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Enhanced recovery after surgery (ERAS) in colorectal surgery: implementation is still beneficial despite modern surgical and anesthetic care

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Abstract

Purpose

Enhanced recovery after surgery (ERAS) protocols have shown beneficial outcomes in the last 20 years. Nevertheless, simultaneously implemented technical improvements such as minimally invasive access or modified anesthesia care may play a crucial role in optimizing patient outcome. The aim of the study was to investigate the effect of ERAS implementation in a highly specialized colorectal center.

Methods

This is a propensity score matched single-center study comparing the short-term outcomes of patients undergoing elective colorectal surgery in a society-indepedent ERAS program from January 2021 to August 2022 to standard perioperative care from January 2019 to December 2020.

Results

Four hundred fifty-six patients were included in the propensity score matched analysis with 228 patients per group (ERAS vs. standard care). Minimally invasive access was used in 80.2% vs. 77.6% (p = 0.88), and there were 16.6% vs. 18.8% (p = 0.92) rectal procedures in the ERAS and standard care group, respectively. Major complications occurred in 10.1% vs. 11.4% (p = 0.65) and anastomotic leakage demanding operative revision in 2.2% vs. 2.6% (p = 0.68) in the ERAS and standard care group, respectively. ERAS lead to a lower number of non-surgical complications compared to standard care (57 vs. 79; p = 0.02). Mean length of stay (LOS) and mean costs per case were lower in ERAS compared to standard care (9.2 ± 5.6 days vs. 12.7 ± 7.4 days, p < 0.01; costs 33,727 ± 15,883 USD vs. 40,309 ± 29,738 USD, p < 0.01).

Conclusion

The implementation of an ERAS protocol may lead to a reduction of LOS, costs, and a lower number of non-surgical complications even in a highly specialized colorectal unit using modern surgical and anesthetic care. (ClinialTrials.gov number NCT05773248)

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References

  1. Kehlet H, Dahl JB (2003) Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 362(9399):1921–1928

    Article  PubMed  Google Scholar 

  2. Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg. 183(6):630–641

    Article  PubMed  Google Scholar 

  3. Fearon KCH, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CHC, Lassen K et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24(3):466–477

    Article  CAS  PubMed  Google Scholar 

  4. Ni X, Jia D, Chen Y, Wang L, Suo J (2019) Is the Enhanced Recovery After Surgery (ERAS) Program Effective and Safe in Laparoscopic Colorectal Cancer Surgery? A Meta-Analysis of Randomized Controlled Trials. J Gastrointest Surg 23(7):1502–1512

    Article  PubMed  Google Scholar 

  5. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev (2):CD007635

  6. Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38(6):1531–1541

    Article  PubMed  Google Scholar 

  7. Jones D, Musselman R, Pearsall E, McKenzie M, Huang H, McLeod RS (2017) Ready to go home? Patients’ experiences of the discharge process in an enhanced recovery after surgery (ERAS) program for colorectal surgery. J Gastrointest Surg 21(11):1865–1878

    Article  CAS  PubMed  Google Scholar 

  8. Thanh NX, Chuck AW, Wasylak T, Lawrence J, Faris P, Ljungqvist O et al (2016) An economic evaluation of the enhanced recovery after surgery (ERAS) multisite implementation program for colorectal surgery in Alberta. Can J Surg 59(6):415–421

    Article  PubMed  PubMed Central  Google Scholar 

  9. Stone AB, Grant MC, Wu CL, Wick EC (2019) Enhanced recovery after surgery for colorectal surgery: a review of the economic implications. In: Clinics in Colon and Rectal Surgery, vol 32. Thieme Medical Publishers, Inc., pp 129–133

    Google Scholar 

  10. Sjetne IS, Krogstad U, Ødegård S, Engh ME (2009) Improving quality by introducing enhanced recovery after surgery in a gynaecological department: consequences for ward nursing practice. Qual Saf Health Care 18(3):236–240

    Article  CAS  PubMed  Google Scholar 

  11. Pędziwiatr M, Mavrikis J, Witowski J, Adamos A, Major P, Nowakowski M, Budzyński A (2018) Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol 35(6):95

    Article  PubMed  PubMed Central  Google Scholar 

  12. Aarts MA, Okrainec A, Glicksman A, Pearsall E, Charles Victor J, McLeod RS (2012) Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surg Endosc 26(2):442–450

    Article  PubMed  Google Scholar 

  13. Spanjersberg WR, van Sambeeck JDP, Bremers A, Rosman C, van Laarhoven CJHM (2015) Systematic review and meta-analysis for laparoscopic versus open colon surgery with or without an ERAS programme. Surg Endosc 29(12):3443–3453

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Saklad M (1941) Grading of patients for surgical procedures. Anesthesiology 2(3):281–284. Available from:. https://doi.org/10.1097/00000542-194105000-00004

    Article  Google Scholar 

  15. Reilly HM, Martineau JK, Moran A, Kennedy H (1995) Nutritional screening–evaluation and implementation of a simple Nutrition Risk Score. Clin Nutr 14(5):269–273

    Article  CAS  PubMed  Google Scholar 

  16. Charlson ME, Pompei P, Ales KL, MacKenzie CR (1987) A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 40(5):373–83

    Article  CAS  PubMed  Google Scholar 

  17. Dell-Kuster S, Gomes NV, Gawria L, Aghlmandi S, Aduse-Poku M, Bissett I et al (2020) Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study. BMJ 25:370

    Google Scholar 

  18. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–96

    Article  PubMed  Google Scholar 

  19. Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258(1):1–7

    Article  PubMed  Google Scholar 

  20. Rubin DB (1997) Estimating causal effects from large data sets using propensity scores. Ann Intern Med 127(8 Pt 2):757–63

    Article  CAS  PubMed  Google Scholar 

  21. Van Rompaey B, Elseviers MM, Schuurmans MJ, Shortridge-Baggett LM, Truijen S, Bossaert L (2009) Risk factors for delirium in intensive care patients: a prospective cohort study. Crit Care 13(3):R77

    Article  PubMed  PubMed Central  Google Scholar 

  22. Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC et al (2010) Diagnosis, prevention, and treatment of catheter-aassociated urinary tract infection in adults: 2009 international clinical practice guidelines from the infectious diseases society of America. Clin Infect Dis 50:625–663

    Article  PubMed  Google Scholar 

  23. Forsmo HM, Pfeffer F, Rasdal A, Østgaard G, Mohn AC, Körner H et al (2016) Compliance with enhanced recovery after surgery criteria and preoperative and postoperative counselling reduces length of hospital stay in colorectal surgery: results of a randomized controlled trial. Color Dis 18(6):603–611

    Article  CAS  Google Scholar 

  24. Squires DA (2011) The U.S. health system in perspective: a comparison of twelve industrialized nations. Issue Brief (Commonw Fund) 16:1–14

  25. Roulin D, Donadini A, Gander S, Griesser AC, Blanc C, Hübner M, Schäfer M, Demartines N (2013) Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 100(8):1108–14

    Article  CAS  PubMed  Google Scholar 

  26. Ren L, Zhu D, Wei Y, Pan X, Liang L, Xu J, Zhong Y, Xue Z, Jin L, Zhan S, Niu W, Qin X, Wu Z, Wu Z (2012) Enhanced Recovery After Surgery (ERAS) program attenuates stress and accelerates recovery in patients after radical resection for colorectal cancer: a prospective randomized controlled trial. World J Surg 36(2):407–414

    Article  CAS  PubMed  Google Scholar 

  27. Lee L, Li C, Landry T, Latimer E, Carli F, Fried GM, Feldman LS (2014) A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery. Ann Surg 259(4):670–676

    Article  PubMed  Google Scholar 

  28. Aarts MA, Rotstein OD, Pearsall EA, Victor JC, Okrainec A, McKenzie M et al (2018) Postoperative ERAS interventions have the greatest impact on optimal recovery. Ann Surg 267(6):992–997

    Article  PubMed  Google Scholar 

  29. Wei IH, Pappou EP, Smith JJ, Widmar M, Nash GM, Weiser MR, Paty PB, Guillem JG, Afonso A, Garcia-Aguilar J (2020) Monitoring an Ongoing Enhanced Recovery After Surgery (ERAS) Program: Adherence Improves Clinical Outcomes in a Comparison of Three Thousand Colorectal Cases. Clin Surg 5:2909

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Acknowledgements

We explicitly thank the very dedicated ERAS team of the St. Clara Hospital for their outstanding work in the implementation and daily adherence to the ERAS protocol.

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Author notes

  1. Julian Süsstrunk, Remo Mijnssen, Alexander Wilhelm, and Daniel C. Steinemann share equal contribution

Authors and Affiliations

  1. Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital, 4002, Basel, Switzerland

    Julian Süsstrunk, Marco von Strauss, Beat Peter Müller, Alexander Wilhelm & Daniel C. Steinemann

  2. Department of Surgery, University Hospital Basel, 4031, Basel, Switzerland

    Julian Süsstrunk, Marco von Strauss, Beat Peter Müller, Alexander Wilhelm & Daniel C. Steinemann

  3. Medical Faculty, University of Basel, 4001, Basel, Switzerland

    Remo Mijnssen

  4. Surgical Outcome Research Center Basel, University Hospital Basel, 4002, Basel, Switzerland

    Alexander Wilhelm

Authors
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Contributions

Study conception and design: JS, RM, MVS, BPM, AW, and DCS. Acquisition of data: JS, RM, and AW. Analysis and interpretation of data: JS, RM, AW, and DCS. Drafting of manuscript: JS, RM, DCS, and MVS. Critical revision of manuscript: JS, RM, MVS, BPM, AW, and DCS.

Corresponding author

Correspondence to Julian Süsstrunk.

Ethics declarations

The abstract was presented at the Annual Meeting of the Swiss Society of Gastroenterology, the Swiss Society of Visceral Surgery, the Swiss Association for the Study of the Liver and the Swiss Society of Endoscopy Nurses and Associates in Interlaken, Switzerland, 2023 and at the Annual Meeting of the Swiss College of Surgeons in Basel, Switzerland, 2023.

Dr. Julian Süsstrunk, Remo Mijnssen, PD Dr. Marco von Strauss, Prof. Beat Peter Müller, Dr. Alexander Wilhelm and PD Dr. Daniel C. Steinemann have no conflicts of interest to declare. All procedures performed were in accordance with the ethical standards of the local research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Research data supporting this publication is available upon reasonable request.

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Süsstrunk, J., Mijnssen, R., von Strauss, M. et al. Enhanced recovery after surgery (ERAS) in colorectal surgery: implementation is still beneficial despite modern surgical and anesthetic care. Langenbecks Arch Surg 409, 5 (2024). https://doi.org/10.1007/s00423-023-03195-7

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