Annals of Surgical Oncology

, Volume 26, Issue 3, pp 782–790 | Cite as

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



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.


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.


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.


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.



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.


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


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

10434_2018_7150_MOESM1_ESM.jpg (565 kb)
Supplementary material 1 (JPEG 565 kb)
10434_2018_7150_MOESM2_ESM.jpg (612 kb)
Supplementary material 2 (JPEG 612 kb)


  1. 1.
    Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152:292–8.CrossRefGoogle Scholar
  2. 2.
    Manso M, Schmelz J, Aloia T. ERAS-anticipated outcomes and realistic goals. J Surg Oncol. 2017;116:570–7.CrossRefGoogle Scholar
  3. 3.
    Connor S, Cross A, Sakowska M, et al. Effects of introducing an enhanced recovery after surgery programme for patients undergoing open hepatic resection. HPB (Oxford). 2013;15:294–301.CrossRefGoogle Scholar
  4. 4.
    Coolsen MM, van Dam RM, van der Wilt AA, et al. Systematic review and meta-analysis of enhanced recovery after pancreatic surgery with particular emphasis on pancreaticoduodenectomies. World J Surg. 2013;37:1909–18.CrossRefGoogle Scholar
  5. 5.
    Hughes MJ, McNally S, Wigmore SJ. Enhanced recovery following liver surgery: a systematic review and meta-analysis. HPB (Oxford). 2014;16:699–706.CrossRefGoogle Scholar
  6. 6.
    Lau CS, Chamberlain RS. Enhanced recovery after surgery programs improve patient outcomes and recovery: a meta-analysis. World J Surg. 2017;41:899–913.CrossRefGoogle Scholar
  7. 7.
    Song W, Wang K, Zhang RJ, et al. The enhanced recovery after surgery (ERAS) program in liver surgery: a meta-analysis of randomized controlled trials. SpringerPlus. 2016;5:207.CrossRefGoogle Scholar
  8. 8.
    Visioni A, Shah R, Gabriel E, et al. Enhanced recovery after surgery for noncolorectal surgery? A systematic review and meta-analysis of major abdominal surgery. Ann Surg. 2018;267:57–65.CrossRefGoogle Scholar
  9. 9.
    Aloia TA, Zimmitti G, Conrad C et al. Return to intended oncologic treatment (RIOT): a novel metric for evaluating the quality of oncosurgical therapy for malignancy. J Surg Oncol. 2014;110:107–14.CrossRefGoogle Scholar
  10. 10.
    Day RW, Cleeland CS, Wang XS, et al. Patient-reported outcomes accurately measure the value of an enhanced recovery program in liver surgery. J Am Coll Surg. 2015;221:1023–30 e1021–22.Google Scholar
  11. 11.
    Neville A, Lee L, Antonescu I, et al. Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg. 2014;101:159–70.CrossRefGoogle Scholar
  12. 12.
    Takamoto T, Hashimoto T, Inoue K, et al. Applicability of enhanced recovery program for advanced liver surgery. World J Surg. 2014;38:2676–82.CrossRefGoogle Scholar
  13. 13.
    Alcantara-Moral M, Serra-Aracil X, Gil-Egea MJ, et al. Observational cross-sectional study of compliance with the fast track protocol in elective surgery for colon cancer in Spain. Int J Colorectal Dis. 2014;29:477–83.CrossRefGoogle Scholar
  14. 14.
    Schultz NA, Larsen PN, Klarskov B, et al. Evaluation of a fast-track programme for patients undergoing liver resection. Br J Surg. 2013;100:138–43.CrossRefGoogle Scholar
  15. 15.
    Bagnall NM, Malietzis G, Kennedy RH, et al. A systematic review of enhanced recovery care after colorectal surgery in elderly patients. Colorectal Dis. 2014;16:947–56.CrossRefGoogle Scholar
  16. 16.
    Gustafsson UO, Oppelstrup H, Thorell A, et al. Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study. World J Surg. 2016;40:1741–7.CrossRefGoogle Scholar
  17. 17.
    Li P, Fang F, Cai JX, et al. Fast-track rehabilitation vs conventional care in laparoscopic colorectal resection for colorectal malignancy: a meta-analysis. World J Gastroenterol. 2013;19:9119–26.CrossRefGoogle Scholar
  18. 18.
    van Vugt JL, Reisinger KW, Derikx JP, et al. Improving the outcomes in oncological colorectal surgery. World J Gastroenterol. 2014;20:12445–57.CrossRefGoogle Scholar
  19. 19.
    Kim BJ, Aloia TA. What is “enhanced recovery,” and how can i do it? J Gastrointest Surg. 2018;22:164–71.CrossRefGoogle Scholar
  20. 20.
    Patel SH, Kim BJ, Tzeng CD, et al. Reduction of cardiopulmonary/renal complications with serum bnp-guided volume status management in posthepatectomy patients. J Gastrointest Surg. 2018;22:467–76.CrossRefGoogle Scholar
  21. 21.
    Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clin Nutr. 2012;31:783–800.CrossRefGoogle Scholar
  22. 22.
    Lassen K, Coolsen MM, Slim K, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clin Nutr. 2012;31:817–30.CrossRefGoogle Scholar
  23. 23.
    Melloul E, Hubner M, Scott M, et al. Guidelines for perioperative care for liver surgery: enhanced recovery after surgery (ERAS) society recommendations. World J Surg. 2016;40:2425–40.CrossRefGoogle Scholar
  24. 24.
    Mortensen K, Nilsson M, Slim K, et al. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Br J Surg. 2014;101:1209–29.CrossRefGoogle Scholar
  25. 25.
    Nelson G, Altman AD, Nick A, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations–Part II. Gynecol Oncol. 2016;140:323–32.CrossRefGoogle Scholar
  26. 26.
    Nelson G, Altman AD, Nick A, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations–Part I. Gynecol Oncol. 2016;140:313–22.CrossRefGoogle Scholar
  27. 27.
    Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clin Nutr. 2012;31:801–16.CrossRefGoogle Scholar
  28. 28.
    Thorell A, MacCormick AD, Awad S, et al. Guidelines for perioperative care in bariatric surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World J Surg. 2016;40:2065–83.CrossRefGoogle Scholar
  29. 29.
    Scarborough JE, Bennett KM, Englum BR, et al. The impact of functional dependency on outcomes after complex general and vascular surgery. Ann Surg. 2015;261:432–7.CrossRefGoogle Scholar
  30. 30.
    Lasala JD, Heir JS, Mena GE, et al. Implementation of an Enhanced Surgical Recovery Programme (ESRP) gynaecologic oncology: how much did intra-operative opioid administration decrease in first year post implementation? Clin Nutr ESPEN. 2016;12:e42–3.CrossRefGoogle Scholar
  31. 31.
    Aloia TA, Kim BJ, Segraves-Chun YS, et al. A randomized controlled trial of postoperative thoracic epidural analgesia versus intravenous patient-controlled analgesia after major hepatopancreatobiliary surgery. Ann Surg. 2017;266:545–54.CrossRefGoogle Scholar
  32. 32.
    Meyer LA, Lasala J, Iniesta MD, et al. Effect of an enhanced recovery after surgery program on opioid use and patient-reported outcomes. Obstet Gynecol. 2018; 132:281–90.CrossRefGoogle Scholar
  33. 33.
    Van Haren RM, Mehran RJ, Mena GE, et al. Enhanced recovery decreases pulmonary and cardiac complications after thoracotomy for lung cancer. Ann Thorac Surg. 2018;106:272–9.CrossRefGoogle Scholar
  34. 34.
    Zimmitti G, Soliz J, Aloia TA, et al. Positive impact of epidural analgesia on oncologic outcomes in patients undergoing resection of colorectal liver metastases. Ann Surg Oncol. 2016;23:1003–11.CrossRefGoogle Scholar
  35. 35.
    Gotlib Conn L, McKenzie M, Pearsall EA, McLeod RS. Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions’ experiences. Implement Sci. 2015;10:99.CrossRefGoogle Scholar
  36. 36.
    Pedziwiatr M, Kisialeuski M, Wierdak M, et al. Early implementation of Enhanced Recovery After Surgery (ERAS(R)) protocol—Compliance improves outcomes: a prospective cohort study. Int J Surg. 2015;21:75–81.CrossRefGoogle Scholar
  37. 37.
    Kim BJ, Caudle AS, Gottumukkala V, Aloia TA. The impact of postoperative complications on a timely Return to Intended Oncologic Therapy (RIOT): the role of enhanced recovery in the cancer journey. Int Anesthesiol Clin. 2016;54:e33–46.CrossRefGoogle Scholar
  38. 38.
    Merkow RP, Bentrem DJ, Mulcahy MF, et al. Effect of postoperative complications on adjuvant chemotherapy use for stage III colon cancer. Ann Surg. 2013;258:847–53.CrossRefGoogle Scholar
  39. 39.
    Merkow RP, Bilimoria KY, Tomlinson JS, et al. Postoperative complications reduce adjuvant chemotherapy use in resectable pancreatic cancer. Ann Surg. 2014;260:372–7.CrossRefGoogle Scholar

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

Personalised recommendations