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Enhanced recovery is a package of care for bowel cancer surgery: getting fitter and better nourished beforehand, a sugary drink up to two hours before, antibiotic tablets with the bowel preparation, two anti-sickness drugs, no routine tubes or drains, the urinary catheter out the next day, and eating and walking from the day after the operation.
The current ERAS Society colorectal guideline (2025) could not be read: no abstract is indexed and the publisher refused a script. The most recent graded guideline that could be read in full is the 2024 Korean ERAS guideline for colorectal cancer (13 GRADE recommendations). Strong, high-quality: dexamethasone plus a 5-HT3 antagonist rather than either alone for nausea. Conditional for, high quality: oral antibiotics with mechanical bowel preparation. Conditional for, moderate: prehabilitation; preoperative oral nutritional supplements; carbohydrate loading up to 2 hours before; goal-directed fluid therapy in high-risk patients; TAP block; preoperative pharmacological thromboprophylaxis; urinary catheter out on day 1; early feeding and walking from day 1. Conditional against: routine intra-abdominal drain (moderate) and nasogastric tube (low). NICE NG180 offers an enhanced recovery programme to everyone having elective major surgery. On bowel preparation the bodies differ: WHO (2018) and the Korean guideline support oral antibiotics with mechanical preparation; NICE NG125 (recommendation from 2008) says not to use mechanical bowel preparation routinely to reduce infection; EUPEMEN does not recommend mechanical preparation alone.
Why: A coordinated package shortens recovery more than any single change on its own.
“Use an enhanced recovery programme that includes preoperative, intraoperative and postoperative components.”
NICE 2020 · Not graded (NICE NG180 1.2.2)
Why: Getting fitter before surgery helps the body cope with the operation.
“Prehabilitation is recommended for patients scheduled to undergo surgery for colorectal cancer.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Conditional for. Level of evidence: Moderate.
Why: People with bowel cancer often lose weight and appetite, and poor nutrition raises the risk of complications.
“Preoperative nutritional support using oral nutritional supplements is recommended for patients scheduled for colorectal cancer surgery.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Conditional for. Level of evidence: Moderate.
Why: Antibiotic tablets taken with the bowel preparation roughly halved wound infections compared with preparation alone in the trials pooled.
“The use of oral antibiotics in conjunction with mechanical bowel preparation is recommended for patients scheduled for colorectal cancer surgery.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Conditional for. Level of evidence: High.
Why: A long fast leaves people thirsty and more resistant to insulin; a sugary drink shortly before is safe.
“Oral carbohydrate loading up to 2 hours before colorectal cancer surgery is recommended.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Conditional for. Level of evidence: Moderate.
Why: Bowel cancer surgery carries a real risk of blood clots in the legs and lungs.
“Preoperative pharmacologic thromboprophylaxis is recommended for patients scheduled for colorectal cancer surgery.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Conditional for. Level of evidence: Moderate.
Why: Two drugs together prevent more sickness than one, and sickness delays eating and getting up.
“The use of dexamethasone in combination with a serotonin receptor antagonist rather than monotherapy is recommended for the prevention of postoperative nausea and vomiting in patients scheduled for colorectal cancer surgery.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Strong for. Level of evidence: High.
Why: Matching fluid to measured need avoids both too much and too little fluid in people least able to cope with either.
“Goal-directed fluid therapy during surgery may be considered for high-risk patients undergoing colorectal cancer surgery.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Conditional for. Level of evidence: Moderate.
Why: A nerve block in the abdominal wall reduces pain and the need for opioids, which cause sickness and slow the bowel.
“Transverse abdominis plane block may be considered for pain control during surgery for colorectal cancer.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Conditional for. Level of evidence: Moderate.
Why: In the trials pooled, drains and stomach tubes did not prevent leaks or complications, and they add discomfort.
“It is suggested not to insert an intra-abdominal drain during surgery for colorectal cancer.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Drain: Conditional against, Moderate. Nasogastric tube: Conditional against, Low.
Why: An early catheter removal helps people walk sooner and go home sooner.
“It is recommended to remove urinary catheters the day after colorectal cancer surgery.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Strength of the recommendation: Conditional for. Level of evidence: Moderate.
Why: Early food and movement support recovery of the bowel and reduce chest problems and clots.
“Early feeding is recommended to start from the day after surgery for colorectal cancer.”
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · Early feeding: Conditional for, Moderate. Early ambulation: Conditional for, Moderate.
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The ERAS Society's 2025 colorectal guideline is the current specialty standard, but its recommendations could not be read for this page. Of what could be read, the 2024 Korean ERAS guideline gives the most recent graded recommendations, built on new meta-analyses of randomised trials: the strongest is two-drug nausea prophylaxis (strong, high); oral antibiotics with bowel preparation (conditional, high) agrees with WHO (conditional, moderate); and avoiding drains and nasogastric tubes, early catheter removal, early feeding and early walking are all supported. NICE NG180 supports an enhanced recovery programme and a 2-hour clear-fluid fast for all elective major surgery. Where they disagree is bowel preparation: NICE NG125 says not to use mechanical preparation routinely to reduce infection (a 2008 recommendation carried into the 2019 guideline) and is silent on oral antibiotics.
Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 · World Health Organization 2018 · NICE 2020 · NICE 2020 · ERAS Society (Surgery) 2025
Where it differs: Uses a thoracic epidural for open colorectal surgery and keeps the urinary catheter routinely for 1 to 3 days, rather than removing it on day 1.
Evidence: Listed as colorectal-specific recommendations of the 2018 ERAS guideline by a 2025 appraisal of all ERAS Society guidelines. The Korean guideline recommends catheter removal on day 1 (conditional, moderate) and a TAP block (conditional, moderate), and does not grade epidurals. Whether the 2025 ERAS edition kept these positions could not be read.
Perioperative Medicine 2025 · Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025
Where it differs: Does not use mechanical bowel preparation routinely to reduce wound infection, and makes no recommendation on oral antibiotics.
Evidence: NICE NG125, a recommendation carried forward from 2008. WHO (2018) recommends against mechanical preparation alone (strong, moderate) and suggests oral antibiotics with it (conditional, moderate); the Korean guideline cites newer network meta-analyses for the combination.
NICE 2020 · World Health Organization 2018 · Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025
Where it differs: A low-residue diet for at least five days and two enemas the afternoon before left-sided operations; mechanical bowel preparation alone is not recommended except for a perioperative colonoscopy; immunonutrition preferred for the malnourished, 7 days before and 5 days after surgery.
Evidence: Consensus of a European multisociety network (2024) built on the literature; its recommendations are not graded item by item in the way GRADE guidelines are.
Enhanced recovery pathways feed people sooner, limit drips and drains and get them walking the day after an operation. Sixteen randomised trials in bowel surgery found 40 per cent fewer complications and stays more than two days shorter, but in 151 American hospitals given a full implementation programme, most failed to improve compliance with its elements.
Anaesthetic guidelines since at least 2011 say adults can drink clear fluids up to two hours before planned surgery and eat up to six hours before. In a study of 50 women having breast cancer surgery published in 2026, the average fast was 15 hours from food and 12 hours from fluids.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Offer an enhanced recovery programme for elective major or complex surgery “Offer an enhanced recovery programme to people having elective major or complex surgery .” | Not graded (NICE NG180 1.2.1) | NICE 2020 |
| Clear fluids until 2 hours before the operation “they may drink clear fluids until 2 hours before their operation” | Not graded (NICE NG180 1.4.1) | NICE 2020 |
| Oral antibiotics with mechanical bowel preparation in elective colorectal surgery “The panel suggests that preoperative oral antibiotics combined with mechanical bowel preparation should be used to reduce the risk of SSI in adult patients undergoing elective colorectal surgery.” | Conditional Moderate | World Health Organization 2018 |
| No mechanical bowel preparation alone “The panel recommends that mechanical bowel preparation alone (without administration of oral antibiotics) should not be used for the purpose of reducing SSI in adult patients undergoing elective colorectal surgery.” | Strong Moderate | World Health Organization 2018 |
| No routine mechanical bowel preparation to reduce infection “Do not use mechanical bowel preparation routinely to reduce the risk of surgical site infection. [2008]” | Not graded (NICE NG125, recommendation dated 2008) | NICE 2020 |
| ERAS 2018: routine urinary catheter for 1 to 3 days (as listed by the 2025 appraisal) “Routine transurethral catheterization is recommended for 1–3 days” | Not stated in the appraisal | Perioperative Medicine 2025 |
| No routine nasogastric tube “It is suggested not to insert a nasogastric tube during surgery for colorectal cancer.” | Conditional against, Low | Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 |
| Early walking from the day after surgery “Early ambulation is recommended to commence on the day after surgery for colorectal cancer.” | Conditional for, Moderate | Korean Society of Surgical Metabolism and Nutrition, ERAS Committee (Annals of Coloproctology) 2025 |
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations.
Shares Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Clear drinks until two hours before an operation, rather than nothing from midnight, Enhanced recovery after liver surgery (ERAS pathway for hepatectomy), Prehabilitation (the pre-treatment window).
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care, Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back.
Shares Blood clot prevention around cancer surgery, including extended prophylaxis after major abdominal and pelvic operations, Enhanced recovery after cancer surgery, with each element's compliance measured and fed back, Rectal cancer, Colorectal cancer.