Table 1 Standardised Enhanced Recovery Programme for the EnROL Trial

Before admission

Conditioning of expectations of patient and carer by receipt of oral and written information at a dedicated preadmission visit, or by telephone counselling, with provision of a dedicated booklet or video sent by post.

Meeting with stoma nurse if stoma anticipated.

Identification of factors that might delay discharge and consideration of solutions e.g. provision of support when discharged if living alone.

Co-morbid risk assessment: optimised pre-morbid health status.

Day before surgery

Avoidance of oral bowel preparation except in patients undergoing total mesorectal excision (TME) and reconstruction.

Nutrition: three high protein/high calorie drinks if receiving oral bowel preparation.

Day of surgery

Pre-operatively

Preoperative oral carbohydrate loading to be given 2-4 hours prior to anaesthesia, using 200ml of fluid containing 12.5g/100ml CHO with a proven safety profile.

Avoidance of long acting sedative medication from midnight prior to surgery.

In theatre

Activation of thoracic epidural (T6-11) prior to skin incision.

Avoidance of abdominal drains at primary operation.

Avoidance of nasogastric drainage in the immediate postoperative period.

Total volume of IV fluid < 3000ml.

The use of upper body forced air heating intraoperatively.

Local anaesthetic infiltration to the largest wound in minimal access surgery.

Open surgery: small transverse or curved incisions when possible.

After theatre

Oral intake of ≥ 800ml fluid (including oral nutritional supplements) postoperatively on the day of surgery, before midnight.

≥ 200ml oral nutritional supplement postoperatively on the day of surgery, before midnight.

Mobilisation by walking or sitting in a chair.

First Postoperative day from midnight – midnight (Day 1)

≥ 2 units of oral nutritional supplement taken.

Termination of IV fluid infusion.

Intake and tolerance of solid food.

Intake of lactulose or a magnesium preparation to enhance bowel movements.

Use of thoracic epidural analgesia.

Mobilisation (out of bed) for at least 6 hours.

Provided patient mobile, termination of urinary drainage on day 1, except after TME when it may be preferable to leave it until day 3

Assisted mobilisation – 4 × 60m walks.

Second Postoperative day from midnight – midnight (Day 2)

Pain relief: termination of the thoracic epidural analgesia.

Use of a multi-modal analgesic regime at, or before, discontinuation of thoracic epidural analgesia e.g. paracetamol and non steroidal anti-inflammatory or equivalent.

Termination of urinary drainage on day 2 or earlier, except after TME when it may be preferable to leave it until day 3.

Discharge

Aim for discharge day 2-3 for colonic and proximal rectal resection; day 5 when a stoma fashioned.

Discharge Criteria: patients must be tolerating normal food, mobilising independently and be managed on oral analgesics to fulfil discharge criteria.

Follow up: provision of hospital contact numbers to allow discussion of problems; expedited review on ward if problems within 2 weeks of surgery.

Review in out patient clinic at two weeks post operation.