Enhanced Recovery Protocol for Colorectal Surgery

This is important because decreasing length of stay can make the anesthesia department more important to the hospital’s administration.

Miller TE, Thacker JK, White WD, et al; Enhanced Recovery Study Group

Anesth Analg. 2014;118:1052-1061

Study Summary

This study investigated the feasibility, clinical effectiveness, and cost savings of a multimodal approach to enhanced recovery after surgery, designed to enable early mobilization and feeding after open or laparoscopic colorectal surgery.

Baseline data were collected on 99 consecutive patients undergoing colorectal surgery and receiving traditional care that included little standardization and was at the discretion of the surgical and anesthesia providers. For example, baseline patients fasted from midnight on the day of surgery, received bowel preparation, and rarely received thoracic epidurals because of a surgical preference for enoxaparin to be given 2 hours preoperatively. Early mobilization and day-of-surgery feeding were not part of the traditional care regimens.

The investigators then implemented a multimodal regimen to enable early mobilization and feeding after surgery. Staff members received training before a 3-month implementation period during which 142 patients were prospectively enrolled, allowing providers to become familiar with the enhanced recovery protocol. A before-and-after comparison of key outcomes was made.

Study Findings

The median length of stay was reduced from 7 to 5 days with the enhanced recovery protocol compared with the traditional group (P less than .001). The reduction in length of stay was significant for both open procedures (median, 6 vs 7 days; P = .01) and laparoscopic procedures (4 vs 6 days; P less than .001). Patients who received the enhanced recovery protocol also had fewer urinary tract infections (13% vs 24%; P = .03) and fewer readmissions (9.8% vs 20.2%; P = .02).

Of interest, even with a shorter length of stay and lower patient ward costs, there was no statistically significant difference in unadjusted total hospital costs for patients who received the enhanced protocol compared with traditional care ($18,377 vs $20,537).

Viewpoint

The 12 investigators who form the Enhanced Recovery Study Group began the article by stating, “Despite lack of evidence for preoperative bowel preparation in colorectal surgery, routine use of nasogastric tubes, and nil by mouth instructions until bowel sounds are heard postoperatively, all 3 are still widely practiced.” In fact, the approach studied here was a bundle of interventions that included:

• No bowel preparation;

• Patients were allowed to drink clear fluids until 3 hours preoperatively; and

• Patients drank a 240-mL beverage (Gatorade™) 3 hours before surgery.

These latter 2 items make sense. If a person is going to run 5 miles at 4 PM, no one would expect that person to go without fluids the entire day. I would assume that running several miles is not unlike the stress to the body of having surgery.

Other aspects of the enhanced recovery bundle included:

• Formally educating patients about what is going to happen and setting expectations for recovery, including walking and eating the evening after surgery;

• Smoking cessation information;

• Two preoperative showers with chlorhexidine sponges;

• Thoracic epidural anesthesia with 5000 U of subcutaneous heparin given after catheter placement (instead of enoxaparin 2 hours preoperatively);

• Goal-directed intravenous fluid therapy;

• Orogastric tube removal before leaving the operating room (it used to be that many of these patients were sent to the ward with a nasogastric tube);

• Urinary catheter taken out in the operating room;

• Diet and ambulation begin the first night of surgery; and

• Head of bed elevated to 30° at all times.

Instead of studying the impact of a single intervention (eg, only thoracic epidural anesthesia, early diet only, or early ambulation), Miller and colleagues used a multimodal perioperative approach that combined a group of interventions. This elegant approach rings true as being relevant and applicable to everyday practice. Thoracic epidural analgesia was used in 92% of recovery group patients compared with 18% of traditional group patients, resulting in reduced use of postoperative morphine and lower pain scores. In the intervention group, 74% of patients began taking clear oral fluids on the day of surgery, compared with 15% in the traditional group.

When you look at the published literature, an often surprising statistic is the complication rate after colon surgery, which can be as high as 25%-40% if one includes pneumonia, urinary tract infection, superficial or deep wound infection, sepsis, and cardiovascular events. In this study, surgical-site infections occurred in 28% of patients receiving the enhanced recovery protocol vs 37% of the traditional group, but this difference did not reach statistical significance.

For patients without complications, length of stay is determined by postoperative ileus. Enhanced recovery programs aim to minimize ileus and facilitate immediate feeding and mobilization on the day of surgery.

This study is another example of how new evidence fundamentally changes traditional best practice in how patients are cared for.