Anda di halaman 1dari 28


December 2009

Association of Surgeons of Great Britain and Ireland


Mr Shakeeb Khan, MBBS, MRCS
Mr Marcel Gatt, MD, FRCS
Mr Alan Horgan, MD, FRCS
Consultant Colorectal Surgeon and National Lead for
Enhanced Recovery Programmes, National Cancer Action Team.

Mr Iain Anderson, MD, FRCS

Consultant Colorectal Surgeon and Director of Education,
Association of Surgeons of Great Britain and Ireland.

Professor John MacFie, MD, FRCS

Consultant Colorectal Surgeon and Vice President,
Association of Surgeons of Great Britain and Ireland.

December 2009
Association of Surgeons of Great Britain and Ireland
35-43 Lincolns Inn Fields, London, WC2A 3PE

Issues in Professional Practice is an occasional series of booklets
published by the Association of Surgeons of Great Britain and
Ireland to offer guidance on a wide range of areas which impact on
the daily professional lives of surgeons. Some topics will focus on
clinical issues, some will cover management and service delivery,
whist others will feature broader aspects of surgical working life
such as education, leadership and the law.
Peri-operative surgical care is undergoing a paradigm shift.
Traditional practices such as prolonged pre-operative fasting (nil
by mouth from midnight), bowel cleansing and the use of
nasogastric decompression are being shunned. These, and other
similar changes, have been formulated into protocols called
Enhanced Recovery after Surgery (ERAS) pathways, and this
booklet offers Guidelines for Implementation of Enhanced
Recovery Protocols.
The Association hopes that this publication, and the others in the
series to follow, will provide concise advice and guidance on major
current issues, and grow into a helpful and accessible resource to
support your professional practice.
Suggestions for any potential topics for future booklets in the
Issues in Professional Practice series would be gratefully received.

Professor Michael Horrocks


Page No.
Summary of Recommendations


Components of Enhanced Recovery

and current recommendations

Special circumstances


Elderly and high risk patients

Emergency surgery
Setting up an ERAS protocol and improving compliance


Future research


Quality of life
Laparoscopic surgery
Gut specific nutrients





Enhanced recovery after surgery


Velocity of blood flow in the descending aorta


Quality of life


Stroke volume


Thrombo-embolic Deterrent stockings


Patient controlled analgesia


Postoperative nausea and vomiting

Peri-operative surgical care is undergoing a paradigm shift.
Traditional practices such as prolonged pre-operative fasting (nil
by mouth from midnight), bowel cleansing and the use of
nasogastric decompression are being shunned. These, and other
similar changes, have been formulated into protocols called
Enhanced Recovery after Surgery (ERAS) pathways. The
Association of Surgeons of Great Britain and Irelands current
recommendations on ERAS are summarised below and will be
presented in more detail in this document:
Pre-operative recommendations
1) Pre-operative counselling and training.
2) A curtailed fast (6 hours to solids and 2 hours to clear liquids)
and pre-operative carbohydrate loading.
3) Avoidance of mechanical bowel preparation.
4) Deep vein thrombosis prophylaxis using low molecular weight
5) A single dose of prophylactic antibiotics covering both aerobic
and anaerobic pathogens.
Peri-operative recommendations
1) High (80%) inspired oxygen concentration in the peri-operative
2) Prevention of hypothermia.
3) Goal directed intra-operative fluid therapy.
4) Preferable use of short and transverse incisions for open
5) Avoidance of post-operative drains and nasogastric tubes.
6) Short duration of epidural analgesia and local blocks.
Post-operative recommendations
1) Avoidance of opiates and the use of Paracetamol and non
steroidal anti-inflammatory drugs (NSAIDS).
2) Early commencement of post-operative diet.
3) Early and structured post-operative mobilisation.
4) Administration of restricted amounts of intravenous fluid.
5) Regular audit.

Enhanced recovery after surgery (ERAS) protocols, also known as
fast-track surgery or multimodal optimisation, are a combination
of evidence based peri-operative strategies which work
synergistically to expedite recovery after surgery [1, 2]. These
strategies include, for example, a curtailed pre-operative fast, preoperative carbohydrate loading, pre-emptive analgesia and early
post-operative mobilisation together with expedited re-introduction
of diet and fluids. Although each of these individual strategies is
beneficial, to some extent, on its own, to achieve maximum benefit
they have to be used together in the form of a package. Using
ERAS protocols, post-operative stays following colorectal resection
can be safely reduced to around two to four days. This expedited
discharge is not achieved by lowering the prerequisites for release
from hospital, but rather by fulfilling standard discharge criteria
earlier due to an accelerated post-operative phase. The advantages
of ERAS have been repeatedly borne out in a number of
randomised clinical trials and meta-analyses. The underlying
mechanism of ERAS protocols is thought to be an attenuation of
the peri-operative stress response [3-5], although there is increasing
evidence to suggest that benefits of ERAS are actually mediated by
return of organ, particularly gut function [6].
The purpose of this document is threefold: To present the various
components of enhanced recovery along with the rationale behind
their inclusion; to suggest strategies to facilitate their
implementation and compliance in day-to-day clinical practice,
and; to propose directions for future research. Specific emphasis
shall be given to ERAS in colorectal surgery as a reflection of the
majority of research having been performed in this field. Many of
the strategies are, however, transferrable to other branches of
surgery. It is also noteworthy that different ERAS protocols have
been trialled and validated in the literature. They have all been
shown to produce similar results, suggesting that protocols can be
tailored to take into account local requirements and available
resources. Nonetheless, it must be emphasised that the principles of
ERAS presented in this document are guidelines only and may not
be applicable, particularly in the care of patients undergoing
complex procedures.


Components of ERAS protocols can be broadly categorised into
pre-operative, peri-operative and post-operative interventions.
These shall be considered in turn, together with a brief review of
the evidence and current recommendations.
Pre-operative components
1) Pre-operative counselling and training:
Recommendation: All patients undergoing elective surgery should
be counselled. Patients should be provided with both verbal as well
as written information.
All patients undergoing elective surgery should be counselled
adequately. This process involves not only members of the surgical
team who will be directly involved with the proposed procedure,
but should also include other health professionals, such as
physiotherapists, dieticians, stoma and nutrition nurses, who will
also be involved in the peri-operative care of the patient. Some
units have a dedicated ERAS nurse. Counselling necessitates close
collaboration between all members of the surgical team and the
provision of both written and verbal information. Provision of this
information to patients may occur in the out-patient clinic, the preassessment clinic or the patients home. Patient information leaflets
on ERAS should be produced to facilitate patient education.
Information discussed should include:

What enhanced recovery involves, its core components and

envisaged benefits.

ii.) What the patient should expect during the course of the
hospital stay. This should include specifics of how ERAS
is implemented locally and which modalities are employed.
iii.) Specific issues which may delay discharge (such as lack of
social support).
iv.) Clear and specific instructions should be given about
mobilisation, early introduction of diet and breathing
exercises. Active participation of the patients themselves in
their recovery should be sought, and daily targets for the
patient to achieve should be set up.

Patients who may require a stoma should be identified and

appropriately trained such that they are proficient at stoma
care, ideally prior to surgery [7].

Pre-operative information and education has been shown to

improve patient satisfaction [8, 9], allay anxiety [10] and improve pain
[11] and other outcomes [12].

2) Curtailed fasting and preoperative carbohydrate loading

Recommendation: Patients should be fasted for 6 hours to solids
but they should be allowed small amounts of clear free fluids for up
to 2 hours before induction of general anaesthesia. In addition, a
clear carbohydrate rich drink (e.g. Polycal Liquid (Nutricia
Clinical Ltd, Trowbridge, Wiltshire, UK), Preload (Vitaflo
International Ltd. Liverpool, UK), Maxijul (SHS- Nutrition,
Liverpool, UK)) should be administered orally the night before
surgery and 3 hours prior to induction of anaesthesia.
Fasting for a minimum of 8 hours before a general anaesthetic has
been normal surgical practice for many years. It aims to reduce the
volume and acidity of stomach contents, thereby reducing the risk
of regurgitation or aspiration. Recent studies, however, have
demonstrated that a short (3 hour) period of fasting after ingestion
of clear fluids is safe and more acceptable to patients. This
minimises patient thirst and improves post-operative well being. A
short fast in combination with pre-operative carbohydrate loading
has been shown to maintain nitrogen balance and reduce postoperative insulin resistance [13-15]. Carbohydrate loading involves the
administration of apposite carbohydrate drinks, such as Polycal
Liquid (200 ml), the night before surgery and 3 hours prior to
surgery. Each carton of Polycal Liquid liquid provides 494 Kcal,
equivalent to approximately 120 grams of carbohydrates. Any
commercially available preparation may be used. However, care
should be taken that the formulation used is clear and residue free.
Special circumstances:
Non-insulin dependent diabetics: Pre-operative carbohydrate loading
has been shown to be safe in non-insulin dependent diabetic
patients, and their use is also recommended in this subgroup of
patients. In diabetic patients, a pre-operative carbohydrate load has
not been shown to result in adverse effects such as hyper-glycaemia
or delayed gastric emptying. However, monitoring of blood glucose
levels should be carried out at regular intervals [16].
3) Avoidance of mechanical bowel preparation:
Recommendation: Oral mechanical bowel preparation should not
be used routinely in patients undergoing colonic resection. If
clearance of the rectum is required for a left sided anastomosis, a
single phosphate enema on the morning of the surgery may be used
to evacuate the rectum.
Oral mechanical bowel clearing has traditionally been thought to
reduce the severity of sepsis in the event of an anastomotic leak.
However, a number of meta-analyses have suggested that, in
patients undergoing colorectal procedures, the avoidance of
mechanical bowel preparation is safe and does not result in
increased sepsis in the event of an anastomotic leak [17-20].

Additionally, the use of mechanical bowel preparation can result in

serious adverse events, such as fluid imbalance, in certain patient
subgroups, including the elderly. We recognise that the evidence for
omitting bowel preparation in patients undergoing rectal surgery
alone is equivocal.
4) Deep vein thrombosis prophylaxis
Recommendation: All patients undergoing surgery should be
started on a once daily low molecular weight heparin (Enoxaparin
20 mg) the night before surgery and continued for the entire length
of the patients hospital stay. In addition, graduated compression
thromboembolic deterrent stockings (TEDs) should be used. During
the procedure, pneumatic mechanical compression stockings should
be used. Prophylaxis should be considered for up to one month
after discharge, especially in those at a higher risk of
thromboembolic complications, such as those with residual
malignancy or previous episodes of thrombosis.
A single daily dose of low molecular weight heparin is
recommended for deep vein thrombosis prophylaxis because of its
ease of administration and lower risk of bleeding complications [21].
The use of low molecular weight heparin in conjunction with
graduated compression stockings was found to be the most
effective anti-thromboprohylactic prophylaxis in a recent Cochrane
review [22, 23]. There is an increased risk of thrombotic complications
up to one month after surgery, due to a hypercoaguble state, and
prolonged (up to 1 month after discharge) antithrombotic
prophylaxis with low molecular weight heparin confers significant
benefit in terms of reduction of thrombotic complications [24, 25].
5) Antibiotic prophylaxis
Recommendation: A single dose of antibiotics, covering both
aerobic and anaerobic organisms, should be administered just
prior to incising the skin. In prolonged procedures (more than 4
hours) or if there is major blood loss (greater than 1500 mls.) a
second dose may be administered.
Antibiotic prophylaxis is used to reduce the rates of wound
infection after surgery. Multiple doses have not been found to
confer any additional advantages and result in increased costs and
risk of infections such as Clostridium difficile. For this reason, a
single dose of antibiotics covering both aerobic and anaerobic
organisms should be administered just prior to incising the skin in
all clean procedures which do not involve the insertion of
prosthetic materials. When deciding the type of antibiotic used,
local resistance patterns should be considered. Increased risk of
acquiring a Clostridium difficile infection after using a third

generation cephalosporin should also be considered. In those who

are known to be carriers of MRSA (Methicillin resistant
Staphylococcus aureus), prophylaxis with a glycopeptide antibiotic
(Vancomycin, Teicoplanin) should be considered.
Peri-operative components
1) High inspired oxygen concentrations
Recommendation: Eighty percent (80%) oxygen should be
administered during anaesthesia and then continued for at least 6
hours postoperatively. A face mask may be required to deliver this
high concentration of oxygen.
Molecular oxygen is required by polymorphonuclear cells to
produce free radicals which form an important line of defence
against pathogens [26-28]. In addition, it plays an important role in
the synthesis of collagen for wound healing and angiogenensis.
Higher tissue oxygenation levels in the immediate post-operative
period as a result of 80% inspired oxygen have been shown to
improve perfusion at the anastomotic site and reduce the risk of
surgical site infections [29]. In addition, there is some evidence that
it may also reduce postoperative nausea and vomiting (PONV)
although this is contentious [30, 31].
2) Prevention of hypothermia
Recommendation: Hypothermia (core temperature less than
36C) should be actively prevented using warm-air blankets.
Warming should be continued for as long as the patient is in
recovery. If the procedure is expected to last for more than an
hour, then warmed intravenous fluids should be used. An
oesophageal probe should be used during the procedure for
measurement of core body temperature.
General anaesthesia can disrupt the normal thermoregulatory
processes and result in hypothermia. In addition, exposure of the
patient to the cold theatre environment also contributes.
Hypothermia (core temperature less than 36C) can, in turn, lead
to an increase in the incidence of surgical site infections, thought
to be due to peripheral vasoconstriction induced hypoxia [32, 33] and
an altered immune response. Other undesirable effects of
hypothermia include coagulopathy [34], increased cardiac
morbidity [35] and increased levels of circulating catecholamines
with a resultant exaggerated catabolic response [36]. Active
prevention of hypothermia during the peri-operative period has
been shown to reduce blood loss and prevent infective [33, 37] and
cardiac complications [38].

For these reasons, hypothermia should be actively prevented using

warm-air blankets. Warming should be continued for as long as the
patient is in recovery. If the procedure is expected to last for more
than an hour, then warmed intravenous fluids should be used [39, 40].
An oesophageal probe should be used during the procedure for
measurement of core body temperature.
3) Goal directed intra-operative fluid therapy
Recommendation: An oesophageal Doppler probe (or other
minimally invasive methods of stroke volume measurement such
as LiDCO plus and LiDCO rapid) should be used to
continuously measure the cardiac output, and fluid
administration should be titrated according to variations in the
cardiac output.
A degree of intra-operative splanchnic hypoperfusion may go
undetected with conventional monitoring, and this plays an
important role in post-operative delay of return of gut function.
In addition, occult hypoperfusion can lead to bacterial
translocation across the gut wall which can result in sepsis
syndrome. On the other hand, the administration of excessive
amounts of fluid during surgery can also result in delayed return
of gut function and cardiac morbidity. An oesophageal Doppler
probe is a minimally invasive method of determining the
hemodynamic status in the peri-operative period and allows
guided fluid management targeted against indicators of cardiac
output. The intra-operative use of an oesophageal Doppler probe
has been shown to accelerate the return of gut function and
expedite discharge after surgery [41]. The haemodynamic status of
the patient should first be optimised using an oesophageal
Doppler probe such that the cardiac output is maximum. Further
boluses of colloids (on a background of maintenance fluids)
should then be administered against variations in stroke volume
(SV) and velocity of blood flow in the descending aorta (FTc). If
resources do not permit the universal use of oesophageal
Doppler, then its use may be restricted to high risk (ASA 3 and
above) and elderly patients. A schema for administering Doppler
guided fluid is shown in Figure 1.
Other minimally invasive methods of optimising the fluid
balance include LiDCO plus and LiDCO rapid and may be
used instead of the oesophageal Doppler. These systems depend
on a Lithium dilution technique to measure changes in
haemodynamic parameters, such as cardiac output and stroke
volume, and provide continuous real-time measurements.

Monitor FTc and SV

FTc <350ms


Monitor FTc and SV

Colloid Challenge
7 ml/kg first bolus (if low FTc)
3 ml/kg subsequent bolus (or initial SV)


FTc <350ms or
SV decrease >10%

FTc <350ms
FTc >400ms


Monitor FTc and SV

SV increased >10%
since previous
bolus or measurement


Figure 1: Algorithm of fluid administration using an oesophageal Doppler (taken

from Noblett et al. British Journal of Surgery 2009)

4) Surgical approach and incisions

Recommendation: Both a laparoscopic or an open approach may
be used, depending on local expertise and available resources. For
open surgery, a lower transverse incision should be used whenever
possible. If a transverse incision is not possible, then a selectively
lower or upper midline incision is recommended. The length of the
incision should be kept as short as possible.
Laparoscopic colorectal techniques have been shown to improve
outcomes over similar open surgery techniques. These improvements
include an earlier return of organ function, reduced post-operative
analgesic requirement and an earlier discharge from hospital [42].
However, the major trials which have compared laparoscopic to open
colorectal surgery have not taken ERAS into account and have,
instead, compared laparoscopic surgery to conventional open surgery.
Only three, single-centred and small-sized, randomised trials have
compared the outcomes of laparoscopic and open colorectal surgery
within the setting of ERAS, and these have produced conflicting
results. At least two large multi-centre randomised trials,
investigating the role of laparoscopic surgery within ERAS
pathways, are currently ongoing and their results should, hopefully,
clarify this issue to some extent [43, 44]. It is currently not possible to
recommend whether or not the use of the laparoscopic approach
within an ERAS pathway would result in indisputable advantages to
the patient, over and above to those offered by open surgery in
conjunction with ERAS. However, laparoscopic colorectal resection
may be undertaken if local resources and expertise allow.

When undertaking open procedures, a number of considerations

need to be borne in mind. Short transverse incisions are thought to
be less painful, impair lung function to a lesser extent, and reduce
subsequent post-operative analgesic requirement when compared
to vertical wounds. In addition, there is some evidence that the
incidence of wound dehiscence may be reduced in transverse
incisions. These were the conclusions of a Cochrane review in
2005 [45]. However, the results of a recent large randomized trial
did not find that transverse incisions were less painful than
longitudinal ones [46].
5) Avoidance of post-operative drains and nasogastric tubes
Recommendation: Routine abdominal drains and nasogastric tubes
should be avoided. If gastric decompression is required during
surgery, a nasogastric tube may be inserted temporarily and
removed at the end of the procedure.
Nasogastric tubes may be painful and cause considerable
discomfort. This can render post-operative mobilisation difficult.
There is good evidence that routine use of nasogastric
decompression delays the return of gut function, leads to an
increase in pulmonary complication and fever and prolongs
hospital stay. These findings are supported by at least two metaanalyses [47-49].
Abdominal drains have been traditionally placed to evacuate postoperative collections at the site of surgery and drain any possible
anastomotic leak. However, similar to nasogastric tubes, they
cause considerable discomfort and can hinder mobilisation.
Moreover, at least three meta-analyses have revealed that routine
prophylactic drainage of the abdominal cavity does not confer any
advantages [50-52].
6) Short duration of epidural analgesia and local blocks
Recommendation: All patients undergoing open colorectal surgery
should receive epidural analgesia. It should be initiated at the
beginning of the procedure and continued for a maximum of 48
hours. Weaning from epidural analgesia should start 12 hours postoperatively. Care should be taken that the equipment does not
interfere with mobilisation. Patients undergoing laparoscopic
resection may or may not be administered epidural analgesia
depending upon the preference of the operating surgeon and
A fine bore catheter placed into the epidural space at the level of
T9 and T10 can be used to deliver a mixture of a short acting
opiate (Fentanyl 2mcg/ml) and a local anaesthetic solution
(Bupivacaine 0.15%). This results in a blockade of the spinal

nerves. Epidurals analgesia directly attenuates the post-operative

stress response and promotes the return of gut function by blocking
the sympathetic activity [53, 54]. However, this sympathetic blockade
can result in hypotension due to vasodilatation which can prove
difficult to manage as it may not respond to intravenous fluids. In
these situations, an early decision to transfer the patient to a high
dependency unit must be taken and inotropic or vasopressor
support initiated. Another disadvantage is that the equipment can
interfere with postoperative mobilisation. Whenever epidurals are
utilised, these should be initiated at the beginning of the procedure
and continued for a maximum of 48 hours. Weaning from epidural
analgesia should start 12 hours post-operatively. Alternatives to
epidural analgesia include transversus abdominis plane (TAP)
blocks and other infiltrations with local anaesthetic aimed at
reducing post-operative opiate usage.
The role of epidural analgesia in relation to laparoscopic colorectal
surgery is not clear. A small number of studies have questioned the
use of epidural analgesia in the setting of laparoscopic surgery.
They argue that analgesic requirements after laparoscopic surgery
are lower and, as such, epidurals may not have an added advantage
and, on the other hand, only increase the risk of epidural related
complications [55-57]. However, a small number of trials have
produced contradictory results and have shown that additional
advantages may be obtained when epidurals and laparoscopic
surgery are used together [58, 59]. The current evidence level is weak
and insufficient to advocate the universal use of epidural analgesia
in laparoscopic colorectal resection. However, this should not
preclude the surgeon or the anaesthetist to use epidural analgesia
for laparoscopic surgery if they deem it to be safe and useful in
their local setting.
Post-operative Components
1) Avoidance of opiates and the use of Paracetamol and non
steroidal anti-inflammatory drugs (NSAIDS)
Recommendation: Post-operatively, patients should be prescribed
regular Paracetamol and NSAIDS such as Ibuprofen or Diclofenac
if there are no contraindications to their use. Opiates, including
Codeine preparations and Tramadol, should only be reserved for
breakthrough pain. Whenever opiates are used, attention should be
paid to prevent nausea and vomiting and regular antiemetics
Early return of gut function and prevention of its various adverse
sequels is thought to be one of the underlying mechanisms by
which ERAS protocols work. Opiates are known to delay the return
of gut function and should be avoided whenever possible. In
addition, they can cause considerable post-operative nausea and

vomiting (PONV). Opiate minimisation should include the

avoidance of Codeine and Tramadol preparations as well as opiate
containing patient controlled analgesia (PCA) infusions. In their
stead, patients should be prescribed paracetamol and NSAIDS, if
there are no contraindications to their use. Opiates should be used
only for purposes of rescue analgesia. Liberal use of antiemetics
should be employed, but the limitation of these medications in
expediting the recovery of post-operative gut function should be
recognised [60].
2) Early postoperative diet
Recommendation: Patients should be allowed oral fluids as
tolerated on the day of the surgery and built up to an oral diet over
the next 24 hours. Patients who are not meeting their nutritional
requirements by 72 hours after surgery should be assessed by a
Traditionally, oral diet and fluid has been reintroduced cautiously
and gradually after bowel surgery, often rendering the patients nil
by mouth or on oral sips only for many days in the post-operative
period. This, it was thought, was necessary for adequate healing of
bowel anastomoses. However, recently, early introduction of diet
and fluids (within 24 hours post-operatively) has been shown to be
safe [61, 62]. In addition, there is some evidence that early feeding
may be beneficial in reducing the risks of anastomotic dehiscence,
infections and reducing the length of stay [63]. In our view, tolerance
to early feeding provides a more objective evaluation of gut
function than assessment on the basis of bowel sounds of passage
of flatus.
3) Early postoperative mobilisation
Recommendation: A structured mobilisation plan should be in
place. Patients should be helped to sit out in a chair on the evening
of surgery and definitely by the first post-operative day. This should
be followed by gentle assisted mobilisation either the same day or
the next day. Patients should be seen by a named physiotherapist
pre-operatively with the aim of explaining the mobilisation plan.
This physiotherapist should then help enforce this plan throughout
the post-operative period.
Even short periods of immobilisation can lead to deleterious
consequences such as thromboembolism, loss of muscle strength,
pulmonary atelectasis and worsening of pulmonary function.
Continuous patient education regarding the benefits of mobilisation
is recommended. It was shown in a randomised trial that avoidance
of bed-side entertainment systems is one pragmatic approach to
encourage mobilisation [64].

4) Restricted amounts of intravenous fluid

Recommendation: It is not possible to recommend a single point in
time by which all intravenous fluid administration should be
stopped. However, in the majority of patients, this should be
possible by the second post-operative day, by which time adequate
oral fluids should be tolerated and indwelling epidural catheters
During the post-operative phase, intravenous fluids may be required
as long as adequate oral fluid intake has not been achieved and/or
epidural catheters are still in situ. However, excessive amounts of
intravenous fluid should be avoided. A daily regime of 1.5 to 2.5 L
should suffice for most patents. The ability of individuals to get rid
of accumulated sodium is greatly curtailed in the post-operative
period. For this and other reasons, balanced intravenous solutions
such as Hartmanns should be prescribed in preference to Normal
Saline (0.9% NaCl) in an attempt to avoid sodium overload,
hyperchloremic acidosis and a delayed return of gut function [65].
5) Audit
Recommendation: Clinical outcomes, including readmission rates
and compliance to the various ERAS strategies, should be regularly
audited. Readmission rates after ERAS implementation should not
exceed 10%. Audit findings should be discussed in regular audit
meetings attended by medical, nursing and other ancillary staff.
Results should also be disseminated using the local IT systems such
as the intranet and e-mail.
A perceived disadvantage of many ERAS protocols is that, by
discharging patients home sooner, one is simply transferring their
responsibility on to primary care providers whilst also predisposing
patients to higher readmission rates, despite the risks associated
with such practices. This has not been borne out in trials, where the
emphasis was to enhance patients recovery in preference to fast
tracking patients through their hospital stay [66].
Continued audit should permit such problems to be detected early,
and necessary modifications made to discharge criteria, so as to
ensure that patients receive the best possible care. Readmission
rates after ERAS implementation should not exceed 10%.
Additionally, a continuous audit cycle should ensure detection of
any institutional problems associated with ERAS implementation
as well ascertaining a continuously up-to-date and evidenced based
ERAS practice.


1) Elderly patients and those with high co-morbidity
Such patients have been shown to benefit from enhanced recovery
and should be included in these programmes. There is no evidence
for concern in including ASA 3 and 4 patients into ERAS
programmes, although the literature in this area is limited [67].
Elderly patients may not be able to cope at home after discharge if
there is no one to assist them. This may delay patient discharge,
cognisant of the fact that the overarching aim of ERAS is to
enhance post-operative recovery, not to discharge patients home
earlier. The elderly may require a degree of input after discharge
and this may be in the form of regular telephone calls, a home-visit
by a healthcare professional or even by a relative. Therefore,
discharge planning should be initiated at a very early stage for
these patients.
Certain components of ERAS protocols may be even more relevant
in this cohort of patients. For example, Doppler guided fluid
therapy may be particularly useful in the elderly and high risk
patients in whom accurate fluid administration is possibly more
important due to the increased risk of fluid overload.
2) Emergency surgery
Although ERAS pathways have been primarily studied in the
elective setting, they should still be applied to the emergency
situation. Although in emergencies implementation of the preoperative components may not be possible, every effort should be
made to implement as many components as possible [68].



Enhanced recovery programmes require a multi-disciplinary
approach and co-ordination. This can render their initiation and
implementation difficult. Compliance to these packages has often
been reported to be low, especially in the post-operative period and
outwith the remits of clinical trials.Factors which can facilitate
introduction and implementation of enhanced recovery pathways
and improve protocol compliance include:
1) Selected anaesthetic input
Patients should be managed by a selected group of anaesthetists
who are committed to the concept of enhanced recovery.
2) Patients should be managed on specific wards
The management of patients by a select group of medical and
nursing staff trained in the principles of enhanced recovery may
improve compliance. If resources permit, specialised units
dedicated to implementing ERAS called Enhanced Recovery
Units should be set up. This may facilitate the organisational
aspects of running ERAS protocols. Such units can also play a role
in patient education, where patients are continuously reminded of
the importance of their active participation in the success of
enhanced recovery. This may be facilitated by direct staff contact as
well as by using apposite posters and pamphlets.
3) Continuous staff education
The majority of strategies of ERAS pathways are simple measures
which can be implemented by junior medical and nursing staff.
Therefore, whenever junior medical staff rotate into a unit that
practices enhanced recovery, targeted teaching sessions should be
held to ensure that all staff are familiar with the practices of the unit.
4) A multidisciplinary team approach
An ERAS team should be in place and should comprise one or
more surgeons, anaesthetists, nurses, dieticians and
physiotherapists. These individuals should be signed up to the
concept of enhanced recovery. In the majority of hospitals, it
should not be necessary to expand the work force to formulate such
teams and a reconfiguration and collaboration of existing services
should be sufficient. The ERAS team may replace and take over the
role of other previously existing teams such as the Pain
Management Team whose members can, in turn, be trained to be a
part of the new ERAS team. This would ensure that aspects such as
pain control are dealt with in accordance with the principles of
ERAS. In addition to the clinical care, the ERAS team should take

up additional roles such as ensuring compliance, auditing outcomes

and continuous staff and patient education to facilitate
implementation of ERAS.
5) A local champion
Successful implementation of enhanced recovery packages
necessitates a local champion. Such a person is essential to
coordinate the various aspects of enhanced recovery packages from
pre-assessment until discharge. This may be any senior member of
the ERAS multi-disciplinary team outlined above.
6) Audit and research
Regular auditing and dissemination of results should be
undertaken. Wherever possible, an active research programme on
ERAS related issues is recommended. Regular audit and research
can facilitate the development of local ERAS protocols tailored to
the specific requirements of the institution.


The safety and applicability of ERAS, in terms of reducing the
post-operative length of stay and morbidity, is well established from
well designed randomised clinical trials and meta-analyses.
However, certain issues related to ERAS require further research:
1) Influence on quality of life (QoL) and patient satisfaction
Although ERAS pathways have not been shown to adversely
influence patient satisfaction or quality of life, the full impact of
the various strategies employed, as well as earlier discharge from
hospital after major surgery, requires further research for a better
understanding [69].
2) Role of laparoscopic surgery within an ERAS programme
Both laparoscopic surgery and ERAS significantly shorten postoperative lengths of stay. However, whether or not the inclusion of
laparoscopic surgery within a successful ERAS protocol offers any
further advantage to that of ERAS alone is not clear. There is
currently no adequately powered study in the literature to answer
this question, but the results of on-going appropriately designed
studies are awaited [43, 44]. Current evidence seems to suggest that, in
the presence of a well implemented ERAS pathway, similar results
can be obtained with or without the laparoscope. Future research
should also compare the costs and quality of life after inclusion of
the laparoscopic approach within an ERAS pathway.
3) Inclusion of gut specific nutrients in ERAS pathways
ERAS pathways are thought to work by preserving organ function
and particularly gut function. Glutamine is a conditionally
essentially amino acid which is used as a preferential nutrient
source by the gut enterocytes and cells of the immune system.
Glutamine levels are known to be sub-normal in catabolic states
such as after surgery, trauma or burns. Preliminary research has
shown that pre-operative oral Glutamine supplementation reduces
septic complications and length of stay after surgery. However,
further research in the form of well designed and appropriately
powered randomised trials is required [70-73].
4) Cost-benefit analysis
Whilst it is self-evident to some that ERAS should be cost effective,
targeted studies investigating the cost-benefit interplay of ERAS
protocols are conspicuous by their scarcity [74-77]. A sound economic
basis for implementing ERAS protocols in various surgical
specialties would greatly enhance the argument in favour of ERAS.
In many branches of surgery, such studies are eagerly awaited.



Antibiotic prophylaxis


15, 18

Deep vein thrombosis prophylaxis



Elderly patients


Emergency surgery


Enhanced recovery units


Epidural analgesia




Goal directed intra-operative fluid therapy


Gut specific nutrients


High (80%) inspired oxygen concentration




Intravenous fluids


Laparoscopic surgery

11, 19

Local blocks


Mechanical bowel preparation

Nasogastric tubes


Non steroidal anti-inflammatory drugs (NSAIDS)


Oesophageal Doppler




Postoperative diet


Postoperative mobilisation


Preoperative counselling and training

Preoperative fasting

Preoperative carbohydrate loading

Quality of life




Staff education


Surgical drains


Thromboembolic deterrent stockings (TEDs)


Kehlet H, Wilmore D W. Fast-track surgery. British Journal of Surgery 2005; 92: 34


Kehlet H, Wilmore D W. Evidence-based surgical care and the evolution of fast-track

surgery. Ann Surg. 2008 Aug;248(2):1 89-98.


Kehlet H, Wilmore D W. Multimodal strategies to improve surgical outcome. Am J

Surg. 2002 Jun; 183(6):630-41.


Fearon K C H, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong C H, Lassen K

et al. Enhanced recovery after surgery: A consensus review of clinical care for patients
undergoing colonic resection. Clinical Nutrition 2005; 24: 466-477


Basse L, Raskov H H, Hjort Jakobsen D, Sonne E, Billesblle P, Hendel H W,

Rosenberg J, Kehlet H. Accelerated postoperative recovery programme after colonic
resection improves physical performance, pulmonary function and body composition.
Br J Surg. 2002 Apr;89(4):446-53


Gatt M, Anderson A D, Reddy B S, Hayward-Sampson P, Tring I C, MacFie J.

Randomized clinical trial of multimodal optimization of surgical care in patients
undergoing major colonic resection. Br J Surg 2005; 92: 13541362.


Gatt M, Reddy B S, Mainprize K S. Day-case stoma surgery: is it feasible? Surgeon.

2007 Jun;5(3):143-7


Disbrow E A, Bennett H L, Owings J T. Effect of preoperative suggestion on

postoperative gastrointestinal motility. West J Med 1993; 158: 488492.


Lee A, Gin T. Educating patients about anaesthesia: effect of various modes on patients
knowledge, anxiety and satisfaction. Curr Opin Anaesthesiol. 2005 Apr;18(2):205-8

[10] Kiyohara L Y, Kayano L K, Oliveira L M, Yamamoto M U, Inagaki M M, Ogawa N Y et

al. Surgery information reduces anxiety in the pre-operative period. Rev Hosp Clin Fac Med
Sao Paulo. 2004 Apr;59(2):51-6.
[11] Egbert L D, Battit G E, Welch C E, Bartlett M K. Reduction of postoperative pain by
encouragement and instruction of patients. A study of doctorpatient rapport. N Engl
J Med 1964;270:8257.
[12] Kruzik N. Benefits of preoperative education for adult elective surgery patients. AORN
J. 2009 Sep;90(3):381-7.
[13] Soop M, Nygren J, Thorell A, Weidenhielm L, Lundberg M, Hammarqvist F,
Ljungqvist O. Preoperative oral carbohydrate treatment attenuates endogenous
glucose release 3 days after surgery. Clin Nutr. 2004 Aug;23(4):733-41
[14] Svanfeldt M, Thorell A, Hausel J, Soop M, Rooyackers O, Nygren J, Ljungqvist O.
Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on
postoperative whole-body protein and glucose kinetics.. Br J Surg. 2007
[15] Nygren J, Soop M, Thorell A, Efendic S, Nair K S, Ljungqvist O. Preoperative oral
carbohydrate administration reduces postoperative insulin resistance. Clin Nutr. 1998
[16] Gustafsson U O, Nygren J, Thorell A, Soop M, Hellstrm P M, Ljungqvist O,
Hagstrm-Toft E. Pre-operative carbohydrate loading may be used in type 2 diabetes
patients. Acta Anaesthesiol Scand. 2008 Aug;52(7):946-51
[17] Guenaga K K, Matos D, Wille-Jrgensen P. Mechanical bowel preparation for elective
colorectal surgery. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001544. Review
[18] Pineda C E, Shelton A A, Hernandez-Boussard T, Morton J M, Welton M L.
Mechanical bowel preparation in intestinal surgery: a meta-analysis and review of the
literature. J Gastrointest Surg. 2008 Nov;12(11):2037-44. Epub 2008 Jul 12.
[19] Bucher P, Mermillod B, Gervaz P, Morel P. Mechanical bowel preparation for elective
colorectal surgery: a meta-analysis. Arch Surg. 2004 Dec;139(12):1359-64; discussion 1365
[20] Slim K, Vicaut E, Launay-Savary M V, Contant C, Chipponi J. Updated systematic
review and meta-analysis of randomized clinical trials on the role of mechanical bowel
preparation before colorectal surgery. Ann Surg. 2009 Feb;249(2):203-9. Review
[21] Levine M N, Raskob G, Landefeld S, Kearon C. Hemorrhagic complications of
anticoagulant treatment. Chest. 2001 Jan;119(1 Suppl):108S-121S.


[22] Gould M K, Dembitzer A D, Doyle R L, Hastie T J, Garber A M. Low-molecularweight heparins compared with unfractionated heparin for treatment of acute deep
venous thrombosis. A meta-analysis of randomized, controlled trials. Ann Intern Med.
1999 May 18;130(10):800-9.
[23] Wille-Jrgensen P, Rasmussen M S, Andersen B R, Borly L. Heparins and mechanical
methods for thromboprophylaxis in colorectal surgery. Cochrane Database of
Systematic Reviews 2004, Issue 1. Art. No.: CD001217.
[24] Rasmussen M S, Jrgensen L N, Wille-Jrgensen P. Prolonged thromboprophylaxis
with Low Molecular Weight heparin for abdominal or pelvic surgery. Cochrane
Database of Systematic Reviews 2009, Issue 1. Art. No.: CD004318. DOI:
[25] Huo M H, Muntz J. Extended thromboprophylaxis with low-molecular-weight
heparins after hospital discharge in high-risk surgical and medical patients: a review.
Clin Ther. 2009 Jun;31(6):1129-41. Review.
[26] Babior B M. Oxygen-dependent microbial killing by phagocytes. N Engl J Med
[27] Allen D B, Maguire J J, Mahdavian M, et al. Wound hypoxia and acidosis limit
neutrophil bacterial killing mechanisms. Arch Surg 1997;132: 991-6.
[28] Hopf H W, Hunt T K, West J M, et al. Wound tissue oxygen tension predicts the risk of
wound infection in surgical patients. Arch Surg. 1997;132(9):997-1004.
[29] Qadan M, Aka O, Mahid S S, Hornung C A, Polk HC Jr. Perioperative supplemental
oxygen therapy and surgical site infection: a meta-analysis of randomized controlled
trials. Arch Surg. 2009 Apr;144(4):359-66; discussion 366-7.
[30] Greif R, Laciny S, Rapf B, Hickle R S, Sessler D I. S upplemental oxygen reduces the
incidence of postoperative nausea and vomiting. Anesthesiology 1999; 91: 12461252.
[31] Orhan-Sungur M, Kranke P, Sessler D, Apfel C C Does supplemental oxygen reduce
postoperative nausea and vomiting? A meta-analysis of randomized controlled trials.
Anesth Analg. 2008 Jun;106(6):1733-8.
[32] Ozaki M, Sessler D I, Suzuki H, Ozaki K, Tsunoda C, Atarashi K. Nitrous oxide
decreases the threshold for vasoconstriction less than sevoflurane or isoflurane.
Anesth Analg. 1995 Jun;80(6):1212-6.
[33] Melling A C, Ali B, Scott E M, Leaper D J. Effects of preoperative warming on the
incidence of wound infection after clean surgery: a randomised controlled trial.
Lancet. 2001 Sep 15;358(9285):876-80
[34] Schmied H, Kurz A, Sessler D I, Kozek S, Reiter A. Mild hypothermia increases blood
loss and transfusion requirements during total hip arthroplasty. Lancet. 1996 Feb
[35] Frank S M, Fleisher L A, Breslow M J, Higgins M S, Olson K F, Kelly S, Beattie C.
Perioperative maintenance of normothermia reduces the incidence of morbid cardiac
events. A randomized clinical trial. JAMA. 1997 Apr 9;277(14):1127-34.
[36] Frank S M, Higgins M S, Breslow M J, Fleisher L A, Gorman R B, Sitzmann J V, Raff
H, Beattie C. The catecholamine, cortisol, and hemodynamic responses to mild
perioperative hypothermia. A randomized clinical trial. Anesthesiology. 1995
[37] Wong P F, Kumar S, Bohra A, Whetter D, Leaper D J. Randomized clinical trial of
perioperative systemic warming in major elective abdominal surgery. Br J Surg. 2007
[38] Elmore J R, Franklin D P, Youkey J R, Oren J W, Frey C M. Normothermia is
protective during infrarenal aortic surgery. J Vasc Surg. 1998 Dec;28(6):984-94.
[39] Smith C E, Gerdes E, Sweda S, Myles C, Punjabi A, Pinchak A C, Hagen J F.
Warming intravenous fluids reduces perioperative hypothermia in women undergoing
ambulatory gynecological surgery. Anesth Analg. 1998 Jul;87(1):37-41
[40] Lindwall R, Svensson H, Sderstrm S, Blomqvist H. Forced air warming and
intraoperative hypothermia. Eur J Surg. 1998 Jan;164(1):13-6.
[41] Noblett S E, Snowden C P, Shenton B K, Horgan A F. Randomized clinical trial
assessing the effect of Doppler-optimized fluid management on outcome after elective
colorectal resection. Br J Surg. 2006 Sep;93(9):1069-7.


[42] Reza M M, Blasco J A, Andradas E, Cantero R, Mayol J. Systematic review of

laparoscopic versus open surgery for colorectal cancer. Br J Surg. 2006
[43] Wind J, Hofland J, Preckel B, Hollmann M W, Bossuyt P M, Gouma D J, et al.
Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal
management versus standard care (LAFA trial). BMC Surg. 2006 Nov 29;6:16
[44] Conventional versus laparoscopic surgery for colorectal cancer within an enhanced
[45] Brown S R, Goodfellow P B. Transverse verses midline incisions for abdominal
surgery. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD005199.
[46] Seiler C M, Deckert A, Diener M K, Knaebel H P, Weigand M A, Victor N, Bchler M
W. Midline versus transverse incision in major abdominal surgery: a randomized,
double-blind equivalence trial (POVATI: ISRCTN60734227). Ann Surg. 2009
[47] Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal
surgery. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004929.
[48] Cheatham M L, Chapman W C, Key S P, Sawyers J L. A meta-analysis of selective
versus routine nasogastric decompression after elective laparotomy. Ann Surg. 1995
[49] Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric
decompression after abdominal operations. Br J Surg. 2005 Jun;92(6):673-80.
[50] Karliczek A, Jesus E C, Matos D, Castro A A, Atallah A N, Wiggers T. Drainage or
nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis.
Colorectal Dis. 2006 May;8(4):259-65.
[51] Jesus E C, Karliczek A, Matos D, Castro A A, Atallah A N. Prophylactic anastomotic
drainage for colorectal surgery. Cochrane Database Syst Rev. 2004 Oct
[52] Urbach D R, Kennedy E D, Cohen M M. Colon and rectal anastomoses do not require
routine drainage: a systematic review and meta-analysis. Ann Surg. 1999
[53] Holte K, Kehlet H. Epidural anaesthesia and analgesia - effects on surgical stress
responses and implications for postoperative nutrition. Clin Nutr. 2002
[54] Marret E, Remy C, Bonnet F. Postoperative Pain Forum Group. Meta-analysis of
epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J
Surg. 2007 Jun;94(6):665-73
[55] Neudecker J, Schwenk W, Junghans T, Pietsch S, Bhm B, Mller J M. Randomized
controlled trial to examine the influence of thoracic epidural analgesia on
postoperative ileus after laparoscopic sigmoid resection. Br J Surg. 1999
[56] Zafar N, Davies R, Greenslade G L, Dixon A R. The evolution of analgesia in an
Accelerated recovery programme for resectional laparoscopic colorectal surgery
with anastomosis. Colorectal Dis. 2009 Jan 16. Accepted Article; doi: 10.1111/j.14631318.2009.01768.x
[57] Levy B F, Tilney H S, Dowson H M, Rockall T A. A systematic review of post-operative
analgesia following laparoscopic colorectal surgery. Colorectal Dis. 2009 Feb 7.
Accepted Article; doi: 10.1111/j.1463-1318.2009.01799.x
[58] Zingg U, Miskovic D, Hamel C T, Erni L, Oertli D, Metzger U. Influence of thoracic
epidural analgesia on postoperative pain relief and ileus after laparoscopic colorectal
resection: Benefit with epidural analgesia. Surg Endosc. 2009 Feb;23(2):276-82.
[59] Senagore A J, Whalley D, Delaney C P, Mekhail N, Duepree H J, Fazio V W. Epidural
anesthesia-analgesia shortens length of stay after laparoscopic segmental colectomy
for benign pathology. Surgery. 2001 Jun;129(6):672-6.
[60] Traut U, Brgger L, Kunz R, Pauli-Magnus C, Haug K, Bucher H C, Koller M T.
Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus
following abdominal surgery in adults. Cochrane Database Syst Rev. 2008 Jan


[61] Andersen H K, Lewis S J, Thomas S. Early enteral nutrition within 24h of colorectal
surgery versus later commencement of feeding for postoperative complications.
Cochrane Database Syst Rev. 2006 Oct 18;(4):CD004080
[62] Lewis S J, Andersen H K, Thomas S. Early enteral nutrition within 24 h of intestinal
surgery versus later commencement of feeding: a systematic review and metaanalysis. J Gastrointest Surg. 2009 Mar;13(3):569-75.
[63] Lewis S J, Egger M, Sylvester P A, Thomas S. Early enteral feeding versus nil by
mouth after gastrointestinal surgery: systematic review and meta-analysis of
controlled trials. BMJ. 2001 Oct 6;323(7316):773-6.
[64] Papaspyros S, Uppal S, Khan S A, Paul S, ORegan D J. Analysis of bedside
entertainment services effect on post cardiac surgery physical activity: a prospective,
randomised clinical trial. Eur J Cardiothorac Surg. 2008 Nov;34(5):1022-6
[65] Powell-Tuck J, Gosling P, Lobo D N, Allison S P, Carlson G L, Gore M et al. British
Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients
(GIFTASUP). London: NHS National Library of Health. 2008112340_GIFTASUP%20 FINAL_31-10-08.pdf
[66] Jakobsen D H, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery
with fast-track vs conventional care. Colorectal Dis. 2006 Oct;8(8):683-7
[67] Delaney C P, Fazio V W, Senagore A J, Robinson B, Halverson A L, Remzi F H. Fast
track postoperative management protocol for patients with high co-morbidity
undergoing complex abdominal and pelvic colorectal surgery. Br J Surg. 2001
[68] Finan P J, Campbell S, Verma R, MacFie J, Gatt M, Parker M C, Bhardwaj R, Hall N
R. The management of malignant large bowel obstruction: ACPGBI position
statement. Colorectal Dis. 2007 Oct;9 Suppl 4:1-17.
[69] Khan S, Wilson T, Ahmed J, Owais A, MacFie J. Quality of Life and Patient
Satisfaction with Enhanced Recovery Protocols. Colorectal Dis. 2009 Jul 6. Accepted
Article; doi:10.1111/j.1463-1318.2009.01997.x
[70] Grimble R F. Nutritional modulation of immune function. Proceedings of the nutrition
society 2001; 60: 389-397.
[71] Buchman A L. Glutamine: is it a conditionally required nutrient for the human
gastrointestinal system. Jour of Am College of Nutr 1996; 15: 199-205
[72] Jian Z M, Cao J D, Zhu X G, Zhao W X, Yu J C, Ma E L, Wang X R, Zhu M W, Shu
H, Liu Y W. The impact of alanyl-glutamine on clinical safety, nitrogen balance,
intestinal permeability, and clinical outcome in postoperative patients: a randomized,
double-blind, controlled study of 120 patients. J. Parenter. Enteral Nutr (1999). 23:
[73] Morlion B J, Stehle P, Wachtler P, Siedhoff H P, Kller M, Knig W, Frst P,
Puchstein C. Total parenteral nutrition with glutamine dipeptide after major
abdominal surgery: a randomized, double-blind, controlled study. Ann Surg. 1998
[74] King P M, Blazeby J M, Ewings P, Longman R J., Kipling R M., Franks PJ et al. The
influence of an enhanced recovery programme on clinical outcomes, costs and quality
of life after surgery for colorectal cancer. Colorectal Disease 2006; 8: 506513
[75] Kariv Y, Delaney C P, Senagore A J, Manilich E A, Hammel J P, Church J M, Ravas J,
Fazio V W. 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 Feb;50(2):137-46
[76] Bosio R M, Smith B M, Aybar P S, Senagore A J. Implementation of laparoscopic
colectomy with fast-track care in an academic medical center: benefits of a fully
ascended learning curve and specialty expertise. Am J Surg. 2007 Mar;193(3):413-5;
discussion 415-6.
[77] King P M, Blazeby J B, Ewings P, Franks P J, Longman R J, Kendrick A H et al.
Randomized clinical trial comparing laparoscopic and open surgery for colorectal
cancer within an enhanced recovery programme. Br J Surg 2006; 93: 300308.


Association of Surgeons of Great Britain and Ireland

Printed on
recycled paper

35-43 Lincolns Inn Fields, London, WC2A 3PE

Tel: 020 7973 0300 Fax: 020 7430 9235
A Company limited by guarantee, registered in England 06783090