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Tebala et al. Mini-invasive Surg 2018;2:32 I http://dx.doi.org/10.20517/2574-1225.2018.37 Page 3 of 18

[16]
not need readmission .

ERAS is by its own nature a multidisciplinary approach, where the paradigm of surgical treatment has
been shifted from the surgeon to the team, consisting of surgeons, anaesthetists, physiotherapists, dieti-
cians, physician assistants and specialist nurses. Adherence to the protocols is crucial to get the positive
effects of ERAS in terms of better recovery, fewer complications, reduced LOS, reduction of costs and in-
[17]
creased patient satisfaction .
Although ERAS principles are gradually spreading to every surgical specialty, due to local or national ar-
[12]
rangements, the initial and still greatest interest is in colorectal surgery . Within this specific field, a fur-
[18]
[6]
ther division has been done between colonic and rectal surgery. Although this differentiation sounds
to us a bit forced - as any excessive subspecialisation - we cannot deny that some issues specific to rectal
surgery still exist and will be highlighted in the present review. With respect to colonic surgery, extraperi-
toneal rectal surgery is often associated with higher risk of complications due to (1) critical blood supply to
the rectal stump and the proximal colonic stump in anterior resection due to anatomical reasons; (2) more
difficult surgical technique and longer operation time; (3) previous pelvic radiotherapy; and (4) more fre-
quent need for covering stoma. For these reasons, postoperative length of stay is usually longer after rectal
resection with respect to colonic resection.

The ER protocols have 3 fundamental steps: (1) preoperative; (2) intraoperative; and (3) postoperative [Figure 1].
This artificial division does not reflect into the reality, as the three components overlap and interlace very
often and one influences the others.

PREOPERATIVE STAGE
The preoperative phase of the ERAS protocols is crucial for the success of the whole treatment. For this
reason, the full potential of ERAS can be obtained only in elective patients, as those needing an emergency
operation may miss this important step. To try and extend the benefits of ER also to patients admitted as
emergencies, one of the Authors endorsed a staged approach in patients with acutely complicated colorec-
tal cancer, with an initial damage control procedure followed by an elective resection after the patient has
[19]
been stabilized and fully investigated and prepared .

However, quite recently, emergency operations have been included into ER protocols, as it was felt that
[20]
emergency patients can benefit from some of the improvements yielded by ERAS .

Preoperative counseling
One of the great advantages of ERAS is that the patient has been brought back to the centre of the whole
experience and has been empowered to take care of him/herself and their recovery. The first meetings with
the patient before their surgery are paramount to ensure the correct application of the ERAS protocol.

During the first encounters, after discussing diagnosis and treatment, the patient is offered to be included
into the ERAS programme. Actually, the advantages of ERAS versus the traditional perioperative protocols
have already been extensively demonstrated, so in our opinion there is no need to consider ERAS as a “spe-
cial” measure and the ERAS principles must be considered at the basis of the standard and routine man-
agement of surgical patients. Placing special attention on ERAS - with specific paperwork - makes it appear
as if it is still a sort of “experimental” treatment needing a “special” consent - which is clearly not the case.

It is true, however, that patients must be accurately informed before the operation, which is best practice
anyway, of the kind of management they can expect before, during and after surgery. All the elements
must be discussed, including bowel and systemic preparation, DVT and antibiotic prophylaxis, surgical