SPECIAL ARTICLE

Laparoscopy Plus Enhanced Recovery: Optimizing the Benefitsof MIS Through SAGES ‘SMART’ Program

Liane S. Feldman • Conor P. Delaney

Received: 27 December 2013 / Accepted: 27 December 2013 / Published online: 21 March 2014

� Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2014

The introduction of minimally invasive surgery (MIS)

revolutionized abdominal surgery. Laparoscopy dramati-

cally changed the impact of major operations. No longer

would undergoing a cholecystectomy mean a week in the

hospital and many more weeks until full recovery. These

more advanced surgical techniques significantly lessened

the impact of major surgery for our patients, reducing

complications and accelerating recovery.

For many surgeons, interest in laparoscopic techniques

was fueled by this desire to improve outcomes. However,

there is a limit to what can be accomplished using surgical

techniques alone, and factors that keep people hospitalized

and delay their return to normal functioning are multiple

and complex. These include the surgical stress response,

pain, postoperative nausea and vomiting, limited mobility,

fluid overload, fatigue and deconditioning, even in the

absence of surgical complications [1]. The Society of

American Gastrointestinal and Endoscopic Surgeons

(SAGES) recognizes that more can be done to improve the

surgical patient experience beyond the use of device

technology and is committed to helping its members learn

methods of enhanced recovery utilizing a multidisciplinary

approach.

The limitations encountered when surgeons focus only on

MIS to improve recovery is illustrated by colorectal surgery.

Here, the laparoscopic approach is associated with less pain,

shorter duration of ileus, improved pulmonary function,

decreased morbidity, shorter length of stay [2], and better

preserved immune function compared with open surgery [3].

Yet, despite these important advances, a significant propor-

tion of surgical patients do not derive the maximal benefit

from these interventions, or may not even be offered an MIS

approach. In addition, morbidity remains high for some

procedures [4], and recovery, even for relatively ‘minor’

procedures, takes longer than we think [5, 6].

There are many other aspects of perioperative care in

addition to the operation that have the potential to improve

recovery through their impact on the surgical stress response

[1] (Fig. 1). These variables include afferent neural blockade

using local infiltration, peripheral nerve blocks, or epidural/

spinal anesthesia; pharmacological interventions such as

non-opioid multimodal analgesia, anti-emetics, systemic

local anesthetics, and glucocorticoids; and other aspects of

care such as goal-directed fluid management, pre-operative

carbohydrate loading, modern fasting guidelines, and pre-

vention of intra-operative hypothermia.

For many practicing surgeons, much peri-operative care

still relies greatly on tradition and personal experience

acquired during training, perpetuating some historical,

unsupported practices. Even when there is evidence for a

different approach, it is not necessarily translated into

practice. For example, standard practice is for patients to be

‘nil by mouth after midnight’, regardless of when their

procedure is scheduled. However, a Cochrane review of 22

randomized controlled trials supports the safety of allowing

patients with normal gastric emptying to ingest clear fluids

up to 2 h before elective surgery [7]. In fact, Anesthesia

Society guidelines from many countries actually

The members of the SAGES SMART task force are listed in the

Appendix.

L. S. Feldman (&)

Department of Surgery, McGill University Health Centre,

Montreal, QC, Canada

e-mail: liane.feldman@mcgill.ca

C. P. Delaney

Division of Colorectal Surgery, University Hospitals Case

Medical Center, Case Western Reserve University, Cleveland,

OH, USA

123

Surg Endosc (2014) 28:1403–1406

DOI 10.1007/s00464-013-3415-4

and Other Interventional Techniques

recommend a 6-h fast for solids and a 2-h fast for clear

fluids for most elective surgical patients [8]. Evidence

shows that patients benefit from being in the fed state,

rather than the starved state, when undergoing an opera-

tion. Benefits of feeding patients prior to operation include

reducing thirst, hunger, and anxiety, decreasing postoper-

ative nitrogen losses, and improving muscle strength [9–

11]. Despite multiple studies and guidelines, this evidence

has not been translated into widespread clinical care and, in

fact, the highly ingrained practice of being nil by mouth

after midnight is likely deleterious. This is an example of a

situation in which a team change is necessary—a surgeon

cannot make this transition alone without the support of

anesthesia colleagues and pre-operative allied health, or

would risk the cancellation of cases when patients have not

been ‘nil by mouth after midnight’.

Recent guidelines make 20 evidence-based recommen-

dations for peri-operative care in colorectal and pancreatic

surgery [12–14]. Many are ‘strong’ recommendations based

on high-level evidence, or based on lower-level evidence

where there was confidence that benefits outweighed the

risks and burdens. Some of these elements may be part of

modern surgical care but there remains significant variability

both in processes and in outcomes of care between individual

surgeons and institutions [15, 16]. Also, many recommen-

dations involve multiple stakeholders, including surgeons,

anesthesiologists, nurses, and the patients themselves.

Unfortunately, at many institutions, surgeons, anesthesiol-

ogists, and nurses tend to work in silos, providing their

specific elements of peri-operative care individually.

Enhanced recovery programs (ERPs) represent a para-

digm shift from this traditional model. ERPs are stan-

dardized, integrated, evidenced-based plans for peri-

operative care [1, 17]. They combine multiple individual

elements of peri-operative care, each of which may have a

small benefit in isolation, into a coordinated care plan for a

specific surgical procedure. The goal is to improve recov-

ery, decrease complications, and decrease variability in

practice, which in turn will be reflected in a shorter hospital

stay and lower costs. ERPs also challenge traditions in peri-

operative care for which there is a lack of evidence for

benefit that may in fact hamper recovery, such as routine

full mechanical bowel preparation and the routine use of

catheters, tubes, drains, and intravenous fluid.

While ERPs are procedure-specific and may differ

depending on practice environment, provider training, and

patient population, the principal elements include the

following.

Fig. 1 Peri-operative interventions that reduce surgical stress. Minimally invasive surgery is an important strategy, but can be integrated with

other interventions to further improve outcomes. Reproduced from Kehlet and Wilmore [1], with permission. �2008 Annals of Surgery

1404 Surg Endosc (2014) 28:1403–1406

123

1. Pre-operative: formal pre-operative instruction and

discussion, supplemented by written patient informa-

tion and patient optimization.

2. Intra-operative: surgical, anesthetic, and analgesic

techniques that decrease surgical stress, pain, and

postoperative nausea and vomiting.

3. Postoperative: early, structured rehabilitation, includ-

ing narcotic sparing analgesia, early oral nutrition,

ambulation, and avoidance or early removal of urinary

catheters, drains, and lines.

Meta-analyses of randomized trials in colon surgery

suggest that implementation of the ERP approach is asso-

ciated with reduced morbidity, faster return of gastroin-

testinal function, and shorter hospital stay without

increased readmissions [18], and is less costly [19].

Emerging evidence suggests consistent results can also be

obtained in other types of operations, such as gastric cancer

surgery [20, 21] and liver resection [22].

Most studies comparing ERPs and traditional care are in

the setting of open surgery. But evidence also supports the

role for integrated peri-operative care pathways to further

improve outcomes in laparoscopic surgery. The LAFA

(LAparoscopy and/or FAst track multimodal management

vs. standard care) trial included four arms (laparoscopy/ERP

vs. laparoscopy/traditional vs. open/ERP vs. open/tradi-

tional) and concluded that ‘‘optimal perioperative treatment

for patients requiring segmental colectomy for colon cancer

is laparoscopic resection embedded in a fast-track program.’’

After laparoscopic surgery, the ERP patients achieved five

discharge criteria earlier than the standard group and were

discharged 1 day sooner, while morbidity was the same [23].

Similar results have been reported in two subsequent ran-

domized controlled trials, including in patients older than

65 years [24, 25]. Consistent findings are reported in two

studies of laparoscopic gastrectomy for cancer, where the

addition of an ERP decreased length of stay, improved pain

management, hastened return of bowel function, improved

quality of life after discharge and decreased costs [26, 27]. In

laparoscopic sleeve gastrectomy for obesity, an ERP

decreased length of stay without increasing morbidity and

was cost effective [28].

Truly integrated, multidisciplinary ERPs have not yet

been widely adopted in North America. Implementation

involves numerous stakeholders, letting go of ingrained

traditions and needing to reach consensus about a stan-

dardized approach to a specific patient population. It

requires real-time audit information about processes and

outcomes. Like any real change in culture, it requires

dedicated surgical, anesthesia, and nursing champions with

a positive outlook and leadership skills. Yet this approach

to perioperative care has been successfully adopted in a

variety of practice settings all over the world [29].

To maximize the opportunity for modern surgical

techniques like laparoscopic surgery to minimize morbidity

and facilitate recovery, SAGES has established a multi-

disciplinary Enhancing Recovery Task Force, the Surgical

Multimodal Accelerated Recovery Trajectory (SMART)

program. The task force includes subspecialty surgeons

(colorectal, foregut, bariatrics, hepatopancreaticobiliary,

abdominal wall), anesthesiologists, and nurses. Through

the SMART project, SAGES will promote the adoption of

patient-centered enhanced recovery care principles that

enhance the intrinsic benefits of MIS to further improve

safety, efficiency, and outcomes. The Enhancing Recovery

Task Force will work to develop enduring educational

resources specific for laparoscopic surgery, including

postgraduate courses and workshops, and the development

of guidelines for optimal peri-operative care of patients

undergoing MIS. The Task Force will also work towards

identifying evidence gaps in the literature where further

research may be beneficial, including emerging areas, such

as prehabilitation, exercise, and psychological preparation

for surgery and measurement of patient-centered outcomes

of surgical recovery. The SAGES Task Force will be

identifying/developing metrics to help measure improve-

ments in patient outcomes related to the SMART program.

SAGES is committed to promoting the coordinated

activity of surgeons, anesthesiologists, and nurses to pro-

vide a seamless peri-operative care plan capable of

extending the value-based advantages of minimally inva-

sive gastrointestinal surgery. It will foster this effort

through educational and research activities that promote

wider implementation of ERPs.

Appendix

This article was prepared and revised by the SAGES

SMART task force: Rajesh Aggarwal, Hospital of the

University of Pennsylvania, Philadelphia; Franko Carli,

McGill University, Montreal, QC, Canada; Conor P. Del-

aney, (Co-chair), Case Medical Center, Cleveland, Ohio;

Robert Fanelli, The Guthrie Clinic, Sayre, Pennsylvania;

Liane S. Feldman, (Co-chair), McGill University, Mon-

treal, QC, Canada; Lorenzo Ferri, McGill University,

Montreal, QC, Canada; Gerald M. Fried, McGill Univer-

sity, Montreal, QC, Canada; Tong Joo Gan, Duke Uni-

versity Medical Center, Durham, North Carolina; Allan

Okrainec, University of Toronto, Ontario, Canada; Michael

Rosen, Case Medical Center, Cleveland, Ohio; Bruce

Schirmer, University of Virginia Health Sciences Center,

Charlottesville; Anthony Senagore, Central Michigan

University College of Medicine, Saginaw; ToniaYoung-

Fadok, Mayo Clinic Scottsdale, Arizona; William Rich-

ardson, Ochsner Clinic, New Orleans, Louisiana; Debbie

Surg Endosc (2014) 28:1403–1406 1405

123

Watson, McGill University, Montreal, QC, Canada. This

article was reviewed and approved by the Board of

Governors of the Society of American Gastrointestinal and

Endoscopic Surgeons (SAGES).

References

1. Kehlet H, Wilmore DW (2008) Evidence-based surgical care and

the evolution of fast-track surgery. Ann Surg 248:189–198

2. Schwenk W, Haase O, Neudecker J, Muller JM (2005) Short term

benefits for laparoscopic colorectal resection. Cochrane Database

Syst Rev 3:CD003145

3. Gupta A, Watson DI (2001) Effect of laparoscopy on immune

function. Br J Surg 88(10):1296–1306

4. Schilling PL, Dimick JB, Birkmeyer JD (2008) Prioritizing

quality improvement in general surgery. J Am Coll Surg 207(5):

698–704

5. Lawrence VA, Hazuda HP, Cornell JE, Pederson T, Bradshaw

PT, Mulrow CD, Page CP (2004) Functional independence after

major abdominal surgery in the elderly. J Am Coll Surg

199(5):762–772

6. Feldman LS, Kaneva P, Demyttenaere S, Carli F, Fried GM,

Mayo NE (2009) Validation of a physical activity questionnaire

(CHAMPS) as an indicator of postoperative recovery after lapa-

roscopic cholecystectomy. Surgery 146(1):31–39

7. Brady M, Kinn S, Stuart P (2003) Preoperative fasting for adults

to prevent perioperative complications. Cochrane Database Syst

Rev 4:23

8. Ljungqvist O, Søreide E (2003) Preoperative fasting. Br J Surg

90:400–406

9. Hausel J, Nygren J, Lagerkranser M et al (2001) A carbohydrate-

rich drink reduces preoperative discomfort in elective surgery

patients. Anesth Analg 93:1344–1350

10. Ljungqvist O, Nygren J, Thorell A (2002) Modulation of post-

operative insulin resistance by pre-operative carbohydrate load-

ing. Proc Nutr Soc 61:329–336

11. Yuill KA, Richardson RA, Davidson HI et al (2005) The

administration of oral carbohydrate-containing fluid prior to

major elective upper gastrointestinal surgery preserves skeletal

muscle mass postoperatively. Clin Nutr 24:32–37

12. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D,

Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A,

Kennedy RH, Lobo DN, Fearon K, Ljungqvist O, Enhanced

Recovery After Surgery Society (2012) Guidelines for perioperative

care in elective colonic surgery: Enhanced Recovery After Surgery

(ERAS�) Society recommendations. Clin Nutr 31(6):783–800

13. Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN,

Ljungqvist O, Soop M, Ramirez J, Enhanced Recovery After

Surgery (ERAS) Society, for Perioperative Care, European Society

for Clinical Nutrition and Metabolism (ESPEN), International

Association for Surgical Metabolism and Nutrition (IASMEN)

(2013) Guidelines for perioperative care in elective rectal/pelvic

surgery: Enhanced Recovery After Surgery (ERAS�) Society

recommendations. World J Surg 37(2):285–305

14. Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento

JE, Schafer M, Parks RW, Fearon KC, Lobo DN, Demartines N,

Braga M, Ljungqvist O, Dejong CH, ERAS� Society, European

Society for Clinical Nutrition and Metabolism, International

Association for Surgical Metabolism and Nutrition (2012)

Guidelines for perioperative care for pancreaticoduodenectomy:

Enhanced Recovery After Surgery (ERAS�) Society recom-

mendations. Clin Nutr 31(6):817–830

15. Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH,

von Meyenfeldt MF, Hausel J, Nygren J, Andersen J, Revhaug

A, Enhanced Recovery After Surgery Group (2005) Patterns

in current perioperative practice: survey of colorectal sur-

geons in five northern European countries. BMJ 330(7505):

1420–1421

16. Lassen K, Dejong CH, Ljungqvist O, Fearon K, Andersen J,

Hannemann P, von Meyenfeldt MF, Hausel J, Nygren J, Revhaug

A (2005) Nutritional support and oral intake after gastric resec-

tion in five northern European countries. Dig Surg 22(5):346–352

17. Kehlet H, Wilmore DW (2002) Multimodal strategies to improve

surgical outcome. Am J Surg 183:630–641

18. Zhuang C-L, Ye X-Z, Zhang X-D, Chen B-C, Yu Z (2013)

Enhanced recovery after surgery programs versus traditional care

for colorectal surgery: a meta-analysis of randomized controlled

trials. Dis Col Rec 56:667–678

19. Lee L, Li C, Landry T, Latimer E, Carli F, Fried GM, Feldman L

(2013) A systematic review of economic evaluations of enhanced

recovery pathways for colorectal surgery. Ann Surg. doi:10.1097/

SLA.0b013e318295fef8

20. Feng F, Ji G, Li JP, Li XH, Shi H, Zhao ZW et al (2013) Fast-

track surgery could improve postoperative recovery in radical

total gastrectomy patients. World J Gastroenterol 19:3642–3648

21. Wang D, Kong Y, Zhong B, Zhou X, Zhou Y (2010) Fast-track

surgery improves postoperative recovery in patients with gastric

cancer: a randomized comparison with conventional postopera-

tive care. J Gastrointest Surg 14:620–627

22. Jones C, Kelliher L, Dickinson M, Riga A, Worthington T, Scott

MJ et al (2013) Randomized clinical trial on enhanced recovery

versus standard care following open liver resection. Br J Surg

100:1015–1024

23. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel

AF et al (2011) Laparoscopy in combination with fast track

multimodal management is the best perioperative strategy in

patients undergoing colonic surgery: a randomized clinical trial

(LAFA-study). Ann Surg 254:868–875

24. Wang Q, Suo J, Jiang J, Wang C, Zhao YQ, Cao X (2009)

Effectiveness of fast-track rehabilitation vs conventional care in

laparoscopic colorectal resection for elderly patients: a random-

ized trial. Colorectal Dis 14:1009–1013

25. Wang G, Jiang ZW, Zhao K, Gao Y, Liu FT, Pan HF et al (2012)

Fast track rehabilitation programme enhances functional recovery

after laparoscopic colonic resection. Hepatogastroenterology

59:2158–2163

26. Kim JW, Kim WS, Cheong JH, Hyung WJ, Choi SH, Noh SH

(2012) Safety and efficacy of fast-track surgery in laparoscopic

distal gastrectomy for gastric cancer: a randomized clinical trial.

World J Surg 36:2879–2887

27. Chen HuJ, Xin Jiang L, Cai L, Tao Zheng H, Yuan HuS, Bing

Chen H et al (2012) Preliminary experience of fast-track surgery

combined with laparoscopy-assisted radical distal gastrectomy

for gastric cancer. J Gastrointest Surg 16:1830–1839

28. Lemanu DP, Singh PP, Berridge K, Burr M, Birch C, Babor R

et al (2013) Randomized clinical trial of enhanced recovery

versus standard care after laparoscopic sleeve gastrectomy. Br J

Surg 100:482–489

29. Gillissen F, Hoff C, Maessen JM et al (2013) Structured syncr-

onous implementation of san enhanced recovery program in

elective colonic surgery in 33 hospitals in the Netherlands. World

J Surg 37:1082–1093

1406 Surg Endosc (2014) 28:1403–1406

123