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the strict necessity. Several studies, and consequently the ERAS guidelines, suggest taking it out as soon as
possible, even within the 1st day [18,67] . The American guidelines differentiate colonic and rectal surgery and
suggest removal of the bladder catheter within day 2 in infraperitoneal rectal resections. Obviously, a lon-
ger duration of bladder catheterization may be necessary in patients with increased risk of urinary reten-
[23]
[18]
tion , such as in the presence of epidural analgesia, and in those who had extensive pelvic surgery .
Prevention of postoperative infections
Colorectal surgery patients are more prone to develop infections than any other surgical patients, possibly
due to the high potential for bacterial seeding and/or translocation. Whereas specific infective processes
such as pneumonia have a clear pathophysiology, it is still not perfectly clear why patients develop surgical
site infection (SSI). The traditional view that this may be due to direct contamination during the operation,
suspected on the basis that the most common causative bacteria of SSI are enteric in origin (E. coli, B. fra-
gilis), has been disproved by the fact that cultures of the wound at the end of a surgical operation are not
[68]
predictive of postoperative infection . It has been proposed a “Trojan Horse” hypothesis for SSI, whereby
virulent bacteria normally quiescent within the gastrointestinal tract are simply transferred to the surgical
[69]
wound by neutrophils and macrophages activated by the surgical trauma . The use of oral non-absorbable
antibiotic would therefore be beneficial also in reducing the risk of SSI [23,50] .

A similar mechanism has been invoked for the genesis of anastomotic leak. It has been demonstrated long
[70]
ago that bacteria and not technique are usually responsible for anastomotic leak . Unfortunately, for some
reasons the view that local ischaemia and technical failure are the main causative factor for leak prevailed,
[71]
despite the clinical evidence that oral antibiotics would decrease the risk of leak , until the more recent
[49]
evidences convinced the American Society of Colon and Rectal Surgeons and the Society of American
[23]
Gastrointestinal and Endoscopic Surgeons to include oral antibiotics in their ERAS guidelines .
The adoption of a bundle of measures to reduce SSI is a winning entry. A recent systematic review and me-
ta-analysis showed a reduction of the risk of SSI of more than 50% (15.1% vs. 7%). All the studies considered
in this review had in common the core elements of the SSI-reduction bundles, namely antibiotic prophy-
[72]
laxis, prevention of hypothermia, hair removal, prevention of hyperglycaemia . Other interventions have
been suggested, such as no fluid overload, skin preparation with chlorhexidine, double gloving or change
of gloves and gowns before closing the fascia, lavage of subcutaneous tissue and silver dressing .
[23]

POSTOPERATIVE STAGE
Postoperative analgesia
Control of postoperative pain has always been a hot topic, as it is one of the variables that may affect post-
operative recovery. The traditional use of morphine has always been quite effective, but at the expense of
important side effects, such as prolonged ileus, and potential complications (respiratory, neurologic) and
safety issues (drowsiness, dizziness, falls) in high risk patients. Several different analgesia regimens have
been proposed, with the aim of minimizing patient discomfort while facilitating his or her recovery and
minimizing side effects and complications of drugs. We agree with the American Society for Enhanced
[73]
Recovery (ASER) that a completely painless surgery is a non-achievable goal , so we should aim at the
best possible analgesia that does not impair the patient’s physical recovery. Every analgesic regimen must
also take into consideration the kind of surgical approach, as the requirements of pain control may vary
according to the size and shape of the abdominal incision and the subsequent surgical trauma.

Opioids have been extensively used in the past to control postoperative pain, but at the expense of heavy