve the greatest benefit from prehabilitation.137–139,141,142,152 Preadmission Orders 8. Standardized order sets should be used in enhanced recovery pathways. Grade of recommendation: weak recommendation based on low-quality evidence, 2C. Comprehensive, multifaceted ERPs are complex and require multidisciplinary collaboration between stakeholders, including nursing teams, anesthesiologists, social workers, and surgeons. Increased compliance with ERP components has repeatedly been associated with improved perioperative outcomes.153–156 Dedicated order sets standardize care and are considered essential for improving compliance with ERP elements.2,13,157,158 The use of order sets has proven to be effective in reducing the risk of SSI.157,159,160 PERIOPERATIVE INTERVENTIONS Surgical-Site Infection 9. A bundle of measures should be in place to reduce SSI. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B. Various SSI prevention bundles have been described to decrease SSIs in colorectal surgery. Although there are many commonalities between SSI bundles, there is no universal standardization of elements and it is rare for the impact of any 1 component to be specifically evaluated.161–167 Preoperative measures incorporated into bundles include a chlorhexidine shower, MBP with oral antibiotics, intravenous antibiotics within 1 of and standardization of the surgical preparation with measures typically found in SSI prevention bundles include the use of a wound and before using a dedicated wound and and A meta-analysis evaluating SSI prevention bundles including patients reported risk reductions of in the overall SSI in the superficial infection and in the infection This analysis also reported that of wound MBP with oral antibiotics, and before were considered the most important to Another meta-analysis of patients found that there was significant in SSI reduction bundle component elements and compliance rates from to in the included the of SSI was with a bundle compared to without rates of compliance with specific bundle elements within SSI prevention bundles have repeatedly been associated with significantly lower SSI Pain Control A pain management should be implemented before the induction of anesthesia. 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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. Thoracic epidural has shown efficacy or in pain and in patients undergoing open colorectal However, have no benefit over and abdominal in laparoscopic surgery. In addition, evidence that the benefits by do not into recovery in laparoscopic or open colorectal In may hospital discharge after laparoscopic because of the higher incidence rate of and that postoperative Perioperative and reduces perioperative nausea and Grade of recommendation: strong recommendation based on high-quality evidence, 1A. Several have been to identify patients at