Introduction

Article Outline

• Copyright

This edition of Seminars in Colorectal Surgery is devoted to understanding the evolution, evidence, and implementation of enhanced recovery or “fast track” pathways. I hope this overview is comprehensive and provides trainees, surgeons, and additional support staff with a fundamental understanding of why improved recovery programs have gained momentum at institutions around the globe.

The widespread adoption of minimally invasive surgery revolutionized our thinking regarding perioperative care. Shortened lengths of stay and reductions in morbidity with less invasive techniques have been realized in numerous trials. More recently this approach has been coupled to a better understanding of the optimal patient care pathway in both the preoperative and the postoperative setting.

The emphasis on “quality,” resource allocation, and cost-effective outcomes will be a significant component to our practices in years to come. In an effort to maintain foresight, we must understand the evidence for enhanced perioperative care modules and develop effective means to introduce them into our practice.

Dr Jonathan Laryea appropriately begins the edition with an overview of preoperative risk evaluation and assessment. This often overlooked segment of enhanced care is well outlined in his article. The variety of risk stratification assessment tools and scores are described within and the indications and current guidelines for cardiopulmonary evaluation are addressed. Dr Amanda Ayers and Dr Sang Lee then highlight the salient physiologic and immunologic responses after intestinal resection. Their focus is primarily the “science of laparoscopy.” This approach is appropriate considering that minimally invasive surgery has been an integral, but not essential, component to enhanced perioperative care.

Next, Dr Neil Ellis tackles the evidence for bowel preparation before colectomy. His robust review of the literature and experience addresses the real utility of mandatory mechanical bowel cleansing. He challenges “surgical dogma” that has guided practice for many years. Dr Edward Lee and Dr Renee Huang follow and investigate the most recent evidence and National Surgical Quality Improvement Program parameters for prophylaxis against both deep venous thrombosis and surgical site infections. This timely review stresses the mandatory adherence to evidence based guidelines that have now emerged as standards of care.

Drs Conor Delaney, Fabien Leblanc, and Knut Augestad review pharmacologic agents available for the prevention of postoperative ileus. This thorough overview highlights the evidence for both peripheral mu receptor antagonists, Alvimopan and Methylnaltrexone. They additionally review the evidence for a multitude of other medications that have been studied for the reduction of ileus or to promote gastrointestinal recovery. Drs Sophie Noblett and Alan Horgan address the significance of goal directed perioperative fluid management in the era of fast track recovery protocols. This overview begins with a historical perspective into fluid management and then elaborately discusses the evolution and evidence for perioperative fluid restriction.

Drs Amy Lightner, Mitchell Lin, and James Yoo explore methods for effective anesthesia and postoperative pain management. These are essential elements for optimal perioperative patient care and satisfaction. They review anesthesia and pain management for both ambulatory and major abdominal surgery and describe how, when properly chosen and implemented, the result is better patient care and expedited operative recovery.

Dr Timothy Geiger, Graham Mackay, and Dr Rocco Ricciardi define “fast track pathways,” emphasize the importance of a comprehensive approach, and provide a substantial overview of a complementary preoperative, intraoperative, and postoperative plan. They conclude with a summary of clinical outcomes-based studies for enhanced care pathways.

Drs Theodor Asgeirsson and Anthony Senagore address the economic implications and potential benefits of enhanced care pathways. Their article provides perspective as we continue to practice in a time where allocation of resources and securitization of outcomes are paramount.

Last, Dr Sharon Stein puts it all together and discusses the significant steps required to introduce enhanced recovery programs to your practice and institution. She candidly addresses potential obstacles including: the enormous amount of data on protocol elements, difficulty creating a multidisciplinary team, and preconceptions about convalescence following colorectal surgery.

I would like to thank both my colleagues in colorectal surgery and their trainees for their contributions to this edition. I fully appreciate your efforts and timely submissions despite the multitude of other responsibilities and commitments that you have in your respective lives. I am confident that your well-written reviews will be enjoyed by surgeons and practitioners at all stages of training or their career.