| Preadmission |
| Preadmission orders | | Standardized order sets should be utilized |
| Information, education, and counseling | Patients should receive dedicated preoperative counseling routinely | A preoperative discussion regarding clinical milestones and discharge criteria should be performed. Stoma teaching and counseling regarding how to avoid dehydration should be provided for patients undergoing ileostomy. |
| Preoperative optimization | Medical risk assessment Smoking cessation at least 4 weeks prior to surgery | |
| Nutrition | Preoperative nutritional assessment should be offered. Patients at risk of malnutrition are recommended to have oral nutritional supplementation for 7−10 days. | Oral nutritional supplementation is recommended in malnourished patients (targeting a protein intake of 1.2−1.5 g/kg/day for 1−2 weeks). |
| Prehabilitation | May reduce complications. Patients who are less fit may be more likely to benefit. | May be considered for patients with multiple comorbidities or significant deconditioning. |
| Anemia management | If possible, anemia should be corrected with intravenous iron preoperatively prior to surgery, and blood transfusion should be avoided. | |
| Preoperative |
| Prevention of PONV | A multimodal approach to PONV prophylaxis should be considered. | Similar (recommendations for PONV, pain, SSI prevention, and fluid management are stated in the Perioperative Interventions section). |
| Pre-anesthetic medication | Sedative medication should be avoided if possible before surgery. | A multimodal, opioid-sparing, pain management plan should be implemented before the induction of anesthesia. |
| Opioid-sparing multimodal re-anesthetic medication can be used. | |
| Antimicrobial prophylaxis | Intravenous antibiotic prophylaxis should be given within 60 min before incision as a single-dose administration. | |
| In patients receiving oral mechanical bowel preparation, oral antibiotics should be given. | |
| Skin preparation | Chlorhexidine-alcohol-based preparation | A bundle of measures (preoperative: chlorhexidine shower, bowel preparation, antimicrobial prophylaxis, chlorhexidine/alcohol skin preparation; operative: wound protector, gown and glove changes before fascial closure, antimicrobial sutures, maintaining euglycemia and normothermia) should be in place to reduce SSI perioperatively |
| Bowel preparation | MBP alone with IV antibiotic prophylaxis may be used for rectal surgery. | MBP combined with preoperative oral antibiotics is typically recommended. |
| Preoperative fasting and carbohydrate loading | The patient should be allowed to eat up until 6 h and take clear fluids up until 2 h before anesthetic induction. | Clear liquids may be continued up to 2 h before surgery. |
| Patients with delayed gastric emptying and emergency patients should fast overnight or 6 h before surgery. | |
| Intraoperative | | |
| Standard anesthetic protocol | Avoidance of benzodiazepines | Similar recommendation |
| Use of short-acting anesthetics | |
| Cerebral function monitoring | |
| Monitoring of the level and complete reversal of neuromuscular block | |
| Fluid and electrolyte management | Maintain fluid homeostasis | Even a short duration of MAP<65 mmHg should be avoided (associated with adverse outcomes, in particular myocardial injury and acute kidney injury). |
| GDFT should be adopted, especially in high-risk patients | Similar recommendation |
| Prevention of intraoperative hypothermia | Reliable temperature monitoring should be undertaken. | |
| Surgical access | Minimally invasive surgery is recommended. | Similar recommendation |
| Drain | Pelvic and peritoneal drains should not be used routinely. | Similar recommendation |
| Postoperative | | |
| Nasogastric tube | Should not be used routinely | Similar recommendation |
| If inserted during surgery, it should be removed before reversal of anesthesia. | |
| Postoperative |
| Pain control | Avoid opioids and apply multimodal analgesia. | Similar recommendation |
| TEA is recommended in open colorectal surgery. | TEA is an option for open colorectal surgery (if dedicated pain team is available) |
| Abdominal wall blocks | TAP blocks can reduce opioid consumption and improve recovery. | Laparoscopic-guided TAP block is safe and effective, and seems to be as effective as US-guided TAP block. |
| Thromboprophylaxis | Mechanical prophylaxis by compression stockings and/or intermittent pneumatic compression until discharge | |
| Pharmacological prophylaxis with LMWH for 28 days after surgery | |
| Fluid and electrolyte management | Net "near-zero" fluid and electrolyte balance should be maintained. | Similar recommendation |
| Balanced solutions are preferred. | Similar recommendation |
| | Intravenous fluids should be routinely discontinued in the early postoperative period in the absence of surgical complications or hemodynamic instability |
| Foley catheter | Recommended for 1−3 days | Removed within 24 h for colon−upper rectal resection Removed within 24−48 h for mid/lower rectal resection |
| Nutritional care | Early resumption of oral intake with oral supplementation from the day of surgery. | Patient should be offered a regular diet with 24 h. |
| Perioperative immunonutrition for malnutrition. | The efficacy of immunonutrition over standard high-protein oral nutritional supplements remains controversial. |
| Early mobilization | Through patient education and encouragement | Early and progressive patient mobilization are associated with a shorter length of stay. |
| Discharge criteria | | Hospital discharge prior to return of bowel function may be offered for selected patients. |
| Audit | Collection of key outcome and process data used for repeated audits and feedback is essential | |