Influence of ERAS protocol on postoperative outcomes after elective colorectal resection surgery: A prospective cohort study- two years single center experience
Abstract
Background ERAS (Enhanced Recovery After Surgery) protocol is a multimodal pathway of perioperative surgical care consisting of evidence-based procedures. ERAS protocol is hardly accepted by medical staff because it often opposes well established practice.
Methods We analyzed length of hospital stay, postoperative complications, time until first stool passage and introduction of normal nutrition in patients undergoing elective colorectal resection surgery in University Hospital Center Split from October 2016. to October 2018. Patients were divided into 4 groups considering operation type (open/laparoscopic) and application of ERAS protocol (good/poor). Application of 60% or more ERAS steps was considered as well performed protocol.
Results Groups Laparoscopy/ERAS and Open/ERAS had shorter postoperative hospital stay (Median, IQR; days) than groups Laparoscopy/non-ERAS and Open/non-ERAS (LE 5, 4-8 , OE 6, 5-9 vs LNE 7, 5-8,5 , ONE 7, 6-12). Similar difference was shown in times until first stool passage. Patients operated laparoscopically had shorter times until normal food tolerance (Median, IQR; days): LE 3, 2-3, LNE 3, 2-4 than patients who underwent open surgery (OE 3, 3-4, ONE 4, 3-5). In addition, laparoscopically operated patients had lower overall morbidity (P<0.001). Incidence of unplanned operations and hospital readmissions did not differ significantly among groups.
Conclusions Well performed ERAS protocol can improve length of hospital stay and time until first stool passage in both open and laparoscopic types of operation. Optimal combination for colorectal resection is laparoscopic surgery with ERAS protocol. If open surgery is done, it should be preferably applied with ERAS protocol as well.
Downloads
References
Feldman LS. Introduction to Enhanced Recovery Programs: A paradigm Shift in Perioperative Care. In: The SAGES/ERAS Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery. New York: Springer; 2015. p. 1-8.
Robinson TN, Carli F, Scheede-Bergdahl C. Medical Optimization and Prehabilitation. In: The SAGES/ERAS Society Manual of Enhanced Recovery Programs for Gastrintestinal Surgery. New York: Springer; 2015. p. 25-39.
Egbert LD, Battit GE, Welch CE, Bartlett MK. Reduction of postoperative pain by encouragement and instruction of patients. a study of doctorpatient rapport. N Engl J Med. 1964;270:825-7.
Kiecolt-Glaser JK, Page GG, Marucha PT, MacCallum RC, Glaser R. Psychological influences on surgical recovery. Perspectives from psychoneuroimmunology. Am Psychol. 1998;53(11):1209-121.
Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, et al. ESPEN Guidelines on Enteral Nutrition: Surgery including Organ Transplantation. Clin Nutr. 2006;25(2):224-44.
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. World J Surg. 2013;37:259-284.
Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. World J Surg. 2013;37:285-305.
Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg. 2003;90(4):400-6.
Brady MC, Kinn S, Stuart P, Ness V. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;(4):CD004423.
Ljungqvist O. Preoperative Fasting and Carbohydrate Treatment. In: The SAGES/ERAS Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery. New York: Springer; 2015. p. 41-7.
Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ et al. Timing of Antimicrobial Prophylaxis and the Risk of Surgical Site Infections. Ann Surg. 2009;250(1):10-6.
Nelson RL, Gladman E, Barbateskovic M (2014) Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev. 2014. CD001181.
Sachdeva A, Dalton M, Amaragiri SV, Lees T. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2010;(7):CD001484.
Hill J, Treasure T. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital: summary of the NICE guideline. Heart. 2010;96(11):879-82.
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N et al. Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERASR) Society Recommendations. World J Surg. 2012;37(2):259-84.
Galvao CM, Marck PB, Sawada NO, Clark AM. A systematic review of the effectiveness of cutaneous warming systems to prevent hypothermia. J Clin Nurs. 2009;18(5):627-36.
Thiele RH, Raghunathan K, Brudney CS, Lobo DN, Martin D, Senagore A et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med. 2016;5(1):6-10.
Cheatham ML, Chapman WC, Key SP, Sawyers JL. A Meta-Analysis of Selective Versus Routine Nasogastric Decompression After Elective Laparotomy. Ann Surg. 1995;221(5):469-78.
Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg. 2005;92(6):673-80.
Rao W, Zhang X, Zhang J, Yan R, Hu Z, Wang Q. The role of nasogastric tube in decompression after elective colon and rectum surgery : a meta-analysis. Int J Colorectal Dis. 2010;26(4):423-9.
Gan TJ, Diemunsch P, Habib AS, Kovac A, Kranke P, Meyer TA, et al. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2014;118(1):85-113.
Jorgensen H, Wetterslev J, Moiniche S, Dahl JB. Epidural local anaesthetics versus opioid-based analgesic regimens for postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev. 2000;(4):CD001893.
Nygren J, Soop M, Thorell A, Hausel J, Ljungqvist O. An Enhanced-Recovery Protocol Improves Outcome After Colorectal Resection Already During the First Year. Dis Colon Rectum. 2009;52(5):978-85.
Henriksen M, Jensen M, Hansen H, Jespersen T, Hessov I. Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery. Nutrition. 2002;18(2):147-52.
Fearon KCH, Luff R. The nutritional management of surgical patients: enhanced recovery after surgery. Proc Nutr Soc. 2003;62(04):807-11.
Coyle D, Joyce KM, Garvin JT, Regan M, McAnena OJ, Neary PM et al. Early post-operative removal of urethral catheter in patients undergoing colorectal surgery with epidural analgesia-a prospective pilot clinical study. Int J Surg. 2015;16:94-8.
Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M. Enhanced Recovery Program in Colorectal Surgery: A Meta-analysis of Randomized Controlled Trials. World J Surg. 2013;38(6):1531-41.
Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials. Clin Nutr. 2010;29(4):434-40.
Lv L, Shao Y-F, Zhou Y-B. The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Colorectal Dis. 2012;27(12):1549-54.
Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF et al. Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery. Ann Surg. 2011;254(6):868-75.
Wongyingsinn M, Baldini G, Stein B, Charlebois P, Liberman S, Carli F (2012) Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial. Br J Anaesth 108(5):850-6.
Senagore AJ, Madbouly KM, Fazio VW, Duepree HJ, Brady KM, Delaney CP (2003) Advantages of laparoscopic colectomy in older patients. Arch Surg 138(3):252-256.
Vlug MS, Bartels SA, Wind J, Ubbink DT, Hollmann MW, Bemelman WA (2012) Which fast track elements predict early recovery after colon cancer surgery? Colorectal Dis 14(8):1001-1008.
Srinivasa S, Singh SP, Kahokehr AA, Taylor MH, Hill AG (2012) Perioperative fluid therapy in elective colectomy in an enhanced recovery programme. ANZ J Surg 82(7–8):535-540.
Cakir H, van Stijn MF, Lopes Cardozo AM, Langenhorst BL, Schreurs WH, van der Ploeg TJ et al (2013) Adherence to enhanced recovery after surgery and length of stay after colonic resection. Colorectal Dis 15(8):1019-1025.
Bakker N, Cakir H, Doodeman HJ, Houdijk AP (2015) Eight years of experience with enhanced recovery after surgery in patients with colon cancer: impact of measures to improve adherence. Surgery 157(6):1130-1136.
Levy BF, Scott MJ, Fawcett W, Fry C, Rockall TA (2011) Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. Br J Surg 98(8):1068-1078.
Wongyingsinn, M., Baldini, G., Charlebois, P., Liberman, S., Stein, B., & Carli, F. (2011). Intravenous lidocaine versus thoracic epidural analgesia: a randomized controlled trial in patients undergoing laparoscopic colorectal surgery using an enhanced recovery program. Reg Anesth Pain Med, 36(3):241-248.
Conaghan P, Maxwell-Armstrong C, Bedforth N, Gornall C, Baxendale B, Hong LL et al (2010) Efficacy of transversus abdominis plane blocks in laparoscopic colorectal resections. Surg Endosc 24(10):2480-2484.
Chand M, De’Ath HD, Rasheed S, Mehta C, Bromilow J, Qureshi T (2016) The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. Int J Surg 25:59-63.
Rossi G, Vaccarezza H, Vaccaro CA, Mentz RE, Im V, Alvarez A et al (2013) Two-day hospital stay after laparoscopic colorectal surgery under an enhanced recovery after surgery (ERAS) pathway. World J Surg 37(10):2483-2489.
Keller DS, Bankwitz B, Woconish D, Champagne BJ, Reynolds HL Jr, Stein SL et al (2014) Predicting who will fail early discharge after laparoscopic colorectal surgery with an established enhanced recovery pathway. Surg Endosc 28(1):74-79.
Larson DW, Lovely JK, Cima RR, Dozois EJ, Chua H, Wolff BG et al (2014) Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery. Br J Surg 101(8):1023-1030.
Oh HK, Ihn MH, Son IT, Park JT, Lee J, Kim DW et al (2016) Factors associated with failure of enhanced recovery programs after laparoscopic colon cancer surgery: a single-center retrospective study. Surg Endosc 30(3):1086-1093.
Messenger DE, Curtis NJ, Jones A, Jones EL, Smart NJ, Francis NK. Factors predicting outcome from enhanced recovery programmes in laparoscopic colorectal surgery: a systematic review. Surg Endosc. 2017;31(5):2050-2071.
Feldman LS. Introduction to Enhanced Recovery Programs: A paradigm Shift in Perioperative Care. In: The SAGES/ERAS Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery. New York: Springer; 2015. p. 237-246.
Reichert M, Weber C, Pons-Kuhnemann J, Hecker M, Padberg W, Hecker A. Protective loop ileostomy increases the risk for prolonged postoperative paralytic ileus after open oncologic rectal resection. Int J Colorectal Dis. 2018;33(11):1551-7.
Gustafsson UO. Adherence to the Enhanced Recovery After Surgery Protocol and Outcomes After Colorectal Cancer Surgery. Archives of Surgery. 2011;146(5):571.
The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection. Ann Surg. 2015;261(6):1153-9.
Copyright (c) 2020 Acta Chirurgica Croatica
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The authors hereby authorize the Acta Chirurgica Croatica (ACC) to publish their work.
The authors are aware that although ACC is Open Access journal, the copyright of all material published is vested in ACC. Open access articles are freely available to read, download, and share from the time of publication under the terms of the Creative Commons License Attribution ‐ NonCommerical No Derivative (CC BY‐NC‐ND) license. This license does not permit reuse for any commercial purposes nor does it cover the reuse or modification of individual elements of the work (such as figures, tables, etc.) in the creation of derivative works without specific permission of ACC and appropriate acknowledgment of its source. The authors permit ACC to allow third parties to copy any part of the work without asking for permission, provided that the reference to the source is given and that this is not done for commercial purposes. Except for copyright, other proprietary rights related to the work (e.g., patent or other rights to any process or procedure) shall be retained by the author. To reproduce any text, figures, tables, or illustrations from this work in future works of their own, the author must obtain written permission from ACC.
Each of the author(s) hereby also grants permission to ACC to use such author’s name and likeness in connection with any past, present or future promotional activity by ACC, including, but not limited to, promotions for upcoming issues or publications, circulation solicitations, advertising or other publications in connection with ACC. Also, each of the author(s) hereby grants permission to ACC to use the manuscript in editorial research related to the improvement of editorial conduct, decision making, and issues related to peer review.
Each of the author(s) hereby releases and shall indemnify and hold harmless ACC and its successors, assigns, licensees, officers, directors, employees, and their respective heirs and representatives from and against any and all liabilities, losses, damages and expenses arising out of any claims of any kind that may be asserted against any of them based in whole or in part on any breach of the author(s)’ representations or warranties herein or in the work or anything contained in the work, including but not limited to any claims for copyright infringement or violation of any rights of privacy or publicity.