Many of the outcomes in the epidural analgesia group were significantly worse than those in the spinal analgesia and PCA groups, suggesting that either of these two modalities could replace epidural analgesia.

A 23-hour-stay laparoscopic colectomy is possible with modification of the enhanced recovery program. Patients find it acceptable and it seems to be safe.

Summary It is widely recognised that prolonged fasting for elective surgery in both children and adults serves no purpose, adversely affects patient well‐being and can be detrimental. Although advised fasting times for solids remain unchanged, there is good evidence to support a 1‐h fast for children, with no increase in risk of pulmonary aspiration. In adults, a major focus has been the introduction of carbohydrate loading before anaesthesia, so that patients arrive for surgery not only hydrated but also in a more normal metabolic state. The latter attenuates some of the physiological responses to surgery, such as insulin resistance. As in children, there is no increase in risk of pulmonary aspiration. Further data are required to guide best practice in patients with diabetes.

There is increasing recognition that the entire peri-operative care delivered plays a vital role in determining patient's outcome. Optimisation of this care helps to prevent complications beyond immediate morbidity and mortality. Of the 20 factors described in Enhanced Recovery Programmes, some have a greater impact than others, with analgesia and fluid therapy being two of the main factors. 1 Analgesia - The main analgesic regimes used so far for laparoscopic colorectal surgery have been continuous thoracic epidural and patient controlled analgesia. There is a growing body of opinion that epidural analgesia may not be required for laparoscopic surgery. 2 Individualised goal directed therapy - It is now recognized that measuring flow rather than pressure within the cardiovascular system is more important. Fluid therapy impacts on the outcome by minimizing fluid shifts, optimizing stroke volume and restricting the salt load given whilst maintaining normovolaemia. Analgesia and fluid therapy, together with the remaining enhanced recovery criteria have led to the development of the trimodal approach.

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