World Journal of Surgery

, Volume 38, Issue 6, pp 1531–1541 | Cite as

Enhanced Recovery Program in Colorectal Surgery: A Meta-analysis of Randomized Controlled Trials

  • Massimiliano Greco
  • Giovanni Capretti
  • Luigi Beretta
  • Marco Gemma
  • Nicolò Pecorelli
  • Marco BragaEmail author



Meta-analyses in the literature show that enhanced recovery after surgery (ERAS) is associated with lower morbidity rate and shorter hospital stay after elective colorectal surgery. However, a recent Cochrane review did not indicate the ERAS pathway as being the new standard of care due to the limited number of published trials, together with their poor quality. We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the impact of the ERAS pathway on overall morbidity, single postoperative complications, length of hospital stay, and readmission rate following colorectal surgery.


We searched BioMedCentral, PubMed, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) for RCTs comparing the ERAS pathway to conventional perioperative care. No language restrictions were considered. A quality score was calculated for each trial included.


A total of 2,376 patients in 16 RCTs were included in the analysis. The ERAS pathway was associated with a reduction of overall morbidity [relative ratio (RR) = 0.60, (95 % CI 0.46–0.76)], particularly with respect to nonsurgical complications [RR = 0.40, (95 % CI 0.27–0.61)]. The reduction of surgical complications was not significant [RR = 0.76, (95 % CI 0.54–1.08)]. The ERAS pathway shortened hospital stay (WMD = −2.28 days [95 % CI –3.09 to –1.47]), without increasing readmission rate.


The ERAS pathway reduced overall morbidity rates and shortened the length of hospital stay, without increasing readmission rates. A significant reduction in nonsurgical complications was evident, while no significant reduction was found for surgical complications.


Readmission Rate Relative Ratio Enhance Recovery After Surgery Weighted Mean Difference Elective Colorectal Surgery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Michael John (BA) of the Vita-Salute San Raffaele Medical School in Milan for the English language editing of this manuscript, and Teresa Greco (MSc) for statistical support. We also thank the ERAS Society® for its contribution to improving perioperative care pathways in colorectal surgery.

Conflict of interest


Supplementary material

268_2013_2416_MOESM1_ESM.docx (27 kb)
Supplementary material 1 (DOCX 26 kb)


  1. 1.
    Tjandra JJ, Chan MK (2006) Systematic review on the short term outcome of laparoscopic resection for colon and rectosigmoid cancer. Colorectal Dis 8:375–388PubMedCrossRefGoogle Scholar
  2. 2.
    Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477PubMedCrossRefGoogle Scholar
  3. 3.
    Veenhof AA, Vlug MS, Van Der Pas MH et al (2012) Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial. Ann Surg 255:216–221PubMedCrossRefGoogle Scholar
  4. 4.
    Walter CJ, Collin J, Dumville JC et al (2009) Enhanced recovery in colorectal resections: a systematic review and meta-analysis. Colorectal Dis 11:344–353PubMedCrossRefGoogle Scholar
  5. 5.
    Gouvas N, Tan E, Windsor A et al (2009) Fast-track vs standard care in colorectal surgery: a meta-analysis update. Int J Colorectal Dis 24:1119–1131PubMedCrossRefGoogle Scholar
  6. 6.
    Varadhan KK, Neal KR, Dejong CH et al (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 29:434–440PubMedCrossRefGoogle Scholar
  7. 7.
    Spanjersberg WR, Reurings J, Keus F et al (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev (2):CD007635. doi: 10.1002/14651858.CD007635.pub2
  8. 8.
    Rawlinson A, Kang P, Evans J et al (2011) A systematic review of enhanced recovery protocols in colorectal surgery. Ann R Coll Surg Engl 93:583–588PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Lv L, Shao YF, Zhou YB (2012) The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Colorectal Dis 27:1549–1554PubMedCrossRefGoogle Scholar
  10. 10.
    Eskicioglu C, Forbes SS, Aarts MA et al (2009) Enhanced recovery after surgery (ERAS) programs for patients having colorectal surgery: a meta-analysis of randomized trials. J Gastrointest Surg 13:2321–2329PubMedCrossRefGoogle Scholar
  11. 11.
    Wind J, Polle SW, Fung Kon Jin PH, Dejong CH, von Meyenfeldt MF, Ubbink DT, Gouma DJ, Bemelman WA, Laparoscopy and/or Fast Track Multimodal Management Versus Standard Care (LAFA) Study Group, Enhanced Recovery after Surgery (ERAS) Group (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809PubMedCrossRefGoogle Scholar
  12. 12.
    Vlug MS, Wind J, Hollmann MW et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery. Ann Surg 254:868–875PubMedCrossRefGoogle Scholar
  13. 13.
    Ren L, Zhu D, Wei Y et al (2012) Enhanced Recovery After Surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg 36:407–414. doi: 10.1007/s00268-011-1348-4 PubMedCrossRefGoogle Scholar
  14. 14.
    Wang G, Jiang Z-W, Xu J et al (2011) Fast-track rehabilitation program vs conventional care after colorectal resection: a randomized clinical trial. World J Gastroenterol 17:671–676PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Robinson KA, Dickersin K (2002) Development of a highly sensitive search strategy for the retrieval of reports of controlled trials using PubMed. Int J Epidemiol 31:150–153PubMedCrossRefGoogle Scholar
  16. 16.
    Dear KB, Begg CB (1992) An approach for assessing publication bias prior to performing a meta-analysis. Stat Sci 7:237–245CrossRefGoogle Scholar
  17. 17.
    Liberati A, Altman DG, Tetzlaff J et al (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 339:b2700PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Van Bree S, Vlug M, Bemelman W et al (2011) Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Gastroenterology 141:872–880PubMedCrossRefGoogle Scholar
  19. 19.
    Xu J, Zhong Y, Zhu D et al (2007) Application of the protocol of enhanced recovery after surgery in colorectal surgery. Zhonghua Wei Chang Wai Ke Za Zhi 10:238–244PubMedGoogle Scholar
  20. 20.
    Liu Z, Wang X, Li L (2008) Perioperative fast track programs enhance the postoperative recovery after rectal carcinoma resection. Zhonghua Wei Chang Wai Ke Za Zhi 11:551–553PubMedGoogle Scholar
  21. 21.
    Basse L, Jakobsen DH, Bardram L et al (2005) Functional recovery after open versus laparoscopic colonic resection. Ann Surg 241:416–423PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Holte K, Foss NB, Andersen J et al (2007) Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. Br J Anaesth 99:500–508PubMedCrossRefGoogle Scholar
  23. 23.
    King P, Blazeby J, Ewings P et al (2006) The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis 8:506–513PubMedCrossRefGoogle Scholar
  24. 24.
    King PM, Blazeby JM, Ewings P et al (2006) Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 93:300–308PubMedCrossRefGoogle Scholar
  25. 25.
    MacKay G, Ihedioha U, McConnachie A et al (2007) Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery. Colorectal Dis 9:368–372PubMedCrossRefGoogle Scholar
  26. 26.
    Noblett S, Watson D, Huong H et al (2006) Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Dis 8:563–569PubMedCrossRefGoogle Scholar
  27. 27.
    Raue W, Haase O, Junghans T et al (2004) “Fast-track” multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation. Surg Endosc 18:1463–1468PubMedCrossRefGoogle Scholar
  28. 28.
    Zutshi M, Delaney CP, Senagore AJ et al (2005) Randomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway versus the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection. Am J Surg 189:268–272PubMedCrossRefGoogle Scholar
  29. 29.
    Wang Q, Suo J, Jiang J et al (2012) Effectiveness of fast track rehabilitation vs conventional care in laparoscopic colorectal resection for elderly patients: a randomized trial. Colorectal Dis 14(8):1009–1013PubMedCrossRefGoogle Scholar
  30. 30.
    Anderson AD, McNaught CE, MacFie J et al (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90:1497–1504PubMedCrossRefGoogle Scholar
  31. 31.
    Delaney CP, Zutshi M, Senagore AJ et al (2003) Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 46:851–859PubMedCrossRefGoogle Scholar
  32. 32.
    García-Botello S, Cánovas de Lucas R, Tornero C et al (2001) Implementation of a perioperative multimodal rehabilitation protocol in elective colorectal surgery. A prospective randomised controlled study. Cir Esp 89(3):159–166CrossRefGoogle Scholar
  33. 33.
    Gatt M, Anderson ADG, Reddy BS et al (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 92:1354–1362PubMedCrossRefGoogle Scholar
  34. 34.
    Ionescu D, Iancu C, Ion D et al (2009) Implementing fast-track protocol for colorectal surgery: a prospective randomized clinical trial. World J Surg 33:2433–2438. doi: 10.1007/s00268-009-0197-x PubMedCrossRefGoogle Scholar
  35. 35.
    Khoo CK, Vickery CJ, Forsyth N et al (2007) A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 245:867–872PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Lee TG, Kang SB, Kim DW et al (2011) Comparison of early mobilization and diet rehabilitation program with conventional care after laparoscopic colon surgery: a prospective randomized controlled trial. Dis Colon Rectum 54:21–28PubMedCrossRefGoogle Scholar
  37. 37.
    Muller S, Zalunardo MP, Hubner M et al (2009) A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 136:842–847PubMedCrossRefGoogle Scholar
  38. 38.
    Serclová Z, Dytrych P, Marvan J et al (2009) Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Clin Nutr 28:618–624PubMedCrossRefGoogle Scholar
  39. 39.
    Wang G, Jiang ZW, Zhao K et al (2012) Fast track rehabilitation programme enhances functional recovery after laparoscopic colonic resection. Hepatogastroenterology 59(119):2158–2163PubMedGoogle Scholar
  40. 40.
    Yang D, He W, Zhang S et al (2012) Fast-track surgery improves postoperative clinical recovery and immunity after elective surgery for colorectal carcinoma: randomized controlled clinical trial. World J Surg 36(8):1874–1880. doi: 10.1007/s00268-012-1606-0 PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Wang G, Jiang Z, Zhao K et al (2012) Immunologic response after laparoscopic colon cancer operation within an enhanced recovery program. J Gastrointest Surg 16(7):1379–1388PubMedCrossRefGoogle Scholar
  42. 42.
    Ng WQ, Neill J (2006) Evidence for early oral feeding of patients after elective open colorectal surgery: a literature review. J Clin Nurs 15(6):696–709PubMedCrossRefGoogle Scholar
  43. 43.
    Nelson R, Edwards S, Tse B (2007) Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev (3):CD004929. doi: 10.1002/14651858.CD004929.pub3
  44. 44.
    Haines KJ, Skinner EH, Berney S (2013) Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy 99(2):119–125PubMedCrossRefGoogle Scholar
  45. 45.
    Lassen K (2009) Intravenous fluid therapy. Br J Surg 96(2):123–124PubMedCrossRefGoogle Scholar
  46. 46.
    Zaouter C, Kaneva P, Carli F (2009) Less urinary tract infection by earlier removal of bladder catheter in surgical patients receiving thoracic epidural analgesia. Reg Anesth Pain Med 34(6):542–548PubMedCrossRefGoogle Scholar
  47. 47.
    Pawa N, Cathcart PL, Arulampalam TH et al (2012) Enhanced recovery program following colorectal resection in the elderly patient. World J Surg 36(2):415–423. doi: 10.1007/s00268-011-1328-8 PubMedCrossRefGoogle Scholar
  48. 48.
    Delaney CP, Kiran RP, Senagore AJ et al (2003) Case-matched comparison of clinical and financial outcome after laparoscopic or open colorectal surgery. Ann Surg 238:67–72PubMedCentralPubMedGoogle Scholar
  49. 49.
    Roulin D, Donadini A, Gander S et al (2013) Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 100:1108–1114PubMedCrossRefGoogle Scholar
  50. 50.
    Slim K, Panis Y, Chipponi J (2004) Half of the current practice of gastrointestinal surgery is against the evidence: a survey of the French Society of Digestive Surgery. J Gastrointest Surg 8:1079–1082PubMedCrossRefGoogle Scholar
  51. 51.
    Lassen K, Hannemann P, Ljungqvist O et al (2005) Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 330:1420–1421PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Kehlet H, Buchler MW, Beart RW Jr et al (2006) Care after colonic operation—is it evidence-based? Results from a multinational survey in Europe and the United States. J Am Coll Surg 202:45–54PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • Massimiliano Greco
    • 1
  • Giovanni Capretti
    • 2
  • Luigi Beretta
    • 1
  • Marco Gemma
    • 1
  • Nicolò Pecorelli
    • 2
  • Marco Braga
    • 2
    Email author
  1. 1.Department of Anesthesiology, San Raffaele HospitalVita-Salute UniversityMilanItaly
  2. 2.Department of Surgery, San Raffaele HospitalVita-Salute UniversityMilanItaly

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