Influences on length of stay in an enhanced recovery programme after colonic surgery (original) (raw)
Related papers
Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery?
Medical Oncology, 2016
There is evidence that implementation of enhanced recovery after surgery (ERAS) protocols into colorectal surgery reduces complication rate and improves postoperative recovery. However, most published papers on ERAS outcomes and length of stay in hospital (LOS) include patients undergoing open resections. The aim of this pilot study was to determine the factors affecting recovery and LOS in patients after laparoscopic colorectal surgery for cancer combined with ERAS protocol. One hundred and forty-three consecutive patients undergoing elective laparoscopic resection were prospectively evaluated. They were divided into two subgroups depending on their reaching the targeted length of stay-LOS (75 patients in group 1-B4 days, 68 patients in group 2-[4 days). A univariate and multivariate logistic regression analysis was performed to assess for factors (demographics, perioperative parameters, complications and compliance with the ERAS protocol) independently associated with LOS of 4 days or longer. The median LOS in the entire group was 4 days. The postoperative complication rate was higher (18.7 vs. 36.7 %), and the compliance with ERAS protocol was lower (91.2 vs. 76.7 %) in group 2. There was an association between the pre-and postoperative compliance and the subsequent complications. In uni-and multivariate analysis, the lack of balanced fluid therapy (OR 3.87), lack of early mobilization (OR 20.74), prolonged urinary catheterization (OR 4.58) and use of drainage (OR 2.86) were significantly associated with prolonged LOS. Neither traditional patient risk factors nor the stage of the cancer was predictive of the duration of hospital stay. Instead, compliance with the ERAS protocol seems to influence recovery and LOS when applied to laparoscopic colorectal cancer surgery.
World Journal of Surgery, 2013
Background The present study aims to examine the feasibility and safety of a two-day hospital stay after laparoscopic colorectal resection (LCR) under an enhanced recovery after surgery (ERAS) pathway. Methods Between 2003 and 2010, 882 consecutive patients undergoing LCR were analyzed. Patients were grouped and analyzed according to whether their hospital stay was 2 days (group A) or longer (group B). Demographic, surgical, and postoperative data were compared. To identify independent predictive factors related to a short hospital stay, a multivariate analysis was also performed. Results Group A represented 10.3 % of this series (91 patients). There were no differences regarding age, gender, BMI, ASA, and previous abdominal surgeries between groups. Group A had a lower incidence of rectal cancer and anterior resections than group B (6.6 vs. 17.7 % [p = 0.006] and 14.3 vs. 23.4 % [p = 0.048]), respectively, and a lower mean operative time (170 min vs. 192 min; p = 0.002). Group A had a lower overall morbidity rate than group B (5.5 vs. 16.9 %; p = 0.004) and a lower incidence of surgery-related complications (5.5 vs. 14.9 %; p = 0.001). The overall conversion rate was 10 % (only one patient in group A required conversion), and the difference in conversion rate between groups was statistically significant (1.2 vs. 10.7 %; p = 0.003). Group A had a lower readmission rate (0 vs. 4.9 %; p = 0.089). Multivariate analysis showed that conversion, postoperative morbidity, and rectal prolapse were independently associated with the length of hospital stay. Conclusions A two-day hospital stay after LCR is safe and feasible under an ERAS pathway, without compromising the readmission or complication rate.
Surgical Endoscopy, 2016
Objective To perform a systematic review of published literature for the factors reported to predict outcomes of enhanced recovery after surgery (ERAS) programmes following laparoscopic colorectal surgery. Background ERAS programmes and the use of laparoscopy have been widely adopted in colorectal surgery bringing short-term patient benefit. However, there is a minority of patients that do not benefit from these strategies and their identification is not well characterised. The factors that underpin outcomes from ERAS programmes for laparoscopic patients are not understood. Methods A systematic search of the MEDLINE, Embase and Cochrane databases was conducted to identify suitable articles published between 2000 and 2015. The search strategy captured terms for ERAS, colorectal resection, prediction and outcome measures. Results Thirty-four studies containing 10,861 laparoscopic resections were included. Thirty-one (91 %) studies were confined to elective cases. Predictive analysis of outcome was most frequently based on length of stay (LOS), morbidity and readmission which were the main outcome measures of 29 (85 %), 26 (76 %) and 18 (53 %) of the included studies, respectively. Forty-seven percentage of included studies investigated the impact of ERAS programme compliance on these outcomes. Reduced protocol compliance was the most frequently identified modifiable predictive factor for adverse LOS, morbidity and readmission. Conclusion Protocol compliance is the most frequently reported predictive factor for outcomes of ERAS programmes following laparoscopic colorectal resection. Reduced compliance increases LOS, morbidity and readmission to hospital. The impact of compliance with individual ERAS protocol elements is insufficiently studied, and the lack of a standardised framework for evaluating ERAS programmes makes it difficult to draw definite conclusions about which factors exert the greatest impact on outcome after laparoscopic colorectal resection. Keywords Enhanced recovery Á ERAS Á Outcome Á Prediction Á Colorectal The use of laparoscopy [1, 2] and enhanced recovery after surgery (ERAS) programmes [3] has become well established in colorectal units across the world. Both aim to minimise the stress response to surgery and peri-operative care, by adopting a multimodal approach as first described by Kehlet [4]. Evidence from a number of randomised controlled trials [5-15] and meta-analyses [16-21] has demonstrated that patients undergoing colorectal surgery Presented in part as a podium presentation to the 22nd International Congress of the
International Journal of Surgery, 2010
Background: Enhanced recovery after surgery (ERAS) pathways has been shown to minimize the duration of hospital stay. The aim of this study was to identify which factors have the greatest impact at reducing the length of stay within an enhanced recovery programme. Methods: A retrospective case note review of patients undergoing open elective colorectal resections between August 2007 and May 2009 was performed. Data on numerous pre, peri and postoperative variables were collected. Postoperative complications, readmissions, length of stay and fitness for discharge were recorded. Using logistic regression analysis, univariate and multivariate analysis of predictors for a shorter hospital stay was performed. Odd ratios and ninety-five percent confidence intervals were calculated and a p-value of less than 0.05 was significant. Results: There were 231 patients, of which 130 were female. Median age was 68 (IQR 56e76) years. Median length of stay was 6 (IQR 5e9) days. On multivariate analysis, ASA grade (OR 2.85 (95%CI 1.17 e6.89), p ¼ 0.040), the avoidance of oral opiates in the postoperative period (OR 0.39 (95%CI 0.18e0.84), p ¼ 0.016) and the duration of use of epidurals for postoperative analgesia (OR 0.44 (95%CI 0.12e0.94), p ¼ 0.023) were found to be significant predictors of reduced hospital stay. Conclusion: Lower ASA grade, use of epidurals and avoidance of regular oral opiates are associated with an earlier discharge in an ERAS programme.
Medicine, 2018
There is increasing evidence that minimally invasive techniques associated with Enhanced Recovery After Surgery (ERAS) protocols reduce surgery-related stress and promote faster recovery after major colorectal surgery. As a single tertiary referral center for colorectal surgery, our aim was to analyze the effects of our ERAS protocol on a heterogeneous population undergoing laparoscopic colorectal surgery.Prospectively collected data from 283 patients undergoing laparoscopic colorectal resection at the Division of General and Hepatobiliary Surgery, University of Verona Hospital Trust, between March 2014 and March 2018 were retrospectively analyzed. Patients' adherence to pre-, intra-, and postoperative ERAS protocol items together with surgical short-term outcomes such as morbidity, mortality, length of hospital stay, and readmission rate was considered.The study protocol was approved by the Ethics Committee of Azienda Ospedaliera Universitaria Integrata di Verona (CRINF-1034 CE...
Scientific Reports
Advancement of the surgical modality and perioperative care are the two main dimensions for the modern improvement of surgical outcome. The purpose of this study was to compare the effectiveness of the two by using the data from the single-port laparoscopic surgery and the early recovery after surgery (ERAS) program. Patients who underwent elective surgery for primary adenocarcinoma of the colon were divided into three groups and compared: ERAS (multi-port laparoscopic surgery with ERAS perioperative care), Conventional-SILS (single-port surgery with conventional perioperative care), or Conventional-Multi (multi-port laparoscopic surgery with conventional perioperative care). Ninetyone, 83, and 96 patients were registered, respectively. There were no differences among the three groups in baseline characteristics except pathological stage and operation site in colon. Although the ERAS group started a soft diet earlier and had earlier discharge, there were no differences in intra-and post-operative morbidity rate, readmission rate, or reoperation rate. The ERAS perioperative care was a significant factor for reducing length of hospital stay in the multivariate analysis, while single-port surgery was not. In modern laparoscopic colon cancer treatment, a systemic approach such as the ERAS program appears to be more effective than a technical approach for significantly improving short-term surgical outcomes. Short-and long-term outcomes of colorectal cancer surgery are improving due to a number of advancements, including minimally invasive surgery, the principle of total mesorectal excision/complete mesocolic excision, a multidisciplinary team approach, and the development of chemotherapy in the modern era. The ERAS (Early Recovery After Surgery) program is also known to improve postoperative outcomes following colorectal surgery. ERAS aims to quickly restore patients to preoperative condition after surgery through various efforts such as minimizing fasting time in the perioperative period, encouraging exercise, and intensive control of pain 1. ERAS is known to reduce postoperative complications, hasten recovery, and reduce the length of hospital stay 2,3. Another approach, single-port laparoscopic surgery, is reported to not only have a cosmetic effect, but also decrease intraoperative blood loss and postoperative length of hospital stay by enhancing recovery of bowel movements due to further shortening of the incision length compared to conventional multi-port laparoscopic surgery 4. Both methods can improve short-term performance in colon cancer surgery, but one is a systemic approach requiring cooperation from experts in different fields, and the other is a technical approach, dependent on the ability of the surgeon. Neither has been sufficiently validated with clinical data in Korea. Currently, multi-port laparoscopic surgery with conventional perioperative care is the main surgical treatment for colon cancer in
Colorectal Disease, 2013
Aim This study set out to compare the postoperative health related quality of life (HQoL) of patients undergoing elective open colorectal surgery using a wellestablished enhanced recovery after surgery (ERAS) pathway with those undergoing laparoscopic surgery without an established an ERAS pathway. Method Using a power calculation, it was estimated that 40 patients would be required in each group. HQoL of the two groups was prospectively assessed using SF-12 (Short Form 12) and EORTC QLQ 30 (European Organisation of Research and Treatment of Cancer, Quality of Life Questionnaire) preoperatively, and at 2 and 6 weeks after discharge. Results Data were collected from 83 patients, 41 in the laparoscopic group and 42 in the open-ERAS group. There was a significant difference between the median length of stay of the open-ERAS (5 days) and laparoscopic (7 days, P = 0.028) groups. There were no significant differences between the HQoL score of the two groups at any stage. In both groups, the majority of HQoL scores had improved considerably by 6 weeks. Conclusion Laparoscopic and open-ERAS surgery have a similar impact on postoperative HQoL. HQoL tends to improve by the 6-week stage.
JAMA Surgery, 2019
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.
Updates in Surgery, 2017
Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement. Objective: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals. Methods: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback. Results: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events. Conclusions: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.