Laparoscopy or open surgery for colorectal cancer within an enhanced recovery program?

TO THE EDITOR: Kennedy et al recently published an article examining the postoperative outcomes of laparoscopic surgery versus open resection of colorectal cancer within an enhanced recovery program (ERP). The main finding of their trial, called EnROL (Enhanced Recovery Open Versus Laparoscopic), was that laparoscopic surgery reduced the total postoperative hospital stay by 2 days. We congratulate the authors for their efforts because we know the difficulties of conducting such a trial. However, we think that some limitations of the study should be addressed. First, we noticed that compliance with the ERP components was low, especially with respect to early oral feeding, early mobilization, and optimized analgesia. Early oral feeding has been proven to reduce the length of hospital stay and the total postoperative complications. Failure to mobilize has been associated with prolonged length of hospital stay. In addition, Vlug et al found that hospital stay was reduced by 28% when early oral feeding and early mobilization were achieved. Optimized pain relief, allowing early mobilization and early return of gut function, is a prerequisite for enhanced recovery. Strict adherence to the ERP was associated with reduced length of hospital stay and improved outcome in colonic surgery for malignancy. Thus, the low compliance with the ERP components may have introduced a high risk of bias to the EnROL trial. Second, it was reported that the greater the number of evidencebased components included in the ERP, the better the outcome. However, some key ERP items were not included in the EnROL trial, such as prevention of postoperative nausea and vomiting. Postoperative nausea and vomiting lead to intolerance to oral feeding and is a leading cause of patient dissatisfaction and delayed hospital discharge. The absence of this ERP item probably explains the low compliance with early oral feeding. Above all, the low compliance and the absence of some key ERP components might make the EnROL trial underpowered, despite the substantial work of the authors. Therefore, the question regarding the benefits of laparoscopy within an ERP was not adequately answered by the EnROL trial. Additional large-scale randomized clinical trials are needed to examine the benefits of laparoscopic colorectal resection in the context of an even more optimized ERP than that applied in the EnROL trial.