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Enhanced recovery protocols (ERPs) were developed primarily for the care of the colorectal surgical patient during the late 1990s and demonstrated early success in the 2000s.1-7 These efforts represented consensus from dieticians, nurses, surgeons, and anesthesiologists at the time and ultimately grew into codified components of care with excellent outcomes.8-11 This work truly represents the culmination of the best science that has assessed the surgical stress response and mitigating therapies, principally from the work of Henrik Kehlet who deserves the title of “Father of Enhanced Recovery After Surgery.”8 ERP implementation has evolved from a convoluted and often complex set of care plans to a true discipline for evidence-based care of the surgical patient. Although the early focus was on length of stay, the science has evolved into an approach for improved patient-centric care that deserves the more proper title of “enhanced recovery protocols” (ERPs). The concepts related to preoperative cardiovascular and pulmonary risk assessment and risk modification are well defined by surgical and anesthesia textbooks and preoperative anesthesia clinic processes, and although they are clearly an essential part of a strong perioperative care plan, they are not typically considered ERP components of care. The majority of a gastrointestinal (GI) surgery–related ERP consists of a variety of shared components that will be addressed in a later section. These strategies are designed to recognize and optimize preoperative physiologic adverse factors, the perioperative stress response, narcotic-sparing analgesia, evidence-based reduction of “potentially preventable complications,” early and aggressive ambulation, and early return to enteral intake.3,8 The optimal use of these strategies has consistently demonstrated a significant reduction in hospital stay and costs, while significantly improving patient safety. The potential components of care include preoperative assessment and education, nutritional repletion, improvement in perioperative glycemic management, anesthesia/analgesia, goal-directed fluid therapy, prevention of nausea and ileus, thromboembolic prophylaxis, minimally invasive techniques, temperature monitoring, early postoperative nutrition, and early mobilization.2 The net result of a well-developed program with a high degree of institutional compliance has been a universal improvement in clinical outcomes, reduced length of stay, reduced cost, and most importantly, significantly improved physical recovery of the patient.5,9 An interesting institutional journey is reflected in the work by Bakker et al,10 who determined that the strongest predictors for a shorter duration of stay (5.7 days with high compliance vs 7.3 days with low compliance) were no nasogastric tube, early mobilization, early oral nutrition, early removal of epidural, early removal of catheter, and nonopioid oral analgesia. However, despite the institutional recognition of these fairly simple components of care and the benefits, the mean adherence rate was 73% in 2006 and 2007, 66% in 2008 and 2009, 63% in 2010 and 2011, and 82% in 2012 and 2013.10 This implies that constant monitoring of both process and outcome is essential for durable success with ERPs.

Despite the almost 20-year recognition of the benefits of ERP, the current ...

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