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International Journal of Colorectal Disease

, Volume 33, Issue 11, pp 1543–1550 | Cite as

ERAS protocol validation in a propensity-matched cohort of patients undergoing colorectal surgery

  • Riccardo Lemini
  • Aaron C. Spaulding
  • James M. Naessens
  • Zhuo Li
  • Amit Merchea
  • Julia E. Crook
  • David W. Larson
  • Dorin T. Colibaseanu
Original Article

Abstract

Purpose

Enhanced recovery after surgery (ERAS) provides many benefits. However, important knowledge gaps with respect to specific components of enhanced recovery after surgery remain because of limited validation data. The aim of the study was to validate a mature ERAS protocol at a different hospital and in a similar population of patients.

Methods

This is a retrospective analysis of patients undergoing elective colorectal surgery from 2009 through 2016. Patients enrolled in ERAS are compared with those undergoing the standard of care. Patient demographic characteristics, length of stay, pain scores, and perioperative morbidity are described.

Results

Patients (1396) were propensity matched into two equal groups (ERAS vs non-ERAS). No significant difference was observed for age, Charlson Comorbidity Index, American Society of Anesthesiologists score, body mass index, sex, operative approach, and surgery duration. Median length of stay in ERAS and non-ERAS groups was 3 and 5 days (P < .001). Mean pain scores were lower in the ERAS group, measured at discharge from the postanesthesia unit (P < .001), on postoperative day 1 (P = .002) and postoperative day 2 (P = .02) but were identical on discharge.

Conclusions

This ERAS protocol was validated in a similar patient population but at a different hospital. ERAS implementation was associated with an improved length of stay and pain scores similar to the original study. Different than most retrospective studies, propensity score matching ensured that groups were evenly matched. To our knowledge, this study is the only ERAS validation study in a propensity-matched cohort of patients undergoing elective colorectal surgery.

Keywords

Colorectal surgery Propensity score Patient readmission Pain management Patient discharge 

Notes

Authors’ Contributions

All authors made substantial contribution to the conception and design of the work, as well as the acquisition, analysis, and interpretation of data. All authors were critically involved in drafting and revising this project for important intellectual content. Final approval of the version to be published was given by all authors, and they agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Source of funding

Funding provided by Robert D. and Patricia E. Kern Center for Science of Health Care Delivery. The funder had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Compliance with ethical standards

The Mayo Clinic Institutional Review Board approved this retrospective study. This study followed the reporting guidelines of the Strengthening the Reporting of Observational Studies in Epidemiology.

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Anderson AD, McNaught CE, MacFie J et al (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90(12):1497–1504CrossRefGoogle Scholar
  2. 2.
    Basse L, Raskov HH, Hjort Jakobsen D, Sonne E, Billesbolle P, Hendel HW, Rosenberg J, Kehlet H (2002) Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 89(4):446–453CrossRefGoogle Scholar
  3. 3.
    Kehlet H (1997) Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 78(5):606–617CrossRefGoogle Scholar
  4. 4.
    Moiniche S, Bulow S, Hesselfeldt P et al (1995) Convalescence and hospital stay after colonic surgery with balanced analgesia, early oral feeding, and enforced mobilisation. The Eur J Surg 161(4):283–288Google Scholar
  5. 5.
    Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Feldman LS, Steele SR (2017) Clinical practice guidelines for enhanced recovery after Colon and rectal surgery from the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 60(8):761–784CrossRefGoogle Scholar
  6. 6.
    Delaney CP, Brady K, Woconish D, Parmar SP, Champagne BJ (2012) Towards optimizing perioperative colorectal care: outcomes for 1,000 consecutive laparoscopic colon procedures using enhanced recovery pathways. Am J Surg 203(3):353–355 discussion 5-6CrossRefGoogle Scholar
  7. 7.
    Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J, Enhanced Recovery After Surgery Study Group (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146(5):571–577CrossRefGoogle Scholar
  8. 8.
    Larson DW, Lovely JK, Cima RR, Dozois EJ, Chua H, Wolff BG, Pemberton JH, Devine RR, Huebner M (2014) Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery. Br J Surg 101(8):1023–1030CrossRefGoogle Scholar
  9. 9.
    Stephen AE, Berger DL (2003) Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery 133(3):277–282CrossRefGoogle Scholar
  10. 10.
    Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, von Meyenfeldt M, Fearon KC, Revhaug A, Norderval S, Ljungqvist O, Lobo DN, Dejong CH, Enhanced Recovery After Surgery (ERAS) Group (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced recovery after surgery (ERAS) group recommendations. Arch Surg 144(10):961–969CrossRefGoogle Scholar
  11. 11.
    Kahokehr A, Sammour T, Zargar-Shoshtari K et al (2009) Implementation of ERAS and how to overcome the barriers. Int J Surg (London, England) 7(1):16–19CrossRefGoogle Scholar
  12. 12.
    Ljungqvist O (2015) Sustainability after structured implementation of ERAS protocols. World J Surg 39(2):534–535CrossRefGoogle Scholar
  13. 13.
    Song W, Wang K, Zhang RJ, Dai QX, Zou SB (2016) The enhanced recovery after surgery (ERAS) program in liver surgery: a meta-analysis of randomized controlled trials. Springerplus 5:207CrossRefGoogle Scholar
  14. 14.
    Spanjersberg WR, Reurings J, Keus F, et al. 2011 Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. (2):Cd007635Google Scholar
  15. 15.
    Greco M, Capretti G, Beretta L, Gemma M, Pecorelli N, Braga M (2014) Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 38(6):1531–1541CrossRefGoogle Scholar
  16. 16.
    Rawlinson A, Kang P, Evans J, Khanna A (2011) A systematic review of enhanced recovery protocols in colorectal surgery. Ann R Coll Surg Engl 93(8):583–588CrossRefGoogle Scholar
  17. 17.
    Lovely JK, Maxson PM, Jacob AK, Cima RR, Horlocker TT, Hebl JR, Harmsen WS, Huebner M, Larson DW (2012) Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. Br J Surg 99(1):120–126CrossRefGoogle Scholar
  18. 18.
    Moriarty JP, Daniels PR, Manning DM, O’Meara JG, Ou NN, Berg TM, Haag JD, Roellinger DL, Naessens JM (2017) Going beyond administrative data: retrospective evaluation of an algorithm using the electronic health record to help identify bleeding events among hospitalized medical patients on warfarin. Am J Med Qual 32(4):391–396CrossRefGoogle Scholar
  19. 19.
    Varadhan KK, Neal KR, Dejong CH et al (2010) The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr (Edinburgh, Scotland) 29(4):434–440CrossRefGoogle Scholar
  20. 20.
    Lv L, Shao YF, Zhou YB (2012) The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Color Dis 27(12):1549–1554CrossRefGoogle Scholar
  21. 21.
    Wind J, Hofland J, Preckel B, Hollmann MW, Bossuyt PMM, Gouma DJ, van Berge Henegouwen MI, Fuhring JW, Dejong CHC, van Dam RM, Cuesta MA, Noordhuis A, de Jong D, van Zalingen E, Engel AF, Goei TH, de Stoppelaar IE, van Tets WF, van Wagensveld BA, Swart A, van den Elsen MJLJ, Gerhards MF, de Wit LT, Siepel MAM, van Geloven AAW, Juttmann JW, Clevers W, Bemelman WA (2006) Perioperative strategy in colonic surgery; laparoscopy and/or fast track multimodal management versus standard care (LAFA trial). BMC Surg 6:16CrossRefGoogle Scholar
  22. 22.
    Wind J, Polle SW, Fung Kon Jin PH et al (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93(7):800–809CrossRefGoogle Scholar
  23. 23.
    Bond-Smith G, Belgaumkar AP, Davidson BR et al (2016) Enhanced recovery protocols for major upper gastrointestinal, liver and pancreatic surgery. Cochrane Database Syst Rev 2:Cd011382PubMedGoogle Scholar
  24. 24.
    Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF (2014) Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 101(3):172–188CrossRefGoogle Scholar
  25. 25.
    Hendren S, Morris AM, Zhang W, Dimick J (2011) Early discharge and hospital readmission after colectomy for cancer. Dis Colon Rectum 54(11):1362–1367CrossRefGoogle Scholar
  26. 26.
    Andersen J, Hjort-Jakobsen D, Christiansen PS, Kehlet H (2007) Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery. Br J Surg 94(7):890–893CrossRefGoogle Scholar
  27. 27.
    Bergquist JR, Thiels CA, Etzioni DA, Habermann EB, Cima RR (2016) Failure of colorectal surgical site infection predictive models applied to an independent dataset: do they add value or just confusion? J Am Coll Surg 222(4):431–438CrossRefGoogle Scholar
  28. 28.
    Etzioni DA, Lessow CL, Lucas HD, Merchea A, Madura JA, Mahabir R, Mishra N, Wasif N, Mathur AK, Chang YHH, Cima RR, Habermann EB (2018) Infectious surgical complications are not dichotomous: characterizing discordance between administrative data and registry data. Ann Surg 267(1):81–87CrossRefGoogle Scholar
  29. 29.
    Stone AB, Grant MC, Pio Roda C, Hobson D, Pawlik T, Wu CL, Wick EC (2016) Implementation costs of an enhanced recovery after surgery program in the United States: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center. J Am Coll Surg 222(3):219–225CrossRefGoogle Scholar
  30. 30.
    Nelson G, Kiyang LN, Crumley ET, Chuck A, Nguyen T, Faris P, Wasylak T, Basualdo-Hammond C, McKay S, Ljungqvist O, Gramlich LM (2016) Implementation of enhanced recovery after surgery (ERAS) across a provincial healthcare system: the ERAS Alberta colorectal surgery experience. World J Surg 40(5):1092–1103CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Riccardo Lemini
    • 1
  • Aaron C. Spaulding
    • 2
  • James M. Naessens
    • 2
  • Zhuo Li
    • 3
  • Amit Merchea
    • 1
  • Julia E. Crook
    • 3
  • David W. Larson
    • 4
  • Dorin T. Colibaseanu
    • 1
    • 3
  1. 1.Section of Colon and Rectal Surgery, Mayo ClinicJacksonvilleUSA
  2. 2.Robert D. and Patricia E. Kern Center for Science of Health Care Delivery, Mayo ClinicJacksonvilleUSA
  3. 3.Department of Health Sciences Research, Biostatistics Unit, Mayo ClinicJacksonvilleUSA
  4. 4.Division of Colon and Rectal Surgery, Mayo ClinicRochesterUSA

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