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Determining the Safety and Efficacy of Enhanced Recovery Protocols in Major Oncologic Surgery: An Institutional NSQIP Analysis

  • Rebecca K. Marcus
  • Heather A. Lillemoe
  • David C. Rice
  • Gabriel Mena
  • Brian K. Bednarski
  • Barbra B. Speer
  • Pedro T. Ramirez
  • Javier D. Lasala
  • Neema Navai
  • Wendell H. Williams
  • Bradford J. Kim
  • Rachel K. Voss
  • Vijaya N. Gottumukkala
  • Thomas A. AloiaEmail author
Hepatobiliary Tumors

Abstract

Background

Enhanced-recovery (ER) protocols are increasingly being utilized in surgical practice. Outside of colorectal surgery, however, their feasibility, safety, and efficacy in major oncologic surgery have not been proven. This study compared patient outcomes before and after multispecialty implementation of ER protocols at a large, comprehensive cancer center.

Methods

Surgical cases performed from 2011 to 2016 and captured by an institutional NSQIP database were reviewed. Following exclusion of outpatient and emergent surgeries, 2747 cases were included in the analyses. Cases were stratified by presence or absence of ER compliance, defined by preoperative patient education and electronic medical record order set-driven opioid-sparing analgesia, goal-directed fluid therapy, and early postoperative diet advancement and ambulation.

Results

Approximately half of patients were treated on ER protocols (46%) and the remaining on traditional postoperative (TP) protocols (54%). Treatment on an ER protocol was associated with decreased overall complication rates (20% vs. 33%, p < 0.0001), severe complication rates (7.4% vs. 10%, p = 0.010), and median hospital length of stay (4 vs. 5 days, p < 0.0001). There was no change in readmission rates (ER vs. TP, 8.6% vs. 9.0%, p = 0.701). Subanalyses of high magnitude cases and specialty-specific outcomes consistently demonstrated improved outcomes with ER protocol adherence, including decreased opioid use.

Conclusions

This assessment of a large-scale ER implementation in multispecialty major oncologic surgery indicates its feasibility, safety, and efficacy. Future efforts should be directed toward defining the long-term oncologic benefits of these protocols.

Notes

Acknowledgments

The authors recognize the contributions of Dr. Jay Shah, who was the original surgical lead for the Urology ER program and has since moved to another institution. In addition, they thank our institution Surgical Clinical Reviewers, Annie Philip and Melony Levy, for their diligence and contributions to this study and to our broader patient quality improvement efforts.

Funding

Drs. Rebecca Marcus and Heather Lillemoe are supported by National Institutes of Health grant T32CA009599 and the MD Anderson Cancer Center support grant P30CA016672.

Disclosure

None of the authors have any conflicts of interest associated with this study.

ACS NSQIP Disclaimer

American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein. They have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

Supplementary material

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Supplementary material 1 (JPEG 565 kb)
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Supplementary material 2 (JPEG 612 kb)

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Copyright information

© Society of Surgical Oncology 2019

Authors and Affiliations

  • Rebecca K. Marcus
    • 1
  • Heather A. Lillemoe
    • 1
  • David C. Rice
    • 4
  • Gabriel Mena
    • 3
  • Brian K. Bednarski
    • 1
  • Barbra B. Speer
    • 3
  • Pedro T. Ramirez
    • 2
  • Javier D. Lasala
    • 3
  • Neema Navai
    • 5
  • Wendell H. Williams
    • 3
  • Bradford J. Kim
    • 1
  • Rachel K. Voss
    • 1
  • Vijaya N. Gottumukkala
    • 3
  • Thomas A. Aloia
    • 1
    Email author
  1. 1.Department of Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of Gynecologic Oncology and Reproductive MedicineThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Department of Anesthesiology and Perioperative MedicineThe University of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.Department of Thoracic and Cardiovascular SurgeryThe University of Texas MD Anderson Cancer CenterHoustonUSA
  5. 5.Department of UrologyThe University of Texas MD Anderson Cancer CenterHoustonUSA

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