Enhancing Recovery After Laparoscopic Colorectal Surgery: Effect Of Thoracic Epidural Technique On Length Of Stay


Knee and hip Osteoarthritis is a major issue in elderly population and cause of morbidity in later stage of life (Cross et al. 2014). Due to the rise in ageing population, the demand for hip and knee replacement surgery has increased (Stowers et al. 2016). Knee and hip arthroplasty increases post-operative complication and hospital stay in patient but substantially improves functions after surgery in older people (Maempel et al. 2015).

However, longer hospital stay after surgery is associated with increased overall health care cost (Schairer et al. 2014). Due to this issue, it is necessary to identify strategies that could promote recovery and reduce hospital stay in patient. This issue has been specifically chosen for analysis because of the rise in ageing population and subsequent increase in hip and knee arthroplasty in the future (Culliford et al. 2014; Kremers et al. 2015). Finding relevant intervention is likely to reduce health care burden and cost associated with the problem in elderly (Kurtz et al. 2017).

Studies show that Enhanced Recovery After Surgery (ERAS) programs are effective in reducing length of hospital stay and as reducing morbidity and mortality and improving recovery (Zargar-Shoshtari and Hill 2008; Lemanu et al. 2013; Beamish et al. 2012; Scott et al. 2013; Malviya et al. 2011). The main purpose of this study is to understand the role of enhance recovery in reducing length of hospital stay in knee and hip arthroplasty patient to be implemented in our hospital in Saudi Arabia.


Search strategy:

The main databases that were searched included PubMed, CINAHL, and Cochrane library, Medline via Ovid and Google scholar just to scope the search. The main rationale for taking these databases was that they publish peer-reviewed journal articles containing up-to-date healthcare research studies and journals. These databases are most reliable for topics related to health care and medical science. For example, the Cochrane library covers all important medical literature published from 1947 till date. PubMed is also renowned for storing all health care literature and life science journals:

Search terms:

Arthoplasty, enhanced recovery after surgery, orthopaedic surgery, perioperative care, enhanced recovery programme, total knee arthroplasty, total hip arthroplasty were the key search terms used for identifying relevant research articles related to the topic. More detailed results of the search are provided in the appendix.

The keywords were combined using Boolean Operators like ‘AND’ or ‘OR’. The advantage of using these database in search research literature is that it saves times and eliminates inappropriate hits thus leading to productive results. Hence, Boolean operators work to return maximum number of relevant results when used appropriately (Ecker and Skelly 2010). The main inclusion criteria for searching the literature included the following:

  • The research articles published within last ten year were taken to get up-to-dates information and the major priority was to get maximum number of research articles published within 5 years
  • All research article need to cover enhance recovery program
  • All the research articles needed to have the issue of knee or hip surgery or Arthroplasty in patient.
  • The search was limited to surgical procedures, and post surgical processes done on humans in order to limit the search results to relevant studies that analyze recovery after surgery.
  • Articles were limited to English language only.

Pain Control Strategies

The key exclusion criteria for the literature search included the following:

  • Research article published before 2007 were excluded
  • Research article discussing about problem apart from knee and hip surgery were excluded.

The above search strategy helped to get about 45 relevant articles. However, some of the articles were excluded after reading the abstract and many others were also excluded after analyzing the whole text based on exclusion and inclusion criteria. The final outcome gave 10 results in total (10 each) for studies published between 2007 and 2018.


The review of some published study gave idea about the following advantage of enhanced recovery after surgery (ERAS) in hip and knee arthroplasty patients: 

Improved recovery and shorter hospital stay:

Research evidences showing the effect of ERAS in improving patient outcome may help to determine cost savings in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) is necessary to consider (Ibrahim et al 2013). Furthermore, Stowers et al. (2016) investigated about impact of ERAS and result showed that the index and total median Length of stay (LOS) were significantly different among ERAS group, in contrast to the study control.

After a year of ERAS protocol implementation, there was a reduction of 1 day, in the median LOS for patients undergone TKA and THA (Stowers et al. 2016). The number of readmissions were also comparatively lesser compared to control group; however the difference was statistically insignificant (Wood et al. 2017).  Moulton et al. (2015) also showed a lower mean cost with ERAS implementation, compared to patient’s undergone TKA and THA surgeries before the implementation of ERAS.

The main strength of the study by Stowers et al. (2016) was its research design. The selection of both retrospective and prospective participant group with and without intervention helped in analysis of effectiveness of ERAS on target population group (Blome and Augustin 2015). Strength was that the study highlighted the true value of ERAS in reducing pre-operative morbidity which would have good implication in long-term service improvement and reducing cost compared to standard care (Ljungqvist et al 2017). 

Reduce transfusion requirement and hospital stay:

Another study by de Burlet et al. (2016) also investigated about the enhanced recovery (ER) protocol in patients undergoing elective arthroplasty, however, the uniqueness of this study compared to Stowers et al. (2016) was that it evaluated ER protocol by outcome measure of transfusion rate, number of venous thromboembolism complication and LOS.  ER group and traditional protocol (TP) group were formed. Statistically significant difference in number of transfusion was seen in TP and ER group. For instance, 7.7% transfusion rate was found in TP group compared to 4.3% in ER group (de Burlet et al. (2016).

Effect of TEA on Postoperative Pain and PCA

This was seen mostly due to the effect of tranexamic acid which plays a role in reducing transfusion rates in patients undergoing arthroplasty (Alshryda et al. 2014). In additional improvement was also seen in total observed complications rate and LOS. Despite this result, one of the major limitation of the study is taking two participants groups from different time period For reliability and credibility of ER protocol, participants in the same time period were necessary to ensure equal treatment for each group apart from intervention (Andreasen et al. 2017).

Despite this, beneficial cost implication of the ER is proved which is also consistent with other study. A one year follow-up study with patients receiving ERAS in patients with TKA also revealed fast discharge to home with no complication rate and early safe ambulation (McDonald et al. 2012). Another study applying the enhanced recovery principle to reduce LOS and blood transfusion in THA patient proved that ERAS practice is safe and effective in hospital setting (Kent et al. 2017).

Reduced LOS without increase in readmission: 

For ERAS to be regarded as effective in reducing burden of the health care system, it is also necessary to confirm whether the program can control readmission rate or not apart from reduced hospital stay (Larsen et al. 2009). This element was covered by Stambough et al. (2015) who investigated the impact of peri-operative changes and rapid recovery protocol on LOS and readmission rates. The patients were assigned to traditional; enhance pain management and rapid recovery group.

The data of 52% reduction in LOS between traditional and RR pathways clearly gave idea about the benefits of enhanced recovery. Hence, greatest impact was on expected length of stay in case of rapid recovery group. In addition, the odds of readmission in rapid recovery group reduced by 60%. The main strength of the study is systematic evaluation of changes in thirteen year period (Drummond et al. 2015). The study gives the implication that systematic changes in peri-operative care can solve the problem of increased LOS and readmissions for TKA and THA patient (Gupta and Gan 2016). However, this research was mainly done with younger group of patient thus limiting application for elderly patient.

ERAS protocol in improving post operative pain and blood loss in patient

The studies above clearly gave idea about different clinical benefits of implementing ERAS for THA and TKA patient. However, evaluating its effectiveness based on complications like perioperative blood loss and post-operative pain is also necessary because this factor also prevents early mobilization and discharge for TKA patient (Su and Su 2016). Dhawanet  al. (2017) investigated the role of ER protocol in reducing post operative pain, LOS and blood loss by taking and intervention group and control group. The intervention group who received the ER protocol were found to have reduced blood loss level and LOS also reduced by 1.5 days in both makes and females.

Alternative Analgesic Regimens for LCS

It proved enhanced recovery as an useful tool in decreasing perioperative morbidity in patient and length of hospital stay.  Kahokehr et al. (2009) pointed out that the efficacy of the ER protocol can be strengthened by effectively implementing the procedure. The method of implementation of ERAS can be challenging, and gaining momentum can be difficult. Hence, investigating the course of implementation of ERAS protocol on the basis of their adherence in daily practice is an innovative piece of research work. Ahmed et al. (2010) also highlights the importance of audit and compliance of ERAS programs as vital aspects in the evaluation of standard pathway in clinical practice. Hence, the effect of standardization of practices and compliance to evidence based practices can never be undermined.

The study by Auyong et al. (2015) is also significant to support ways to effectively implement ERAS for orthopaedic surgery, Considering this area was necessary because readmissions after surgery also increase overall cost in joint arthroplasty program. Hence, there was a need for updates and specific ERAS to address any limitation leading to readmissions. The examination of the effect of evidenced based ERAS on LOS, clinical outcome and readmissions revealed significant decrease in mean LOS after implementing the program(Kehlet and Jorgensen 2016).

The main highlight was that the improvement was achieved without an increase in readmission rate. This is a remarkable finding which was achieved mainly due to many quality measures like post-operative rehabilitation programs and regional anaesthesia(Kaplan et al 2018). The optimization of the program was also possible by means of partnership with orthopaedic surgeons, Theatre practitioner, anaesthetist and administrative group. Such kind of optimization of the program can also be facilitated by implementing nutrition screening for patient (Wischmeyer et al. 2018).


With an overview of the findings of the key studies, it can be concluded that orthopaedic specific ERAS programs can reduce the length of stay in hospitals, reduce readmission rates and significantly reduces the postoperative morbidity and mortality among patients, while maintaining the quality of the healthcare provided and reducing the burden of cost incurred by the patients (Kurtz et al. 2017). The studies not only supports the implementation ERAS to enable faster recovery, but also promises a change that can ensure optimized utilization of in hospital resources in surgical procedures (Kehlet and Jorgensen 2016). Moreover, ERAS have been shown to be safe as well as effective.

In the present context enhanced recovery after surgery protocol can be implemented for elective hip and knee Arthoplasty, which can reduce the length of stay in hospitals. This can be attained through systematic changes in the peri operative care that focuses on recovery after surgery. Also, post operative rehabilitation as well as use of regional anaesthesia during surgery has been shown to enhance the recovery period, which can be implemented in the ERAS program.

Effect of TEA on Postoperative Ileus and Bowel Motility

ERAS programs have shown substantial changes in perioperative care, and have been shown to reduce the stay in hospitals and speed up recovery. This can help to reduce the waiting lists for surgical procedures, while upholding the quality of care. Reducing the length of stay will also ensure the providence of care for more number of people, and hence allow a better performance of healthcare. 


Ahmed, J., Khan, S., Gatt, M., Kallam, R. and MacFie, J., 2010. Compliance with enhanced recovery programmes in elective colorectal surgery. British journal of surgery, 97(5), pp.754-758. 

Alshryda, S., Sukeik, M., Sarda, P., Blenkinsopp, J., Haddad, F.S. and Mason, J.M., 2014. A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement. Bone Joint J, 96(8), pp.1005-1015. 

Andreasen, S.E., Holm, H.B., Jørgensen, M., Gromov, K., Kjærsgaard-Andersen, P. and Husted, H., 2017. Time-driven activity-based cost of fast-track total hip and knee arthroplasty. The Journal of arthroplasty, 32(6), pp.1747-1755. 

Auyong, D.B., Allen, C.J., Pahang, J.A., Clabeaux, J.J., MacDonald, K.M. and Hanson, N.A., 2015. Reduced length of hospitalization in primary total knee arthroplasty patients using an updated enhanced recovery after orthopedic surgery (ERAS) pathway. The Journal of arthroplasty, 30(10), pp.1705-1709. 

Beamish, A.J., Chan, D.S.Y., Reid, T.D., Barlow, R., Howell, I., Blackshaw, G., Clark, G. and Lewis, W.G., 2012. OC-122 Enhanced recovery after upper gastrointestinal surgery (ERAUGIS) improves outcomes in upper gastrointestinal (UGI) cancer. Gut, 61(Suppl 2), pp.A53-A53.. 

Blome, C. and Augustin, M., 2015. Measuring change in quality of life: bias in prospective and retrospective evaluation. Value in Health, 18(1), pp.110-115. 

Cross, M., Smith, E., Hoy, D., Nolte, S., Ackerman, I., Fransen, M., Bridgett, L., Williams, S., Guillemin, F., Hill, C.L. and Laslett, L.L., 2014. The global burden of hip and knee osteoarthritis: estimates from the global burden of disease 2010 study. Annals of the rheumatic diseases, pp.annrheumdis-2013. 

Culliford, D., Maskell, J., Judge, A., Cooper, C., Prieto-Alhambra, D. and Arden, N.K., 2015. Future projections of total hip and knee arthroplasty in the UK: results from the UK Clinical Practice Research Datalink. Osteoarthritis and cartilage, 23(4), pp.594-600. 

de Burlet, K.J., Widnall, J., Barton, C., Gudimetla, V. and Duckett, S., 2016. Enhanced Recovery Protocol Reduces Transfusion Requirements and Hospital Stay in Patients Undergoing an Elective Arthroplasty Procedure. Advances in Orthopedic Surgery, 2016. 

Dhawan, R., Rajgor, H., Yarlagadda, R., John, J. and Graham, N.M., 2017. Enhanced recovery protocol and hidden blood loss in patients undergoing total knee arthroplasty. Indian journal of orthopaedics, 51(2), p.182. 

Drummond, M.F., Sculpher, M.J., Claxton, K., Stoddart, G.L. and Torrance, G.W., 2015. Methods for the economic evaluation of health care programmes. Oxford university press. 

Placement and Mixture of Drugs for TEA

Ecker, E.D. and Skelly, A.C., 2010. Conducting a winning literature search. Evidence-based spine-care journal, 1(01), pp.9-14. 

Gupta, R. and Gan, T.J., 2016. Peri?operative fluid management to enhance recovery. Anaesthesia, 71(S1), pp.40-45. 

Ibrahim, M.S., Alazzawi, S., Nizam, I. and Haddad, F.S., 2013. An evidence-based review of enhanced recovery interventions in knee replacement surgery. The Annals of The Royal College of Surgeons of England, 95(6), pp.386-389. 

Kahokehr, A., Sammour, T., Zargar-Shoshtari, K., Thompson, L. and Hill, A.G., 2009. Implementation of ERAS and how to overcome the barriers. International Journal of Surgery, 7(1), pp.16-19. 

Kaplan, N. and Kates, S.L., 2018. Quality and Safety. In Proximal Femur Fractures (pp. 151-181). Springer, Cham. 

Kehlet, H. and Jørgensen, C.C., 2016. Advancing surgical outcomes research and quality improvement within an enhanced recovery program framework. Annals of surgery, 264(2), pp.237-238. 

Kent, M., Calvert, N., Blades, K., Swann, A. and Yates, P., 2017. Enhanced recovery principles applied to revision hip and knee arthroplasty reduces length of stay and blood transfusion. Journal of orthopaedics, 14(4), pp.555-560. 

Kremers, H.M., Larson, D.R., Crowson, C.S., Kremers, W.K., Washington, R.E., Steiner, C.A., Jiranek, W.A. and Berry, D.J., 2015. Prevalence of total hip and knee replacement in the United States. The Journal of bone and joint surgery. American volume, 97(17), p.1386. 

Kurtz, S.M., Lau, E.C., Ong, K.L., Adler, E.M., Kolisek, F.R. and Manley, M.T., 2017. Which clinical and patient factors influence the national economic burden of hospital readmissions after total joint arthroplasty?. Clinical Orthopaedics and Related Research®, 475(12), pp.2926-2937. 

Kurtz, S.M., Lau, E.C., Ong, K.L., Adler, E.M., Kolisek, F.R. and Manley, M.T., 2017. Which clinical and patient factors influence the national economic burden of hospital readmissions after total joint arthroplasty?. Clinical Orthopaedics and Related Research®, 475(12), pp.2926-2937. 

Larsen, K., Hansen, T.B., Thomsen, P.B., Christiansen, T. and Søballe, K., 2009. Cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. JBJS, 91(4), pp.761-772. 

Lemanu, D.P., Singh, P.P., Berridge, K., Burr, M., Birch, C., Babor, R., MacCormick, A.D., Arroll, B. and Hill, A.G., 2013. Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy. British Journal of Surgery, 100(4), pp.482-489. 

Ljungqvist, O., Scott, M. and Fearon, K.C., 2017. Enhanced recovery after surgery: a review. JAMA surgery, 152(3), pp.292-298. 

Maempel, J.F., Riddoch, F., Calleja, N. and Brenkel, I.J., 2015. Longer hospital stay, more complications, and increased mortality but substantially improved function after knee replacement in older patients: A study of 3,144 primary unilateral total knee replacements. Actaorthopaedica, 86(4), pp.451-456. 

Malviya, A., Martin, K., Harper, I., Muller, S.D., Emmerson, K.P., Partington, P.F. and Reed, M.R., 2011. Enhanced recovery program for hip and knee replacement reduces death rate: a study of 4,500 consecutive primary hip and knee replacements. Actaorthopaedica, 82(5), pp.577-581. 

McDonald, D.A., Siegmeth, R., Deakin, A.H., Kinninmonth, A.W.G. and Scott, N.B., 2012. An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom—follow up at one year. The Knee, 19(5), pp.525-529. 

Moulton, L.S., Evans, P.A., Starks, I. and Smith, T., 2015. Pre-operative education prior to elective hip arthroplasty surgery improves postoperative outcome. International orthopaedics, 39(8), pp.1483-1486. 

Schairer, W. W., Sing, D. C., Vail, T. P., and Bozic, K. J. 2014. Causes and frequency of unplanned hospital readmission after total hip arthroplasty. Clinical Orthopaedics and Related Research®, 472(2), 464-470. 

Scott, N.B., McDonald, D., Campbell, J., Smith, R.D., Carey, A.K., Johnston, I.G., James, K.R. and Breusch, S.J., 2013. The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units—an implementation and follow-up at 1 year, 2010–2011: a report from the Musculoskeletal Audit, Scotland. Archives of orthopaedic and trauma surgery, 133(1), pp.117-124. 

Stambough, J.B., Nunley, R.M., Curry, M.C., Steger-May, K. and Clohisy, J.C., 2015. Rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. The Journal of arthroplasty, 30(4), pp.521-526. 

Stowers, M.D., Manuopangai, L., Hill, A.G., Gray, J.R., Coleman, B. and Munro, J.T., 2016. Enhanced recovery after surgery in elective hip and knee arthroplasty reduces length of hospital stay. ANZ journal of surgery, 86(6), pp.475-479. 

Su, E.P. and Su, S., 2016. Strategies for reducing peri-operative blood loss in total knee arthroplasty. Bone Joint J, 98(1 Supple A), pp.98-100. 

Wischmeyer, P. E., Carli, F., Evans, D. C., Guilbert, S., Kozar, R., Pryor, A., … & Shaw, A. D. (2018). American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Nutrition Screening and Therapy Within a Surgical Enhanced Recovery Pathway. AnesthAnalg. 

Wood, T., Aarts, M.A., Okrainec, A., Pearsall, E., Victor, J.C., McKenzie, M., Rotstein, O. and McLeod, R.S., 2017. Emergency Room Visits and Readmissions Following Implementation of an Enhanced Recovery After Surgery (iERAS) Program. Journal of Gastrointestinal Surgery, pp.1-8. 

Appendix A:

Search Strategy: Google Scholar database search results:

 Appendix B:Components of ERAS programs:Preoperative assessment and planningPatient selectionPatient educationAnesthesiaassessment and teachingIntraoperative considerationsThoracic epidural catheter using local anestheticLimit intravenous fluidsMaintain normothermiaUse of minimally invasive approach or small incisionPostoperative care Supplemental oxygenNo nasogastric tube/early feedingMultimodal pain managementlimiting narcoticsEarly ambulationDischarge planning/case management beginningPost-operative day #1 





Knee Arthoplasty



Hip Arthoplasty






enhanced recovery after surgery



orthopaedic surgery



perioperative care



enhanced recovery programme



“enhanced recovery” AND “total knee arthroplasty”



“enhanced recovery” AND “total hip arthroplasty”



Reduced short-term complications


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