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Randomized trials and meta-analysis identified a significantly shorter length of stay and lower in-hospital postoperative complications (maybe secondary to the shorter length of hospital stay) [6].These advantages are mainly attributed to fluid restriction and epidural analgesia.

Other outcome improvements attributed to ERAS programs are shorter duration of postop‐ erative ileus [6], better oral intake, better pain control, less cardiopulmonary morbidity, better preservation of body mass and exercise performance [36], an improvement in grip strength (all of them suggesting an overall improvement in muscular function), earlier resumption of normal activities and a reduced need for daytime sleep [37].

Early discharge is the goal of Fast-Track protocols, and should not be offset by a higher rate of hospital readmission. However, the overall rate of readmission for patients managed with early discharge is comparable to patients with a longer median length of hospital stay [34].Regarding the economical issues, it must be pointed out that the increased cost in laparoscopic approach must be balanced with savings from a shorter length of hospital stay, lower morbidity and no differences in readmission rates.

7. The research initiatives The confirmation of the initial results should prompt the ERAS methodology embracing in other kind of major surgical procedures as gastric or pancreatic procedures.

The possibility of applying some components of fast-track programs in patients undergoing emergency colorectal surgery must be also evaluated, especially in order to reduce preopera‐ tive stress.

New drugs like Ketamina, Lidocaina, Alvimopan could have an important role in the future because of their properties in analgesia and in gastrointestinal resumption.

8. Summary and recommendations

–  –  –

The success of this program depends on pre-operative setting of expectations including the concept of patients being partners in their care and taking part-ownership of post-operative rehabilitation.

Best results are achieved when the whole multidisciplinary team believe and take part in the program and individual interventions are implemented all together.

The keys of ERAS are: patient information, preservation of gastrointestinal function, minimize organ dysfunction, active pain control and to promote the patient´s autonomy.

Early discharge is the goal of ERAS protocols and patients usually reach the discharge criteria sooner than in traditional care.

Although most of the studies tend to find a lower morbidity, there are no clear advantage in mortality and we think that more studies are needed to confirm the results and focalized in mortality and long-term results of ERAs methodology. We can conclude that at least there are no significant differences in mortality and morbidity with traditional care (ERAs methodology is not dangerous for patients and probably represents a big benefice) and ERAS are more costeffectiveness than traditional care.

Author details Raúl Sánchez-Jiménez1*, Alberto Blanco Álvarez2, Jacobo Trebol López1, Antonio Sánchez Jiménez3, Fernando Gutiérrez Conde4 and José Antonio Carmona Sáez1 *Address all correspondence to: raulsj34@gmail.com 1 Department of General Surgery, Nuestra Señora de Sonsoles Hospital, Ávila, Spain 2 Department of General Surgery, Santos Reyes Hospital, Burgos, Spain 3 Physiotherapist, Cadiz University, Cádiz, Spain 4 Department of General Surgery, University Hospital of Salamanca, Salamanca, Spain References [1] Kehlet H, Wilmore DW. Fast-track surgery. Br.J.Surg. 2005;92:3-4.

[2] Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a mul‐ timodal rehabilitation programme. Br.J.Surg. 1999;86:227-230.

[3] Kehlet H. Multimodal approach to control postoperative pathophysiology and reha‐ bilitation. Br.J.Anaesth. 1997;78:606-617.

502 Colorectal Cancer - Surgery, Diagnostics and Treatment [4] Basse L, Hjort JD, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann.Surg. 2000;232:51-57.

[5] Wind J, Polle SW, Fung Kon Jin PH et al. Systematic review of enhanced recovery programmes in colonic surgery. Br.J.Surg. 2006;93:800-809.

[6] Gouvas N, Tan E, Windsor A, Xynos E, Tekkis PP. Fast-track vs standard care in col‐ orectal surgery: a meta-analysis update. Int.J.Colorectal Dis. 2009;24:1119-1131.

[7] Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane.Database.Syst.Rev.

2011CD007635.

[8] Kehlet H, Buchler MW, Beart RW, Jr., Billingham RP, Williamson R. Care after colon‐ ic operation--is it evidence-based? Results from a multinational survey in Europe and the United States. J.Am.Coll.Surg. 2006;202:45-54.

[9] Zutshi M, Delaney CP, Senagore AJ, Fazio VW. Shorter hospital stay associated with fastrack postoperative care pathways and laparoscopic intestinal resection are not as‐ sociated with increased physical activity. Colorectal Dis. 2004;6:477-480.

[10] Desborough JP. The stress response to trauma and surgery. Br.J.Anaesth.

2000;85:109-117.

[11] Carli F, Charlebois P, Baldini G, Cachero O, Stein B. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal sur‐ gery. Can.J.Anaesth. 2009;56:837-842.

[12] Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011;114:495-511.

[13] Soop M, Carlson GL, Hopkinson J et al. Randomized clinical trial of the effects of im‐ mediate enteral nutrition on metabolic responses to major colorectal surgery in an enhanced recovery protocol. Br.J.Surg. 2004;91:1138-1145.

[14] Mathur S, Plank LD, McCall JL et al. Randomized controlled trial of preoperative or‐ al carbohydrate treatment in major abdominal surgery. Br.J.Surg. 2010;97:485-494.

[15] Guenaga KK, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane.Database.Syst.Rev. 2009CD001544.

–  –  –

[18] Lobo DN, Bostock KA, Neal KR et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled tri‐ al. Lancet 2002;359:1812-1818.

[19] Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective ver‐ sus routine nasogastric decompression after elective laparotomy. Ann.Surg.

1995;221:469-476.

[20] Petrowsky H, Demartines N, Rousson V, Clavien PA. Evidence-based value of pro‐ phylactic drainage in gastrointestinal surgery: a systematic review and meta-analy‐ ses. Ann.Surg. 2004;240:1074-1084.

[21] Urbach DR, Kennedy ED, Cohen MM. Colon and rectal anastomoses do not require routine drainage: a systematic review and meta-analysis. Ann.Surg. 1999;229:174-180.

[22] Francom M. Stop drug price increases. Am.Pharm. 1991;NS31:6, 8.

[23] Tiippana EM, Hamunen K, Kontinen VK, Kalso E. Do surgical patients benefit from perioperative gabapentin/pregabalin? A systematic review of efficacy and safety. An‐ esth.Analg. 2007;104:1545-56, table.

[24] Kehlet H, Holte K. Review of postoperative ileus. Am.J.Surg. 2001;182:3S-10S.

[25] Leslie JB, Viscusi ER, Pergolizzi JV, Jr., Panchal SJ. Anesthetic Routines: The Anesthe‐ siologist's Role in GI Recovery and Postoperative Ileus. Adv.Prev.Med.

2011;2011:976904.

[26] Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ 2001;322:473-476.

[27] Hendren S, Morris AM, Zhang W, Dimick J. Early discharge and hospital readmis‐ sion after colectomy for cancer. Dis.Colon Rectum 2011;54:1362-1367.

[28] Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011;149:830-840.

[29] Basse L, Madsen JL, Kehlet H. Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative. Br.J.Surg.

2001;88:1498-1500.

[30] Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery

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