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

Abstract

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 is in patients to elective colorectal surgery. of recommendation based on quality Interventions should be as of bowel are associated with in and of recommendation based on quality Interventions to return of bowel may be in patients undergoing minimally invasive with and of recommendation based on quality Recommendations Preadmission bowel with is to elective colorectal of recommendation based on not for use in laparoscopic colorectal surgery, is for open colorectal surgery a dedicated is available for postoperative of recommendation based on should be to and or and of recommendation based on high-quality should be for and in patients undergoing colorectal surgery. There is no to the use of for of recommendation based on In patients and in patients undergoing colorectal surgery with the use of may be of based on should be within after rectal of recommendation based on quality search clinical practice guideline; for systematic and - The Grading Recommendations and quality of evidence quality evidence and or vice without or evidence from studies can to most patients in most circumstances without quality evidence and or vice with or or evidence from studies can to most patients in most circumstances without or quality evidence and or vice studies or recommendation but may quality evidence available quality evidence with and without or evidence from studies best may on circumstances or or quality evidence with and with or or evidence from studies best may on circumstances or or or quality evidence in the of and and may be studies or other may be Preadmission 1. A regarding clinical and should be performed surgery. of recommendation based on Preadmission regarding and are a of systematic and have the of using that and compliance with that patient is associated with decreased LOS and decreased complication the can be which may may provide undergoing creation should and regarding to of recommendation based on The creation of ostomy is for LOS after colorectal and studies as well as a systematic review have shown that patient quality of and hospital LOS and hospital can also readmission is the most of readmission after patients regarding is of In a of patients of in which patients were in ostomy with for and set with reduced the readmission for from to have in readmission rates for using on ostomy in a of that the hospital readmission within for from to after Preadmission Nutrition and Bowel may be to 2 of recommendation based on high-quality to 2 of to from multiple is safe and of The same have also that within 2 to of surgery is associated with and the of surgery. 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