Perioperative Care in Colorectal Cancer Surgery before a Structured Implementation Program of the ERAS Protocol in a Regional Network. The Piemonte EASY-NET Project

Background: In 2019, the Enhanced Recovery After Surgery (ERAS) protocol for colorectal cancer surgery was adopted by a minority of hospitals in Piemonte (4.3 million inhabitants, north-west Italy). The present analysis aims to compare the level of application of the ERAS protocol between hospitals already adopting it (ERAS, N = 3) with the rest of the regional hospitals (non-ERAS, N = 28) and to identify possible obstacles to its application. Methods: All patients surgically treated for a newly diagnosed colorectal cancer during September–November 2019, representing the baseline period of a randomized controlled trial with a cluster stepped-wedge design, were included. Indicators of compliance to the ERAS items were calculated overall and for groups of items (preoperative, intraoperative and postoperative) and analyzed with a multilevel linear model adjusting for patients’ characteristics, considering centers as random effects. Results: Overall, the average level of compliance to the ERAS protocol was 56% among non-ERAS centers (N = 364 patients) and 80% among ERAS ones (N = 79), with a difference of 24% (95% CI: −41.4; −7.3, p = 0.0053). For both groups of centers, the lowest level of compliance was recorded for postoperative items (42% and 66%). Sex, age, presence of comorbidities and American Society of Anesthesiologists (ASA) score were not associated with a different probability of compliance to the ERAS protocol. Conclusions: Several items of the ERAS protocol were poorly adopted in colorectal surgery units in the Piemonte region in the baseline period of the ERAS Colon-Rectum Piemonte study and in the ERAS group. No relevant obstacles to the ERAS protocol implementation were identified at patient level.

Factors Predicting Increased Length of Stay in Abdominal Wall Reconstruction

Background Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)–specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol. Methods A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8). Results Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (β0.04,SE0.02), BMI (β0.06,SE0.03), hernia defect size (β0.003,SE0.001), active mesh infection or mesh fistula (β1.8,SE0.72), operative time (β0.02,SE0.002), and ASA score >4 (β3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence ( P = .06). Conclusions Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.

The Implementation of Modified ERAS Protocol in Laparoscopic Radical Cystectomy: An Outcome at Universitas Gadjah Mada Urological Institute

Background: Enhanced recovery after surgery (ERAS) protocol is multimodal perioperative care designed to achieve enhanced postoperative outcomes. Unfortunately, all these elements are not always fully applied due to each center’s limitations. In this study, the ERAS protocol was modified and implemented in patients with bladder cancer who underwent laparoscopic radical cystectomy (LRC). This study aimed to evaluate the outcomes of the modified ERAS protocol in LRC surgery. Methods: The retrospective study design was used to evaluate 35 patients (27 males and 8 females) who underwent LRC with the application of the perioperative modified ERAS protocol. All information relating to perioperative, intraoperative, and postoperative patient data was obtained from medical records. All complications that occurred were classified according to the Clavien-Dindo classification.Results: The mean age in this study was 58.3 ± 9.2, and the most common pathological finding was urothelial carcinoma. Intraoperative blood loss was 318.5 ± 112.5 cc with those requiring intraoperative blood transfusion of 4.8 ± 2.0 patients. The mean first diet was 2.1 ± 1.2 days. For bowel activities, the first flatulence was 1.6 ± 0.8 days. The mean mobilization with first sitting was 1.8 ± 0.9 days. Seventeen percent of patients experienced intraoperative complications and postoperative complications were encountered in 28.6% of patients. According to the ClavienDindo classification, most complications were grades 1-2 (17.1%). There was no incidence of mortality in this study.Conclusions: These promising results, including the postoperative recovery and complications rates, require validation with multi-center and randomized studies to confirm the benefits of the modified ERAS protocol in minimally invasive procedures, especially LRC surgery

The impact of Enhanced Recovery after Surgery (ERAS) pathways with regard to perioperative outcome in patients with ovarian cancer

Purpose Major surgery for ovarian cancer is associated with significant morbidity. Recently, guidelines for perioperative care in gynecologic oncology with a structured “Enhanced Recovery after Surgery (ERAS)” program were presented. Our aim was to evaluate if implementation of ERAS reduces postoperative complications in patients undergoing extensive cytoreductive surgery for ovarian cancer. Methods 134 patients with ovarian cancer (FIGO I-IV) were included. 47 patients were prospectively studied after implementation of a mandatory ERAS protocol (ERAS group) and compared to 87 patients that were treated before implementation (pre-ERAS group). Primary endpoints of this study were the effects of the ERAS protocol on postoperative complications and length of stay in hospital. Results Preoperative and surgical data were comparable in both groups. Only the POSSUM score was higher in the ERAS group (11.8% vs. 9.3%, p < 0.001), indicating a higher surgical risk in the ERAS group. Total number of postoperative complications (ERAS: 29.8% vs. pre-ERAS: 52.8%, p = 0.011), and length of hospital stay (ERAS: 11 (6–23) vs pre-ERAS: 13 (6–50) days; p < 0.001) differed significantly. A lower fraction of patients of the ERAS group (87.2%) needed postoperative admission to the ICU compared to the pre-ERAS group (97.7%), p = 0.022). Mortality within the ERAS group was 0% vs. 3.4% (p = 0.552) in the pre-ERAS group. Conclusion The implementation of a mandatory ERAS protocol was associated with a lower rate of postoperative complications and a reduced length of stay in hospital. If ERAS has influence on long-term outcome needs to be further evaluated.

Enhanced Recovery After Surgery Multi-Modality Pain Regimen Performs Similar to PRN Narcotics on Outcomes and Pain Control After Cardiac Surgery: A Quality Improvement Project

Background: While enhanced recovery after surgery (ERAS) pathways have been successfully applied for cardiac surgery, there has been limited research directly comparing ERAS protocols to ad hoc narcotic use after surgery. We hypothesized that a standardized ERAS protocol would provide similar pain management and psycho-emotional outcomes while decreasing the use of opioids in the hospital and after discharge. Methods: As part of a 7-month quality improvement project, cardiac surgery patients on a fast tracked to extubate pathway were assigned PRN narcotic pain management for 3 months (n=49). After a 1-month ERAS protocol optimization period, a separate group of patients were given the ERAS protocol (n=34). Clinical outcomes were gathered, and participants completed a quality of recovery survey that allowed for the assessment of pain and symptom control at 4 time-points post-surgery. Results: Among 83 participants, 66% were male and the mean age was 53 years. There were no differences in patient characteristics between PRN and ERAS groups (all p>0.244). There were no differences between ERAS and PRN groups for surgery characteristics (all p>0.060), inpatient outcomes (all p>0.658), or after-discharge outcomes (all p>0.397). Furthermore, across all time-point comparisons, there were no supported differences in patient-reported outcome and pain control between the ERAS and PRN narcotic groups (all p>0.075). Conclusions: An ERAS protocol demonstrated similar patient outcomes and pain control to traditional opioid use for postoperative cardiac surgery patients. Further research is recommended to further confirm the results of this study.

Comment on Klek et al. Enhanced Recovery after Surgery (ERAS) Protocol Is a Safe and Effective Approach in Patients with Gastrointestinal Fistulas Undergoing Reconstruction: Results from a Prospective Study. Nutrients 2021, 13, 1953

We read and appreciated the prospective study by Klek et al. [...]

Reply to Lauro, A.; Ripoli, M.C. Comment on “Klek et al. Enhanced Recovery after Surgery (ERAS) Protocol Is a Safe and Effective Approach in Patients with Gastrointestinal Fistulas Undergoing Reconstruction: Results from a Prospective Study. Nutrients 2021, 13, 1953”

We would like to thank you for the opportunity to respond to the issues raised in Dr Lauro’s and Ropoli’s letter, to clarify aspects of our methodology in relation to these concerns [...]

Enhanced recovery after surgery: importance of compliance audits

Background: The enhanced recovery after surgery (ERAS) protocol is associated with improved clinical outcomes. However, implementation of ERAS in clinical practice is difficult because it requires a multidisciplinary approach and complex standardization. Moreover, maintenance and auditing of ERAS protocols is another challenge.Current Concepts: The ERAS society provides guidelines for surgery in almost all areas, and each guideline consists of approximately 20 items. Audits are performed to determine whether the items are being applied appropriately in a compliant manner as well as monitor and improve ERAS protocols. Numerous studies have reported that even with the application of the same ERAS protocol, postoperative short-term outcomes such as reductions of hospital stay and postoperative complications were better in the high-compliance group than in the low-compliance group. In addition, some recent studies have reported that application of ERAS protocols with high compliance can improve the long-term survival outcomes in cancer patients. In this regard, ERAS has been hypothesized to improve long-term oncological outcomes by minimizing surgical stress and reducing the postoperative inflammatory response and damage to immune function.Discussion and Conclusion: In addition to the development of appropriate protocols, auditing of compliance is also an important part of ERAS implementation. High compliance may lead to improved clinical outcomes.