ERAS in colorectal surgery

Research Doctorate - Doctor of PhilosophyEnhanced Recovery After Surgery (ERAS) is terminology recently developed in order to describe clinical pathways that facilitate rapid recovery with minimal morbidity, following colorectal surgery. The aim of this thesis was to identify areas in which recovery following colorectal surgery could be further enhanced beyond the existing ERAS pathways. In order to achieve this, a literature review was performed, to quantify existing knowledge, as well as identify deficiencies in the knowledge base. In doing so, three broad areas of recovery were identified that appeared to result in delay or morbidity following colorectal surgery: infection, pain and delayed gastrointestinal function. This thesis by publication, involves 5 randomised clinical trials (RCTs), all in the field of colorectal surgery. Within the above three areas of recovery, these trials addressed different aspects and attempted to identify ways to enhance recovery following colorectal surgery. All trials have been performed with patients receiving current best surgical care, in comparison with current best surgical care and intervention. The thesis is divided into a literature review on ERAS and its science, followed by a review of the three broad areas that increase morbidity following colorectal surgery. Within each area, the randomised clinical trials are emedded. Within the area of infection the first presented trial is an RCT assessing the role of wound protectors, in decreasing surgical site infection (SSI) following colorectal surgery. The second trial presented is an RCT assessing a form of wound closure (purse-string) in decreasing SSI following ileostomy reversal surgery. Within the area of pain there are two RCT’s assessing the role of local anaesthetic blockade in improving pain following laparoscopic colorectal surgery: the first looks at infusions into the neuromuscular plane, while the second assesses peri-operative abdominal wall blockade. Within the area of delayed gastrointestinal function, there is a two-armed (open and laparoscopic) RCT, assessing the role of sham feeding to improve gut function following colorectal surgery