Implementation of an Enhanced Recovery After Surgery program in elective colorectal surgery: a prospective cohort study

Mercedes, Cabellos Olivares; María, Labalde Martínez; Miguel, Torralba; Ramón, Rodríguez Fraile José; Carlos, Atance Martínez Juan

doi:10.1016/j.jcol.2019.05.012

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Journal of Coloproctology (Rio de Janeiro)

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Original Articles • J. Coloproctol. (Rio J.) 39 (3) • Jun-Sep 2019 • https://doi.org/10.1016/j.jcol.2019.05.012 copy

Implementation of an Enhanced Recovery After Surgery program in elective colorectal surgery: a prospective cohort study

Implantação de um programa de recuperação aprimorada após cirurgia colorretal eletiva: um estudo prospectivo de coorte

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To evaluate the results of an Enhanced Recovery After Surgery (ERAS) protocol in elective colorectal surgery compared to the historical cohort of this hospital with standard care, in terms of hospital Length Of Stay (LOS), 30 days readmissions rate and 3-5 Clavien-Dindo Complications (CDC).

Methodology:

Data were collected from consecutive patients during 2 time periods, before (135 patients from hospital database) and after implementation of an ERAS protocol (121 with prospective follow up). Multivariate lineal or logistic regressions were used to assess the impact of ERAS program, adjusting by gender, age, laparoscopy and 3-5 CDC.

Results:

The two groups were homogeneous in terms of demographic and surgery details, with the exception of the operative approach, with increased use of laparoscopy in the ERAS group. The ERAS protocol decreased LOS (9.8 ± 3.7 vs. 11 ± 3.8, p = 0.018) without increasing 30 days readmission rate or the number of severe CDC. In a multivariate analysis, age and 3-5 CDC were independently associated with a longer LOS while male gender, ERAS protocol and laparoscopic surgery with a decreased LOS. 3-5 CDC increased readmissions (OR = 3.5, 95% CI 1.2-10.2) while laparoscopic surgery decreased them (OR = 0.2, 95% CI 0.1-0.8). ERAS improved compliance with secondary variables in a statistically significant way: more laparoscopic surgery; more regional analgesia in the intraoperative period; earlier adherence to ambulation; faster onset of oral liquid diet and analgesia by mouth; and lower requirements of opioids.

Conclusions:

ERAS protocol and laparoscopic surgery decreased LOS without increasing 30 days readmission rate. Severe CDC increased LOS and readmissions.

Keywords:
Colorectal surgery; Enhanced recovery after surgery; Laparoscopy

Grades	Definition
I	Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions. Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgesics, diuretics and electrolytes and physiotherapy. This grade also includes wound infections opened at the bedside
II	Requiring pharmacological treatment with drugs other than such allowed for Grade I complications. Blood transfusions and total parenteral nutrition are also included
III	Requiring surgical, endoscopic or radiological intervention
IV	Life-threatening complication requiring ICU (intensive care unit) management
V	Death

	PreERAS group (n = 135)	ERAS group (n = 121)	p-value
Age	68.4 ± 12.3	68.4 ± 13.4	0.169
Female	94 (69.7%)	77 (63.6%)	0.309
Body mass index	27.4 ± 3.9	26.7 ± 4.6	0.331
ASA			0.325
Grade 1	10 (7.4%)	12 (9.9%)
Grade 2	86 (64.7%)	66 (54.6%)
Grade 3	39 (28.9%)	43 (35.5%)
Smokers	30 (22.2%)	16 (13.2%)	0.061
Alcohol intake	14 (10.4%)	20 (16.5%)	0.15
Diabetes	44 (32.6%)	28 (23.1%)	0.093
Hypertension	79 (58.5%)	77 (63.6%)	0.373
Chronic heart disease	24 (17.8%)	23 (19.1%)	0.8
Pulmonary disease	21 (15.6%)	21 (17.4%)	0.69
Renal disease			0.8
CrCl <50 mL/min	17 (12.6%)	14 (11.6%)
CrCl >50 mL/min	118 (87.4%)	107 (88.4%)
Anticoagulant therapy	16 (11.9%)	9 (7.4%)	0.24
Preoperative hemoglobin	13.3 (8.6-16.6)	13.1 (8.5-16.7)	0.73
Diagnosis			0.309
Colorectal cancer	116 (85.9%)	109 (90.1%)
Reconstruction of transit	19 (14.1%)	6 (4.9%)
Inflammatory bowel disease	0	4 (3.3%)
Diverticular disease	0	2 (1.7%)
Type of surgery			0.163
Ileocecal resection	0	1 (0.8%)
Subtotal colectomy	2 (1.5%)	1 (0.8%)
Total colectomy	1 (0.7%)	0
Reconstruction of transit	19 (14.1%)	7 (5.8%)
Right colectomy	29 (21.5%)	36 (29.8%)
Left colectomy	16 (11.9%)	19 (15.7%)
Resection of the colon	1 (0.7%)	1 (0.8%)
Sigmoidectomy	20 (14.8%)	26 (21.5%)
Low anterior resection	38 (28.2%)	23 (19%)
Hartmann	0	1 (0.8%)
Abdominoperineal resection	9 (6.7%)	6 (5%)
With stoma	34 (25.2%)	20 (16.5%)	0.09
Operative approach			0.006
Laparoscopic	27 (20%)	45 (37.2%)
Open surgery	105 (77.8%)	74 (61.2%)
Reconversion from laparoscopic to open surgery	3 (2.2%)	2 (1.7%)
Length of procedure (min)	244.1 ± 72.5	239.9 ± 82.6	0.67
Length of surgery (min)	219.5 ± 70	213.8 ± 83.3	0.56

Variable	Pre ERAS (p = 135)	ERAS (p = 121)	p-value
1. Intensive preoperative advice, written instructions and an informational pamphlet	0	95 (78.5%)	<0.001
2. Drink clear liquid until 2 h prior to the time of procedure and solids until 6 h	0	121 (100%)	<0.001
3. Evaluation of nutritional status	0	95 (78.5%)	<0.001
4. Protocol of optimization of preoperative anemia (with oral or intravenous iron of erythropoietin)	0	95 (78.5%)	<0.001
Patients who received in the preoperative period
Oral iron	21 (15.6%)	16 (13.2%)	0.722
Intravenous iron	3 (2.23%)	31 (25.6%)	<0.001
Erythropoietin	0	2 (1.6%)	0.22
5. Use of incentive spirometer
Preoperative period	0	95 (78.5%)	<0.001
POD 0	8 (5.9%)	107 (88.4%)	<0.001
POD 1	43 (31.9%)	111 (91.7%)	<0.001
POD 2	52 (38.5%)	113 (93.4%)	<0.001
6. Avoidance of full mechanical preparation for colon resection, with the exception of left sided and rectal lesions	111 (82.2%)	77 (63.6%)	0.001
7. Administrations of carbohydrate-rich drinks two hours prior to surgery	0	96 (79.3%)	<0.001
8. DVT prophylaxis with subcutaneous heparin from the day prior to the surgery	131 (97%)	121 (100%)	0.056
9. Compression stockings from the day prior to the surgery	0	112 (92.6%)	<0.001
10. Intraoperative pneumatic legs compression to DVT prophylaxis	0	63 (52.1%)	<0.001
11. Intraoperative warm air body heating	0	114 (94.2%)	<0.001
12. Restrictive intraoperative fluid therapy (zero balance: fluid replacement with crystalloids: 3.5 mL/kg/h in laparoscopic surgery and 5-7 mL/kg/h in open surgery)	0	121 (100%)	<0.001
Intraoperative fluids (mL of crystalloids and colloids) (mean ± D)	2143.7 ± 860.6	1575.83 ± 868.8	<0.001
13. Avoidance of nasogastric tubes (patients without nasogastric tubes)	118 (87.4%)	102 (84.2%)	0.502
14. Avoidance of drains (patients without drains)	16 (11.9%)	16 (13.2%)	0.74
Withdrawal of drainage in the postoperative period, days (mean ± D)	6.5 ± 2.9	6.1 ± 3	0.270
15. Minimizing opioids administration	-^a a This variable could not be quantified because data from the preERAS group was collected in retrospect from the database of the hospital computer system.	90 (74.4%)	-^a a This variable could not be quantified because data from the preERAS group was collected in retrospect from the database of the hospital computer system.
Patients requiring opioids
POD 0	106 (78.5%)	44 (36.4%)	<0.001
POD 1	88 (65.2%)	44 (36.4%)	<0.001
POD 2	84 (62.2%)	43 (35.5%)	<0.001
16. Antiemetic prophylaxis	-^a a This variable could not be quantified because data from the preERAS group was collected in retrospect from the database of the hospital computer system.	121 (100%)	-^a a This variable could not be quantified because data from the preERAS group was collected in retrospect from the database of the hospital computer system.
17. Taking in oral fluids about POD 0 and soft-food diet in POD 1	13 (9.6%)	45 (37.2%)	<0.001
Onset of oral liquid diet
POD 1	13 (9.6%)	45 (37.2%)	<0.001
POD 2	56 (41.4%)	55 (45.5%)	0.484
Onset of analgesia by mouth, days (mean ± D)	6.1 ± 3	4.9 ± 1.9	0.009
18. Early mobilization (from bed to the sofa)
POD 0	2 (1.5%)	52 (43%)	<0.001
POD 1	82 (60.7%)	89 (76.6%)	0.023
19. Urinary catheter removal in
POD 0	7 (5.2%)	1 (0.8%)	0.07
POD 1	18 (13.3%)	31 (25.6%)	0.016
20. Multimodal analgesia (thoracic epidural catheter (T7-T10) in open surgery)	53 (39.3%)	49 (40.5%)	0.84
Other analgesia techniques used during the intraoperative period
TAP block	3 (2.2%)	10 (8.3%)	0.028
Wound infiltration with local anesthetic	3 (2.2%)	31 (27.6%)	0.001
Regional analgesia used during the postoperative period
NSAIDs	43 (31.9%)	43 (35.5%)	0.533
Epidural	53 (39.3%)	44 (36.4%)	0.634
TAP blocks	1 (0.7%)	5 (4.1%)	0.104
PCA with morphine iv	38 (28.2%)	28 (23.1%)	0.360

Variable	Pre ERAS	ERAS	p-value
With complications	49 (36.3%)	38 (31.4%)	0.49
Clavien-Dindo complications			0.174
Grade 1	21 (15.5%)	8 (6.6%)
Grade 2	13 (9.6%)	17 (14%)
Grade 3	14 (10.4%)	11 (9.1%)
Grade 4	0 (0%)	0 (0%)
Grade 5	1 (0.7%)	2 (1.7%)
Complications
1. Medical complications	8 (5.9%)	9 (7.4%)	0.669
Hematuria	2 (1.5%)	1 (0.8%)
Urinary tract infection	3 (2.2%)	1 (0.8%)
Delirium	0	1 (0.8%)
Liver failure	0	1 (0.8%)
Urticaria	2 (1.5%)	3 (2.5%)
Pneumonia	1 (0.7%)	2 (1.7%)
2. Surgical complications	41 (30.4%)	29 (24%)	0.178
Paralytic ileus	10 (7.4%)	2 (1.7%)
Surgical wound infection	8 (5.9%)	2 (1.7%)
Abdominal abscess	4 (3%)	3 (2.5%)
Emphysematous colitis	0	1 (0.8%)
Intestinal fistula	4 (3%)	8 (6.6%)
Anastomotic dehiscence	14 (10.4%)	11 (9.1%)
Death	1 (0.7%)	2 (1.7%)
Mortality at 30 days	1 (0.7%)	2 (1.7%)	0.498
LOS, days (mean ± SD)	11 ± 3.8	9.8 ± 3.7	0.018
Readmission rate at 30 day all cause	15 (11.1%)	12 (9.9%)	0.756
Readmission rate reoperation for any indication within 30 days	6 (4.4%)	6 (5%)	0.832

LOS	Beta estimates	p	95% CI
ERAS protocol	-0.91	0.031	-1.74	-0.083
Male sex	-0.89	0.046	-1.77	-0.02
Age	0.041	0.012	0.009	0.074
Laparoscopy	-1.3	0.006	-2.23	-0.39
3-5 Clavien-Dindo complications	6.7	<0.001	5.41	-8.05

Readmissions at 30 days	OR	p	95% CI	OR
ERAS protocol	1.1	0.9	0.5	2.5
Male sex	0.9	0.8	0.4	2.2
Age	0.98	0.2	0.95	1
Laparoscopy	0.2	0.02	0.1	0.8
3-5 Clavien-Dindo complications	3.5	0.021	1.2	10.2

3-5 Clavien-Dindo	OR	p	95% CI	OR
ERAS protocol	1.79	0.257	0.65	4.97
Male sex	1.26	0.659	0.45	3.55
Age	1.01	0.594	0.96	1.06
Laparoscopy	4.13	0.013	1.35	12.61
LOS	1.46	0.000	1.30	1.65

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E-mail: sbcp@sbcp.org.br

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[1] *Corresponding author. E-mail: m.cabellos.olivares@gmail.com (C.O. Mercedes).