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Page 12 of 18 Tebala et al. Mini-invasive Surg 2018;2:32 I http://dx.doi.org/10.20517/2574-1225.2018.37

[105]
nal rehabilitation programme resulted in further reduced morbidity and LOS .

Immunonutrition is associated with reduced rate of complications and reduced length of stay [106,107] . In fact,
it has been demonstrated that the administration of nutritional supplements containing mainly glutamine,
arginine, omega-3 fatty acid and ribonucleic acid is able to reduce the inflammation and improve the im-
mune response. The mechanism of action of immunonutrition has not been fully clarified yet. Apparently,
its main effect is to reduce bacterial translocation by maintaining the integrity of the intestinal mucosa and
[107]
reducing its permeability, thus reducing the risk of infectious complications .

[108]
The main barrier to a correct postoperative nutrition is patient information , so once again it is im-
portant to emphasize the need for patient engagement also in nutritional care at the preoperative
[109]
encounters .

Early mobilization
Early postoperative mobilization has beneficial effects on the whole postoperative recovery. In fact, it
reduces catabolism and bowel recovery and improves ventilator function and bronchial clearance (reduc-
ing the risk of pneumonia and atelectasis), reduces the risk of DVT and prevents muscle loss and insulin-
[18]
resistance. Ultimately, it reduces postoperative LOS, encourages independence and reduces discomfort .
[23]
Several different modalities and targets have been proposed , but no specific protocol has been identified.
[23]
A frequent approach is to allow liberal mobilization as soon as possible after surgery , but in high risk pa-
tients, strong support by specialized staff may be needed.

Quality control
Auditing outcome data is the only way to improve the service we are offering. Once an ERAS programme
has been started, it is likely that this will become part of the “routine” management of surgical patients.
Nonetheless, there is good recent evidence that habituation can lead to over-confidence and the application
of some of the ERAS elements can reduce with time [110,111] . The exact quality indicators of ERAS protocols
are yet to be defined, but it is obvious that LOS is not necessarily the main endpoint. Fit-for-discharge as a
[112]
parameter can be more reliable than LOS . The ERAS Society recommends also considering morbidity
and mortality, need for transfusions, duration of surgery, readmission rate and total cost. We would also
add reoperation rate and patient satisfaction as key factors for quality control. Moreover, it must be empha-
sized that the ultimate aim of rectal resection is to cure a malignant condition; therefore we believe that
oncologic outcomes, such as rate of radical resections and rate of adequate lymphadenectomies must also
be taken as quality parameters.

Another parameter that must be recorded and audited is the compliance with the elements of ERAS. En-
gagement of the whole multidisciplinary department is paramount and adherence to the process is crucial
to obtain the advantages of ERAS [17,113] .

To the best of our knowledge, adherence to ERAS protocols has never been analysed in relation to the size
of the department, however we feel that in a small department it should be relatively easy to implement the
necessary changes leading to the full potential of ERAS principles, with respect to a big-size department
where engagement of all the relevant people can be tricky and sometimes frustratingly impossible. One
of the Authors’ past experience with implementing ERAS in a rural hospital has shown that evolutionary
changes aiming at improving postoperative recovery in colorectal surgery can be implemented relatively
[5]
quickly, and the learning curve of the whole team is quite short . In more sizeable departments, the in-
troduction of the ERAS protocol should be more gradual, focusing initially on prevention of hypothermia,
[114]
early postoperative feeding, early removal of the bladder catheter and no nasogastric tube . Actually,
the Perioperative Italian Society who released this statement in a very recent publication added no bowel