ORIGINAL CONTRIBUTION

Randomized Controlled Trial of Enhanced Recovery

Program Dedicated to Elderly Patients After
Colorectal Surgery
Sandrine Ostermann, M.D., Ph.D.1,2 • Philippe Morel, M.D.1
Jean-Jacques Chalé, M.D., M.P.H.3 • Pascal Bucher, M.D.2 • Béatrice Konrad1
Raphaël P. H. Meier, M.D., Ph.D.1 • Frederic Ris, M.D.1 • Eduardo R. C. Schiffer, M.D.4
1 Visceral Surgery, Department of Surgery, University Hospital Geneva, Geneva, Switzerland
2 Hirslanden Clinique La Colline, Geneva, Switzerland
3 Medical Documentation and Coding, Financial Direction, University Hospital Geneva, Geneva, Switzerland
4 Anaesthesiology, Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital Geneva, Geneva,
Switzerland

BACKGROUND:  Enhanced recovery program is a
multimodal, multidisciplinary-team, evidence-based care
approach to reduce perioperative surgical stress, decrease
morbidity and hospital stay, and improve recovery after
surgery. This program may be most beneficial for elderly
(≥70 y), but sparse series have investigated this question.
OBJECTIVE:  Feasibility and efficiency of a dedicated
enhanced recovery program in the elderly as compared
with standard care were studied.
Funding/Support: None reported.
Financial Disclosure: This randomized trial was supported by the
Tremplin Academic Grant (to improve the career of women researchers)
in 2011 and by a senior scientific fellow from the University of Geneva,
2012–2014. The authors received an institutional subvention (Research
& Development Project from the Medical Direction, University Hospi-
tal of Geneva) and a financial grant by Fresenius Kabi (Switzerland) AG
for this trial.
Presented at the Swiss Meeting of Swiss Society of Surgery (preliminary
results), Bern, Switzerland, May 21 to 23, 2014; the Plenary Colorectal
Session at the Annual Congress of the French Association of Surgery,
Paris, France, September 30 to October 2, 2015; the Symposium of Fran-
cophone Group of Enhanced Recovery After Surgery, Paris, France, May
29, 2015; the dedicated enhanced recovery after surgery session of the
French Academy of Surgery, Paris, France, October 12, 2016; the Mas-
terclass E-Congrès, Paris, France, October 27, 2017.
Correspondence: Sandrine Ostermann, M.D., Ph.D., Division of Vis-
ceral Surgery, Department of Surgery, University Hospital of Geneva,
Gabrielle-Perret-Gentil, 4 CH-1211 Geneva, Switzerland. E-mail: san-
drine.ostermann@lacolline.ch. Twitter: @MdSandrine
Dis Colon Rectum 2019; 62: 1105–1116
DOI: 10.1097/DCR.0000000000001442
© The ASCRS 2019
DISEASES OF THE COLON & RECTUM VOLUME 62: 9 (2019)
DESIGN:  This was a nonblinded, randomized controlled
study.
SETTINGS:  This study was conducted in a single high-
volume university hospital.
PATIENTS:  A total of 150 eligible elderly patients
undergoing elective colorectal surgery were included.
INTERVENTIONS:  Enhanced recovery after colorectal
elective surgery in elderly patients was studied.
MAIN OUTCOME MEASURES:  The primary outcome was
30-day postoperative morbidity. Additional outcomes
included hospital stay, readmission, postoperative pain,
opioid consumption, independence preservation, and
protocol compliance.
RESULTS:  An enhanced recovery program reduces
postoperative morbidity according to Clavien-Dindo
classification by 47% as compared with standard care
(35% vs 65%; p = 0.0003), total number of complications
(54 vs 118; p = 0.0003), and infectious complications
(13 vs 29; p = 0.001). No anastomotic leak was recorded
in the enhanced recovery group versus 5 for the standard
group (p = 0.01). The enhanced recovery program
resulted in shorter hospital stay (7 vs 12 d; p = 0.003)
and better independence preservation (home discharge,
87% vs 67%; p = 0.005). A high protocol compliance of
77.2% could be achieved in this population. According
to multivariate analysis, enhanced recovery program was
strongly associated with reduced morbidity (OR = 0.23
(95% CI, 0.09–0.57); p = 0.001), less severe complications
(OR = 0.36 (95% CI, 0.15–0.84); p = 0.02), and shorter
hospital stay (OR = 2.07 (95% CI, 1.33–3.22); p = 0.001).
LIMITATIONS:  Limitations were a single-center
recruitment and the impossibility of subject or healthcare
1105

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 1106
professional blinding attributed to the nature of this
multimodal program.
CONCLUSIONS:  Enhanced recovery program is safe and
improves postoperative recovery in elderly patients with
decreased morbidity, shorter hospital stay, and better
maintenance of independence. It should therefore be
considered as a standard of care for elective colorectal
surgery in elderly patients. See Video Abstract at http://
links.lww.com/DCR/A981.
TRIAL REGISTRATION:  clinicaltrials.gov identifier:
NCT01646190.
ENSAYO CONTROLADO ALEATORIZADO DE UN
PROGRAMA DE RECUPERACIÓN INTENSIFICADA
DEDICADO A PACIENTES DE EDAD AVANZADA DESPUÉS
DE CIRUGÍA COLORECTAL
ANTECEDENTES:  El Programa de Recuperación
Intensificada es un enfoque de atención multimodal,
multidisciplinaria y basada en evidencia para reducir el
estrés quirúrgico perioperatorio, disminuir la morbilidad
y la estancia hospitalaria, y mejorar la recuperación
después de la cirugía. Este programa puede ser más
beneficioso para las personas mayores (≥70 años), pero
pocas series han investigado esta pregunta.
OBJETIVO:  Viabilidad y eficiencia del Programa de
Recuperación Intensificada dedicado en personas de edad
avanzada en comparación con la atención estándar.
DISEÑO:  Este fue un estudio controlado, aleatorizado, sin
método ciego.
ESCENARIO:  Este estudio se realizó en un único hospital
universitario de alto volumen.
PACIENTES:  Un total de 150 pacientes de edad avanzada
elegibles sometidos a cirugía colorrectal electiva fueron
incluidos.
INTERVENCIONES:  Recuperación Intensificada después de
cirugía electiva colorrectal en pacientes de edad avanzada.
PRINCIPALES MEDIDAS DE RESULTADO:  El resultado
primario fue la morbilidad postoperatoria a 30 días. Los
resultados adicionales incluyeron estancia hospitalaria,
reingreso, dolor postoperatorio, consumo de opioides,
preservación de la independencia y cumplimiento del
protocolo.
RESULTADOS:  El Programa de Recuperación Intensificada
reduce la morbilidad postoperatoria según la clasificación
de Clavien-Dindo en un 47% en comparación con la
atención estándar (35% vs 65%; p = 0.0003), número
total de complicaciones (54 vs 118; p = 0.0003) y
complicaciones infecciosas (13 vs 29; p = 0.001). No
se registró ninguna fuga anastomótica en el grupo de
Recuperación Intensificada frente a 5 para el grupo
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
OSTERMANN ET AL: ENHANCED RECOVERY AFTER SURGERY IN ELDERLY
estándar (p = 0.01). El Programa de Recuperación
Intensificada dio como resultado una estancia hospitalaria
más corta (7 contra 12 días; p = 0.003) y una mejor
conservación de la independencia (alta hospitalaria: 87%
vs 67%; p = 0.005). Se pudo lograr un alto cumplimiento
del protocolo del 77.2% en esta población. De acuerdo
con el análisis multivariable, el Programa de Recuperación
Intensificada se asoció fuertemente con la reducción de
morbilidad (OR = 0.23; IC 95%: 0.09–0.57; p = 0.001),
menos complicaciones graves (OR = 0.36; IC 95%:
0.15–0.84; p = 0.02) y estancia hospitalaria más corta (OR
= 2.07; IC 95%: 1.33–3.22; p = 0.001).
LIMITACIONES:  Las limitaciones fueron un centro único
de reclutamiento y la imposibilidad de que los pacientes o
el profesional de la salud tuvieran cegamiento debido a la
naturaleza de este programa multimodal.
CONCLUSIONES:  El Programa de recuperación
Intensificada es seguro y mejora la recuperación
postoperatoria en pacientes de edad avanzada, con
menor morbilidad, menor estancia hospitalaria y mejor
mantenimiento de la independencia. Por lo tanto, debe
considerarse como un estándar de atención para la cirugía
colorrectal electiva en pacientes de edad avanzada. Vea el
Resumen en video en http://links.lww.com/DCR/A981.
KEY WORDS:  Colorectal; Elderly; Enhanced recovery after
surgery; Enhanced recovery program; Enhanced recovery
protocol; Fast track; Lidocaine; Multivariate analysis; Old
patients; Surgery.
E
nhanced recovery program (ERP) or fast-track
surgery or enhanced recovery after surgery path-
ways, initially proposed by Dr Henrik Kehlet and
colleagues from Denmark in the 1990s, is a multimodal,
multidisciplinary approach designed to reduce periop-
erative surgical stress, decrease morbidity, and improve
recovery.1,2 Numerous studies, including randomized con-
trolled trials (RCT), a Cochrane review, and numerous
recent meta-analyses have shown that ERPs decrease post-
operative morbidity from 30% to 50% as compared with
standard care (SC), shorten hospital stay, and improve
patient satisfaction after colorectal surgery.3–6 To date, the
elderly represent 15% to 18% of the Western population
and that percentage is likely to double during the next de-
cades because of increased life expectancy. Elderly patients
are defined as ≥70 years old according to the gradual ap-
pearance of frailty defined by nutritional, functional, cog-
nitive, social, and autonomy criteria.7–9
Today, 50% of colorectal surgery is performed in eld-
erly patients. Postoperative morbidity (10.0%–43.0%) and
mortality rates (2.5%–11.0%) reported are higher than in
the younger population. Higher age, potentially associated
with higher number and severity of comorbidities and
 DISEASES OF THE COLON & RECTUM VOLUME 62: 9 (2019)
r­ educed functional reserve, is an independent risk factor of
perioperative morbidity and mortality.8,9 Thus, improve-
ment of elderly condition preoperatively and periopera-
tively could reduce morbidity and mortality by decreasing
the deleterious effect of surgical stress. This could have
a substantial impact in outcome in this population and,
moreover, could better preserve their independence.7–9
ERP after colorectal surgery combines the latest evi-
dence-based medicine elements of perioperative care.10–13
It includes a dedicated preoperative consultation with
patient information and education, optimization of or-
gan dysfunction, preoperative nutritional support, oral
carbohydrate load before surgery, optimized pain control
with multimodal analgesia, individualized goal-directed
intravenous therapy, maintenance of normothermia, no
routine use of nasogastric tubes and drains, early catheter
removal, early oral feeding, and active mobilization.
Although ERP has been widely investigated in the ge-
neral population,3–6 and despite a plethora of cohort stud-
ies, audit registries, and systematic reviews,14–26 since first
reported by Bardram et al27 in early 2000, no large random-
ized trial dedicated to elderly patients has been published
to date. Indeed, only 1 small RCT including highly selected
elderly patients has evaluated the feasibility of ERP after
colorectal surgery and demonstrated encouraging results
with shorter hospital stay and very low postoperative mor-
bidity28 (a second RCT was recently retracted29). Here, we
report a large-scale, prospective RCT including nonse-
lected elderly patients evaluating feasibility, efficiency, and
compliance of ERP after colorectal surgery.
PATIENTS AND METHODS
Patients
All elderly patients ≥70 years of age scheduled to undergo
elective laparoscopic or open colorectal surgery for malig-
nant or benign disease, with or without stoma, were eligi-
ble for the trial over a 2-year period. Patients undergoing
emergency surgery or multiorgan surgery and those who
had a contraindication to systemic lidocaine were disre-
garded for inclusion. The ability to understand either
French or English and to provide written informed con-
sent was required. The protocol was conducted according
to the Declaration of Helsinki and International Confer-
ence on Harmonisation of Technical Requirements for
Registration of Pharmaceuticals for Human Use 10 Guide-
lines. The protocol was approved by the institutional re-
view board (Medical Ethics Committee: NAC08-060) and
registered (clinicaltrials.gov No. NCT01646190).
Design
Eligible patients were randomly (1:1 ratio) allocated to either
the ERP or SC group according to a pre-established institu-
tional block-randomization table. An independent office not
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
1107
involved in the trial oversaw the randomization process. To
avoid involuntary crossover treatment by the nursing staff,
patients were admitted either to a dedicated ERP unit or to
a standard visceral surgery unit. Blinding of patients, nurses,
or surgeon was not possible during hospitalization because
of differences in perioperative care regimens.
Perioperative Care Management
ERP is described in detail in Table 1. Common elements be-
tween ERP and SC included no preoperative bowel prepa-
ration (except in case of low rectal resection), no systematic
premedication, antimicrobial prophylaxis (cefuroxime 1.5 g,
metronidazole 500 mg intravenous, 30 min before skin inci-
sion), short-acting anesthetic agents, maintenance of nor-
mothermia (liquid heater, upper body air-warming blanket),
postoperative nausea and vomiting prevention (ondansetron
30 min before end of surgery in high-risk patients), throm-
boembolic prophylaxis (6H postoperatively low-molecular-
weight heparin), intravenous fluids discontinuation on the
day of oral diet tolerance, and transfer to postoperative anes-
thesia care unit, with discharge according to Aldrete score ≥8
and 30 minutes after systemic lidocaine completion.
ERP notably differs from SC by its dedicated preop-
erative counseling (preadmission education, information,
patient optimization, nutritional status assessment, and
autonomy evaluation with geriatric Activities of Daily Liv-
ing and Instrumental Activities of Daily Living scores),
multimodal analgesia including intraoperative systemic
lidocaine, individualized goal-directed fluid therapy, post-
operative early feeding with oral nutritional support if
needed, and rapid mobilization.
Preoperative nutritional status was assessed accord-
ing to the validated nutritional risk score31 that screens for
impaired nutritional status, integrates severity of disease,
and adjusts final score to age (1 more if ≥70 y). Patients
with a nutritional risk score ≥3 are considered at risk for
postoperative complications and benefit from periopera-
tive nutritional support according to European Society for
Clinical Nutrition and Metabolism guidelines.31,32
Surgical Technique
Surgical expertise was guaranteed by ≥1 specialized colo-
rectal surgeon in the operative field for all of the cases. The
same surgeons team performed surgery in both groups.
Laparoscopy was always the first choice, although surgi-
cal approach remains at surgeon discretion. Laparoscopy,
as 1 of the ERP items, was considered as converted in the
case of unplanned enlargement of incision not attributed
to specimen extraction (eg, adhesions, abscess or fistula, or
anastomosis technical difficulties).
Discharge
Standard discharge criteria33 included no evidence of
complications or organ dysfunction, afebrile state for
 1108 OSTERMANN ET AL: ENHANCED RECOVERY AFTER SURGERY IN ELDERLY

TABLE 1.   Perioperative enhanced recovery program management

Preoperative • Dedicated preoperative counseling
  ✓ Verbal and written patient and family information
  ✓ Patient education
  ✓ Organ dysfunction optimizationa
  ✓ Nutritional status assessment (NRS 2002) Oral nutritional support: 2 times per day for 7 d if NRS ≥3, according
to ESPEN guidelinesb
• Fasting restricted to 6 h for solids and 2 h for liquids before surgery
• Oral carbohydrate loading (100 g in the evening and 50 g 2 h before surgery)c
Intraoperative •  Individualized esophageal US-Doppler goal-directed therapyd
• Multimodal opioid-sparing analgesia with systemic lidocaine (loading dose of 1.5 mg/kg followed by
continuous infusion of 2 mg/kg/h until 4 h after skin closure), short-acting general anesthetics
•  Laparoscopic approach
•  No systematic abdominal drainage
•  Nasogastric tube removal after surgery, at operating room
Day of surgery (POD 0) • Intravenous opioid sparing analgesia (paracetamol 1 g 3–4 times per day; ketorolac 30 mg 3 times per day if no
contraindication, proton pump inhibitor)
• Initiation of clear liquids (300–500 mL) at 6 h postoperative
• Early mobilization: ≥2 h at chair at 6 h postoperative
• Chest physiotherapy if needed
First postoperative day • Initiation of oral opioid-sparing analgesia/nonsteroidal anti-inflammatory drugs (paracetamol 1g 3–4 times per
(POD1) day, ibuprofen 400 mg 3 times per day for 48 h)
• Removal of urinary catheter on the morning
• Initiation of solid diet at breakfast, if oral intake tolerated, associated with free oral drinks
• Active mobilization: ≥4 h out of bed, 1 small walk around room with physiotherapist (if required)
Second postoperative day • Oral nutritional support (protein-rich drink) twice a day from POD2 to POD7
(POD2) • Active mobilization: ≥6 h out of bed, 2 walks around the ward
Third postoperative day • Complete mobilization: ≥8 h out of bed (as preoperative)
(POD3) • Discharge criteria evaluation on the afternoon, and subsequently 1 time per day
ESPEN = European Society for Clinical Nutrition and Metabolism; POD = postoperative day.
a
Organ dysfunction optimization: stabilization of coexisting diseases (eg, hypertension, diabetes mellitus, or pulmonary, cardiac, or renal dysfunction and comorbidities),
correction of iron or vitamin deficiency anemia, encourage smoking and alcohol cessation (see Kehlet et al2).
b
Oral nutritional support: Resource Protein (Nestlé Health Science, Vevey, Switzerland), Fresubin 2kcal Drink (Fresenius Kabi Schweiz AG, Oberdorf, Switzerland), or Fortimel
energy, (Nutricia, St-Ouen, France), depending on patient choice.
c
Oral carbohydrate loading: ProvideXtra Drink (Fresenius Kabi, Schweiz AG, Oberdorf, Switzerland).
d
Intraoperative intravenous fluid administration was guided by an algorithm depending on the Doppler estimations of stroke volume and opening time (FTc = flow time
corrected in milliseconds) of the aortic valve, described by Gan et al.30

>48 hours, adequate pain control with oral analgesia (2
consecutives visual analog scale (VAS) ≤3), tolerance of 3
consecutive meals, return of bowel function, independent
mobilization, and patient acceptance. Hospital discharge
criteria were the same for the 2 groups and were evalu-
ated daily by their own nurses and systematically by the re-
search nurse as early as the third postoperative day (POD),
or before, if requested by the clinical nurse, if the discharge
criteria had been met. They defined the theoretical length
of stay for each patient.
Outcomes
Primary outcome was 30-day postoperative morbidity
according to the validated Clavien-Dindo classification
of complications.34,35 As described by Dindo et al, “Com-
plications were defined as any deviation from the normal
postoperative course…The therapy used to correct a spe-
cific complication remains the cornerstone to rank a com-
plication.34” Analysis and classification were achieved by
investigators and double-checked on patient clinical files
by an external investigator blinded to randomization, sur-
gery, and operators.
Secondary outcomes included length of hospital
stay (LOS), maintenance of independence at discharge,
need for rehabilitation stay, readmission rate, total hospi-
tal stay, postoperative pain, opioid consumption, 1-year
survival, and ERP protocol compliance. LOS was de-
fined as the number of days between surgery and hos-
pital discharge. Rehabilitation stay in dedicated clinics
was recorded in days. Readmission was defined as every
unplanned hospitalization occurring within 30 days after
surgery.
Postoperative pain was first measured at rest at 6 hours
on POD 0, then every morning at rest from POD 1 to POD
3 using 0 to 10 VAS by unit nurses. Opioid consumption
was monitored from POD 0 to POD 3 as intravenous mor-
phine equivalents administered to achieve a VAS ≤3.
Maintenance of independence at discharge was defined
by any modification of preoperative independence status,
including requirement of rehabilitation stay, nursing home

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 DISEASES OF THE COLON & RECTUM VOLUME 62: 9 (2019)
assistance, or nursing home placement at discharge or at
1 year. The mean rate of protocol compliance was defined
per patient as the numbers of elements fulfilled divided by
the total number of ERP elements. Items common to both
ERP and SC groups, such as lack of preoperative bowel
preparation, no systematic premedication, antimicrobial
prophylaxis, use of short-acting anesthetics, maintenance
of normothermia, prevention of postoperative nausea and
vomiting, and antithrombotic prophylaxis, were not con-
sidered to assess ERP compliance.
Data Collection
Anonymous data were collected via a secured and insti-
tutional server. Data including patient demographics,
surgical procedures, and perioperative and postoperative
outcomes (morbidity, LOS, rehabilitation, readmission,
maintenance of independence, pain, opioid consumption,
and 1-year survival) were documented on a standardized
case report form. Until discharge, a dedicated study nurse
recorded patient progress and protocol compliance daily
through review of patient files. Time to achieve discharge
criteria, delay, and adverse events that influenced effective
hospital discharge, as well as rehabilitation stay, were re-
corded. The study nurse followed up with patients at least
until 1 year postoperatively regarding complications, pain,
and maintenance of independence for each patient.
Statistical Analysis
Using an α-error of 5% with a β-power of 80%, a total
sample size of 150 patients was determined to detect a
22% reduction in morbidity for the ERP care group com-
pared with the SC group. This difference was estimated
according to previous reports of ERP care in the general
population according to literature.3–6 Statistical analyses
were performed by our biostatistician using SPSS ver-
sion 18 for Windows (SPSS Inc, Chicago, IL). Data were
assessed according to the intention-to-treat principle.
Continuous variables were summarized as median (inter-
quartile range), whereas categorical variables were sum-
marized as frequencies and percentage. For dichotomous
outcomes, treatment groups were compared by means
of the χ2 or Fisher exact test. Two-sample t tests or Wil-
coxon rank-sum tests were used to compare continuous
normally distributed variables. At a second time point,
because some covariates possibly influenced outcomes
(morbidity, severity of complications, or hospital stay),
covariate-adjusted ORs were produced using logistic re-
gression for morbidity and complication severity, with
a Cox proportional hazards model for hospital stay and
survival. A p value of <0.05 was considered to be statisti-
cally significant. Covariates identified as significant with a
p value of <0.20 in univariate analysis (ERP, ASA score ≥3,
Charlson comorbidity index >3, BMI <21 kg/m2, anemia,
age ≥80 y, open surgery, prolonged operative time >4 h,
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
1109
rectal surgery, and advanced cancer) were selected to per-
form multivariate analysis.
RESULTS
Over a 3-year period, 193 consecutive patients from a sin-
gle center were offered trial participation; 150 eligible eld-
erly patients planned for elective colorectal surgery were
randomly assigned to either the ERP or SC group (Con-
solidated Standards of Reporting Trials flow chart, Fig. 1)
and followed at 1 year after surgery (until the end of 2014).
Overall, patient demographics were similar with respect
to age, sex, ASA score, Charlson comorbidity index, BMI,
pathology, nutritional and functional status, duration of
surgery, and surgical procedures between the 2 groups
(Table 2).
Outcomes
Postoperative morbidity at 30 days, according to Cla-
vien-Dindo classification, was 47% lower in the ERP
group compared with the SC group (35% vs 65%;
p = 0.0003). As summarized in Table 3, the total number
of complications (some patients with >1 complication)
was reduced in the ERP group (54 vs 118 complications;
p = 0.0003). Infectious complications were also reduced
by 52% in the ERP group (13 vs 29; p = 0.0003), with no
anastomotic leak (AA leak) reported in the ERP group as
compared with 5 cases (3 grade II AA leaks requiring in-
travenous antibiotherapy; 2 grade IIIb AA leaks requiring
relaparotomy) in the SC group (p = 0.01). Reoperation
rates were similar in the 2 groups (8% for both group).
The number of patients with GI complications (16 vs 32;
p = 0.008), as well as cardiovascular (4 vs 16; p = 0.007)
or metabolic complications (4 vs 13; p = 0.04), was also
reduced in the ERP group. Mortality rates were not sta-
tistically different in the ERP and SC groups. There was
1 death in the ERP group, 2 in the SD group (2 cardio-
pulmonary arrests and 1 multiple organ failure because
of disseminated intravascular coagulation after heparin-
induced thrombocytopenia in the SD group). The 1-year
survival rates were 93% and 87% for the ERP and SC
groups (p = 0.11). Type and grade of complications are
reported in Table 4.
Elderly patients in the ERP group reached their dis-
charge criteria 4 days earlier than those in the SC group
(POD 5 vs POD 9; p = 0.009). Discharge was delayed by
a median of 2 days in both groups, mainly because of in-
patient rehabilitation/nursing assistance waiting lists or
personal reasons. Median length of hospital stay was re-
duced by 42% for patients in ERP (7 d (3–53 d) vs 12 d
(5–42 d) for SC; p = 0.007). Total hospital stays includ-
ing ­rehabilitation and readmission remained shorter in
the ERP group (8 d (3–53 d) vs 15 d (5–129 d) for SC;
p = 0.001).
 1110 OSTERMANN ET AL: ENHANCED RECOVERY AFTER SURGERY IN ELDERLY

Assessed for eligibility: n = 193

elderly undergoing elective colorectal surgery

Primary exclusion: n = 42
Enrollment Absolute indication for epidural: n = 25
Multiples abdominal resection: n = 8
Refusal of participation: n = 2
Severe cognitive disease: n = 7

Randomized: n = 151

Randomized to SC group: n = 75 Randomized to ERP group: n = 76

Allocation

Secondary exclusion: n = 1
Secondary exclusion: n = 0
Age under 70 years: n = 1

Received SC: n = 75 Received ERP: n = 75

Follow-up

Lost to follow-up: Lost to follow-up:

n=0 n=0
Analysis

Intention-to-treat analysis for Intention-to-treat analysis for

primary and secondary primary and secondary
endpoints: n = 75 endpoints: n = 75

FIGURE 1.  Study flow chart. Randomized controlled trial compared enhanced recovery program (ERP) with standard care (SC) after colorectal
surgery in elderly. Primary exclusions for multiple abdominal resections were hepatectomy/metastasectomy, splenopancreatectomy, Nissen
fundopicature, and complex pelvic exenteration. Procedures requiring absolute epidural analgesia were abdominoperineal resection, pelvic
exenteration, multiple intestinal resections, previous multiple laparotomies.

The 30-day readmission rate was similar for both (8%
vs 7%). Reasons for readmissions were as follows (ERP/SC
groups): Clavien-Dindo grade II pneumonia (1/0), grade
I constipation with anal fissure (1/0), grade II GI hemor-
rhage under anticoagulant treatment (1/1), grade IV se-
vere hemorrhage requiring IC (0/1), grade II cardiac heart
failure (1/1), grade IIIb incisional herniation (0/1), grade
IIIb hematoma requiring surgical decompression (1/0),
grade IIIb adhesional small bowel obstruction (1/0), and
grade IIIb anastomotic leak (0/1).
Better maintenance of independence was achieved in
the ERP group, with 87% vs 67% of elderly discharged at
home without rehabilitation (p = 0.005). There were no
permanent nursing home requirements at 1 year for both
groups.
for postoperative ileus in the ERP group. Postoperative
pain scores and opioid consumption were evaluated from
POD 0 to POD 3. Total opioid consumption was reduced
in the ERP versus SC group (19 mg (0–118 mg) vs 32 mg
(0–182 mg); p = 0.028) to achieve a VAS <3.
Protocol Compliance
The mean rate of ERP protocol compliance was 77.2% ±
12.9%, with a median of 13 (3–16) ERP elements for a to-
tal of 16 elements followed. Compliance to each ERP item
is detailed in Table 5. As shown in Figure 2, clear liquids
initiation could be achieved at 6 hours postoperatively for
>80% of our elderly patients. Oral feeding was tolerated
on the first postoperative day for two thirds of them and
for 84% on the second postoperative day.

Postoperative Recovery Multivariate Analysis

Return of bowel function (regular flatus: POD 2 vs POD
3, p = 0.0004; time to defecation: POD 3 vs POD 4,
p = 0.03) was accelerated in the ERP group. Although 87%
of ­nasogastric feeding tubes were removed in the operat-
ing room in the ERP group (vs 61% for SC; p = 0.0005),
there was no more nasogastric feeding tube replacement
ERP was strongly associated with reduced morbidity (OR
= 0.23 (95% CI, 0.09–0.57); p = 0.001), less severe grade
III to V complications (OR = 0.36 (95% CI, 0.15–0.84);
p = 0.02), shorter length of stay (OR = 2.07 (95% CI, 1.33–
3.22); p = 0.001), and total hospital stay (OR = 1.54 (95%
CI, 1.03–2.30); p = 0.04). Charlson comorbidity index >3

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 DISEASES OF THE COLON & RECTUM VOLUME 62: 9 (2019) 1111

TABLE 2.   Demographics and intraoperative variables

ERP SC
Characteristics and intraoperative variables (n = 75) (n = 75) p
Age, median (range), y 80 (70–91) 78 (70–90) 0.10
Sex ratio (male/female), n (%) 26/49 35/40 0.10
ASA score, median (range) 3 (1–4) 3 (1–4) 0.10
Charlson comorbidity index, median (range) 3 (1–7) 3 (1–9) 0.10
Previous abdominal surgery, n (%) 38 (50.7) 44 (58.6) 0.21
Preoperative radiotherapy, n (%) 10 (13) 5 (7) 0.14
Anticoagulant/antiplatelet treatments, n (%) 24 (32) 27 (36) 0.36
BMI, median (range), kg/m2 25 (16–39) 24.6 (18–37) 0.68
Nutritional score (NRS 2002), median (range) 3 (2–6) 3 (2–6) 0.16
Functional status: ADLs score, median (range)a 6 (5–6) 6 (1–6) 0.05
IADLs score, median (range)b 8 (2–8) 8 (2–8) 0.33
Colon/rectum diseases, ratio 61/14 64/11 0.19
Benign/malignant diseases, ratioc 34/41 29/46 0.61
Surgical procedures, n (%)
  Right-sided hemicolectomy 17 (23) 19 (25) 0.28
  Left-sided hemicolectomy or sigmoidectomy 28 (37) 25 (33) 0.37
  Hartmann reversal procedure 13 (17) 17 (23) 0.27
  Proctectomy/abdominoperineal amputation 4 (5) 3 (4) 0.71
  Terminal colostomy 3 (4) 3 (4)
  Procedures with a temporary diversion (ileostomy) 12 (16) 6 (8) 0.11
Median duration of surgery, median (range), min 219 (30–470) 225 (71–495) 0.65
Data are medians with range in parentheses for continuous variables. Data are numbers with percentages in parentheses for categorical variables. For dichotomous out-
comes, treatment groups were compared by means of the χ2 or Fisher exact test. Two-sample t tests or Wilcoxon rank-sum tests were used to compare continuous normally
distributed variables.
ERP = enhanced recovery program; SC = standard care.
a
ADLs are basic Activity of Daily Living scale, including 6 elements (bathing, dressing, going to toilet, transferring, continence, and feeding), with a score of 1 for independent
functioning on each and a maximal score of 6.
b
IADLs are Instrumental Activities for Daily Living scale, including 8 elements (ability to use telephone, shopping, food preparation, housekeeping, laundry, mode of trans-
portation, responsibility for own medication, and ability to handle finances), with a score of 1 for independent functioning on each and a maximal score of 8.
c
Type of benign diseases (in ERP/SC groups) include low-grade adenomas (4/2), lipoma (1/0), diverticulitis (23/19), volvulus (1/2), fistula/stenosis (2/4), iatrogenic perforation
during screening coloscopy (2/2), and fecal incontinence after radiotherapy (1/0).

TABLE 3.   Outcomes

ERP SC
Outcomes (n = 75) (n = 75) p HR (95% CI)
30-d postoperative morbidity, n (%) 26 (34.7) 49 (65.3) 0.0003*
Reoperation, n (%) 6 (8.3) 6 (8.3)
Anastomotic leakage, n (%) 0 5 (2.6) 0.01
Total number of complications 54 118 0.0003*
30-d mortality, n (%) 1 (1.3) 2 (2.7) 0.81
Discharge criteria achieved, median (range), d 5 (3–43) 9 (3–32) 0.009*
Delay, median (range), d 2 (0–10) 2 (0–11) 0.45
Discharged home, n (%) 65 (86.7) 50 (66.7) 0.005*
Readmission, n (%) 6 (8.3) 5 (7.1) 0.50
Outcomes assessed by Cox proportional hazards regression
Length of hospital stay, median, d 7 12 0.0001* 2.16 (1.45–3.06)
Total hospital stay, median, da 8 15 0.0003* 1.84 (1.32–2.57)
1-y survival, n 70 65 0.18 0.48 (0.17–1.41)
Follow-up, median, mo 27.2 27.5 0.12 0.54 (0.25–1.18)
Data are medians with range in parentheses for continuous variables. Data are numbers with percentages in parentheses for categorical variables. For dichotomous out-
comes, treatment groups were compared by means of the χ2 or Fisher exact test. Two-sample t tests or Wilcoxon rank-sum tests were used to compare continuous normally
distributed variables. For LOS and survival, Cox proportional hazards model was used.
ERP = enhanced recovery program; SC = standard care.
a
This includes total hospital stay including primary hospital stay, rehabilitation stay, and 30-d readmission.
*P value < 0.05 is significant.

(OR = 3.92 (95% CI, 1.21–12.75); p = 0.02), ASA ≥3 (OR cancer (OR = 2.05 (95% CI, 0.96–4.37); p = 0.008), and
= 2.77 (95% CI, 1.08–7.09); p = 0.03), preoperative ane- open surgery (OR = 3.22 (95% CI, 1.38–7.50); p = 0.007)
mia (OR = 2.68 (95% CI, 1.06–6.79); p = 0.04), advanced were independent predictors of increased morbidity.

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 1112 OSTERMANN ET AL: ENHANCED RECOVERY AFTER SURGERY IN ELDERLY

TABLE 4.   Postoperative complications according to Clavien-Dindo classification34

Nonsurgical complications Type Grade ERP SC
Cardiovascular Bradyarrhythmia spontaneously resolute I 0 1
Atrial fibrillation converted by Cordarone II 3 2
Hypertension requiring therapy II 0 3
Heart failure requiring therapy II 0 2
Atrial fibrillation treated by pacemaker IIIa 0 1
Myocardial infarction, stenting IIIb 1 0
Heart failure with low-output syndrome IVa 0 3
Hypovolemic shock IVa 1 4
Cardiopulmonary arrest V 1 1
Deep venous thrombosis, anticoagulated II 0 1
Arterial occlusion treated by thrombolysis IIIb 0 1
General Rash treated with corticosteroids II 0 1
Disseminated intravascular coagulation IVa 0 1
Multiple organ failure V 0 1
Metabolic Total parenteral nutritiona II 4* 11*
Diabetic decompensation II 0 1
Gout crisis treated by colchicine II 0 1
Neurologic Delirium requiring or not therapy I/II 2 5
Hiccup requiring neuroleptic therapy II 0 1
Transient severe delirium requiring IC IVa 1 0
Renal Transient elevation of serum creatinine (>48 h) I 2 2
Catheterization for urinary retention I 4 2
Urinary tract infection requiring antibiotherapyb II 2 4
Respiratory Pneumonia treated by antibiotherapyb II 2 1
Dyspnea treated par intensive physiotherapy II 1 0
Pulmonary embolism II 0 1
Pleural effusion drained IIIa 1 0
Acute respiratory distress syndrome requiring IC IVa 1 3
Laryngeal edema requiring intubation and IC IVa 1 0
Lung + renal failure IVb-d 1 2
Surgical complications Anal fissure with coprostasedema 0
GI Parastomal hernia I 0 1
Noninfectious diarrhea I 0 3
Delayed return of bowel functiona I 2* 7*
Infectious diarrhea treated by antibiotherapy II 0 1
Abdominal infection, source uncertaina,b II 0* 5*
Ileus treated by nasogastric tube II 4 9
GI bleed requiring transfusionsa II 7* 15*
Surgical treatment of bowel occlusion IIIb 2 0
Small bowel volvulus requiring relaparotomy IIIb 0 1
Hemorrhagic shock IVa 0 2
Surgical site infection (SSI)b SSI (superficial) treated at bedside I 2 3
SSI (superficial) requiring specialized carea II 1* 6*
SSI (deep) requiring radiologic drainage IIIa 3 2
SSI (deep) requiring relaparotomy IIIb 2 1
SSI (organ/space) treated by antibiotherapy II 0 1
Anastomotic leak Anastomotic leak treated by intravenous antibiotherapya II 0* 3*
Anastomotic leak requiring relaparotomya IIIb 0* 2*
Urological Obstructive pyelonephritis IIIb 1 0
Bladder suture leak requiring relaparotomy IIIb 1 0
Total 54 118
IC = intensive care; SSI = surgical site infection; ERP = enhanced recovery program; SC = standard care.
a
P < 0.05: Total parenteral nutrition requirement (p = 0.02), delayed return of bowel function more than postoperative day 5 (p = 0.05); fever or inflammatory syndrome of
unknown origin confirmed by negative CT scan control (p = 0.01); GI bleed requiring transfusions (p = 0.02); wound infections requiring specialized nursing care (p = 0.03)
and anastomotic leak (p = 0.01).
b
Definitions of urinary tract infection, pneumonia, and abdominal infection, source uncertain; SSI according to the US Centers for Disease Control and Prevention.
*P value is significant.

Longer hospital stay was associated with severe com- open surgery (OR = 0.55 (95% CI, 0.37–0.84); p = 0.005),
plications (OR = 0.29 (95% CI, 0.17–0.48); p = 0.001), ad- low BMI (<21 kg/m2; OR = 0.32 (95% CI, 0.15–0.68);
vanced cancer (OR = 0.40 (95% CI, 0.23–0.68); p = 0.001), p = 0.003), prolonged operative time >4 hours (OR =

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 DISEASES OF THE COLON & RECTUM VOLUME 62: 9 (2019) 1113

TABLE 5.   Protocol compliance

ERP SC
ERP elements (N = 75), n (%) (N = 75), n (%)
Preoperative 1. Dedicated ERP preoperative counselling 75 (100) NA
2. Preoperative carbohydrate loading 74 (99) NA
Intraoperative 3. Individualized IV goal-directed therapy 52 (69) 3 (4)
4. Perioperative IV lidocaine 66 (88) 18 (24)
5. No systematic abdominal drainage 49 (65) 42 (56)
6. Laparoscopy 44 (59) 33 (44)
Postoperative 7. NGT removal (POD0) 65 (87) 46 (61)
8. Clear liquids initiation (POD0) 62 (83) 18 (24)
9. Mobilization (2 h at chair at 6 h on POD0) 61 (81) 2 (3)
10. Bladder catheter removal (POD1) 43 (57) 13 (17)
11. Free liquid diet (POD1) 61 (81) 23 (31)
12. Solid diet (POD1) 49 (65) 2 (3)
13. Out of bed (>4 h on POD1) 62 (82) 2 (3)
14. Oral nutritional support (POD2) 50 (66) 3 (4)
15. Out of bed (>6 h on POD2) 58 (77) 4 (5)
16. Complete mobilization (POD3) 55 (73) 4 (5)
Protocol compliance (mean ± SD) 77.2% ± 12.9% 17.6% ± 13%
ERP = enhanced recovery program; IV = intravenous; NA = nonapplicable; NGT = nasogastric tube; POD = postoperative day.

0.57 (95% CI, 0.37–0.89); p = 0.01), and rectal surgery
(OR = 0.49 (95% CI, 0.26–0.93); p = 0.03). For sur-
vival analysis, postoperative morbidity (OR = 6.29 (95%
CI, 2.07–19.16); p = 0.001) and severe complications
(OR = 3.34 (95% CI, 1.27–8.78); p = 0.02), as well as anae-
mia (OR = 0.20 (95% CI, 0.08–0.55); p = 0.002), male sex
(OR = 3.55 (95% CI, 1.33–9.50); p = 0.01), and advanced
cancer (OR = 3.89 (95% CI, 1.37–11.10), p = 0.01), are
strong independent predictors for poorer survival.
DISCUSSION
In this article, we report the first large RCT comparing
ERP with SC in unselected, consecutives elderly patients
undergoing elective colorectal surgery. Our results first
confirm the safety and feasibility of ERP care in the elderly
population. Moreover, this trial demonstrates an absolute
30% reduction in postoperative morbidity (35% vs 65%)
and a shorter LOS with ERP (7 vs 12 d) as compared with
SC. These results are in accordance with a previous RCT
in a younger population,3 a recent meta-analysis,4–6 and
a Cochrane review (reduction in postoperative morbidity,
37% to 57%).4 Our results in elderly patients are relevant,
because this high-risk population is particularly vulnera-
ble during the postoperative phase; thus, accelerated re-
covery, rapid independence, and early discharge reduce
the risk of hospital-acquired complications.
It is interesting to note that, although the elderly al-
ready represent 15% to 18% of Western population and
≈50% of colorectal surgery, no previously dedicated RCTs
have investigated in depth or independently the role of
ERP in the elderly population. In their report, Rumstadt
et al16 argue against application of ERP in elderly patients
assuming a lesser compliance and considering that they
are unable to tolerate early feeding and early mobilization
and require longer convalescence after surgery. However,
our results demonstrate excellent compliance to ERP pro-
tocol by elderly (77.2%), which compares favorably with
previously reported series19,20 and a recent large audit
­
from the ERAS Society on the general colorectal popula-
tion (mean compliance = 76.6%; morbidity = 40.0%; LOS
= 6 d; readmission rate = 9.2%).36 Furthermore, time to
reach discharge criteria was shortened by ≈40% in the ERP
group, consequently leading to a shorter hospital stay and,
importantly, a shorter duration of rehabilitation stay not
associated with a higher readmission rate.
This RCT is unique for several reasons. First, it clearly
demonstrates superiority of ERP in an unselected elderly
population (median age = 80 y; median ASA score = 3),
with an absolute 30% reduction of postoperative mor-
bidity and shorter LOS. Second, these outcomes were
controlled at the analytic stage and confirmed by the first
multivariate analysis performed on elderly after colorectal
surgery, to our knowledge. As such, this analysis revealed
that older age (>80 y) was not a negative predictor of in-
creased morbidity, unlike a high Charlson comorbidity
index and ASA grade ≥3, preoperative anemia, open sur-
gery, and advanced cancer. In comparison with enhanced
recovery after surgery, multivariable analysis on an adult
population (median age = 59 y), independent predictors
for increased morbidity were ASA grade 3 to 4, male sex,
and rectal surgery.36,37 Third, this trial confirms the effi-
cacy of systemic perioperative lidocaine as part of multi-
modal analgesia in an ERP care protocol in terms of pain
control, reducing opioid consumption, and accelerated
digestive recovery, as reported previously with traditional
care or ERP, including epidural analgesia. The use of ep-
idural analgesia is subject to controversy in laparoscopic

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 1114 OSTERMANN ET AL: ENHANCED RECOVERY AFTER SURGERY IN ELDERLY

Preoperative counselling
Oral carbohydrates loading
US-Doppler goal-directed therapy
Intravenous lidocaine
No abdominal drainage
Laparoscopy
No nasogastric tube
Clear liquids 6H POD0
Early mobilization ≥2H POD0
Unnary catheter ablation POD1
Free drinks POD1
Solid food POD1
Mobilization ≥4H POD1
Mobilization ≥6H POD2
Oral nutritional support POD2
Mobilization ≥8H POD3
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

FIGURE 2.  Enhanced recovery program compliance. POD = postoperative day.

procedures because of a reduction in patient mobility and
a need for prolonged urinary catheter and its adverse ef-
fects,38,39 which is not the case for systemic lidocaine.
This trial clearly confirms that compliance and, fur-
thermore, applicability should not be limits to ERP in
elderly patients, and the relative benefit from ERP may ac-
tually be higher in this elderly population. However, this
requires that all patients and family, if possible, undergo
a specific preoperative consultation, which may imply an
additional cost; nevertheless, this additional expense will
allow for significant savings in postoperative care. Accord-
ing to our experience, preoperative counseling seems to
positively influence patient compliance and correlates
with previous reports showing that preoperative infor-
mation and optimization are essential parts of ERP, which
results in reduced postoperative pain, anxiety, and hospi-
tal stay.2,9,10 This finding was also recently highlighted by a
Norwegian RCT from Forsmo et al,40 which confirms that
repeated perioperative counseling enhances recovery and
reduces LOS by 2 days.
As observed in this study, a higher rate of anastomotic
leakage has been observed in the SC group compare with
the ERP group. We have to admit that it may have influ-
enced some of the secondary end points, but it did not
prospectively influence the primary end point (morbid-
ity). Moreover the lower rate observed in the ERP group
may potentially be explained by preoperative and post-
operative patient optimization, absence of fasting, and/
or anaesthesia specificities in the ERP group. This issue,
although recently described in 2 others retrospective stud-
ies, should be further investigated in future randomized
trials.26,41 Limitations of this RCT were a single-center re-
cruitment and impossibility of subjects or healthcare pro-
fessional blinding because of the nature of multimodal
ERP care as for all ERP protocol analysis.
CONCLUSION
This trial investigated ERP in nonselected elderly patients
and reveals that it is not only safe and feasible but that
it greatly improves results in terms of reduced morbidity,
maintenance of independence, and shorter hospital stays,
with an excellent protocol compliance. Thus, ERP proto-
cols should be proposed as a standard of care for all elderly
patients undergoing elective colorectal surgery.
ACKNOWLEDGMENTS
The authors particularly thank the elderly patients who par-
ticipated in the study. They also thank Dr C. Klopfenstein (ge-
neral supervisor of the Anaesthetic Team, University Hospital
of Geneva), Dr E. Andereggen (general supervisor of the E-
mergency Team Unit, University Hospital of Geneva), and Dr
P. Gervaz (general supervisor of the Colorectal Unit, Univer-
sity Hospital of Geneva). They are grateful to A. Blancheteau,
dietician, and Dr D. Hubmann, chief executive of Fresenius
Kabi (Switzerland) AG, for their financial support and en-
thusiasm during all this trial period. Dr Ostermann also espe-

Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
 DISEASES OF THE COLON & RECTUM VOLUME 62: 9 (2019)
cially thanks Prof R. Stupp, her former PhD thesis supervisor
(Feinberg School of Medicine, Chicago, IL), for his precious
writing assistance, critical review, and expert comments on
this article.
REFERENCES
1. Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet
H. Recovery after laparoscopic colonic surgery with epidural
analgesia, and early oral nutrition and mobilisation. Lancet.
1995;345:763–764.
2. Kehlet H, Wilmore DW. Evidence-based surgical care and the
evolution of fast-track surgery. Ann Surg. 2008;248:189–198.
3. Vlug MS, Wind J, Hollmann MW, et al.; LAFA study group.
Laparoscopy in combination with fast track multimodal man-
agement is the best perioperative strategy in patients undergo-
ing colonic surgery: a randomized clinical trial (LAFA-study).
Ann Surg. 2011;254:868–875.
4. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast
track surgery versus conventional recovery strategies for colo-
rectal surgery. Cochrane Database Syst Rev. 2011;16:CD007635.
5. Lau CS, Chamberlain RS. Enhanced recovery after surgery pro-
grams improve patient outcomes and recovery: a meta-analysis.
World J Surg. 2017;41:899–913.
6. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Bra-
ga M. Enhanced recovery program in colorectal surgery: a
meta-analysis of randomized controlled trials. World J Surg.
2014;38:1531–1541.
7. Keller DS, Bankwitz B, Nobel T, Delaney CP. Using frailty to
predict who will fail early discharge after laparoscopic colorec-
tal surgery with an established recovery pathway. Dis Colon Rec-
tum. 2014;57:337–342.
8. Massarweh NN, Legner VJ, Symons RG, McCormick WC, Flum
DR. Impact of advancing age on abdominal surgical outcomes.
Arch Surg. 2009;144:1108–1114.
9. Colorectal Cancer Collaborative Group. Surgery for colo-
rectal cancer in elderly patients: a systematic review. Lancet.
2000;356:968–974.
10. Carmichael JC, Keller DS, Baldini G, et al. Clinical practice
guidelines for enhanced recovery after colon and rectal surgery
from the American Society of Colon and Rectal Surgeons and
Society of American Gastrointestinal and Endoscopic Surgeons.
Dis Colon Rectum. 2017;60:761–784.
11. Alfonsi P, Slim K, Chauvin M, Mariani P, Faucheron JL, Fletcher
D; Working Group of Société française d’anesthésie et réanima-
tion (SFAR); Société française de chirurgie digestive (SFCD).
French guidelines for enhanced recovery after elective colorec-
tal surgery. J Visc Surg. 2014;151:65–79.
12. Gustafsson UO, Scott MJ, Schwenk W, et al.; Enhanced Recov-
ery After Surgery (ERAS) Society, for Perioperative Care; Euro-
pean Society for Clinical Nutrition and Metabolism (ESPEN);
International Association for Surgical Metabolism and Nutri-
tion (IASMEN). Guidelines for perioperative care in elective
colonic surgery: Enhanced Recovery After Surgery (ERAS(®))
Society recommendations. World J Surg. 2013;37:259–284.
13. Nygren J, Thacker J, Carli F, et al.; Enhanced Recovery After Sur-
gery (ERAS) Society, for Perioperative Care; European Society
for Clinical Nutrition and Metabolism (ESPEN); International
Association for Surgical Metabolism and Nutrition (IASMEN).
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
1115
Guidelines for perioperative care in elective rectal/pelvic sur-
gery: Enhanced Recovery After Surgery (ERAS(®)) Society rec-
ommendations. World J Surg. 2013;37:285–305.
14. DiFronzo LA, Yamin N, Patel K, O’Connell TX. Benefits of early
feeding and early hospital discharge in elderly patients under-
going open colon resection. J Am Coll Surg. 2003;197:747–752.
15. Scharfenberg M, Raue W, Junghans T, Schwenk W. “Fast-track”
rehabilitation after colonic surgery in elderly patients–is it fea-
sible? Int J Colorectal Dis. 2007;22:1469–1474.
16. Rumstadt B, Guenther N, Wendling P, et al. Multimodal periop-
erative rehabilitation for colonic surgery in the elderly. World J
Surg. 2009;33:1757–1763.
17. Pawa N, Cathcart PL, Arulampalam TH, Tutton MG, Motson
RW. Enhanced recovery program following colorectal resection
in the elderly patient. World J Surg. 2012;36:415–423.
18. Baek SJ, Kim SH, Kim SY, Shin JW, Kwak JM, Kim J. The safety
of a “fast-track” program after laparoscopic colorectal surgery
is comparable in older patients as in younger patients. Surg En-
dosc. 2013;27:1225–1232.
19. Bagnall NM, Malietzis G, Kennedy RH, Athanasiou T, Faiz
O, Darzi A. A systematic review of enhanced recovery care
after colorectal surgery in elderly patients. Colorectal Dis.
2014;16:947–956.
20. Khan MA, Pandey S. Clinical outcomes of the very elderly un-
dergoing enhanced recovery programmes in elective colorectal
surgery. Ann R Coll Surg Engl. 2016;98:29–33.
21. Gonzalez-Ayora S, Pastor C, Guadalajara H, et al. Enhanced
recovery care after colorectal surgery in elderly patients: com-
pliance and outcomes of a multicenter study from the Spanish
working group on ERAS. Int J Colorectal Dis. 2016;31:1625–1631.
22. Slieker J, Frauche P, Jurt J, et al. Enhanced recovery ERAS for
elderly: a safe and beneficial pathway in colorectal surgery. Int J
Colorectal Dis. 2017;32:215–221.
23. Forsmo HM, Erichsen C, Rasdal A, Körner H, Pfeffer F. En-
hanced recovery after colorectal surgery (ERAS) in elderly
patients is feasible and achieves similar results as in younger
patients. Gerontol Geriatr Med. 2017;3:2333721417706299.
24. Ljungqvist O, Hubner M. Enhanced recovery after surgery-
ERAS-principles, practice and feasibility in the elderly. Aging
Clin Exp Res. 2018;30:249–252.
25. Braga M, Beretta L, Pecorelli N, et al.; PeriOperative Italian So-
ciety Group. Enhanced recovery pathway in elderly patients un-
dergoing colorectal surgery: is there an effect of increasing ages?
Results from the perioperative Italian Society Registry. Updates
Surg. 2018;70:7–13.
26. Tejedor P, Pastor C, Gonzalez-Ayora S, Ortega-Lopez M, Gua-
dalajara H, Garcia-Olmo D. Short-term outcomes and benefits
of ERAS program in elderly patients undergoing colorectal sur-
gery: a case-matched study compared to conventional care. Int J
Colorectal Dis. 2018;33:1251–1258.
27. Bardram L, Funch-Jensen P, Kehlet H. Rapid rehabilitation in
elderly patients after laparoscopic colonic resection. Br J Surg.
2000;87:1540–1545.
28. Wang Q, Suo J, Jiang J, Wang C, Zhao YQ, Cao X. Effectiveness
of fast-track rehabilitation vs conventional care in laparoscopic
colorectal resection for elderly patients: a randomized trial. Co-
lorectal Dis. 2012;14:1009–1013.
 1116 OSTERMANN ET AL: ENHANCED RECOVERY AFTER SURGERY IN ELDERLY

29. Compagna R, Aprea G, De Rosa D, et al. Retraction notice to
“Fast track for elderly patients: is it feasible for colorectal sur-
gery?” [Int J Surg. 2014;12:S20–S22]. Int J Surg. 2017;47:152.
30. Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraopera-
tive fluid administration reduces length of hospital stay after
major surgery. Anesthesiology. 2002;97:820–826.
31. Weimann A, Braga M, Carli F, et al. ESPEN guideline: clinical
nutrition in surgery. Clin Nutr. 2017;36:623–650.
32. van Stijn MF, Korkic-Halilovic I, Bakker MS, van der Ploeg T,
van Leeuwen PA, Houdijk AP. Preoperative nutrition status and
postoperative outcome in elderly general surgery patients: a sys-
tematic review. JPEN J Parenter Enteral Nutr. 2013;37:37–43.
33. Fiore JF Jr, Browning L, Bialocerkowski A, Gruen RL, Faragher
IG, Denehy L. Hospital discharge criteria following colorectal
surgery: a systematic review. Colorectal Dis. 2012;14:270–281.
34. Dindo D, Demartines N, Clavien PA. Classification of sur-
gical complications: a new proposal with evaluation in a
cohort of 6336 patients and results of a survey. Ann Surg.
2004;240:205–213.
35. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo
classification of surgical complications: five-year experience.
Ann Surg. 2009;250:187–196.
36. ERAS Compliance Group. The impact of enhanced recovery pro-
tocol compliance on elective colorectal cancer resection: results
from an international registry. Ann Surg. 2015;261:1153–1159.
37. Hendry PO, Hausel J, Nygren J, et al.; Enhanced Recovery After
Surgery Study Group. Determinants of outcome after colorectal
resection within an enhanced recovery programme. Br J Surg.
2009;96:197–205.
38. Joshi GP, Bonnet F, Kehlet H; PROSPECT collaboration. Evi-
dence-based postoperative pain management after laparoscopic
colorectal surgery. Colorectal Dis. 2013;15:146–155.
39. Hübner M, Blanc C, Roulin D, Winiker M, Gander S, Demar-
tines N. Randomized clinical trial on epidural versus patient-
controlled analgesia for laparoscopic colorectal surgery within
an enhanced recovery pathway. Ann Surg. 2015;261:648–653.
40. Forsmo HM, Erichsen C, Rasdal A, Tvinnereim JM, Körner H,
Pfeffer F. Randomized controlled trial of extended periopera-
tive counseling in enhanced recovery after colorectal surgery.
Dis Colon Rectum. 2018;61:724–732.
41. Togores PT, Pastor C, Ayora SG, et al. Colorectal surgery in
older patients under ERAS: Outcomes, benefits and implemen-
tation barriers. Clin Nutr. 2016;12:e52.

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