Enhanced Recovery After Surgery: Can We Rely on the Key Factors or Do We Need the Bel Ensemble?

• Published in: World journal of surgery Vol. 41; no. 10; pp. 2464 - 2470
• Main Authors: Jurt, Jonas, Slieker, Juliette, Frauche, Pierre, Addor, Valerie, Solà, Josep, Demartines, Nicolas, Hübner, Martin
• Format: Journal Article
• Language: English
• Published: Cham Springer International Publishing 01.10.2017; Springer Nature B.V
• Subjects: Abdominal Hernia Repair; Abdominal Surgery; Adhesion; Aged; Aged, 80 and over; Analgesia; Analgesia, Epidural - adverse effects; Cardiac Surgery; Clinical Protocols; Colon - surgery; Complications; Confidence intervals; Data processing; Demographics; Demography; Digestive System Surgical Procedures - adverse effects; Drainage - adverse effects; Drains; Female; General Surgery; Guideline Adherence; Humans; Intubation, Gastrointestinal - adverse effects; Length of Stay; Logistic Models; Male; Medicine; Medicine & Public Health; Middle Aged; Minimal Invasive Approach; Minimally Invasive Surgical Procedures - adverse effects; Original Scientific Report; Pain perception; Patients; Perfect Protocol; Perioperative Care - methods; Postoperative Complications - etiology; Postoperative Complications - prevention & control; Recovery; Recovery of Function; Rectum - surgery; Regression analysis; Retrospective Studies; Segmental Colectomy; Statistical analysis; Stoma Procedure; Surgery; Surgical drains; Thoracic Surgery; Thoracic Vertebrae; Thorax; Tubes; Vascular Surgery; Abdominal Hernia Repair; Stoma Procedure; Perfect Protocol; Minimal Invasive Approach; Segmental Colectomy
• ISSN: 0364-2313; 1432-2323
• DOI: 10.1007/s00268-017-4054-z

Background The success of enhanced recovery (ERAS) pathways depends on the actual application of the intended protocol (adherence), but its full implementation remains challenging. In order to potentially streamline the pathway, it is indispensable to know the impact of individual items and the entire protocol on clinical outcomes. Methods Retrospective analysis including all consecutive colorectal ERAS patients since implementation (May 2011) until February 2014; demographics, adherence and outcomes were retrieved from a prospectively maintained database. Primary outcome was the impact of individual item and of the entire protocol on complications (overall and major) and length of hospital stay. Statistical analysis included logistic multivariate regression and adjustment for confounding factors. Results There were 328 patients with complete data sets analyzed. A minimally invasive approach [odd ratio (OR) 0.62; confidence interval (CI) 0.4–0.9] was significantly associated with less overall complications. In contrast, the use of prophylactic nasogastric tubes (OR 3.18; CI 1.4–7.4), prophylactic abdominal and pelvic drains (OR 1.96; 1.2–3.2) and intraoperative thoracic epidural analgesia (OR 1.76; CI 1.3–2.4) were associated with more overall complications. Minimal invasive approach was further associated with reduced hospital stay (OR 0.5; CI 0.4–0.7) and less major complications (OR 0.58; CI 0.4–0.8). Higher adherence to the entire ERAS protocol was associated with significantly less complications ( P  < 0.001) and shorter hospital stay ( P  < 0.001). Conclusions Minimally invasive surgery was the single most important component of the ERAS pathway while nasogastric tubes, drains and epidurals should be avoided. Overall, increasing adherence with the protocol was associated with better outcomes and should be the goal.