American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Featured Commentary

Our online subscription format, SRGS Connect, features 10 commentaries on recently published articles in top medical journals with each new edition. The commentaries are by practicing surgeons and focus on the strengths and weaknesses of the research and its contribution to advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of SRGS Connect, What You Should Know.

Keenan JE, Speicher PJ, Nussbaum DP, et al. Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs. J Am Coll Surg. 2015;221(2):404-414 e401.

Commentary by: Steven D. Wexner, MD, PhD (Hon), FACS, FASCRS

Keenan and co-workers have very capably demonstrated that sequential implementation of the enhanced recovery program (ERP) and the surgical site infection (SSI) bundle provided incremental improvements in colorectal surgery (CRS) outcomes. These admirable achievements were noted while controlling hospital costs and thus the authors concluded that sequential implementation of these programs supports their combined efficacy as an effective strategy to improve quality patient care.

This study represents the culmination of several decades of enhancements, all of which were designed to improve patient outcomes. Perhaps the cycle began when the routine use of postoperative nasogastric tubes was challenged. Even prior to the widespread advent of laparoscopy, we undertook and published two randomized controlled trials confirming that early oral feeding could be tolerated after laparotomy.1, 2 Kehlet, Senagore, and Delaney, among others, added to early oral feeding, early ambulation, fluid restriction, appropriate postoperative analgesic management, and other enhancements. These various fast-track, accelerated recovery, and ERP efforts further decreased morbidity and offered improvements in both medical patient outcomes and financial hospital outcomes.3-9 Other efforts focused upon by some of the same investigators have utilized goal directed fluid therapy to help further decrease morbidity and improve outcomes.10 An additional piece of the puzzle has been the renewed interest in reducing SSI's through SSI bundles, such as the one outlined in this report.11, 12 These programs include a return to the previously used oral mechanical bowel preparation as well as oral and parenteral perioperative antibiotic use. However, other facets have been added.

The common denominators of successful programs are patient participation, which of course requires patient counseling and multidisciplinary team acknowledgment and synergy to ensure the implementation of these programs. As our health care system continues to evolve and the amount of money that can be spent on individual patients continues to decrease, increased scrutiny and, by necessity, increased implementation of cost-effective programs aimed at improving patient outcomes, is the natural expectation. I applaud the authors on having quite capably demonstrated that these goals can be very reasonably and reproducibly implemented.


  1. Reissman P, Teoh TA, Cohen SM, Weiss EG, Nogueras JJ, Wexner SD. Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial. Ann Surg. 1995;222(1):73-7. Free Full Text
  2. Binderow SR, Cohen SM, Wexner SD, Nogueras JJ. Must early postoperative oral intake be limited to laparoscopy? Dis Colon Rectum. 1994;37(6):584-9.
  3. Foss NB, Kristensen MT, Kristensen BB, Jensen PS, Kehlet H. Effect of postoperative epidural analgesia on rehabilitation and pain after hip fracture surgery: a randomized, double-blind, placebo-controlled trial. Anesthesiology. 2005;102(6):1197-204.
  4. Basse L, Jakobsen DH, Bardram L, Billesbølle P, Lund C, Mogensen T, Rosenberg J, Kehlet H. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg. 2005;241(3):416-23. Free Full Text
  5. Senagore AJ, Emery T, Luchtefeld M, Kim D, Dujovny N, Hoedema R. Fluid management for laparoscopic colectomy: a prospective, randomized assessment of goal-directed administration of balanced salt solution or hetastarch coupled with an enhanced recovery program. Dis Colon Rectum. 2009;52(12):1935-40.
  6. Kariv Y, Delaney CP, Senagore AJ, Manilich EA, Hammel JP, Church JM, Ravas J, Fazio VW. Clinical outcomes and cost analysis of a "fast track" postoperative care pathway for ileal pouch-anal anastomosis: a case control study. Dis Colon Rectum. 2007;50(2):137-46.
  7. Ludwig K, Enker WE, Delaney CP, et al. Gastrointestinal tract recovery in patients undergoing bowel resection: results of a randomized trial of alvimopan and placebo with a standardized accelerated postoperative care pathway. Arch Surg. 2008;143:1098–1105.
  8. Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP. Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery. 2011;149(6):830-40.
  9. Adamina M, Senagore AJ, Delaney CP, Kehlet H. A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery. Ann Surg. 2015;261(5):e138.
  10. Waldron NH, Miller TE, Thacker JK, Manchester AK, White WD, Nardiello J, Elgasim MA, Moon RE, Gan TJ. A prospective comparison of a noninvasive cardiac output monitor versus esophageal Doppler monitor for goal-directed fluid therapy in colorectal surgery patients. Anesth Analg. 2014;118(5):966-75.
  11. Keenan JE, Speicher PJ, Nussbaum DP, Adam MA, Miller TE, Mantyh CR, Thacker JK. Improving Outcomes in Colorectal Surgery by Sequential Implementation of Multiple Standardized Care Programs. J Am Coll Surg. 2015;221(2):404-14.e1.
  12. Cohen ME, Liu Y, Ko CY, Hall BL. Improved Surgical Outcomes for ACS NSQIP Hospitals Over Time: Evaluation of Hospital Cohorts With up to 8 Years of Participation. Ann Surg. 2015 Feb 26. [Epub ahead of print]