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 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. Grade of recommendation: strong recommendation based on moderate-quality evidence, 1B. studies have demonstrated that after colorectal surgery is associated with return of bowel function and shorter of the to limit use is to such as and rather on an There have been ongoing the postoperative of in this However, a Cochrane review concluded that can cause a reduction in function in the early postoperative period should not be from with normal preoperative In addition, and observational clinical studies have shown that may the risk of anastomotic and has demonstrated that this on anastomotic leak to be and has been associated with the risk of leak in this In a retrospective cohort study of patients undergoing elective colorectal surgery, the risk of anastomotic leak rate was versus (p = in patients but there was no differences in leak rates related to other 2 meta-analyses have demonstrated an overall risk of anastomotic leak with but no in the risk of anastomotic leak with the use of as 2 In these studies, use was associated with an leak rate 95% CI, p < and = 95% CI, p < 0.001), and were not associated with anastomotic In addition, a multicenter cohort study in showed no differences in anastomotic leak rate with Perioperative and also have been to improve and reduce and postoperative The of is because 2 database studies reported that use after colorectal or surgery was associated with postoperative pulmonary complications and no reduction in postoperative A meta-analysis evaluating the perioperative use of also reported no significant from use and that the routine use of these could not be Meanwhile, a perioperative can be in patients with However, adverse and may in elderly as a or is also associated with a decrease in postoperative and can be a and wound have shown benefit in reduction patients undergoing open and laparoscopic colorectal There are an increasing of including but not limited to and meta-analyses of demonstrated decreased LOS compared with use in laparoscopic colorectal A recent systematic review and meta-analysis demonstrated that is safe and effective for pain management in minimally invasive surgery and to be as effective as with to early pain control and reducing postoperative remain regarding the of benefit with such as in reducing postoperative Another with can be used in the perioperative Studies and meta-analyses have shown that is effective intravenous in laparoscopic surgery and is associated with lower pain The related to this has not been and guidelines for postoperative have been 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. 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