Peri-Op Protocols Enhancing Recovery After Colorectal Surgery

The goal of any perioperative protocol is to improve patient outcomes after surgery. In colorectal surgery, however, there is minimal evidence to support traditional perioperative practices, such as bowel preparation and fasting before surgery.

In the mid-1990s, this gap in understanding prompted a group of surgeons, led by Henrik Kehlet, MD, PhD, from Copenhagen, to begin implementing early recovery efforts. Following Dr. Kehlet’s work, a multinational group of surgeons and anesthesiologists began collaborating as the Enhanced Recovery After Surgery (ERAS) research group. The aim of ERAS is to systematically study patients’ physiologic responses to surgery and develop a multifaceted, evidence-based approach to patient care in colorectal surgery and other disciplines.

At the 22nd International Congress of the European Association for Endoscopic Surgery (EAES), Nader Francis, MBChB, PhD, and his colleagues presented an up-to-date review of ERAS in colorectal surgery, pinpointing factors that may allow surgeons to enhance and ultimately predict patient outcomes (abstract O074).

“There are many features that impact patient outcomes and we don’t necessarily know which are the most relevant to recovery,” said Dr. Francis, consultant colorectal surgeon at Yeovil District Hospital, in Somerset, England. “Our ongoing research is working to uncover the key factors in perioperative care.”

Although no standard ERAS protocol yet exists in colorectal surgery, most include formal patient education, eliminating bowel preparation and allowing clear fluids up to three hours before surgery. Intraoperatively, studies show that laparoscopic surgery, goal-directed fluid management, less operative time and reduced blood loss aid patient recovery (JSLS2014;18:265-272). Postoperatively, the use of thoracic epidural analgesia, avoidance of nasogastric tubes, and early feeding, mobilization, discontinuation of IV fluid and removal of urethral catheters are important features as well (Ann Surg 2000;232:51-57).

Despite the lack of consensus, a growing body of research shows that employing ERAS principles reduces hospital length of stay and complications in colorectal surgery (Ann Surg 2000;232:51-57; Br J Surg 2006;93:800-809; Anesth Analg 2014;118:1052-1061). For instance, in a 2014 study comparing outcomes in a traditional care (99 patients) and ERAS group (142 patients), Julie Thacker, MD, and her colleagues at Duke University Medical Center, Durham, N.C., found that patients following an enhanced recovery protocol had a significantly shorter length of stay (five vs. seven days; P less than 0.001), fewer urinary tract infections (13% vs. 24%; P=0.03), reductions in duration of ileus and lower readmission rates (9.8% vs. 20.2%; P=0.02). The Duke enhanced recovery protocol was also associated with lower medical costs, about $2,000 per patient or a 10% decrease in the costs of traditional care.

“This reduction in cost is a huge bonus for patients and the health system,” said Dr. Thacker, assistant professor in the Department of Surgery. “It could save hundreds of thousands of dollars a year and would require minimal to no extra costs for hospitals to realize.”

But, given the abundance of perioperative factors being studied and the complexity of different health systems, ERAS can be difficult to implement. In a 2012 study (Colorectal Dis 14:e727-e734), Dr. Francis and his colleagues retrospectively analyzed outcomes of 385 patients who underwent elective laparoscopic or open colorectal resection at Yeovil District Hospital between 2002 and 2009, and found that 31% of patients stayed more than one week (delayed discharge), and 41% deviated from the ERAS protocol. The authors concluded that failing to comply with ERAS one day after surgery was strongly associated with delayed discharge.

In a recent analysis, Dr. Francis and his colleagues tried to determine what factors cause patients to deviate from an enhanced recovery protocol. After prospectively collecting data from 178 patients who had undergone open or laparoscopic colorectal surgery between January 2006 and December 2009, the surgeons found that of the 32% of patients who deviated from the program, the most common reasons cited were failure to mobilize after surgery (80.7%), continued use of IV fluids beyond 24 hours (59.7%), failure to resume an oral diet (45.6%) and inadequate pain control (10.5%).

The adoption of ERAS across Europe and the United States has also seen varied success. In the United Kingdom, hospitals are encouraged to adopt enhanced recovery for colorectal surgery, and their payment schemes are tied to protocol compliance. “Over the last 10 years, we’ve seen an amazing spread of ERAS,” Dr. Francis said. “The program now exists in every hospital in England.”

But looking beyond the United Kingdom to the rest of Europe and the United States, ERAS is not taking hold as quickly. “National mandates, transparent audits and government-funded implementation efforts in the U.K. create a very different picture than surgeon and anesthesiologist-driven work in the U.S.,” said Dr. Thacker. “Trying to change a little bit about everything included in perioperative care in the U.S. is extraordinarily challenging.”

Part of the difficulty is that each hospital in the United States has different capabilities and guidelines, which means the challenges to implementing an enhanced recovery protocol will vary by hospital, Dr. Thacker noted.

Despite these complex barriers, Dr. Thacker has started to garner support from surgical societies throughout the United States. “The more interest we get at the society and health system level, the easier it will be to improve perioperative care.”