Association between enhanced recovery after surgery protocol compliance and clinical complications: a cohort study
Enhanced Recovery After Surgery (ERAS) protocol is composed by evidence-based interventions that aim to improve recovery through a reduction in surgical stress response. Although ERAS protocols have been introduced across the globe, exhaustive implementation is not as common. We aimed to study the ERAS protocol compliance in colorectal surgery, assessing the relationship between compliance and postoperative complications.
A single-center cohort study was conducted. All consecutive patients admitted to elective colorectal surgery were included. We assessed study endpoints according to ERAS protocol perioperative compliance score above 75%. Our primary endpoint was a composite of postoperative events, which includes in-hospital postoperative complications and need for reoperation after 30 days and need for readmission after discharge. Secondary endpoints were surgery-to-discharge time, postoperative use of only non-opioid adjuvants and the individual components of the primary endpoint.
A total of 224 colorectal patients were included. The primary endpoint occurred in 59.2% (n = 58) of non-compliant patients comparing to 34.1% (n = 43) in compliant patients. In univariate analysis, compliance to ERAS protocol had an inferior risk for the primary endpoint (p < 0.001). In a logistic regression model, compliance was independently associated with a reduced risk for the primary endpoint with a odds-ratio of 0.42 (95% CI 0.23–0.75, p = 0.004).
Compliance with the ERAS protocol is associated with less complications, a reduced surgery-to-discharge time and use of only non-opioid adjuvants in the postoperative period. More studies are needed to target the most appropriate compliance goal.
1 K.C.H. Fearon, O. Ljungqvist, M. Von Meyenfeldt, et al. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection Clin Nutr., 24 (2005), pp. 466-477
2 U.O. Gustafsson, M.J. Scott, M. Hubner, et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018 World J Surg., 43 (2019), pp. 659-695
3 L. Wijk, R. Udumyan, B. Pache, et al. International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery Am J Obstet Gynecol., 221 (2019), pp. 237.e1-237.e11
4 K.M. Elias, A.B. Stone, K. McGinigle, et al. The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS® and ERAS® USA Societies World J Surg., 43 (2019), pp. 1-8
5 J. Ripollés-Melchor, J.M. Ramírez-Rodríguez, R. Casans-Francés, et al. Association between Use of Enhanced Recovery after Surgery Protocol and Postoperative Complications in Colorectal Surgery: The Postoperative Outcomes Within Enhanced Recovery after Surgery Protocol (POWER) Study JAMA Surg., 154 (2019), pp. 725-736
6 J. Ripollés-Melchor, M.L. de Fuenmayor-Varela, S. Criado Camargo, et al. Enhanced recovery after surgery protocol versus conventional perioperative care in colorectal surgery. A single center cohort study Brazilian J Anesthesiol., 68 (2018), pp. 358-368
7 J. Li, H. Li, Z.K. Xv, et al. Enhanced recovery care versus traditional care following laminoplasty: A retrospective case-cohort study Medicine (Baltimore)., 97 (2018), Article e13195
8 N.L.T. Tan, J.L. Hunt, S.M. Gwini Does implementation of an enhanced recovery after surgery program for hip replacement improve quality of recovery in an Australian private hospital: A quality improvement study BMC Anesthesiol., 18 (2018), pp. 1-10
9 S. Moningi, A. Patki, N. Padhy, et al. Enhanced recovery after surgery: An anesthesiologist’s perspective Srilata Moningi, Abhiruchi Patki, Narmada Padhy, and Gopinath Ramachandran Department J Anaesthesiol Clin Pharmacol., 35 (2019), pp. S5-S13
10 U.F. Teixeira, P.R. Fontes, C.W. Conceição, et al. Implementation of enhanced recovery after colorectal surgery (ERAS) protocol: Initial results of the first Brazilian experience Arq Bras Cir Dig., 32 (2019), pp. 4-7
11 U.F. Teixeira, M.B. Goldoni, F.L. Waechter, et al. Recuperação otimizada (ERAS) após cirurgia hepática: estudo comparativo de um centro terciário brasileiro Arq Bras Cir Dig., 32 (2019), Article e1424
12 U.O. Gustafsson, J. Hausel, A. Thorell, et al. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery Arch Surg., 146 (2011), pp. 571-577
13 M. Pisarska, M. Pędziwiatr, P. Małczak, et al. Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A prospective cohort study Int J Surg., 36 (2016), pp. 377-382
14 P. Cavallaro, L. Bordeianou Implementation of an ERAS Pathway in Colorectal Surgery Clin Colon Rectal Surg., 32 (2019), pp. 102-108
15 A. Gharaibeh, S.J. Koppikar, F. Bonilla-Escobar Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) in the International Journal of Medical Students Int J Med Students., 2 (2014), pp. 36-37
16 G. Ogrinc, L. Davies, D. Goodman, et al. SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process BMJ Qual Saf., 25 (2016), pp. 986-992
17 L. Gianotti, U. Fumagalli Romario, et al. Association Between Compliance to an Enhanced Recovery Protocol and Outcome After Elective Surgery for Gastric Cancer. Results from a Western Population-Based Prospective Multicenter Study World J Surg., 43 (2019), pp. 2490-2498
18 C. Zaouter, P. Oses, S. Assatourian, et al. Reduced Length of Hospital Stay for Cardiac Surgery—Implementing an Optimized Perioperative Pathway: Prospective Evaluation of an Enhanced Recovery After Surgery Program Designed for Mini-Invasive Aortic Valve Replacement J Cardiothorac Vasc Anesth., 33 (2019), pp. 3010-3019
19 L. Arrick, K. Mayson, T. Hong, et al. Enhanced recovery after surgery in colorectal surgery: Impact of protocol adherence on patient outcomes J Clin Anesth., 55 (2019), pp. 7-12
20 J.B. Williams, G. McConnell, J.E. Allender, et al. One-year results from the first US-based enhanced recovery after cardiac surgery (ERAS Cardiac) program J Thorac Cardiovasc Surg., 157 (2019), pp. 1881-1888
21 P. Małczak, M. Wysocki, H. Twardowska, et al. Impact of Adherence to the ERAS® Protocol on Short-term Outcomes after Bariatric Surgery Obes Surg., 30 (2020), pp. 1498-1505
22 M. Pisarska, G. Torbicz, N. Gajewska, et al. Compliance with the ERAS Protocol and 3-Year Survival After Laparoscopic Surgery for Non-metastatic Colorectal Cancer World J Surg., 43 (2019), pp. 2552-2560
23 A.T. Petrick, C.D. Still, C.G. Wood, et al. Feasibility and impact of an evidence-based program for gastric bypass surgery J Am Coll Surg., 220 (2015), pp. 855-862
24 P. Kjølhede, O. Bergdahl, W.N. Borendal, et al. Effect of intrathecal morphine and epidural analgesia on postoperative recovery after abdominal surgery for gynecologic malignancy: An open-label randomised trial BMJ Open., 9 (2019), pp. 1-10
25 M.J. Scott, T.E. Miller Pathophysiology of major surgery and the role of enhanced recovery pathways and the anesthesiologist to improve outcomes Anesthesiol Clin., 33 (2015), pp. 79-91
26 P.S. Myles, P.J. Devereaux Pros and cons of composite endpoints in anesthesia trials Anesthesiology., 113 (2010), pp. 776-778