Attitudes towards Enhanced Recovery after Surgery (ERAS) interventions in colorectal surgery: nationwide survey of Australia and New Zealand colorectal surgeons

James Wei Tatt Toh,Grahame Ctercteko,Nimalan Pathma-Nathan,Stephen Smith,Geoffrey Peter Collins,Toufic El-Khoury,Arthur Richardson,Alexander Engel

doi:10.1007/s00423-022-02488-7

Abstract

BackgroundWhilst Enhanced Recovery after Surgery (ERAS) has been widely accepted in the international colorectal surgery community, there remains significant variations in ERAS programme implementations, compliance rates and best practice recommendations in international guidelines.MethodsA questionnaire was distributed to colorectal surgeons from Australia and New Zealand after ethics approval. It evaluated specialist attitudes towards the effectiveness of specific ERAS interventions in improving short term outcomes after colorectal surgery. The data were analysed using a rating scale and graded response model in item response theory (IRT) on Stata MP, version 15 (StataCorp LP, College Station, TX).ResultsOf 300 colorectal surgeons, 95 (31.7%) participated in the survey. Of eighteen ERAS interventions, this study identified eight strategies as most effective in improving ERAS programmes alongside early oral feeding and mobilisation. These included pre-operative iron infusion for anaemic patients (IRT score = 7.82 [95% CI: 6.01–9.16]), minimally invasive surgery (IRT score = 7.77 [95% CI: 5.96–9.07]), early in-dwelling catheter removal (IRT score = 7.69 [95% CI: 5.83–9.01]), pre-operative smoking cessation (IRT score = 7.68 [95% CI: 5.49–9.18]), pre-operative counselling (IRT score = 7.44 [95% CI: 5.58–8.88]), avoiding drains in colon surgery (IRT score = 7.37 [95% CI: 5.17–8.95]), avoiding nasogastric tubes (IRT score = 7.29 [95% CI: 5.32–8.8]) and early drain removal in rectal surgery (IRT score = 5.64 [95% CI: 3.49–7.66]).ConclusionsThis survey has demonstrated the current attitudes of colorectal surgeons from Australia and New Zealand regarding ERAS interventions. Eight of the interventions assessed in this study including pre-operative iron infusion for anaemic patients, minimally invasive surgery, early in-dwelling catheter removal, pre-operative smoking cessation, pre-operative counselling, avoidance of drains in colon surgery, avoiding nasogastric tubes and early drain removal in rectal surgery should be considered an important part of colorectal ERAS programmes.

Highlights

Enhanced Recovery after Surgery (ERAS) programmes have been shown to improve morbidity, recovery and hospital length of stay (LOS) in both laparoscopic and open colorectal surgery [1, 2]
We provide a Likert Scale analysis with item response theory (IRT) statistical modelling to rank the ERAS interventions in order of importance, and provide a recommendation based on specialist colorectal surgeons’ opinions and attitudes for the interventions that should be considered an important part of any ERAS programme
ERAS Society guidelines, American Society of Colorectal Surgeons (ASCRS) guidelines and American College of Surgeons National Surgical Quality Improvement Programme (NSQIP) data variables were used to inform the elements of ERAS assessed in this survey [3, 4, 8], of which eighteen ERAS interventions were evaluated in this survey

Summary

Introduction

Enhanced Recovery after Surgery (ERAS) programmes have been shown to improve morbidity, recovery and hospital length of stay (LOS) in both laparoscopic and open colorectal surgery [1, 2]. Whilst Enhanced Recovery after Surgery (ERAS) has been widely accepted in the international colorectal surgery community, there remains significant variations in ERAS programme implementations, compliance rates and best practice recommendations in international guidelines. Of eighteen ERAS interventions, this study identified eight strategies as most effective in improving ERAS programmes alongside early oral feeding and mobilisation These included pre-operative iron infusion for anaemic patients (IRT score = 7.82 [95% CI: 6.01–9.16]), minimally invasive surgery (IRT score = 7.77 [95% CI: 5.96–9.07]), early in-dwelling catheter removal (IRT score = 7.69 [95% CI: 5.83–9.01]), pre-operative smoking cessation (IRT score = 7.68 [95% CI: 5.49–9.18]), pre-operative counselling (IRT score = 7.44 [95% CI: 5.58–8.88]), avoiding drains in colon surgery (IRT score = 7.37 [95% CI: 5.17–8.95]), avoiding nasogastric tubes (IRT score = 7.29 [95% CI: 5.32–8.8]) and early drain removal in rectal surgery (IRT score = 5.64 [95% CI: 3.49–7.66]). Eight of the interventions assessed in this study including pre-operative iron infusion for anaemic patients, minimally invasive surgery, early in-dwelling catheter removal, pre-operative smoking cessation, preoperative counselling, avoidance of drains in colon surgery, avoiding nasogastric tubes and early drain removal in rectal surgery should be considered an important part of colorectal ERAS programmes

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