Influence of ERAS protocol on postoperative outcomes after elective colorectal resection surgery: A prospective cohort study- two years single center experience

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

THE OUTCOMES OF SURGICAL TREATEMENT IN OPERATION OF COLON CANCER BY ANTERIOR DIXON RESECTION : INFLUENCE OF ERAS- PROTOCOL

CILJ ISTRAŽIVANJA: ERAS protokol je multimodalni način peripoerativne kirurške njege koji se sastoji od znanstveno dokazanih postupaka. Neki od postupaka, iako su znanstveno dokazani, teško su prihvaćeni od strane kirurga i ostalog osoblja jer se protive dosad ustaljenoj praksi. Spomenuti protokol je dio Odjela za koloproktologiju KBC-a Split od listopada 2016. godine. Koristi se za svakog elektivno operiranog pacijenta s dijagnozom kolorektalnog karcinoma. Cilj istraživanja je usporediti duljine postoperativnog boravka, učestalost komplikacija i neplaniranih operacija između skupina koje su se pridržavale ERAS protokola i onih koje nisu. ISPITANICI I METODE: Ova studija uključuje sve pacijente s dijagnozom kolorektalnog karcinoma elektivno operirane donjom anteriornom resekcijom (operacija po Dixonu) u razdoblju od listopada 2016. do svibnja 2018. Pacijenti su podijeljeni u 3 skupine- otvoreno operirani s loše provedenim ERAS protokolom (Otvoreno ne-ERAS ili „ONE”), otvoreno operiranim s dobro provedenim ERAS protokolom (Otvoreno ERAS ili „OER”), laparoskopski operirani s dobro provedenim ERAS protokolom (Laparoskopski ERAS ili „LER”). Više od 60% primjenjenih ERAS stavki (od ukupno 24 koje smo bilježili) smo smatrali dobro provedenim ERAS protokolom. Analizirani su duljina postoperativnog boravka, broj komplikacija i neplaniranih reoperacija. REZULTATI: Pacijenti koji su bili dio „ONE” grupe su imali dulje vrijeme postoperativnog boravka od obje grupe u kojima je dobro provođen ERAS protokol (“OER” i “LER”): 11,32±5,57 dana, 95% CI 8,63-14,00 naspram 8,57±2,79 dana, 95% CI 6,96-10,18 za grupu “OER” i 6,21±3,50, 95% CI 4,91-7,47 za grupu “LER”. Statistički značajna razlika pronađena je samo između skupine „ONE” i “LER” (P<0,001). Prateći postoperativne komplikacije uočena je statistički značajna povećana učestalost komplikacija kod ispitanika grupe „ONE” u odnosu na grupe “OER” i “LER” (P= 0,002). ZAKLJUČAK: Rezultati naše studije sugeriraju da primjena ERAS protokola može smanjiti postoperativni boravak i morbiditet te posljedično poboljšati vrijednost kirurške njege za pacijenta. Potpuna primjena ERAS protokola trebala bi smanjiti i troškove liječenja i poboljšati općenito klinički ishod.OBJECTIVE: The ERAS (Enhanced Recovery After Surgery) protocol is multimodal care pathway of perioperative surgical care consisting of evidence-based procedures. Some of the procedures, in spite of being scientifically proven, are hardly accepted by surgeons and other staff because it opposes well established practice. Mentioned protocol is a part of Department for colorectal surgery in University Hospital Split since October 2016. It is used for every patient with colorectal cancer that undergoes elective surgery. Objective of our research was to compare length of postoperative stay, frequency of complications and unplanned reoperations among groups with or without well performed ERAS protocol. PATIENTS AND METHODS: This study includes all patients undergoing lower anterior (Dixon) resection in University Hospital Split in from October 2016. to May 2017. Patients were divided in three groups: open operation with poorly performed ERAS (Open non ERAS or „ONE”), open operation with well performed ERAS (Open ERAS or „OER”) and minimal invasive surgery with well performed ERAS (Laparoscopy ERAS or „LER”). More than 60% of all ERAS steps (total of 24 steps have been noted in our ERAS protocol) applied in one patient was considered as a well performed ERAS protocol. Length of hospital stay, number of complications and unexpected reoperations were analyzed. RESULTS: Patients that were part of „ONE” group had a longer postoperative stay than patients in groups with well performed ERAS protocol („OER” and „LER”): 11.32±5.57 days, 95% CI 8.63-14.00 comparing to 8.57±2.79 days, 95% CI 6.96-10.18 for group “OER” and 6.21±3.50 days, 95% CI 4.91-7.47 for group“LER”. Statistically significant difference was found only between groups „ONE” and „LER” (P<0.001) By keeping track of postoperative complications statistically significant higher rate was noticed in group „ONE” in relation to other two groups (P=0.002). CONCLUSION: Results of our study suggest that application of ERAS protocol can decrease hospital stay and morbidity, and consequently improve the value of surgical care for patients. The complete ERAS implementation should result in major improvements in clinical outcomes and cost