Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track perioperative care programs. Both focus on enhanced recovery and shorter hospital stay as compared to open surgery and traditional care. Laparoscopic colectomy was first described in 1991. Since then a lot of effort has been made to establish its feasibility and safety particularly in laparoscopic colectomy for cancer. Recently, several randomized trials comparing laparoscopic with open colectomy indicated that laparoscopic surgery can be applied safely both for malignant and benign diseases [2–7]. Several systematic reviews that assessed the evidence on the laparoscopic approach for colorectal cancer reported that laparoscopic surgery, in a traditional perioperative care setting was associated with less morbidity, less postoperative pain, earlier recovery and shorter hospital stay[2, 8, 9]. Furthermore, short term cancer related outcomes such as cancer free resection margins and the number of harvested lymph nodes, as well as long term cancer related outcomes such as disease free survival were comparable between laparoscopic and open surgery. These results stimulated many surgeons in the Netherlands to set up a laparoscopic colorectal program.
At the same time, enthusiasm was raised for the so-called fast track perioperative care program, also referred to as Enhanced Recovery After Surgery (ERAS®), which essentially is a modification of the program initially developed by the Danish surgeon Henrik Kehlet [10–13]. This multimodal program, involving optimalization of several aspects of the perioperative management of patients undergoing colectomy, enables patients to recover earlier and therefore go home as early as three days after open colectomy. Furthermore, postoperative morbidity was reduced [14–19]. The essence of a fast track perioperative care program consists of extensive preoperative counseling, no bowel preparation, no sedative premedication, no preoperative fasting but carbohydrate loaded liquids until two hours prior to surgery, tailored anesthesiology encompassing thoracic epidural anesthesia and short acting anesthetics, perioperative intravenous fluid restriction, minimally invasive surgery (i.e. through small incisions or laparoscopy), non-opioid pain management, no routine use of drains and nasogastric tubes, early removal of bladder catheter, standard laxatives and prokinetics, and early and enhanced postoperative feeding and mobilization [10–19].
As these new developments have been introduced in clinical practice, time has come to evaluate their feasibility, safety, and cost-effectiveness in large bowel surgery in a randomized controlled setting. It can be hypothesized that fast track and/or laparoscopy are associated with less attenuation of the patient's condition after surgery resulting in a shorter postoperative hospital stay, a faster recovery to full activity at home, and a better quality of life.
Since it has not been established which combination of perioperative management and surgical approach i.e. standard care, fast track care, laparoscopic surgery or open surgery is best in terms of postoperative hospital stay, quality of life, postoperative morbidity, readmission rate, overall costs and patient satisfaction, this is the subject of the present study proposal.