In order to handle the metabolic response of surgery and speed up the recovery of patients, several enhanced recovery protocols have been formulated with encouraging results. Reduced inci-dence of postoperative morbidity and mortality, shorter hospital stay, as well as reduction in healthcare costs were among these results [1]. The steps to achieve an accelerated recovery begin with a thorough preoperative assessment in the first clinic encounter embedded with appropriate patient education and counseling with a physiotherapist and a stoma nurse when feasible. The prolonged period of preoperative overnight fasting is replaced with carbohydrate loading with drinks up to 4 hours prior to induction of anesthesia. For pain management, epidural analgesia is treasured. Careful fluid therapy is essential. Early ‘enforced’ ambulation, enteral nutrition and rehabilitation are encouraged postoperatively [2,3].

However, different versions of the enhanced recovery protocols have been established by combining various sets of elements, and no set is considered an ‘ideal’ protocol of enhanced recovery; thus, authors all around the world have been utilizing a series of programs that focus on specific key components to improve the recovery pathway [4]. This study was designed to implement the concept of fast track care and to set a policy of enhanced recovery after surgery protocols into the surgical management of patients with a colorectal carcinoma at our oncology center. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Demographic data regarding patients' age, sex, and location of the tumor (Table 2) were similar in the 2 study groups. Operative techniques were standardized with subsequent similar durations of surgery, types of laparoscopic surgery, and types of incisions utilized in assisted laparoscopies (Table 3).

Patients in the enhanced recovery group were compliant to enforced mobilization within 24 hours after surgery (POD 0) while only five patients in the control group were ambulated successfully within that period (P < 0.001). Similarly, patients in the en-hanced recovery group tolerated earlier oral feeding (fluids) without severe PONV (P < 0.001). The times of removal of urinary catheters were similar in the 2 groups (P = 0.202). As the removals of NGTs and intra-abdominal drains were linked to successful oral feeding, noticeable significance was noted as regards their times of removal (P < 0.001). Subsequently, enhanced recovery patients met the pre-emptive discharge criteria earlier and thus left the hospital earlier (P < 0.001) (Table 4). The readmission rates were similar in the 2 groups (11.4% each) (Table 4). Four patients in the conventional group were readmitted: one for urine leak (managed by re-exploration and repair), another 2 for anastomotic ‘intestinal’ leakage (managed by re-exploration and repair), and the last for a complete bursting of the abdominal wound, which required debridement and closure. The enhanced recovery group also had 4 readmissions: 2 for abdominal collections (managed by tubal drainage), another for a UTI and urine retention (managed by catheterization and urine cul-tures), and the last for severe late-onset PONV (managed conservatively without any further surgical intervention).

Surgical complications are presented in Table 5. Regarding postoperative complications, patients in the enhanced recovery group had lower incidences of complications some of which were statistically significant, such as wound infection (P < 0.001), respiratory tract infections (P = 0.025) and anastomotic leak (P = 0.05). Two patients in the conventional recovery group died of pulmonary artery embolism within the first 30 days following surgery (intrahospital mortality) while the enhanced group showed no intrahospital mortality (P = 0.493).

Metabolic response to injury has been an intriguing topic to surgeons over time. With an aim to lessen the postoperative morbidity and mortality, a pathway was developed for the patients to allow them to benefit from an understanding of the body's response to surgical trauma in order to accelerate that response [5]. Ongoing clinical trials have explored many of the components of these fast track programs with the aim of formulating a standard protocol for enhancing the recovery and thus minimizing the surgical trauma. Several recent randomized trials have reported the use of 4 to 12 enhanced recovery elements, with a mean of 9, following colorectal resections [6]. Kehlet and Wilmore [7] for example proposed a protocol with 15 elements while Wind et al. [1] used 17 elements in their systemic review. Fifteen items were formulated into an enhanced recovery protocol in our study.

Our study showed that employing enhanced recovery protocols helped in boosting the recovery pathway with favorable outcomes, including faster return of GIT functions, reduced postoperative morbidities, and an earlier hospital discharge, after a resection of colorectal cancer. Enhanced recovery trials in the literature show a noticeable reduction in the duration of postoperative hospital stay. The enhanced recovery group in our study had a mean hospital stay of 4.5 days (P < 0.001) compared to the mean hospital stays reported by Wang et al. [8] in China (5.1 ± 3.1 days, P = 0.001), Šerclová et al. [9] in the Czech Republic (7.4 ± 1.3 days, P < 0.001), Vlug et al. [10] in the Netherlands (mean, 5 days; P < 0.001), García-Botello et al. [11] in Spain (4.15 ± 2.2 days, P < 0.001) and lastly Greco et al. [12] in Italy who analyzed the outcome of 16 clinical trials (mean, 5.8 days) [8,9,10,11,12].

Preoperative counseling has been considered an indispensible factor by some authors [8]. Education and counseling stimulates patients to actively participate in the different tasks offered to them, such as early food intake and early ambulation postoperatively, and helps reduce the psychological stress and fear of the suggested procedures. Highlighted counseling of patients preoperatively are also a requirement of the enhanced program in the protocol guidelines carried out in the United Kingdom, France, Italy and Sweden [13,14,15,16].

Late removal of NGTs was considered common practice following GIT surgery because of the belief that those tubes facilitated gastric emptying, helped avoid pulmonary aspiration, and decreased the risk of leakage from GIT anastomoses. However, their use in the literature is now decreasing after a meta-analysis done by Verma and Nelson [17] that showed an increased complication rate with their routine use. NGTs were removed in 57.1% of the patients in the enhanced recovery group on the day of surgery while they were removed in 62.9% of the patients in the conventional recovery group on POD 3. In our study, an association was found between the time of removal of NGTs in the enhanced recovery group and the duration of hospital stay (P = 0.032), indicating that the earlier the NGTs were removed, the faster the patients in this group were discharged.

One of the important discharge criteria to be fulfilled is sufficient enteral nutrition. In our study, the enhanced group patients were allowed to take oral sips, when tolerated, within the first 24 hours, irrespective of the return of bowel functions. Carbohydrate-rich drinks were given to the patients to increase their caloric intake and hasten recovery. Early oral feeding was found to promote the return of GIT functions and to reduce the incidence of ileus and the risk of infections by improving the immunity [18,19].

Although uncommon in surgical practice, fast track protocols in the literature did not recommend the routine use of abdominal drains following colorectal surgeries except in selective circumstances, such as severe bleeding and difficult dissection, and when they were used, they were removed as early as POD 1 [20] or POD 2 [11]. The mean time of removal of drains within the enhanced recovery group in our study was 2.94 ± 1.06 days compared to 9.06 ± 3.76 days in the conventional group. Although meta-analyses have reported no value of the routine use of drains for colorectal surgeries regarding the postoperative morbidities [21,22,23], we found that they were useful in detecting anastomotic leaks. Six out of 8 patients, in both groups, with intestinal leakage showed intestinal contents in the drains.

The overall postoperative complications in our study were relatively high compared with those of the studies reported in the literature because minor complications, such as mild wound infection and vomiting, were taken into account. Nonetheless, owing to the utilization of an evidence-based set of elements in the protocols of the enhanced recovery group, we observed a remarkable reduction in the incidence of these complications (25.7% in the enhanced recovery group vs. 65.7% in the conventional recovery group, P = 0.001). Certain morbidities, such as wound infection (P < 0.001), respiratory tract infections (P = 0.025) and anastomotic leakage (P = 0.05), were significantly reduced in the enhanced group. Similarly, Greco's meta-analysis of 16 randomized controlled trials reported a significant reduction in the overall morbidity (P = 0.001). However, it only showed a remarkable decrease in the nonsurgical complications (P < 0.001) while the reduction in surgical complications was insignificant (P = 0.13) [12].

Readmission of a patient was defined as hospitalizing that patient for at least one day after successful discharge. In this study, the reason for readmission was either anastomotic leakage, abdominal wall dehiscence, intra-abdominal collection, or persistent PONV. The difference between the groups in our study was not significant (P = 1.000), which was also the result when compared to different clinical trials applying these fast track protocols [10,11,24].

In conclusion, implementation of enhanced recovery protocols within the health care pathway in our oncology center was successful, leading to more rapid recovery and fewer incidences of complications amongst those patients undergoing major abdominal/pelvic surgeries. The implementation of these protocols allowed earlier restoration of gut functions and faster hospital discharge while having no effect on the re-admission or the intrahospital mortality rate.