Enhanced recovery for gastrointestinal surgery

### Key points The perioperative care of patients undergoing elective inpatient surgery has undergone marked changes in the last 20 yr, resulting in significant reductions in length of hospital stay (LOS). Kehlet's unit in Denmark was the first to demonstrate very impressive reductions in LOS, and the process became known as fast-track surgery. From these concepts evolved the UK Enhanced Recovery (ER) Programme, which started in four specialities—colorectal, orthopaedics, urology, and gynaecology. In the last few years, there has been a wealth of data from nearly every major surgical speciality, although the majority of evidence comes from colorectal surgery. A major driver for ER has been the benefits not only for patients, but also clinicians and hospital managers. Patients not only leave hospital more quickly, but their subsequent return to normal activity is hastened. Other benefits are a reduction in the physiological stress response (see below), perioperative complications,1,2 and perhaps commencement of further therapy (e.g. chemotherapy) at an earlier stage. Clinicians and hospital managers are able to reduce LOS and either increase throughput or reduce the numbers of beds required accordingly, the latter with significant cost reductions. The individual steps for ER for colorectal surgery were described several years ago and still form the basis of modern ER for all GI surgery (Fig. 1). The adherence to these multimodal, evidenced-based …