Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials

Current developments and future directions in respiratory physiotherapy

Respiratory physiotherapists have a key role within the integrated care continuum of patients with respiratory diseases. The current narrative review highlights the profession's diversity, summarises the current evidence and practice, and addresses future research directions in respiratory physiotherapy. Herein, we describe an overview of the areas that respiratory physiotherapists can act in the integrated care of patients with respiratory diseases based on the Harmonised Education in Respiratory Medicine for European Specialists syllabus. In addition, we highlight areas in which further evidence needs to be gathered to confirm the effectiveness of respiratory therapy techniques. Where appropriate, we made recommendations for clinical practice based on current international guidelines.

Rural context, single institution prospective outcomes after enhanced recovery colorectal surgery protocol implementation

Background

Rural hospitals face unique challenges to adopting Enhanced Recovery protocols after colorectal surgical procedures. There are few examples of successful implementation in the United States, and fewer yet of prospective, outcomes-based trials.

Methods

This study drew data from elective bowel resection prospectively collected, retrospectively analyzed cases 2 years prior (n = 214) and 3 years after (n = 224) implementing an ERAS protocol at a small, rural health network in upstate New York. Primary outcomes were cost, length-of-stay, readmission rate, and complications.

Results

The implementation required changes and buy-in at multiple levels of the institution. There was a statistically significant reduction in mean length of stay (6.9 versus 5.1 days) and per-patient savings to hospital ($3000) after implementation of ERAS protocol. There was no significant change in rate of 30-day readmissions or complications.

Conclusions

The authors conclude that for rural-specific barriers to implementation of Enhanced Recovery protocols there are specific organizational strategies that can ultimately yield sustainable endpoints.

Enhanced Recovery after Surgery (ERAS): a Systematic Review of Randomised Controlled Trials (RCTs) in Bariatric Surgery

OBJECTIVE

Our aim was to conduct an up-to-date systematic review of randomised controlled trials (RCTs) to determine the benefits and harms of enhanced recovery after surgery (ERAS) programme in bariatric surgery.

METHODS

MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library were searched for RCTs on ERAS versus standard care (SC) until April 2020. The primary endpoint was the length of hospital stay (LOS).

RESULTS

Five RCTs included a total of 610 procedures. ERAS adoption is capable of significantly reducing LOS (MD of - 0.51; 95% CI - 0.92 to - 0.10; P = 0.01) and postoperative nausea and vomiting (PONV) (OR 0.42; 95% CI 0.19 to 0.95; P = 0.04). No significant differences in terms of adverse events and readmissions.

CONCLUSIONS

The implementation of ERAS in bariatric surgery produces a significant reduction in LOS and PONV.

Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada

Background

Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term.

Methods

We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars.

Results

The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated.

Conclusion

These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.

Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols

Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.

Assessing effectiveness and implementation of a perioperative enhanced recovery protocol for children undergoing surgery: study protocol for a prospective, stepped-wedge, cluster, randomized, controlled clinical trial

BACKGROUND

Perioperative enhanced recovery protocols (ERPs) have been found to decrease hospital length of stay, in-hospital costs, and complications among adult surgical populations but evidence for pediatric populations is lacking. The study is designed to evaluate the adoption, effectiveness, and generalizability of a 21-element ERP, adapted for pediatric surgery.

METHODS

The multicenter study is a stepped-wedge, cluster-randomized, pragmatic clinical trial that will evaluate the effectiveness of the ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) intervention while also assessing site-specific adaptations, implementation fidelity, and sustainability. The target patient population is pediatric patients, between 10 and 18 years old, who undergo elective gastrointestinal surgery. Eighteen (N = 18) participating sites will be randomly assigned to one of three clusters with each cluster, in turn, being randomly assigned to an intervention start period (stepped-wedge). Each cluster will participate in a Learning Collaborative, using the National Implementation Research Network's five Active Implementation Frameworks (AIFs) (competency, organization, and leadership), as drivers of facilitation of rapid-cycle adaptations and implementation. The primary study outcome is hospital length of stay, with implementation metrics being used to evaluate adoption, fidelity, and sustainability. Additional clinical outcomes include opioid use, post-surgical complications, and post-discharge healthcare utilization (clinic/emergency room visits, telephone calls to clinic, and re-hospitalizations), as well as, assess patient- and parent-reported health-related quality of life outcomes. The protocol adheres to the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) checklist.

DISCUSSION

The study provides a unique opportunity to accelerate the adoption of ERPs across 18 US pediatric surgical centers and to evaluate, for the first time, the effect of a pediatric-specific ENRICH-US intervention on clinical and implementation outcomes. The study design and methods can serve as a model for future pediatric surgical quality improvement implementation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04060303 . Registered on 07 August 2019.

Enhanced Recovery Program in Laparoscopic Colorectal Surgery: An Observational Controlled Trial

Background: Most of the evidence for enhanced recovery programs (ERPs) in colorectal surgery relies on nonrandomized studies with control groups either historical or operated on at different facilities. The aim of this study was to investigate ERP in coeval groups admitted in different wards at the same hospital. Materials and Methods: A prospective cohort of consecutive patients (n = 100) undergoing elective laparoscopic colorectal resection completing a standardized ERP (ERP group) was compared with patients (n = 100) operated with traditional perioperative care in the same period at the same institution (non-ERP group). The two groups were located in separate wards and shared the same anesthesiologists. The exclusion criteria were: >80 years old, American Society of Anesthesia (ASA) IV, metastatic disease, and inflammatory bowel disease. The primary outcome was hospital length of stay (LoS), used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, readmission rate, mortality, and protocol adherence. Results: The ERP group protocol adherence was 81%. The LoS was significantly reduced in the ERP group (4 versus 7 days). The number of 30-day postoperative complications was lower in the ERP group (P < .001). No increase was found in 30-day readmission or mortality. Conventional perioperative protocol was the only predictor of any postoperative complication and, together with male sex and age 65-74 years old, was the only factor associated with prolonged LoS. Conclusion: Implementing a colorectal ERP is feasible, safe, and efficient for functional recovery, but high protocol adherence is needed. Following traditional perioperative care is associated with more postoperative complications and prolonged LoS.

Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy

BACKGROUND

Peroral endoscopic myotomy (POEM) has previously been shown to be equally if not more expensive than laparoscopic Heller myotomy (LHM). We compare perioperative outcomes and charges between POEM and LHM at a single institution.

METHODS

Outcomes and charge data of 33 patients who underwent LHM and 126 patients who underwent POEM were analyzed. Patients who did not present electively were excluded.

RESULTS

There were no demographic differences between groups. Patients who underwent POEM had a significantly shorter mean operative time and median length of stay (both p < 0.001). Patients who underwent POEM stopped narcotics earlier and had faster return to activities of daily living (both p < 0.05). When adjusted for inflation, POEM incurred less in hospital charges than LHM (35.5 ± 12.8 vs 30.7 ± 10.3 in thousands of US dollars, p = 0.006).

CONCLUSIONS

Patients who underwent POEM compared to LHM had significantly better perioperative outcomes. Our results suggest POEM may be the more cost-effective option.

Standardized Care Pathways as a Means to Improve Patient Safety

The literature overwhelmingly supports standardized, evidence-based care to improve patient safety in the surgical setting, including checklists and enhanced recovery programs. Although local culture, patient complexity, and hospital setting can represent barriers to implanting standardized practices, they can be overcome with thoughtful strategies.

Safety and Efficacy of an Enhanced Recovery Protocol After Hepatic Resection

Enhanced recovery protocols (ERPs) have shown to improve outcomes in multiple specialties and were recently applied to hepatic resections. The objective of this study was to determine the safety and efficacy of ERP in hepatic resection. Between 2013-2017, 208 patients underwent hepatectomy. The ERP included early ambulation, early oral intake, and multimodal analgesia. Primary study end points were hospital length of stay (LOS) and overall morbidity; secondary end points were return of bowel function (ROBF), 30-day readmission, and 90-day mortality. Major hepatectomies were selected for separate analysis. Overall, pre-ERP (N = 99) and ERP (N = 109) were similar in demographics. ERP patients had earlier oral intake and ROBF with similar overall morbidity. Although median LOS was 5 days, 43% of ERP patients had LOS ≤4 days vs. 27% in the pre-ERP cohort (P = .02). 30-day readmission was similar (12%), and 90-day mortality was 2.8% vs. 3.0% (pre-ERP vs. ERP, P = .90). In major hepatectomies, pre-ERP (N = 41) and ERP (N = 33) demographics and operative characteristics were similar. ERP patients had earlier oral intake and ROBF with similar morbidity and mortality. There was no significant difference in median LOS; however, 36% of the major hepatectomy ERP patients had LOS ≤4 days vs. 17% of pre-ERP patients, P = .06. In conclusion, ERP can be safely implemented in hepatectomy, with earlier oral intake and ROBF, shorter LOS in some patients, and no increase in morbidity or mortality.

Time-dependent displacement of commensal skin microbes by pathogens at the site of colorectal surgery

BACKGROUND

Although the healthy human skin microbiome has been the subject of recent studies, it is not known whether alterations among commensal microbes contribute to surgical site infections (SSIs). The objective of this study was to characterize temporal and spatial variation in the skin microbiota of patients undergoing colorectal surgery and to determine if dysbiosis contributes to SSIs.

METHODS

Sixty (60) adults scheduled to undergo elective colon or rectal resection were identified by convenience sampling. By analyzing bacterial 16S rRNA gene sequences isolated from clinical samples, we used a culture-independent strategy to monitor perioperative changes in microbial diversity of fecal samples and the skin.

RESULTS

990 samples were analyzed from 60 patients. Alpha diversity on the skin decreased after surgery but later recovered at the postoperative clinic visit. In most patients, we observed a transient postoperative loss of skin commensals (Corynebacterium and Propionibacterium) at the surgical site, which were replaced by potential pathogens and intestinal anaerobes (e.g. Enterobacteriaceae). These changes were not observed on skin that was uninvolved in the surgical incision (chest wall). One patient developed a wound infection. Incisional skin swabs from this patient demonstrated a sharp postoperative increase in the abundance of Enterococcus, which was also cultured from wound drainage.

CONCLUSION

We observed reproducible perioperative changes in the skin microbiome following surgery. The low incidence of SSIs in this cohort precluded analysis of associations between dysbiosis and infection. We postulate that real time monitoring of the skin microbiome could provide actionable findings about the pathogenesis of SSIs.

ERAS pathway in colorectal surgery: structured implementation program and high adherence for improved outcomes

Although there is clear evidence that an Enhanced Recovery After Surgery (ERAS) program in colorectal surgery leads to significantly reduced morbidity rates and length of hospital stay (LOS), it is still unclear what modalities and levels of implementation of the program are necessary to achieve these results. The purpose of this study is to analyze the methods and results of the first year of structured implementation of a colorectal ERAS program in two surgical units of the Azienda Sanitaria Unica Regionale (ASUR) Marche in Italy. A two-center observational study on a prospectively maintained database was performed on 196 consecutive colorectal resections (excluding emergencies and American Society of Anesthesiologists class > III cases) over a 1-year period. More than 50 variables including adherence to the individual items of the ERAS program were considered. Primary outcomes were overall morbidity, major morbidity, mortality and anastomotic leakage rates; secondary outcomes were LOS, re-admission and re-operation. The results were evaluated by univariate and multivariate analyses through logistic regression. After a median follow-up of 39.5 days, we recorded complications in 72 patients (overall morbidity 36.7%), major complications in 14 patients (major morbidity 7.1%), 6 deaths (mortality 3.1%), anastomotic dehiscence in 9 cases (4.9%), mean overall LOS of 6.6 days, 10 readmissions (5.1%) and 13 reoperations (6.7%). The mean adherence rate to the items of the ERAS program was 85.4%, showing a significant dose-effect curve for overall and major morbidity rates, anastomotic leakage rates and LOS. The implementation methods of a colorectal ERAS program in this study led to a high adherence (> 80%) to the program items. High adherence had significant effects also on major morbidity and anastomotic leakage rates.

Thirty-day outcomes after gynecologic oncology surgery: A single-center experience of enhanced recovery after surgery pathways

INTRODUCTION

The purpose of the study is to evaluate the impact of an enhanced recovery after surgery (ERAS) program implemented in a Gynecologic Oncology population undergoing a laparotomy at a Canadian tertiary care center.

MATERIAL AND METHODS

Prospectively collected data, using the American College of Surgeons' National Surgical Quality Improvement Program dataset (ACS NSQIP), was used to compare 30-day postoperative outcomes of gynecologic oncology patients undergoing a laparotomy before and after the 2018 implementation of an ERAS program in a Canadian regional cancer center. Patient demographics, surgical variables and postoperative outcomes of 187 patients undergoing surgery in 2019 were compared with those of 441 patients undergoing surgery between January 2016 and December 2017. Student's t, Mann-Whitney U and Chi-square tests, as well as multivariate linear and logistic regressions were used to evaluate baseline characteristics and 30-day postoperative complications.

RESULTS

Length of stay was significantly shortened in the study population after introducing the ERAS protocol, from a mean of 4.7 (SD = 3.8) days to a mean of 3.8 (SD = 3.2) days (P = .0001). The overall complication rate decreased from 24.3% to 16% (P = .02). Significant decreases in the rates of postoperative infections (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.31-0.99) and cardiovascular complications (adjusted OR 0.27, 95% CI 0.09-0.79) were noted, without a significant increase in readmission rate (adjusted OR 0.50, 95% CI 0.21-1.07).

CONCLUSIONS

Introducing an ERAS program for gynecologic oncology patients undergoing laparotomy was effective in shortening length of stay and the overall complication rate without a significant increase in readmission. Advocacy for broader implementation of ERAS among gynecologic oncology services and ongoing discussion on challenges and opportunities in the implementation process are warranted to improve patient outcomes and experiences.

Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections

BACKGROUND

Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery.

METHODS

This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS.

RESULTS

A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R).

CONCLUSION

ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.

Feasibility of Enhanced Recovery in Emergency Colorectal Operation

BACKGROUND

Emergency colorectal operations account for considerable surgical morbidity, leading to increased recognition of the importance of standardized care. Enhanced recovery pathways (ERPs) have successfully provided a framework to standardize elective surgical care, with some ERP elements spreading to emergency procedures. This study aims to characterize the degree of spread and demonstrate feasibility of ERP extension to emergency colorectal operations.

STUDY DESIGN

Patients undergoing colorectal operations were identified from a national ERP collaborative. Adherence to ERP process measures-multimodal pain control, early Foley removal, postoperative venous thromboembolism prophylaxis, early mobilization, early feeding, and 30-day clinical outcomes-was analyzed. Multivariable logistic regression was used to evaluate association between process measure adherence and 30-day clinical outcomes.

RESULTS

A total of 31,511 patients underwent colorectal operations at 235 hospitals; 3,086 were emergencies and 28,425 were elective. For emergency cases, rates of early Foley removal (92.0%) and venous thromboembolism prophylaxis (75.7%) were highest. Rates of multimodal pain control (55.9%), early mobilization (37.1%), and early liquid intake (33.4%) were modest. Nonadherence was more common in patients younger than 65 years (43.4%), with independent functional status (94%), American Society of Anesthesiologists Physical Status Classification 1 to 3 (62.5%), and without physiologic derangement (39.9%). Lack of mobilization or liquid intake was independently associated with increased odds of ileus (odds ratio [OR] 1.43; 95% CI, 1.18 to 1.75 and OR 2.41; 95% CI, 1.96 to 2.95) and prolonged length of stay (OR 2.29; 95% CI, 1.85 to 2.83 and OR 2.05; 95% CI, 1.70 to 2.47).

CONCLUSIONS

Although the unplanned nature of emergency colorectal operations historically excluded patients from ERPs, our findings suggest ERPs have observable diffusion beyond elective surgical procedures. Deliberate implementation with adherence auditing can improve ERP uptake and outcomes in emergency colorectal operations.

Preoperative opioid, sedative, and antidepressant use is associated with increased postoperative hospital costs in colorectal surgery

Background

Opioid (OPD), sedative (SDT), and antidepressant (ADM) prescribing has increased dramatically over the last 20 years. This study evaluated preoperative OPD, SDT, and ADM use on hospital costs in patients undergoing colorectal resection at a single institution.

Methods

This study was a retrospective record review. The local ACS-NSQIP database was queried for adult patients (age ≥ 18 years) undergoing open/laparoscopic, partial/total colectomy, or proctectomy from January 1, 2013 to December 31, 2016. Individual patient medical records were reviewed to determine preoperative OPD, SDT, and AD use. Hospital cost data from index admission were captured by the hospital cost accounting system and matched to NSQIP query-identified cases. All ACS-NSQIP categorical patient characteristic, operative risk, and outcome variables were compared in medication groups using chi-square tests or Fisher’s exact tests, and continuous variables were compared using Mann–Whitney U tests.

Results

A total of 1185 colorectal procedures were performed by 30 different surgeons. Of these, 27.6% patients took OPD, 18.5% SDT, and 27.8% ADM preoperatively. Patients taking OPD, SDT, and ADM were found to have increased mean total hospital costs (MTHC) compared to non-users (30.8 vs 23.6 for OPD, 31.6 vs 24.4 for SDT, and 30.7 vs 23.8 for ADM). OPD and SDT use were identified as independent risk factors for increased MTHC on multivariable analysis.

Conclusion

Preoperative OPD and SDT use can be used to predict increased MTHC in patients undergoing colorectal resections.

Validation of an enhanced recovery after surgery protocol in gynecologic surgery: an Italian randomized study

BACKGROUND

The enhanced recovery after surgery concept, which was introduced 20 years ago, is based on a multimodal approach to improve the functional rehabilitation of patients after surgery.

OBJECTIVE

This study aimed to validate an enhanced recovery after surgery protocol in gynecologic surgery for both benign and malignant diseases (endometrial cancer and advanced ovarian cancer) and to measure the adherence to the enhanced recovery after surgery protocol items in a randomized trial setting.

STUDY DESIGN

In this trial (NCT03347409), we randomly assigned patients to undergo standard perioperative care or enhanced recovery after surgery protocol. The primary outcome is a shorter length of stay in favor of the enhanced recovery after surgery protocol. Secondary outcomes include measurement of adherence to the enhanced recovery after surgery protocol items: comparison of postoperative pain, vomiting, and nausea; anesthesiologic and surgical complications up to 30 days after surgery; rate of readmissions; the time to event in hours for bowel movements, flatus, drinking, hunger, eating, and walking; and the quality of recovery using a validated questionnaire (QoR-15). Finally, we explored the length of stay in the prespecified subgroups at randomization, based on the type of surgical access and gynecologic disease.

RESULTS

A total of 168 women were available for analysis: 85 women (50.6%) were assigned to the standard perioperative care group, and 83 women (49.4%) were assigned to the enhanced recovery after surgery protocol group. The 2 groups were similar for age, body mass index, comorbidities, anesthesiological risk, smoking habits, surgical access, and complexity of surgical procedures. Seventy-two patients (42.9%) underwent surgery for benign disease, 48 (28.6%) for endometrial cancer, and 48 (28.6%) for ovarian cancer. Women in the enhanced recovery after surgery protocol group had a shorter length of stay (median: 2 [interquartile range, 2-3] vs 4 [interquartile range, 4-7] days; P<.001). A decreased rate of postoperative complications was noted for the enhanced recovery after surgery protocol group, as well as an earlier time to occur for all the events. Mean adherence to protocol items was 84.8% (95% confidence interval, 79.7-89.8), and we registered a better satisfaction in the enhanced recovery after surgery protocol group. The shortening of the length of stay was confirmed also in the prespecified subgroup analysis.

CONCLUSION

Application of the enhanced recovery after surgery protocol in gynecologic surgery translated to a shorter length of stay regardless of surgical access and type of gynecologic disease. Adherence to the enhanced recovery after surgery protocol items in the setting of a randomized trial was high.

A baseline assessment of enhanced recovery protocol implementation at pediatric surgery practices performing inflammatory bowel disease operations

BACKGROUND

Enhanced recovery protocols (ERPs) have been used to improve patient outcomes and resource utilization after surgery. These evidence-based interventions include patient education, standardized anesthesia protocols, and limited fasting, but their use among pediatric populations is lagging. We aimed to determine baseline recovery practices within pediatric surgery departments participating in an ERP implementation trial for elective inflammatory bowel disease (IBD) operations.

METHODS

To measure baseline ERP adherence, we administered a survey to a staff surgeon in each of the 18 participating sites. The survey assessed demographics of each department and utilization of 21 recovery elements during patient encounter phases. Mixed-methods analysis was used to evaluate predictors and barriers to ERP element implementation.

RESULTS

The assessment revealed an average of 6.3 ERP elements being practiced at each site. The most commonly practiced elements were using minimally invasive techniques (100%), avoiding intraabdominal drains (89%), and ileus prophylaxis (72%). The preoperative phase had the most elements with no adherence including patient education, optimizing medical comorbidities, and avoiding prolonged fasting. There was no association with number of elements utilized and total number of surgeons in the department, annual IBD surgery volume, and hospital size. Lack of buy-in from colleagues, electronic medical record adaptation, and resources for data collection and analysis were identified barriers.

CONCLUSIONS

Higher intervention utilization for IBD surgery was associated with elements surgeons directly control such as use of laparoscopy and avoiding drains. Elements requiring system-level changes had lower use. The study characterizes the scope of ERP utilization and the need for effective tools to improve adoption.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Mixed-methods survey.

IMPROVED OUTCOMES WITH IMPLEMENTATION OF AN ENHANCED RECOVERY AFTER SURGERY (ERAS) PATHWAY FOR PATIENTS UNDERGOING ELECTIVE COLORECTAL SURGERY IN THE PHILIPPINES

Objective

This study aims to evaluate surgical outcomes (i.e. length of stay, 30-day morbidity, mortality, reoperation, and readmission rates) with the use of the ERAS pathway, and determine its association with the rate of compliance to the different ERAS components.

Methodology

This was a prospective cohort of patients, who underwent the following elective procedures: stoma reversal (SR), colon resection (CR), and rectal resection (RR). The primary endpoint was to determine the association of compliance to an ERAS pathway and surgical outcomes. These were then compared to outcomes prior to the implementation of ERAS.

Results

A total of 267 patients were included in the study. The overall compliance to the ERAS component was 92% (SR:91.75%, CR:93.06%, RR:90.65%). There was an associated decrease in morbidity rates across all types of surgery, as compliance to ERAS increased. The average total LOS decreased in all groups but was only found to have statistical significance in SR (12.06 ± 6.67 vs 10.02 ± 5.43 days; p=0.002) and RR (19.85 ± 11.38 vs 16.85 ± 10.45 days; p=0.04) groups. Decreased postoperative LOS was noted in all groups. Morbidity rates were significantly higher after ERAS implementation, but reoperation and mortality rates were found to be similar.

Conclusion

Implementation of ERAS improved outcomes, particularly length of stay. Although an actual increase in morbidity was noted, that may be explained by the improved reporting and documentation that accompanied the implementation of the protocol, a decreased likelihood of developing complications is foreseen with increased compliance to ERAS.

Effectiveness and safety of the enhanced recovery program in colorectal surgery: overview of systematic reviews

Introduction: Multimodal enhanced recovery programs are a new paradigm in perioperative care. Objective: To evaluate the certainty of evidence pertaining to the effectiveness and safety of the multimodal perioperative care program in elective colorectal surgery. Data source: A search was conducted in the Medline, EMBASE, and Cochrane databases, up until February 2020. Eligibility criteria: Systematic reviews that take into account the perioperative multimodal program in patients with an indication for colorectal surgery were included. The primary outcomes were morbidity and postoperative deaths. The secondary outcome was hospital length of stay. Study quality and synthesis method: The reviews were evaluated with AMSTAR-2 and the certainty of the evidence with the GRADE methodology. The findings are presented with measures of frequency, risk estimators, or differences. Results: Six systematic reviews of clinical trials with medium and high quality in AMSTAR-2 were included. Morbidity was reduced between 16 and 48%. Studies are inconclusive regarding postoperative mortality. Hospital length of stay was reduced by an average of 2.5 days (p <0.05). The certainty of the body of evidence is very low. Limitations: The effect of the program, depending on the combination of elements, is not clear. Conclusions and implications: Despite the proven evidence that the program is effective in reducing global postoperative morbidity and hospital stay, the body of evidence is of very low quality. Consequently, results may change with new evidence and further research is required.

Perioperative Enteral Nutrition Improves Postoperative Recovery for Patients with Primary Liver Cancer: A Randomized Controlled Clinical Trial

OBJECTIVE

The role of perioperative protein-enriched enteral nutrition for patients with primary liver cancer is unclear. We investigated the efficacy of perioperative protein-enriched enteral nutrition for patients with primary liver cancer followed hepatectomy.

METHODS

Patients with primary liver cancer that underwent hepatectomy between January 2016 and 2018 were enrolled. Patients in the treatment group was given enteral nutrition (TP-MCT) in addition to the regular diet. The primary outcome measures were duration of hospital stay and length of postoperative hospital stay. Secondary outcome measures included time to first flatus and time to first defecation.

RESULTS

There was a significant reduction of time to first flatus and time to first defecation in the treatment group, when compared with the control group (time to first flatus: P = 0.001, time to first defecation: P < 0.001).

CONCLUSIONS

It is found that addition of protein-enriched enteral nutrition (TP-MCT) improved postoperative recovery for patients with primary liver cancer following hepatectomy, with a significant reduction in time to first flatus and time to first defecation.

The Effect of Chronic Preoperative Opioid Use on Surgical Site Infections, Length of Stay, and Readmissions

BACKGROUND

Chronic opioid use in the United States is a well-recognized public health concern with many negative downstream consequences. Few data exist regarding the use of preoperative opioids in relation to outcomes after elective colorectal surgery.

OBJECTIVE

The purpose of this study was to determine if chronic opioid use before colorectal surgery is associated with a detriment in postoperative outcomes.

DESIGN

This is a retrospective review of administrative data supplemented by individual chart review.

SETTING

This study was conducted in a single-institution, multisurgeon, community colorectal training practice.

PATIENTS

All patients undergoing elective colorectal surgery over a 3-year time frame (2011-2014) were selected.

MAIN OUTCOME MEASURES

Opioid use was stratified based on total dose of morphine milligram equivalents (naive, sporadic use (>0-15 mg/day), regular use (>15-45 mg/day), and frequent use (>45 mg/day)). Primary outcomes were surgical site infections, length of hospital stay, and readmissions.

RESULTS

Of the 923 patients, 23% (n = 213) were using opioids preoperatively. The preoperative opioid group contained more women (p = 0.047), underwent more open surgery (p = 0.003), had more nonmalignant indications (p = 0.013), and had a higher ASA classification (p = 0.003). Although median hospital stay was longer (4.7 days vs 4.0, p < 0.001), there was no difference in any surgical site infections (10.3% vs 7.1%, p = 0.123) or readmissions (14.2% vs 14.1%, p=0.954). Multivariable analysis identified preoperative opioid use (17.0% longer length of stay; 95% CI, 6.8%-28.2%) and ASA 3 or 4 (27.2% longer length of stay; 95% CI, 17.1-38.3) to be associated with an increase in length of stay.

LIMITATIONS

Retrospectively abstracted opioid use and small numbers limit the conclusions regarding any dose-related responses on outcomes.

CONCLUSIONS

Although preoperative opioid use was not associated with an increased rate of surgical site infections or readmissions, it was independently associated with an increased hospital length of stay. Innovative perioperative strategies will be necessary to eliminate these differences for patients on chronic opioids. See Video Abstract at http://links.lww.com/DCR/B280. EFECTOS DEL CONSUMO CRÓNICO DE OPIOIDES EN EL PREOPERATORIO CON RELACIÓN A LAS INFECCIONES DE LA HERIDA QUIRÚRGICA, LA DURACIÓN DE LA ESTADÍA Y LA READMISIÓN: El consumo crónico de opioides en los Estados Unidos es un problema de salud pública bien reconocido a causa de sus multiples consecuencias negativas ulteriores. Existen pocos datos sobre el consumo de opioides en el preoperatorio relacionado con los resultados consecuentes a una cirugía colorrectal electiva.El propósito es determinar si el consumo crónico de opioides antes de la cirugía colorrectal se asocia con un detrimento en los resultados postoperatorios.Revisión retrospectiva de datos administrativos complementada por la revisión de un gráfico individual.Ejercicio durante la formación de multiples residentes en cirugía colorrectal enTodos los pacientes de cirugía colorrectal electiva durante un período de 3 años (2011-2014).El uso de opioides se estratificó en función de la dosis total de equivalentes de miligramos de morfínicos (uso previo, uso esporádico [> 0-15 mg / día], uso regular (> 15-45 mg / día) y uso frecuente (> 45 mg / día)). Los resultados primarios fueron las infecciones de la herida quirúrgica, la duración de la estadía hospitalaria y la readmisión.De los 923 pacientes, el 23% (n = 213) consumían opioides antes de la operación. El grupo con opioides preoperatorios tenía más mujeres (p = 0.047), se sometió a una cirugía abierta (p = 0.003), tenía mas indicaciones no malignas (p = 0.013) y tenía una clasificación ASA más alta (p = 0.003). Aunque la mediana de la estadía hospitalaria fue más larga (4,7 días frente a 4,0; p <0,001), no hubo diferencia en ninguna infección de la herida quirúrgica (10,3% frente a 7,1%, p = 0,123) o las readmisiones (14,2% frente a 14,1%, p = 0,954). El análisis multivariable identificó que el uso de opioides preoperatorios (17.0% más larga LOS; IC 95%: 6.8%, 28.2%) y ASA 3 o 4 (27.2% más larga LOS; IC 95%: 17.1, 38.3) se asocia con un aumento en LOS.La evaluación retrospectiva poco precisa del consumo de opioides y el pequeño número de casos limitan las conclusiones sobre cualquier respuesta relacionada con la dosis - resultado.Si bien el consumo de opioides preoperatorios no se asoció con un aumento en la tasa de infecciones de la herida quirúrgica o las readmisiones, ella se asoció de forma independiente con un aumento de la LOS hospitalaria. Serán necesarias estrategias perioperatorias innovadoras para eliminar estas diferencias en los pacientes consumidores cronicos de opioides. Consulte Video Resumen en http://links.lww.com/DCR/B280.

Adapted ERAS Pathway Versus Standard Care in Patients Undergoing Emergency Small Bowel Surgery: a Randomized Controlled Trial

BACKGROUND

Emergency laparotomy for small bowel pathologies comprises a significant number of all emergency surgeries. Application of evidence-based adapted enhanced recovery after surgery (ERAS) protocol can potentially improve the perioperative outcome in these procedures.

AIMS

To determine the feasibility, safety, and efficacy of adapted ERAS pathway in emergency small bowel surgery.

METHODOLOGY

This was a single-center, prospective, open-labeled, superiority, randomized controlled trial. Patients suspected to have small bowel pathology by the emergency surgical team were randomized preoperatively into standard care and adapted ERAS group. Patients with American Society of Anesthesiologist class ≥ 3, polytrauma patients with associated other intra-abdominal organ injuries, duodenal ulcer perforations, patients presenting with refractory shock, and pregnant patients were excluded. Primary outcome parameter was the length of hospitalization (LOH). Morbidity and other functional recovery parameters were also assessed.

RESULTS

Thirty-five patients were included in the adapted ERAS and standard care group. The laboratory and demographic variables were comparable. Patients in the ERAS group had significantly earlier recovery (days) in terms of first fluid diet (1.48 ± 0.18, p < 0.001), solid diet (2.11 ± 0.17, p < 0.001), time to first flatus (1.25 ± 0.24, p < 0.001), and first stool (1.8 ± 0.27, p < 0.001). Postoperative nausea, vomiting (RR 0.69, p = 0.19), pulmonary complications (RR 0.38, p = 0.16), superficial (RR 0.79, p = 0.33), and deep surgical site infections (RR 0.65, p = 0.39) were similar. Compared with the standard care group, ERAS group had significantly shorter LOH (8 ± 0.38 vs. 10.83 ± 0.42; Mean difference, 2.83 ± 0.56; p < 0.001).

CONCLUSION

Adapted ERAS pathways are feasible, safe, and significantly reduces the LOH in select patients undergoing emergency small bowel surgery.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management.

METHODS

The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

RESULTS

Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma.

CONCLUSION

The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced Recovery After Surgery (ERAS®) Society Recommendations - Part II: Postoperative management and special considerations

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations.

METHODS

The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

RESULTS

Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma.

CONCLUSION

The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.

How to Start an Enhanced Recovery After Surgery Cardiac Program

In this review the authors introduce a practical approach to guide the initiation of an enhanced recovery after surgery (ERAS) cardiac surgery program. The first step in implementation is organizing a dedicated multidisciplinary ERAS cardiac team composed of representatives from nursing, surgery, anesthesiology, and other relevant allied health groups. Identifying a program coordinator or navigator who will have responsibilities for developing and implementing educational initiatives, troubleshooting, monitoring progress and setbacks, and data collection is also vital for success. An institution-specific protocol is then developed by leveraging national guidelines and local expertise.

Failure in Systems and Culture: Barriers That Prevent Implementation of Evidence-Based Fasting Times for Patients in the Acute Care Setting

BACKGROUND

There is strong evidence supporting fasting guidelines of 6 hours' fast from solids and 2 hours' fast from fluids prior to surgery. Despite this, patients spend prolonged periods of time fasting for surgery with a lack of research to support translating this evidence into practice, particularly for emergency surgical theater lists. This study aims to explore barriers and enablers to reduce prolonged fasting for patients on emergency surgical lists in the acute care setting.

METHODS

Qualitative interviews were undertaken with 22 health professionals on acute surgical wards within a quaternary referral hospital in Sydney, Australia. Semistructured interviews explored barriers and enablers to implementing evidence-based fasting practices for patients on emergency surgical lists, using a theoretical domains framework. Interviews were transcribed verbatim and analyzed using an inductive thematic approach.

RESULTS

Key barriers to implementing reduced fasting included unpredictable, inflexible systems; cultural concerns; and gaps in knowledge. Major enablers to reducing fasting times are the recognition of patient distress caused by excessive fasting and desire by all 22 interviewees to address the problem.

CONCLUSIONS

This research is the first to explore barriers and enablers to implementing interventions to address excessive fasting. This research highlights the complexity of the issue and the need for a multifaceted translational intervention addressing limitations in systems and cultural barriers.

Readmissions Within 48 Hours of Discharge: Reasons, Risk Factors, and Potential Improvements

BACKGROUND

Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs.

OBJECTIVE

This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge.

DESIGN

This is a retrospective cohort study.

SETTINGS

This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway.

PATIENTS

Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included.

MAIN OUTCOME MEASURES

Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions.

RESULTS

In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours.

LIMITATIONS

Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study.

CONCLUSIONS

Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237.

Management Considerations for the Surgical Treatment of Colorectal Cancer During the Global Covid-19 Pandemic

OBJECTIVE

The COVID-19 pandemic requires to conscientiously weigh "timely surgical intervention" for colorectal cancer against efforts to conserve hospital resources and protect patients and health care providers.

SUMMARY BACKGROUND DATA

Professional societies provided ad-hoc guidance at the outset of the COVID-19 pandemic on deferral of surgical and perioperative interventions, but these lack specific parameters to determine the optimal timing of surgery.

METHODS

Using the GRADE system, published evidence was analyzed to generate weighted statements for stage, site, acuity of presentation, and hospital setting to specify when surgery should be pursued, the time and duration of oncologically acceptable delays, and when to utilize nonsurgical modalities to bridge the waiting period.

RESULTS

Colorectal cancer surgeries-prioritized as emergency, urgent with imminent emergency or oncologically urgent, or elective-were matched against the phases of the pandemic. Surgery in COVID-19-positive patients must be avoided. Emergent and imminent emergent cases should mostly proceed unless resources are exhausted. Standard practices allow for postponement of elective cases and deferral to nonsurgical modalities of stage II/III rectal and metastatic colorectal cancer. Oncologically urgent cases may be delayed for 6(-12) weeks without jeopardizing oncological outcomes. Outside established principles, administration of nonsurgical modalities is not justified and increases the vulnerability of patients.

CONCLUSIONS

The COVID-19 pandemic has stressed already limited health care resources and forced rationing, triage, and prioritization of care in general, specifically of surgical interventions. Established guidelines allow for modifications of optimal timing and type of surgery for colorectal cancer during an unrelated pandemic.

Comprehensive literature review of randomized clinical trials examining novel treatment advances in patients with colon cancer

The treatment of colon cancer has had numerous recent advances, in terms of surgical approach, adjuvant therapies, and more. In this review, the authors examine randomized clinical trials comparing open surgery to laparoscopic surgery (including total mesocolic excision), and also examine the role of robotic surgery. Novel surgical techniques including the no-touch technique, side-to-side anastomosis, suture technique, complete mesocolic excision (CME) with central vascular ligation (CVL), and natural orifice transluminal endoscopic surgery (NOTES) are outlined. The role of placing endoscopic self-expandable metal stents (SEMS) for colonic obstruction is compared and contrasted with the surgical approach, and the effect that the anti-VEGF inhibitor bevacizumab may have on this side effect profile is further explored. The role of the resection of the primary tumor in the setting of metastatic disease is examined with respect to survival benefit. Pathways of perioperative care which can accelerate post-surgical recovery, including enhanced recovery after surgery (ERAS) are examined. The role of adjuvant chemotherapy in patients with high-risk stage II and patients with stage III disease is examined, along with the role on circulating tumor DNA (ctDNA) as well as with the biologic targeted agents cetuximab and bevacizumab. Lastly, the authors detail the postoperative surveillance schedules after surgical resection with respect to survival outcomes.

Impact of intraoperative zero-balance fluid therapy on the occurrence of acute kidney injury in patients who had undergone colorectal cancer resection within an enhanced recovery after surgery protocol: a propensity score matching analysis

PURPOSE

An enhanced recovery after surgery (ERAS) protocol for colorectal cancer resection encourages perioperative euvolemic status, and zero-balance fluid therapy is recommended for low-risk patients. Recently, several studies have reported concerns of increased acute kidney injury (AKI) in patients within an ERAS protocol. In the present study, we investigated the impact of intraoperative zero-balance fluid therapy within an ERAS protocol on postoperative AKI.

METHODS

Patients who underwent elective surgery for primary colorectal cancer were divided into zero-balance and non-zero-balance fluid therapy groups according to intraoperative fluid amount and balance. After propensity score (PS) matching, 210 patients from each group were selected. Incidences of AKI were compared between the two groups according to the Kidney Disease Improving Global Outcomes criteria. Postoperative kidney functions and surgical outcomes were also compared.

RESULTS

AKI was significantly higher in the zero-balance fluid therapy group compared to the non-zero-balance fluid therapy group (21.4% vs. 13.8%, p = 0.040) in PS-matched patients. The decrease in the estimated glomerular filtration rate on the day of surgery was significantly higher in the zero-balance fluid therapy group (- 5.9 mL/min/1.73 m² vs. - 1.4 mL/min/1.73 m², p = 0.005). There were no differences in general morbidity or mortality rate, although surgery-related complications were more common in the zero-balance group.

CONCLUSIONS

Despite the proven benefits of zero-balance fluid therapy in colorectal ERAS protocols, care should be taken to monitor for postoperative AKI. Further studies regarding the clinical significance of postoperative AKI occurrence and optimised intraoperative fluid therapy are needed in a colorectal ERAS setting.

Management of postoperative nausea and vomiting in the context of an Enhanced Recovery after Surgery program

The concept of Enhanced Recovery after Surgery (ERAS) emerged at the turn of the millennium and quickly gained footing worldwide leading to the establishment of institutional ERAS protocols and subspecialty guidelines. While the use of postoperative nausea and vomiting (PONV) prophylaxis predates ERAS by a significant extent, the emergence of ERAS amplified the importance of antiemetic prophylaxis in perioperative care and drew attention to the truly multifactorial nature of postoperative gastrointestinal dysfunction. The following discussion will review key paradigms behind PONV prophylaxis and ERAS, highlight the interrelationship between these two endeavors, and then explore subspecialty ERAS guidelines that uniquely influence PONV prophylaxis. Attention will center on the ERAS Society guidelines (ESGs) as the primary representative of current ERAS practice, though many deviations from the guidelines exist within the literature and institutional practices.

Network meta-analysis of local and regional analgesia following colorectal resection

BACKGROUND

Postoperative pain management after colorectal surgery remains challenging. Systemic opiates delivered on demand or via a patient-controlled pump have traditionally been the mainstay of treatment. Opiate analgesia is associated with slower gastrointestinal recovery and unpleasant side-effects; many regional and local analgesic techniques have been developed as alternatives.

METHODS

MEDLINE, Embase and CENTRAL databases were searched systematically for RCTs comparing analgesic techniques after major colorectal resection. A network meta-analysis was performed using a Bayesian random-effects framework with a non-informative prior. Primary outcomes included pain at rest and cumulative opiate consumption 24 h after surgery. Secondary outcomes included pain at rest and cumulative opiate consumption at 48 h, pain on movement and cough at 24 and 48 h, time to first stool, time to tolerance of oral diet, duration of hospital stay, nausea and vomiting, and postoperative complications.

RESULTS

Seventy-four RCTs, including 5101 patients and 11 different techniques, were included. Some inconsistency and heterogeneity was found. SUCRA scores showed that spinal analgesia was the best intervention for postoperative pain and opiate reduction at 24 h. Transversus abdominus plane blocks were effective in reducing pain and opiate consumption 24 h after surgery. Subgroup analysis showed similar results for open versus minimally invasive surgical approaches, and enhanced recovery after surgery programmes.

CONCLUSION

Spinal analgesia and transversus abdominus plane blocks best balanced pain control and opiate minimization in the immediate postoperative phase following colorectal resection. Multimodal analgesia reduces pain, minimizes systemic opiate use and optimizes postoperative recovery.

Enhanced recovery after surgery on multiple clinical outcomes: Umbrella review of systematic reviews and meta-analyses

BACKGROUND

Previously, many meta-analyses have reported the impact of enhanced recovery after surgery (ERAS) programs on many surgical specialties.

OBJECTIVES

To systematically assess the effects of ERAS pathways on multiple clinical outcomes in surgery.

DESIGN

An umbrella review of meta-analyses.

DATE SOURCES

PubMed, Embase, Web of Science and the Cochrane Library.

RESULTS

The umbrella review identified 23 meta-analyses of interventional study and observational study. Consistent and robust evidence shown that the ERAS programs can significantly reduce the length of hospital stay (MD: -2.349 days; 95%CI: -2.740 to -1.958) and costs (MD: -$639.064; 95%CI:: -933.850 to -344.278) in all the surgery patients included in the review compared with traditional perioperative care. The ERAS programs would not increase mortality in all surgeries and can even reduce 30-days mortality rate (OR: 0.40; 95%CI: 0.23 to 0.67) in orthopedic surgery. Meanwhile, it also would not increase morbidity except laparoscopic gastric cancer surgery (RR: 1.49; 95%CI: 1.04 to 2.13). Moreover, readmission rate was increased in open gastric cancer surgery (RR: 1.92; 95%CI: 1.00 to 3.67).

CONCLUSION

The ERAS programs are considered to be safe and efficient in surgery patients. However, precaution is necessary for gastric cancer surgery.

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

Importance

Enhanced Recovery After Surgery (ERAS) care has been reported to be associated with improvements in outcomes after colorectal surgery compared with traditional care.

Objective

To determine the association between ERAS protocols and outcomes in patients undergoing elective colorectal surgery.

Design, Setting, and Participants

The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study is a multicenter, prospective cohort study of 2084 consecutive adults scheduled for elective colorectal surgery who received or did not receive care in a self-declared ERAS center. Patients were recruited from 80 Spanish centers between September 15 and December 15, 2017. All patients included in this analysis had 1 month of follow-up.

Exposures

Colorectal surgery and perioperative management were the exposures. Twenty-two individual ERAS items were assessed in all patients, regardless of whether they were included in an established ERAS protocol.

Main Outcomes and Measures

The primary study outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS adherence, mortality, readmissions, reoperation rates, and hospital length of stay.

Results

Between September 15 and December 15, 2017, 2084 patients were included in the study. Of these, 1286 individuals (61.7%) were men; mean age was 68 years (interquartile range [IQR], 59-77). A total of 879 patients (42.2%) presented with postoperative complications and 566 patients (27.2%) developed moderate to severe complications. The number of patients with moderate or severe complications was lower in the ERAS group (25.2% vs 30.3%; odds ratio [OR], 0.77; 95% CI, 0.63-0.94; P = .01). The overall rate of adherence to the ERAS protocol was 63.6% (IQR, 54.5%-77.3%), and the rate for patients from hospitals self-declared as ERAS was 72.7% (IQR, 59.1%-81.8%) vs non-ERAS institutions, which was 59.1% (IQR, 50.0%-63.6%; P < .001). Adherence quartiles among patients receiving the highest and lowest ERAS components showed that the patients with the highest adherence rates had fewer moderate to severe complications (OR, 0.34; 95% CI, 0.25-0.46; P < .001), overall complications (OR, 0.33; 95% CI, 0.26-0.43; P < .001), and mortality (OR, 0.27; 95% CI, 0.07-0.97; P = .06) compared with those who had the lowest adherence rates.

Conclusions and Relevance

An increase in ERAS adherence appears to be associated with a decrease in postoperative complications.

Enhanced recovery after surgery pathway in patients with soft tissue sarcoma

BACKGROUND

Patients undergoing surgery for soft tissue sarcoma have high morbidity rates, particularly after preoperative radiation therapy (RT). An enhanced recovery after surgery (ERAS) programme may improve perioperative outcomes in abdominal surgery. This study reported outcomes of an ERAS programme tailored to patients with soft tissue sarcoma.

METHODS

A prospective ERAS protocol was implemented in 2015 at a high-volume sarcoma centre. Patients treated within the ERAS programme from 2015 to 2018 were case-matched retrospectively with patients treated between 2012 and 2018 without use of the protocol, matched by surgical site, surgeon, sarcoma histology and preoperative RT treatment. Postoperative outcomes, specifically wound complications and duration of hospital stay, were reported.

RESULTS

In total, 234 patients treated within the ERAS programme were matched with 237 who were not. The ERAS group had lower wound dehiscence rates overall (2 of 234 (0·9 per cent) versus 31 of 237 (13·1 per cent); P < 0·001), after preoperative RT (0 of 41 versus 11 of 51; P = 0·004) and after extremity sarcoma surgery (0 of 54 versus 6 of 56; P = 0·040) compared with the non-ERAS group. Rates of postoperative ileus or obstruction were lower in the ERAS group (21 of 234 (9·9 per cent) versus 40 of 237 (16·9 per cent); P = 0·016) and in those with retroperitoneal sarcoma (4 of 36 versus 15 of 36; P = 0·007). Duration of hospital stay was shorter in the ERAS group (median 5 (range 0-36) versus 6 (0-67) days; P = 0·003).

CONCLUSION

Treatment within an ERAS protocol for patients with soft tissue sarcoma was associated with lower morbidity and shorter hospital stay.

A Retrospective Review: Patient-Reported Preoperative Prescription Opioid, Sedative, or Antidepressant Use Is Associated with Worse Outcomes in Colorectal Surgery

BACKGROUND

Prescription opioid, sedative, and antidepressant use has been on the rise. The effect of these medications on outcomes in colorectal surgery has not been established.

OBJECTIVE

This study aimed to evaluate the impact of preoperative prescription opioid, sedative, and antidepressant use on postoperative outcomes following colorectal surgery.

DESIGN

This study was a retrospective database and medical record review.

SETTINGS

This study was conducted at University of Kentucky utilizing the local American College of Surgeons National Surgical Quality Improvement Project database.

PATIENTS

All patients ≥18 years of age who underwent colorectal resection for all indications, excluding trauma, between January 1, 2013, and December 31, 2016, were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the rates of 30-day postoperative morbidity and mortality.

RESULTS

Of 1201 patients, 30.2% used opioids, 18.4% used sedatives, and 28.3% used antidepressants preoperatively. Users of any medication class had higher ASA classification, rates of dyspnea, and severe chronic obstructive pulmonary disease than nonusers. Opioid users also had higher rates of ostomy creation, contaminated wound classification, prolonged operation time, and postoperative transfusion. Postoperatively, patients had higher rates of intra-abdominal infection (opioids: 21.5% vs 15.2%, p = 0.009; sedatives: 23.1% vs 15.7%, p = 0.01; antidepressants: 22.4% vs 15.0%, p = 0.003) and respiratory failure (opioids: 11.0% vs 6.3%, p = 0.007; sedatives: 12.2% vs 6.7%, p = 0.008; antidepressants: 10.9% vs 6.5%, p = 0.02). Reported opioid or sedative users had a prolonged hospital length of stay of 2 days (p < 0.001) compared with nonusers. After adjustment for all predictors of poor outcome, opioid and sedative use was associated with increased 30-day morbidity and mortality following colorectal procedures (OR, 1.43; 95% CI, 1.07-1.91 and OR, 1.48; 95% CI, 1.05-2.08).

LIMITATIONS

This study was a retrospective review and a single-institution study, and it had unmeasured confounders.

CONCLUSIONS

We identified that patient-reported prescription opioid and sedative use is associated with higher 30-day composite adverse outcomes in colorectal resections, highlighting the need for the evaluation of opioid and sedative use as a component of the preoperative risk stratification. See Video Abstract at http://links.lww.com/DCR/B226. REVISIÓN RETROSPECTIVA: EL USO DE OPIOIDES, SEDANTES O ANTIDEPRESORES EN EL PREOPERATORIO SE ASOCIAN CON MALOS RESULTADOS EN CIRUGÍA COLORECTAL: El uso de opioides, sedantes y antidepresores esta en aumento. No se ha establecido el efecto de estos medicamentos en los resultados de la cirugía colorrectal.Evaluar el impacto del uso preoperatorio de opioides, sedantes y antidepresores en los resultados después de una cirugía colorrectal.Base de datos retrospectiva y revisión de registros médicos.Este estudio se realizó en la Universidad de Kentucky utilizando la base de datos del Proyecto de Mejora de Calidad Quirúrgica Nacional del Colegio Estadounidense de Cirujanos.Todos los pacientes ≥ 18 años que se sometieron a una resección colorrectal por diversas indicaciones, excluyendo los traumas, entre el 1 de Enero de 2013 y el 31 de Diciembre de 2016.Tasas de morbilidad y mortalidad postoperatorias a los 30 días.De 1201 pacientes, 30.2% usaron opioides, 18.4% usaron sedantes y 28.3% usaron antidepresores antes de la cirugía. Los pacientes tratados con cualquiera de los medicamentos mencionados, presentaban un ASA mas elevado, tasas de disnea y EPOC mas graves en comparación con pacientes sin tratamiento previo. Los consumidores de opioides también tuvieron tasas más altas de creación de ostomías, clasificación mas alta de heridas contaminadas, un tiempo de operación prolongado y transfusión postoperatoria mayor. Después de la cirugía los pacientes que tuvieron tasas más altas de infección intraabdominal (opioides: 21.5% vs 15.2%, p = 0.009, sedantes: 23.1% vs 15.7%, p = 0.01, antidepresivos: 22.4% vs 15.0%, p = 0.003) e insuficiencia respiratoria (opioides: 11.0% vs 6.3%, p = 0.007, sedantes: 12.2% vs 6.7%, p = 0.008, antidepresivos: 10.9% vs 6.5%, p = 0.02). Los consumidores de opioides o sedantes tuvieron una estadía hospitalaria prolongada de más de 2 días (p <0.001) en comparación con los consumidores. Después de haber realizado el ajuste de todos los predictores de mal pronóstico, el uso de opioides y sedantes se asoció con una mayor morbilidad y mortalidad a los 30 días después de cirugía colorrectal (OR 1.43 [IC 95% 1.07-1.91] y OR 1.48 [IC 95% 1.05-2.08], respectivamente)Revisión retrospectiva, estudio de una sola institución, factores de confusión no evaluados.Identificamos que el consumo de opiáceos y sedantes recetados a los pacientes se asocian con resultados adversos complejos más allá de 30 días en casos de resección colorrectal, destacando la necesidad de su respectiva evaluación como componentes de la estratificación de riesgo preoperatorio. Consulte Video Resumen http://links.lww.com/DCR/B226. (Traducción-Dr. Xavier Delgadillo).

Enhanced Recovery after Surgery Protocols Decrease Outpatient Opioid Use in Patients Undergoing Abdominally Based Microsurgical Breast Reconstruction

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols have known benefits in the inpatient setting, but little is known about their impact in the subsequent outpatient setting. On discharge, multimodal analgesia has been discontinued, nerve blocks and pain pumps have worn off, and patients enter a substantially different physical environment, potentially resulting in a rebound effect. The objective of this study was to investigate the effect of ERAS protocol implementation on outpatient opioid use and recovery.

METHODS

Patients who underwent abdominally based microsurgical breast reconstruction before and after ERAS implementation were reviewed retrospectively. Ohio state law mandates that no more than 7 days of opioids may be prescribed at a time, with the details of all prescriptions recorded in a statewide reporting system, from which opioid use was determined.

RESULTS

A total of 105 patients met inclusion criteria, of which 46 (44 percent) were in the pre-ERAS group and 59 (56 percent) were in the ERAS group. Total outpatient morphine milligram equivalents used in the ERAS group were less than in the pre-ERAS group (337.5 morphine milligram equivalents versus 668.8 morphine milligram equivalents, respectively; p =0.016). This difference was specifically significant at postoperative week 1 (p =0.044), with gradual convergence over subsequent weeks. Although opioid use was significantly less in the ERAS group, pain scores in the ERAS group were comparable to those in the pre-ERAS group.

CONCLUSIONS

The benefits of ERAS protocols appear to extend into the outpatient setting, further supporting their use to facilitate recovery, and highlighting their potential role in helping to address the prescription opioid abuse problem.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Colorectal Surgical Site Infection Prevention Kits Prior to Elective Colectomy Improve Outcomes

INTRODUCTION

Patient compliance with preoperative mechanical and antibiotic bowel preparation, skin washes, carbohydrate loading, and avoidance of fasting are key components of successful colorectal ERAS and surgical site infection (SSI)-reduction programs. In July 2016, we began a quality improvement project distributing a free SSI Prevention Kit (SSIPK) containing patient instructions, mechanical and oral bowel preparation, chlorhexidine washes, and carbohydrate drink to all patients scheduled for elective colectomy, with the goal of improving patient compliance and rates of SSI.

METHODS

This was a prospective data audit of our first 221 SSIPK+ patients, who were compared to historical controls (SSIPK-) of 1760 patients undergoing elective colectomy from January 2013 to March 2017. A 1:1 propensity score system accounted for nonrandom treatment assignment. Matched patients' complications, particularly postoperative infection and ileus, were compared.

RESULTS

SSIPK+ (n = 219) and SSIPK- (n = 219) matched patients were statistically identical on demographics, comorbidities, BMI, surgical indication, and procedure. SSIPK+ patients had higher compliance with mechanical (95% vs 71%, P < 0.001) and oral antibiotic (94% vs 27%, P < 0.001) bowel preparation. This translated into lower overall SSI rates (5.9% vs 11.4%, P = 0.04). SSIPK+ patients also had lower rates of anastomotic leak (2.7% vs 6.8%, P = 0.04), prolonged postoperative ileus (5.9% vs 14.2%, P < 0.01), and unplanned intubation (0% vs 2.3%, P = 0.02). Furthermore, SSIPK+ patients had shorter mean hospital length of stay (3.1 vs 5.4 d, P < 0.01) and had fewer unplanned readmissions (5.9% vs 14.6%, P < 0.001). There were no differences in rates of postoperative pneumonia, urinary tract infection, Clostridium difficile colitis, sepsis, or death.

CONCLUSION

Provision of a free-of-charge SSIPK is associated with higher patient compliance with preoperative instructions and significantly lower rates of surgical site infections, lower rates of prolonged postoperative ileus, and shorter hospital stays with fewer readmissions. Widespread utilization of such a bundle could therefore lead to significantly improved outcomes.

Expanded Analysis of a Modified Enhanced Recovery Protocol in Cleft Palatoplasty

OBJECTIVE

We have previously shown the efficacy of an enhanced recovery after surgery (ERAS) protocol in pediatric cleft palatoplasty for proof of concept (POC). We sought to validate the efficacy of ERAS when expanded to patients of variable age and complexity undergoing primary palatoplasty.

MAIN OUTCOME MEASURE(S)

Between April 2017 and December 2018, 100 patients were collected prospectively for the expanded assessment (ERAS₂) and POC (ERAS₁) and compared to historical controls both independently and in aggregate (ERAS_(T)). We compared patient demographics, perioperative narcotic administration, length of stay (LOS), and rates of return to service (RTS).

RESULTS

Despite increased complexity, total narcotic usage (morphine equivalents normalized per weight) during each phase of care was significantly greater in controls when compared to ERAS₁, ERAS₂, or ERAS_T, respectively (intraoperative: 0.44 mg/kg vs 0.013 mg/kg vs 0.016 mg/kg vs 0.014 mg/kg; postanesthesia care unit: 0.061 mg/kg vs 0.006 mg/kg vs 0.007 mg/kg vs 0.007 mg/kg; postoperative: 0.389 mg/kg vs 0.009 mg/kg vs 0.026 mg/kg vs 0.017 mg/kg). ERAS₁ and ERAS₂ groups each demonstrated a decrease in LOS (-36.6%, -26.3%) when compared to controls. Overall, application of ERAS led to a 95.7% reduction in narcotic administration and a 31.7% decrease in LOS when compared to controls. The incidence of RTS was higher in ERAS₂ (13.0%) when compared to ERAS₁ (2.1%) or controls (2.4%), with the strongest independent predictor being a positive perioperative respiratory viral panel (PRVP).

CONCLUSIONS

Application of ERAS to palatoplasty patients of advanced age and complexity evidenced consistency with respect to decreased perioperative narcotic administration and shortened LOS. A positive PRVP was found to be an independent predictor of RTS even when ERAS was applied.

Using a Mobile Application for Real-Time Collection of Patient-Reported Outcomes in Hepatopancreatobiliary Surgery within an ERAS® Pathway

Patient-reported outcomes (PROs) are essential for patient-centered health care. This pilot study implemented a mobile application customized to an hepatopancreatobiliary Enhanced Recovery After Surgery (ERAS®) program—a novel environment—for real-time collection of PROs, including ERAS® pathway compliance. Patients undergoing hepatectomy, distal pancreatectomy, or pancreaticoduodenectomy through the ERAS® program were prospectively enrolled over 10 months. The application provided education and questionnaires before surgery through 30 days postdischarge. Thresholds were set for initial adoption of the application (75%), PRO response rate (50%), and patient satisfaction (75%). Daily postdischarge health checks integrated customized responses to guide out-of-hospital care. Of 165 enrolled patients, 122 met inclusion criteria. Application adoption was 93 per cent (114/122) and in-hospital engagement remained high at 88 per cent (107/122). Patients completed 62 per cent of PRO on quality of life, postoperative pain, nausea, opioid consumption, and compliance to ERAS® pathway items, including ambulation and breathing exercises. During postcharge tracking, 12 patients reported that the application prevented a phone call to the hospital and three patients reported prevention of an emergency room visit. PRO collection through this mobile device created an integrated platform for comprehensive perioperative care, patient-initiated outcome tracking with automatic reporting, and real-time feedback for process change. Improving proactive outpatient management of complex patients through mobile technology could help restructure health-care delivery and improve resource utilization for all patients.

ERAS for Head and Neck Tissue Transfer Reduces Opioid Usage, Peak Pain Scores, and Blood Utilization

OBJECTIVES

We implement a novel enhanced recovery after surgery (ERAS) protocol with pre-operative non-opioid loading, total intravenous anesthesia, multimodal peri-operative analgesia, and restricted red blood cell (pRBC) transfusions. 1) Compare differences in mean postoperative peak pain scores, opioid usage, and pRBC transfusions. 2) Examine changes in overall length of stay (LOS), intensive care unit LOS, complications, and 30-day readmissions.

METHODS

Retrospective cohort study comparing 132 ERAS vs. 66 non-ERAS patients after HNC tissue transfer reconstruction. Data was collected in a double-blind fashion by two teams.

RESULTS

Mean postoperative peak pain scores were lower in the ERAS group up to postoperative day (POD) 2. POD0: 4.6 ± 3.6 vs. 6.5 ± 3.5; P = .004) (POD1: 5.2 ± 3.5 vs. 7.3 ± 2.3; P = .002) (POD2: 4.1 ± 3.5 vs. 6.6 ± 2.8; P = .000). Opioid utilization, converted into morphine milligram equivalents, was decreased in the ERAS group (POD0: 6.0 ± 9.8 vs. 10.3 ± 10.8; P = .010) (POD1: 14.1 ± 22.1 vs. 34.2 ± 23.2; P = .000) (POD2: 11.4 ± 19.7 vs. 37.6 ± 31.7; P = .000) (POD3: 13.7 ± 20.5 vs. 37.9 ± 42.3; P = .000) (POD4: 11.7 ± 17.9 vs. 36.2 ± 39.2; P = .000) (POD5: 10.3 ± 17.9 vs. 35.4 ± 45.6; P = .000). Mean pRBC transfusion rate was lower in ERAS patients (2.1 vs. 3.1 units, P = .017). There were no differences between ERAS and non-ERAS patients in hospital LOS, ICU LOS, complication rates, and 30-day readmissions.

CONCLUSION

Our ERAS pathway reduced postoperative pain, opioid usage, and pRBC transfusions after HNC reconstruction. These benefits were obtained without an increase in hospital or ICU LOS, complications, or readmission rates.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E792-E799, 2021.