Enhanced-recovery pathway may reduce colorectal-surgery complications

Last Updated: 2019-05-17

By Will Boggs MD

NEW YORK (Reuters Health) - Enhanced Recovery After Surgery (ERAS) protocols are associated with significantly fewer moderate to severe postoperative complications in adults undergoing elective colorectal surgery, according to results from the POWER study.

"The most interesting thing was to confirm that the ERAS elements work as a bundle," Dr. Javier Ripolles-Melchor of Infanta Leonor University Hospital, in Madrid, told Reuters Health by email. "However, we should consider many of them as standard care, and certainly most doctors involved in colorectal surgical procedures believe that they do things well, but unfortunately this is not the case."

ERAS protocols (also called enhanced recovery pathways) have been associated with improvements in postoperative outcomes, including complications and hospital length of stay. Uncertainty remains regarding the relative benefit from each component, however.

Dr. Ripolles-Melchor and colleagues in the Spanish Perioperative Audit and Research Network evaluated the incidence of moderate to severe postoperative complications within 30 days after colorectal surgery in 2,084 patients, 62.5% of whom underwent surgery in hospitals that had received specific training in ERAS.

Overall, 42.2% of patients developed postoperative complications, including 27.2% of patients whose complications were graded as moderate or severe.

Significantly fewer patients in the ERAS group (25.2%) than in the non-ERAS group (30.3%) developed moderate to severe complications, the researchers report in JAMA Surgery, online May 8.

The groups did not differ in terms of overall complications, remission, reoperation, or mortality rate.

Overall adherence to the 22 ERAS protocol components was 72.7% at ERAS facilities versus 59.1% at non-ERAS facilities.

Compared with the lowest adherence quartile of ERAS items, the highest adherent quartile was associated with 66% lower odds of moderate to severe complications, 67% lower odds of overall complications and 73% lower odds of mortality.

Most of the individual ERAS items were independently associated with significant reductions in moderate to severe complications. Noninvasive surgery and early mobilization and feeding were strongly associated with more favorable outcomes.

Hospital length of stay averaged one day shorter in the ERAS group than in the non-ERAS group, whereas the median length of stay was three days shorter in the most adherent group than in the least adherent group.

"Much remains to be improved, and most of the things that will allow improving the results are not costly or complex interventions, rather the opposite," Dr. Ripolles-Melchor said. "On the other hand, the low adherence to certain items that should be standard care is worrisome."

Dr. Olle Ljungqvist, a professor of surgery at Oerebro University in Sweden, who wrote an invited commentary, told Reuters Health by email, "What is truly new in this report is the 30-day mortality finding. It also confirms what has been shown in other parts of the world - better compliance to ERAS Society Guidelines yields better outcomes."

"Continuous control of processes and outcomes by use of data is the key," he said. "If you don't know your processes, you will find it hard to understand your outcomes and make the right changes for improvements."

Dr. Ljungqvist is the cofounder and current chairman of the ERAS Society and founder and shareholder of Encare AB, Sweden, a commercial company involved in ERAS implementation.

SOURCE: https://bit.ly/2VzCLNT and https://bit.ly/2WQIVuK

JAMA Surg 2019.