Enhanced recovery after rectal surgery: what we have learned so far

Abstract

Enhanced recovery after surgery (ERAS) protocols are gradually becoming the gold standard in the perioperative management of rectal patients. It is a multimodal and multidisciplinary approach that has the great merit to involve and empower the patient and bring him or her back to the centre of the strategy of care. If applied correctly, ERAS can improve the postoperative recovery, reduce the rate of complications and reduce the postoperative length of stay, in patients who had extensive pelvic dissection. The factors within ERAS and their application do not represent rigid schematizations but fluid concepts that may undergo substantial changes as soon as new evidence becomes available. The ERAS principles must be adapted to the specific environment and each team is expected to set up their own programme and quality control criteria. In this comprehensive review, the latest evidence and trend on enhanced recovery after rectal surgery have been critically appraised and presented.

Keywords

Laparoscopic surgery / rectal surgery / enhanced recovery after surgery

References

[1] Kehlet H.Multimodal strategies to improve surgical outcome.Am J Surg2002;183:630-41

[2] Kehlet H.Evidence-based surgical care and the evolution of fast-track surgery.Ann Surg2008;248:189-98

[3] Khreiss W,Cima RR,Chua HK,Harmsen WS.Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer.Dis Colon Rectum2014;57:557-63

[4] Thiele RH,Turrentine FE,Hassinger TE,Goudreau BJ,Kron IL,Hedrick TL.Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery.J Am Coll Surg2015;220:430-43

[5] Tebala GD,Osman A,Khan AQ.Early discharge after colorectal resection: the positive impact of an enhanced recovery program on a rural colorectal surgery service.Surg Laparosc Endosc Percutan Tech2016;26:e137-44

[6] Gustafsson UO,Schwenk W,Roulin D,McNaught CE,Liberman AS,Hill A,Lobo DN,Ljungqvist O.Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS®) society recommendations.Clin Nutr2012;31:783-800

[7] Greco M,Beretta L,Pecorelli N.Enhanced recovery programme in colorectal surgery: a meta-analysis of randomised controlled trials.World J Surg2014;38:1531-41

[8] Muller S,Hubner M,Demartines N.A fast track program reduces complications and length of hospital stay after open colonic surgery.Gastroenterology2009;136:842-7

[9] Serclová Z,Marvan J,Hankeová Z,Slégrová Z,Trávníková L.Fast-Track in open intestinal surgery: prospective randomized study(clinical trials gov identifier no. NCT00123456)..Clin Nutr2009;28:618-24

[10] Teeuwen PH,Strik C,Brinkert W,van Goor H.Enhanced recovery after surgery (ERAS) versus conventional postoperative care in colorectal surgery.J Gastrointest Surg2010;14:88-95 PMCID:PMC2793377

[11] Gustafsson UO,Thorell A,Soop M.Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery.Arch Surg2011;146:571-7

[12] Grocott MP,Mythen MG.Enhanced recovery pathways as a way to reduce surgical morbidity.Curr Opin Crit Care2012;18:385-92

[13] Forsmo HM,Rasdal A,Mohn AC,Erichsen C.Compliance with enhanced recovery after surgery criteria and preoperative and postoperative counselling reduces length of hospital stay in colorectal surgery: results of a randomized controlled trial.Colorectal Dis2016;18:603-11

[14] Simpson JC,Grocott MP,McMeeking A,Galsworthy MJ.Enhanced recovery from surgery in the UK: an audit of the enhanced recovey partnership programme 2009-2012.Br J Anaesth2015;115:560-8

[15] Khan MA.Clinical outcomes of the very elderly undergoing enhanced recovery programmes in elective colorectal surgery.Ann R Coll Surg Engl2016;98:29-33 PMCID:PMC5234371

[16] Kiran RP,Senagore AJ,Garafalo T.Outcomes and prediction of hospital readmission after intestinal surgery.J Am Coll Surg2004;198:877-83

[17] Portinari M,Targa S,Bonvento B,Camerani S,Volta CA.Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: a prospective cohort study with retrospective control.Int J Surg2018;53:206-13

[18] Nygren J,Carli F,Norderval S,Ljungqvist O,Ramirez J.Guidelines for perioperative care in elective rectal/pelvic surgery: enhanced recovery after surgery (ERAS®) society recommendations.Clin Nutr2012;31:801-16

[19] Tebala GD,Gallucci A,Khan AQ,Mingoli A.Emergency treatment of complicated colorectal cancer.Cancer Manag Res2018;10:827-38 PMCID:PMC5916257

[20] Shida D,Inada K,Seyama Y,Miyamoto S,Umekita N.Modified enhanced recovery after surgery (ERAS) protocols for patients with obstructive colorectal cancer.BMC Surg2017;17:18 PMCID:PMC5314620

[21] Forsmo HM,Rasdal A,Körner H.Randomized controlled trial of extended perioperative counseling in enhanced recovery after colorectal surgery.Dis Colon Rectum2018;61:724-32

[22] Chaudhri S,Hassan I.Preoperative intensive, community-based vs.traditional stoma education: a randomized, controlled trial. Dis Colon Rectum2005;48:504-9

[23] Carmichael JC,Baldini G,Weiss E,Boutros M,Feldman LS.Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the american society of colon and rectal surgeons and Ssociety of american gastrointestinal and endoscopic surgeons.Dis Colon Rectum2017;60:761-84

[24] Singh F,Baker MK,Taaffe DR.Feasibility and efficacy of presurgical exercise in survivors of rectal cancer scheduled to receive curative resection.Clin Colorectal Cancer2017;16:358-65

[25] Minnella EM,Awasthi R,Carli F.Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience.Acta Oncol2017;56:295-300

[26] Carli F,Stein B,Zavorsky G,Scott S.Randomized clinical trial of prehabilitation in colorectal surgery.Br J Surg2010;97:1187-97

[27] Dunne DF,Jones RP,Lythgoe DT,Poston GJ,Fenwick SW.Randomized clinical trial of prehabilitation before planned liver resection.Br J Surg2016;103:504-12

[28] Berkel AEM,van Kamp MS,Weltevreden P,Eijsvogel MMM,Bigirwamungu-Bargeman M,van Det MJ,Klaase JM.The effect of prehabilitation versus usual care to reduce postoperative complications in high-risk patients with colorectal cancer or dysplasia scheduled for elective colorectal resection: study protocol of a randomized controlled trial.BMC Gastroenterol2018;18:29 PMCID:PMC5822670

[29] Gillis C,Bresee L,Gramlich L,Sajobi TT.Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and meta-analysis.Gastroenterology2018;155:391-410

[30] Bousquet-Dion G,Loiselle SE,Agnihotram RV,Carli F.Evaluation of supervised multimodal prehabilitation programme in cancer patients undergoing colorectal resection: a randomized control trial.Acta Oncol2018;57:849-59

[31] Leong KJ.Current data about the benefit of prehabilitation for colorectal cancer patients undergoing surgery are not sufficient to alter the NHS cancer waiting targets.Colorect Dis2017;19:522-4

[32] Curtis NJ,Salib E,Allison AS,Francis NK.Time from colorectal cancer diagnosis to laparoscopic curative surgery - is there a safe window for prehabilitation?.Int J Colorectal Dis2018;33:979-83

[33] Merki-Künzli C,Switalla D,Raptis DA,Mungo G,Gloor S,Breitenstein S.Assessing the value of prehabilitation in patients undergoing colorectal surgery according to the enhanced recovery after surgery (ERAS) pathway for the improvement of postoperative outcomes: protocol for a randomised controlled trial.JMIR Res Protoc2017;6:e199 PMCID:PMC5681719

[34] Wong SG,Harvey D,Sonnadara R.Evaluation of a physiatrist-directed prehabilitation intervention in frail patients with colorectal cancer: a randomized pilot study protocol.BMJ Open2017;7:e015565 PMCID:PMC5734287

[35] Onerup A,Bock D,Fagevik Olsén M,Skullman S,Haglind E.The effect of pre- and post-operative physical activity on recovery after colorectal cancer surgery (PHYSSURG-C): study protocol for a randomized controlled trial.Trials2017;18:212 PMCID:PMC5422966

[36] Minnella EM.Prehabilitation and functional recovery for colorectal cancer patients.Eur J Surg Oncol2018;44:919-26

[37] Yeung SE,Gillis C,Fenton TR.Protein intakes are associated with reduced length of stay: a comparison between enhanced recovery after surgery (ERAS) and conventional care after elective colorectal surgery.Am J Clin Nutr2017;106:44-51

[38] Ljungqvist O.Perioperative fasting.Br J Surg2003;90:400-6

[39] Black PR,Bessey PQ,Wilmore DW.Mechanisms of insulin resistance following injury.Ann Surg1982;196:420-35 PMCID:PMC1352701

[40] Crowe PJ,Royle GT.The effect of pre-operative glucose loading on postoperative nitrogen metabolism.Br J Surg1984;71:635-7

[41] Svanfeldt M,Hausel J,Rooyackers O,Ljungqvist O.Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics.Br J Surg2007;94:1342-50

[42] 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 task force on preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration. Anesthesiology 2017;126:376-93.

[43] Moya P,Ramirez JM,Blasco O,Brugiotti C,Arroyo A.Preoperative standard oral nutrition supplements versus immunonutrition in patients undergoing colorectal resection in an enhanced recovery (ERAS) protocol: a multicenter randomized clinical trial (SONVI study)..Medicine (Baltimore)2016;95:e3704 PMCID:PMC4902354

[44] Guenaga KF,Castro AA,Wille-Jørgensen P.Mechanical bowel preparation for elective colorectal surgery..Cochrane Databasae Syst Rev2005;

[45] Bretagnol F,Rullier E,Berdah S,Portier G,Chipponi J.Rectal cancer surgery with or without bowel preparation: the French GRECCAR III multicenter single-blinded randomized trial.Ann Surg2010;252:863-8

[46] Güenaga KF,Wille-Jørgensen P.Mechanical bowel preparation for elective colorectal surgery..Cochrane Database Syst Rev2011;

[47] Yost MT,Fields AC.Mechanical and oral antibiotic bowel preparation in the era of mini-invasive surgery and enhanced recovery.J Laparoendosc Adv Surg Tech A2018;28:491-5

[48] Leenen JPL,Ockhuijsen HDL.Effectiveness of mechanical bowel preparation versus no preparation on anastomotic leakage in colorectal surgery: a systematic review and meta-analysis..Updates Surg2018;

[49] Kiran RP,Chiuzan C,Forde K.Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery.Ann Surg2015;262:416-25

[50] Alverdy JC.Microbiome medicine: this changes everything.J Am Coll Surg2018;226:719-29

[51] Lobo DN,Neal KR,Rowlands PBJ.Effect of salt and water balance on recovery of gastrointestinal functions after elective colonic resection: a randomized controlled trial.Lancet2002;359:1812-18

[52] MacKay G,McConnachie A,Molloy RG.Randomized clinical trial of the effect of postoperarive intravenous fluid restriction on recovery after elective colorectal surgery.Br J Surg2006;93:1469-74

[53] Gan TJ,Maroof M,Robertson KM,Dwane P.Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery.Anesthesiology2002;97:280-6

[54] Walsh SR,Bass S.Doppler guided intra-operative fluid management during major abdominal surgery: systematic review and meta-analysis.Int J Clin Pract2008;62:466-70

[55] Myles PS,Corcoran T,Peyton P,Christophi C,McGuinness S,Serpell J,Painter T,Minto G.Restrictive versus liberal fluid therapy for major abdominal surgery.N Engl J Med2018;378:2263-74

[56] Song F.Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials.Br J Surg1998;85:1232-41

[57] Nelson RL,Song F.Antimicrobial prophylaxis for colorectal surgery..Cochrane Database Syst Rev2009;

[58] Choi JW,Kin JK,Kim JY.A retrospective analysis on the relationship between intraoperative hypothermia and postoperative ileus after laparoscopic colorectal surgery.PLoS One2018;13:e0190711 PMCID:PMC5757986

[59] van der Pas MH,Cuesta MA,Lacy AM,Bonjer HJ.Laparoscopic versus open surgery for rectal cancer (COLOR II): short term outcomes of a randomized, phase 3 trial.Lancet Oncol2013;14:210-8

[60] Bonjer HJ,Abis GA,van der Pas MH,Lacy AM,Andersson J,Rosenberg J,Haglind E.A randomized trial of laparoscopic versus open surgery for rectal cancer.N Engl J Med2015;372:1324-32

[61] Jesus EC,Matos D,Atallah AN.Prophylactic anastomotic drainage for colorectal surgery..Cochrane Database Syst Rev2004;

[62] Bretagnol F,Faucheron JL.Anterior resection with low colorectal anastomosis.To drain or not? Ann Chir2005;130:336-9

[63] Peeters KC,Marijnen CA,Steup WH,Rutten HJ.Risk factors for anastomotic failure after total mesorectal excision of rectal cancer.Br J Surg2005;92:211-6

[64] Rondelli F,Vedovati MC,Avenia N,Agnelli G.To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis.Colorectal Dis2014;16:35-42

[65] Denost Q,Faucheron JL,Meunier B,Meurette G,Sabbagh C,Benoist S,Sielezneff I,Mauvais F,Barussaud ML,Picat MQ,Laurent C.To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: the GRECCAR 5 randomized trial.Ann Surg2017;265:474-80

[66] Nelson R,Tse B.Prophylactic nasogastric decompression after abdominal surgery..Cochrane Database Syst Rev2007;

[67] Zmora O,Tulchinsky H,Khaikin M.Urinary bladder catheter drainage following pelvic surgery -- is it necessary for that long?.Dis Colon Rectum2010;53:321-6

[68] Gelalis ID,Politis AN,Katonis PG.Bacterial wound contamination during simple and complex spinal procedures.A prospective clinical study. Spine J2011;11:1042-8

[69] Krezalek MA,Zaborin A,Chandrasekar L,Guyton K,Daum RS,Boyle-Vavra S.Can methicillin-resistant staphylococcus aureus silently travel from the gut to the wound and cause postoperative infection? Modeling the "Trojan Horse Hypothesis".Ann Surg2018;267:749-58

[70] Cohen IJr.Antibiotic protection of colon anastomoses.Ann Surg1955;141:707-17

[71] Clarke JS,Bartlett JG,Nichols RL.Preoperative oral antibiotics reduce septic complications of colon operations: results of a prospective, randomized, double-blind clinical study.Ann Surg1977;186:251-9 PMCID:PMC1396345

[72] Tanner J,Assadian O,Kiernan M.Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients.Surgery2015;158:66-77

[73] McEvoy MD,Gordon DB,Thacker JKM,Gan TJ,Shaw AD.American society for enhanced recovery (ASER) and perioperative quality initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part1 - from the preoperative period to PACU.Perioper Med2017;6:8 PMCID:PMC5390366

[74] Maher DP.Proposed mechanisms for association between opioid usage and cancer recurrence after surgery.J Clin Anest2016;28:36-40

[75] Jørgensen H,Møiniche S.Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery..Cochrane Database Syst Rev2000;

[76] Kehlet H.Epidural analgesia and postoperative outcome.Lancet2008;372:2109

[77] Merchea A,Jacob AK,Kelley SR,Spears GM,Larson DW.Efficacy and outcomes of intrathecal analgesia as part of an enhanced recovery pathway in colon and rectal surgical patients..Surg Res Pract2018;

[78] Levy BF,Downson HM.A systematic review of postoperative analgesia following laparoscopic colorectal surgery.Colorect Dis2010;12:5-15

[79] Jibril F,Mohamed A.Intravenous versus oral acetaminophen for pain: systematic review of current evidence to support clinical decision-making.Can J Hosp Pharm2015;68:238-47 PMCID:PMC4485512

[80] Bhangu A,Fitzgerald JE,Tekkis P.Postoperative nonsgteroidal anti-inflammatory drugs and risk of anastomotic leak: meta-analysis of clinical and experimental studies.World J Surg2014;38:2247-57

[81] Modasi A,Godwin M,Curtis B.NSAID administration post colorectal surgery increases anastomotic leak rate: systematic review/meta-analysis..Surg Endosc2018;

[82] McEvoy MD,King AB,Tiwari V,Ehrenfeld JM,Lee LA.A perioperative consult service results in reduction in cost and length of stay for colorectal surgical patients: evidence from a healthcare redesign project.Perioper Med (Lond)2016;5:3 PMCID:PMC4743367

[83] Lloyd GM,Hemingway DM,Miller AS.The RAPID protocol enhances patient recovery after both laparoscopic and open colorectal resections.Surg Endosc2010;24:1434-9

[84] Wang L,Kaushal A,Zhu F.Ketamine added to morphine or hydromorphone patient-controlled analgesia for acute postoperative pain in adults: a systematic review and meta-analysis of randomized trials.Can J Anaesth2016;63:311-25

[85] Guo BL,Hu W,Bao-Cheng Z,Kaye AD,Qu Y.Effects of systemic magnesium on post-operative analgesia: is the current evidence strong enough?.Pain Physician2015;18:405-18

[86] Waldron NH,Gan TJ,Habib AS.Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis.Br J Anaesth2013;110:191-200 PMCID:PMC3544008

[87] Goll V,Greif R,Arkiliç CF,Zoeggeler A,Krieger G,Sessler DI.Ondansetron is no more effective than supplemental intraoperative oxygen for prevention of postoperative nausea and vomiting.Anesth Analg2001;92:112-7

[88] Habib AS,Eubanks S,Gan TJ.A randomized comparison of a multimodal management strategy versus combination antiemetics for the prevention of postoperative nausea and vomiting.Anest Analg2004;99:77-81

[89] Funder JA,Jepsen BN.Postoperative paralytic ileus remains a problem following surgery for advanced pelvic cancers.J Surg Res2017;218:167-73

[90] Lee L,Charlebois P,Kaneva P,Feldman LS.The impact of complications after elective colorectal resection within an enhanced recovery pathway.Tech Colproctol2018;22:191-9

[91] Sugawara K,Nomura Y,Kawasaki K,Koike D,Furuya T.Perioperative factors predicting prolonged postoperative ileus after major abdominal surgery.J Gastrointest Surg2018;22:508-15

[92] Grass F,Jurt J,Solà J,Demartines N.Postoperative ileus in an enhanced recovery pathway - a retrospective cohort study.Int J Colorectal Dis2017;32:675-81

[93] Pohl JM,Thiebes S,Klein-Hitpass L,Gunzer M,Agace WW,Engel DR.Irf4-dependent CD103+CD11b+ dendritic cells and the intestinal microbiome regulate monocyte and macrophage activation and intestinal peristalsis in postoperative ileus.Gut2017;66:2110-20 PMCID:PMC5749346

[94] Engel DR,Wehner S,Schiwon M,Schumak B,Sparwasser T,Knolle PA,Kurts C.T helper type 1 memory cells disseminate postoperative ileus over the entire intestinal tract.Nat Med2010;16:1407-13

[95] Grass F,Jurt J,Solà J,Demartines N.Postoperative ileus in an enhanced recovery pathway - a retrospective cohort study.Int J Colorectal Dis2017;32:675-81

[96] Rohatiner T,Rhodes S,Berel D.A prospective single-institution evaluation of current practices of early postoperative feeding after elective intestinal surgery.Am Surg2012;78:1147-50

[97] Viscusi ER,Leslie JB,Talon MD,Owens G.Peripherally acting mu-opioid recepton antagonists and postoperative ileus: mechanisms of action and clinical applicability.Anesth Analg2009;108:1811-22

[98] Schwenk ES,Torjman MC,Baratta JL.The efficacy of peripheral opioid antagonists in opioid-induced constipation and postoperative ileus: a systematic review of the Literature.Reg Anesth Pain Med2017;42:767-77

[99] Creamer F,Nimmo S,Norrie JD,Fearon KC.Randomized open-label phase II study comparing oxycodone-naloxone with oxycodone in early return of gastrointestinal function after laparoscopic colorectal surgery.Br J Surg2017;104:42-51

[100] Purkayastha S,Darzi AW.Meta-analysis of randomized studies evaluating chewing gum to enhance postoperative recovery following colectomy.Arch Surg2008;143:788-93

[101] Short V,Perry R,Ness AR,Thomas S,Lewis SJ.Chewing gum for postoperative recovery of gastrointestinal function..Cochrane Database Syst Rev2015;

[102] Liu Q,Xu D.Effect of gum ghewing on ameliorating ileus following colorectal surgery: a meta-analysis of 18 randomised controlled trials.Int J Surg2017;47:107-15

[103] Atkinson C,Ness AR,Thomas SJ,Kandiyali R,Lewis SJ.Randomised clinical trial of postoperative chewing gum versus standard care after colorectal resection.Br J Surg2016;103:962-70 PMCID:PMC5084762

[104] Hansen CT,Møller C,Kehlet H.Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double blind, placebo-controlled randomized study.Am J Obstetr Gynecol2007;196:e1-7

[105] Martos-Benítez FD,Soto-García A,Betancourt-Plaza I.Program of gastrointestinal rehabilitation and early postoperative enteral nutrition: a prospective study.Updates Surg2018;70:105-12

[106] Probst P,Klaiber U,Billeter AT,Büchler MW.Meta-analysis of immunonutrition in major abdominal surgery.Br J Surg2017;104:1594-1608

[107] Xu J,Xin Q,Zhan Z,Wu J.Effect of immunonutrition on colorectal cancer patients undergoing surgery: a meta-analysis.Int J Colorect Dis2018;33:273-83 PMCID:PMC5816768

[108] Short V,Ness AR,Burden S.Patient experiences of perioperative nutrition within an enhanced recovery after surgery programme for colorectal surgery: a qualitative study.Colorectal Dis2016;18:O74-80 PMCID:PMC4755035

[109] Rinninella E,D'Ugo D,Cicchetti A,Cintoni M,Gasbarrini A.NutriCatt protocol in the enhanced recovery after surgery (ERAS) program for colorectal surgery: the nutritional support improves clinical and cost-effectiveness outcomes.Nutrition2018;50:74-81

[110] Beloeil H.Sustainability of anaesthesia components of an enhanced recovery program (ERP) in colorectal and orthopaedics surgery..Anaesth Crit Care Pain Med2018;

[111] Veziant J,Pereira B.How does the application of surgical components in enhanced recovery programs for colorectal surgery change over time?.Surgeon2018;

[112] Balvardi S,Castelino T,Liberman AS,Stein B,Mayo NE,Fiore JFJr.Measuring in-hospital recovery after colorectal surgery within a well-established enhanced recovery pathway: a comparison between hospital length of stay and time to readiness for discharge.Dis Colon Rectum2018;61:854-60

[113] Grant MC,Canner JK,Galante D,Gearhart S,Wick E.The impact of anesthesia-influenced process measure compliance on length of stay: results from an enhanced recovery after surgery for colorectal surgery cohort..Anesth Analg2018;

[114] Braga M,Borghi F,Radrizzani D.Identification of core items in the enhanced recovery pathway.Clin Nutr ESPEN2018;25:139-44

[115] Jung AD,Hoehn RS,Johnson BL,Snyder JR,Edwards MJ.Enhanced recovery after colorectal surgery: can we afford not to use it?.J Am Coll Surg2018;226:586-93