Enhanced Recovery After Surgery Compliance Research Articles

NSQIP audit of enhanced recovery after surgery protocols for radical cystectomy.

11009 Background: Utilization of enhanced recovery after surgery (ERAS) protocols for radical cystectomy (RC) has been associated with improved postoperative recovery and shorter hospital stays. The multiple components within ERAS leads itself to heterogenous implementation across different institutions. We aimed to assess the impact of increasing compliance to ERAS components on postoperative outcomes in patients who underwent RC. Methods: The National Surgical Quality Improvement Program database included 3,708 patients who underwent RC from 2019 to 2021. ERAS components of interest included regional anesthesia block, no bowel prep, no prolonged NGT or NPO status, VTE prophylaxis with mechanical and pharmacologic means, and antibiotic duration < 24 hours. Baseline characteristics and complications were stratified by number of ERAS components utilized (≤ 3, 4, or 5). Statistical endpoints included thirty-day complications, length of stay (LOS), and readmissions. Optimal RC outcome was defined as absence of any postoperative complication, reoperation, prolonged LOS (75th percentile, 8 days) with no readmission. Multivariable analyses with Bonferroni correction were performed to assess the association between ERAS compliance and outcomes. Results: Of the 3,708 patients who underwent RC with ERAS components utilized, 1,506 (41%) received ≤ 3 interventions, 1454 (39%) received 4, and 748 (20%) received 5. Baseline characteristics were relatively similar across the three groups. On multivariable analysis adjusted for multiple hypothesis testing, when compared to patients who received ≤ 3 interventions, patients who received 4 and 5 interventions had lower rates of any complication (OR 0.71; 99% CI [0.58 - 0.88], OR 0.74 [0.57 - 0.95], respectively), and shorter LOS (β -1.32 [-1.69, -0.95], β -1.74 [-2.19, -1.28], respectively). Moreover, patients with increased ERAS compliance experienced increased odds of an optimal outcome (OR 1.68 [1.38 – 2.05], OR 1.97 [1.55 – 2.51], respectively). Conclusions: Greater adherence to ERAS protocol interventions yielded superior post-operative outcomes for patients who underwent RC. This large-scale analysis supports that ERAS protocols are beneficial in a dose-dependent fashion and should be utilized. [Table: see text]

Compliance to enhanced recovery program in liver resection surgery: A retrospective cohort study

Abstract Background and Aims: Liver resection is a complex surgery, and optimizing recovery is critical to ensure that patients can promptly regain their health and quality of life. The authors present a retrospective cohort study on Enhanced Recovery After Surgery (ERAS) in liver resection aimed at correlating compliance with ERAS elements to length of stay (LOS) and the incidence of complications in a tertiary-level cancer hospital in Eastern India. Material and Methods: In total, 44 hepatectomy patients were assessed retrospectively from June 2022 to May 2023. Data were collected from electronic medical records and patient charts. Results: The overall compliance was 77.7%. Individual component compliance varied. Lower compliance rates were seen with some aspects such as fasting and carbohydrate loading, minimally invasive surgical techniques used, and avoidance or early removal of the drain. The cohort was divided into two groups. Group 1 had compliance to ≥75% of 21 elements of ERAS, and group 2 had compliance to <75%. Statistical analysis showed higher ERAS compliance and reduced complications, although LOS differences were not statistically significant (group 1 and group 2 with an LOS difference of 1 day). Severe complications such as re-exploration and death were noted in the group of patients with compliance to less than 75% of the components. Conclusion: With increased ERAS compliance, the patients benefited clinically and financially.

Impact of ERAS compliance on the short-term outcomes for distal radius surgery: a single-center retrospective study

BackgroundDistal radius fractures (DRF) account for one in five bony injuries in both primary and secondary trauma care. Enhanced recovery after surgery (ERAS) has been adopted successfully to improve clinical outcomes in multiple surgical disciplines; however, no study has investigated the effect of different degrees of compliance with ERAS protocol on short-term outcomes following distal radius surgery. We aimed to analyze whether different degrees of compliance with the ERAS pathway are associated with clinical improvement following surgery for DRF.MethodsWe retrospectively analyzed all consecutive patients with ERAS who underwent surgery for DRF at our department between May 2019 and October 2022. Their pre-, peri-, and post-operative compliance with the 22 elements of the ERAS program were assessed. We compared parameters between low- (< 68.1%) and high-compliance (> 68.1%) groups, including patient complications, total length of hospitalization, discharge time after surgery, hospital costs, time taken to return to preinjury level performance level, number of visual analogue scale (VAS) pain scores > 3 points during hospitalization, disabilities of the arm, shoulder and hand (DASH) scores. We performed multiple linear regression analyses to assess the impact of ERAS compliance on the postoperative function level (DASH scores).ResultsNo significant differences were detected between the high- and low-compliance groups with respect to demographics, including sex, age, body mass index (BMI), and comorbidities (P > 0.05). We observed significant differences between the high- and low-compliance groups in terms of the DASH score (32.25 ± 9.97 vs. 40.50 ± 15.65, p < 0.05) at 6 months postoperatively, the discharge time after surgery (2.45 ± 1.46 vs. 3.14 ± 1.50, p < 0.05), and number of times when the VAS pain score was > 3 points during hospitalization (0.88, [0.44, 1.31], p < 0.05). Our study demonstrated a significant negative association between ERAS compliance and the function level of patients postoperatively (DASH scores) when adjusted for age, comorbidity, sex, and BMI.ConclusionsThis study provided a realistic evaluation and comparison of the ERAS protocol among patients with DRF and can guide clinical decision making. The ERAS protocol may improve outcomes after surgery, with high postoperative function levels and reduced pain and discharge time after surgery, without increased complication rates or hospital costs.

Impact of an enhanced recovery after surgery program with a multimodal analgesia care pathway on opioid prescribing and clinical outcomes for patients undergoing colorectal surgery

Background Opioids are a mainstay for acute pain management, but their side effects can adversely impact patient recovery. Multimodal analgesia (MMA) is recommended for treatment of postoperative pain and has been incorporated in enhanced recovery after surgery (ERAS) protocols. The objective of this quality improvement study was to implement an MMA care pathway as part of an ERAS program for colorectal surgery and to measure the effect of this intervention on patient outcomes and costs. Methods This pre-post study included 856 adult inpatients who underwent an elective colorectal surgery at three hospitals within an integrated healthcare system. The impact of ERAS program implementation on opioid prescribing practices, outcomes, and costs was examined after adjusting for clinical and demographic confounders. Results Improvements were seen in MMA compliance (34.0% vs 65.5%, P < 0.0001) and ERAS compliance (50.4% vs 57.6%, P < 0.0001). Reductions in mean days on opioids (4.2 vs 3.2), daily (51.6 vs 33.4 mg) and total (228.8 vs 112.7 mg) morphine milligram equivalents given during hospitalization, and risk-adjusted length of stay (4.3 vs 3.6 days, P < 0.05) were also observed. Conclusions Implementing ERAS programs that include MMA care pathways as standard of care may result in more judicious use of opioids and reduce patient recovery time.

Enhanced Recovery After Surgery Protocols in Obese Gynecological Oncology Patients: A Single-Center Experience.

Objective The aim of this study is to present our experience and evaluate the safety and outcomes of the implementation of EnhancedRecoveryAfterSurgery (ERAS) protocols in obese patients who underwent surgery for suspected or confirmed gynecological malignancies. Method From January 2020 to September 2021, 217 patients underwent laparotomy for a confirmed or suspected gynecological malignancy following a 19-element ERAS pathway. The patients were divided into two groups: obese (BMI≥ 30 kg/m2, n = 104) and non-obese (BMI < 30, n =113). Both groups were treated with a 19-element ERAS protocol. Results After dividing the 217 patients into two groups, significantly more comorbidities were observed in the obese group (diabetes mellitus: 23% vs. 8%, p = 0.004; ASA score grade 3: 25.0% vs. 6.2%, p < 0.001), as well as higher rates of endometrial cancer (51.9% vs. 17.7%, p < 0.001) compared to the non-obese group. The overall ERAS compliance rates when matched element by element were similar. Postoperatively, complication rates of all grades were significantly higher in the obese group (46.1% vs. 27.4%, p < 0.001) without differences in the length of stay, readmission, and reoperation rates. Conclusion In this retrospective study, we showed that obese gynecological oncology patients can be safely managed with ERAS protocols perioperativelywhile potentially minimizing the adverse outcomes in these otherwise high-risk patients.

Compliance with enhanced recovery after surgery predicts long-term outcome after hepatectomy for cholangiocarcinoma.

Enhanced recovery after surgery (ERAS) program has been proved to improve postoperative outcome for many surgical procedures, including liver resection. There was limited evidence regarding the feasibility and benefit of ERAS in patients who underwent liver resection for cholangiocarcinoma. To evaluate the feasibility of ERAS in patients who underwent liver resection for cholangiocarcinoma and its association with patient outcomes. We retrospectively analyzed 116 cholangiocarcinoma patients who underwent hepatectomy at Srinagarind Hospital, Khon Kaen University between January 2015 and December 2016. The primary outcome was the compliance with ERAS. To determine the association between ERAS compliance and patient outcomes. the patients were categorized into those adhering more than and equal to 50% (ERAS ≥ 50), and below 50% (ERAS < 50) of all components. Details on type of surgical procedure, preoperative and postoperative care, tumor location, postoperative laboratory results, and survival time were evaluated. The compliance with ERAS was measured by the percentage of ERAS items achieved. The Kaplan-Meier curve was used for survival analysis. The median percentage of ERAS goals achieved was 40% (± 12%). Fourteen patients (12.1%) were categorized into the ERAS ≥ 50 group, and 102 patients were in the ERAS < 50 group. Postoperative hospital stay was significantly shorter in the ERAS ≥ 50 group [8.9 d, 95% confidence interval (CI): 7.3-10.4 d] than in the ERAS < 50 group (13.7 d, 95%CI: 12.2-15.2 d) (P = 0.0217). No hepatobiliary-related complications or in-hospital mortality occurred in the ERAS ≥ 50 group. Overall survival was significantly higher in the ERAS ≥ 50 group. The median survival of the patients in the ERAS < 50 group was 1257 d (95%CI: 853.2-1660.8 d), whereas that of the patients in the ERAS ≥ 50 group was not reached. Overall ERAS compliance for patients who underwent liver resection for cholangiocarcinoma is poor. Greater ERAS compliance could predict in-hospital, short-term, and long-term outcomes of the patients.

Comparison of Enhanced Recovery After Surgery (ERAS) metrics by race among gynecologic oncology patients: Ensuring equitable outcomes

ObjectivesRace and ethnicity are not routinely audited in Enhanced Recovery After Surgery (ERAS) pathways. Given known racial disparities in outcomes in gynecologic oncology, the purpose of this study was to compare differences in ERAS implementation and outcomes by race. MethodsA cohort study was performed among gynecologic oncology patients enrolled in an ERAS pathway at one academic institution from March 2017 to December 2021. Compliance with ERAS metrics, postoperative complications, 30-day survival, reoperations, intensive care unit (ICU) transfers, and readmissions within 30 days were compared by race. ResultsOf 1083 patients (17.0% non-white), non-white women were younger (54.2 years ±13.1 vs. 60.7 years ±13.6, p < 0.001) and proportionally fewer spoke English (75.0% vs. 97.8%, p < 0.001). Fewer non-white women received preadmission ERAS education (73.4% vs. 79.9%, p = 0.05). There were no differences in ERAS implementation by race, including similar rates of preoperative nutritional assessment, carbohydrate loading, antibiotic and thrombosis prophylaxis, and unplanned surgeries by race. There were no differences in complications, reoperations, ICU transfers, or readmissions by race on univariate and multivariate analysis. Four non-white (2.2%) and two white women (0.2%, p = 0.009) died within 30 days of surgery. ConclusionsFewer non-white women received preadmission education, possibly due to language barriers. ERAS compliance, postoperative complications, readmissions, reoperations, and ICU transfers did not differ by race. There were two additional deaths within 30 days postoperatively among non-white women compared to white women - which is difficult to interpret given the rarity of perioperative mortality - but appeared unlikely to be related to differences in ERAS protocol implementation. ERAS programs should ensure educational materials are translated into various languages and audit metrics by race to ensure equitable outcomes.

ERAS failure and major complications in elective colon surgery: Common risk factors

• Male sex, ASA IV, open surgery, and low albumin level predict ERAS failure in colon surgery. • 70% ERAS compliance associates with fewer complications and shorter stay after colon surgery. • Open surgery and failure to mobilize postoperatively predict increased risk of major complications. • Adequate ERAS compliance correlates with decreased mortality. Proper implementation and practice of an Enhanced Recovery After Surgery (ERAS) protocol streamlines perioperative management to its optimum, resulting in fewer complications and lower costs. This study aims to identify potential risk factors for the failure of ERAS and for major postoperative complications in patients with elective colon resection. This was a single center retrospective analysis including all consecutive patients for elective colon resection during June 2017 - June 2019. All patients were treated within an upgraded ERAS program. 908 patients were included. Median ERAS compliance was 67%. Over 70% compliance was associated with a significantly lower median complication index and a shorter median hospital stay and was set as threshold in further analyses. In a multivariate regression analysis, male gender, American Society of Anesthesiologists Physical Status (ASA PS) Classification IV, open surgery, and albumin level < 34 independently predicted increased risk for failure of ERAS. Furthermore, multivariate analyses revealed that male gender, cancer in the right hemicolon/transverse colon/splenic flexure, open surgery, failure to mobilize postoperatively, and administration of > 60 mg oxycodone postoperatively, independently predicted increased risk of postoperative ileus. Volvulus as primary diagnosis, conversion of laparoscopy to open surgery, failure to mobilize postoperatively, and preoperative hemoglobin < 100 g/l were found to independently predict increased risk of anastomotic dehiscence. We suggest that patients of male gender, high ASA class, challenged mobility, and higher risk in open surgery, be managed with powered preoperative counseling, including rigorous physiotherapy, and operated on by two senior colorectal surgeons, in order to diminish the risk of conversion to open surgery and of postoperative complications.

Early postoperative ERAS compliance predicts decreased length of stay and complications following liver resection.

Enhanced recovery after surgery (ERAS) components for liver resection lack standardization and compliance. We evaluated our ERAS protocol and describe the association of postoperative ERAS compliance with length of stay (LOS) and complications. We retrospectively reviewed patients undergoing liver resection at our institution from 2016 to 2020. Pre- and post-ERAS outcomes and compliance at 72h were compared with LOS and complications. LOS beyond 72h was defined as LOS72. 210 patients were included. Post-ERAS patients had significantly shorter LOS (5.1 vs. 7.3 days, p=0.0014) with no difference in 30-day mortality, morbidity, or readmissions. ERAS components associated with shorter LOS72 were regular diet (HR 1.73), fluid discontinuation (HR 1.63), drain removal (HR 1.94), multimodal and oral analgesia (HR 1.51), and ambulation >100ft (HR 2.23). LOS72 was 1-day for ≥9 ERAS component compliance, 4-days for 6-8 components, and 6-days for <6 components. 30-day complication rates for patients with ≥9 components by postoperative day 3 (POD3) were significantly lower than those with 6-8 (12 vs 32%). ERAS decreases LOS after liver resection. Nutritional advancement, drain discontinuation, multimodal and oral analgesia, and ambulation >100ft by POD3 are associated with decreased LOS72. Achieving ≥6 components by POD3 predicts decreased LOS72 and complications.

HERO-Trial: Integration of self-hypnosis in an enhanced recovery after surgery program: A prospective randomized trial (115)

<b>Objectives:</b> Self-hypnosis (SH) induces patients into a relaxed state that may include feelings of dissociation through deep breathing and guided imagery. Studies have shown that SH can reduce patient distress prior to surgery and postoperative pain and anxiety. We evaluated whether adding SH to our enhanced recovery after surgery (ERAS) pathway was feasible and if it could improve patient-reported pain and anxiety and further decrease opioid use. <b>Methods:</b> Patients scheduled for open gynecologic surgery were randomized to either standard ERAS care or ERAS + SH. The 20-minute, 3D, SH audio recording was based on a well-validated medical hypnosis script. Patients in the SH arm were asked to listen to the audio file at least twice before surgery, although they had access to use it ad-lib after consent. The feasibility endpoint was defined as 60% of patients listening to the entire SH audio file in the preoperative holding area. The primary effectiveness outcome was worst pain on POD 1 (24-hour recall) on a 0-10 scale, assessed with the MDASI-PeriOpGYN. Secondary outcomes included anxiety, quality of life, symptom burden, time to the first opioid, quality of recovery (QoR-15), and morphine equivalent daily dose (MEDD) on POD 0-3. Hypnotic suggestibility was assessed by the Tellegen Absorption scale. Expectations and manageability of postoperative symptoms were assessed by the Side-Effect Expectancy Questionnaire (SEEQ). Satisfaction with the SH experience was evaluated. Summary statistics, Fisher's exact test (categorical variables), and Wilcoxon rank-sum test (continuous variables) were utilized. <b>Results:</b> A total of 152 patients were randomized and 138 had surgery and were evaluable (ERAS: <i>n</i> = 67; ERAS+SH: <i>n</i> = 71) (Table 1). Incorporation of SH was considered feasible, with 77.5% of ERAS+SH patients able to listen to the entire SH audio file in the preoperative holding unit. The study was stopped early due to futility in achieving the primary effectiveness outcome (pain on POD1). There were no significant differences in the primary outcome of worst pain on POD 1 (ERAS: 6/10; ERAS+SH: 7/10) (p=.70). The median age was 61 years in the ERAS arm and 54 years in the ERAS+SH arm (Table 1 for demographics). There were no significant differences in ERAS compliance, anesthesia type, or length of stay. No significant differences between the groups were noted on expectations, perceived ability to manage postoperative symptoms or hypnotic suggestibility. Median scores on the five satisfaction questions were 8/10 or above. There were no differences in median preoperative anxiety scores between the arms (ERAS: 4, IQR: 1-6; ERAS+SH: 4, IQR: 3-7). In the ERAS+SH arm, anxiety scores decreased significantly after the SH intervention in the preoperative holding unit -2 points (IQR:-3,-1) to a median score of 2 (p<.001). There were no significant differences in median MEDD on POD 0-3 between the two arms (daily median MEDD ranged from 0-15) or time to the first opioid. The quality of recovery score on the day of discharge was not significantly different between groups (ERAS: 110, IQR: 92-127; ERAS+SH: 107, IQR: 88-121). <b>Conclusions:</b> Incorporating SH into an ERAS pathway was feasible with high levels of satisfaction. While the SH intervention led to a statistically and clinically significant decrease in self-reported anxiety levels preoperatively, there were no group differences in self-reported pain, quality of recovery, time to the first opioid, or hospital MEDD. Given the ease of accessing and listening to an audio file, this SH intervention can be easily integrated into perioperative care to decrease preoperative anxiety.

Enhanced recovery after surgery (ERAS) program in octogenarian patients: a propensity score matching analysis on the "Lazio Network" database.

The aim of this study was to evaluate the safety and compliance with the enhanced recovery after surgery (ERAS) protocol in octogenarian patients undergoing colorectal surgery in 12 Italian high-volume centers. A retrospective analysis was conducted in a consecutive series of patients who underwent elective colorectal surgery between 2016 and 2018. Patients were grouped by age (≥ 80years vs < 80years), propensity score matching (PSM) analysis was performed, and the groups were compared regarding clinical outcomes and the mean number of ERAS items applied. Out of 1646 patients identified, 310 were octogenarians. PSM identified 2 cohorts of 125 patients for the comparison of postoperative outcomes and ERAS compliance. The 2 groups were homogeneous regarding the clinical variables and mean number of ERAS items applied (11.3 vs 11.9, p-ns); however, the application of intraoperative items was greater in nonelderly patients (p 0.004). The functional recovery was similar between the two groups, as were the rates of postoperative severe complications and 30-day mortality rate. Elderly patients had more overall complications. Furthermore, the mean hospital stay was higher in the elderly group (p 0.027). Multivariable analyses documented that postoperative stay was inversely correlated with the number of ERAS items applied (p < 0.0001), whereas age ≥ 80years significantly correlated with the overall complication rate (p 0.0419). The ERAS protocol is safe in octogenarian patients, with similar levels of compliance and surgical outcomes. However, octogenarian patients have a higher rate of overall complications and a longer hospital stay than do younger patients.

Enhanced Recovery After Surgery Protocol for Oblique Lumbar Interbody Fusion.

Enhanced recovery after surgery (ERAS) attempts to decrease the surgical stress response to minimize postoperative complications and improve functional rehabilitation after major surgery, but it has not been widely utilized in spinal surgery. The study reported the development and implementation of an ERAS pathway for patients with lumbar spondylolisthesis undergoing oblique lumbar interbody fusion (OLIF). Seventy-six patients underwent OLIF surgery from January 2018 to December 2019 were enrolled. Thirty-seven patients were included in pre-ERAS group and 39 patients were included in ERAS group. Major outcomes that were collected included demographics, comorbidities, blood loss, operative time, length of hospital stay (LOS), cost, time to walk, blood transfusion, complications, Visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) and factors affecting LOS were also recorded. The ERAS pathway and compliance with pathway elements were also recorded. After ERAS implementation, the blood loss, LOS, the financial costs, and the time to walk were significantly lower in the ERAS group compared to the pre-ERAS group (all P < 0.05). There was no significant difference in operative time, complications, and blood transfusion between both groups. VAS and ODI between the two groups showed a significant difference during postoperative 3days and postoperative 1month (both P < 0.05). The preoperative time to walk was significant factors for hospital stay at the final follow-up. Institution of an ERAS protocol for OLIF surgery appears to accelerate functional recovery, reduce length of stay and financial costs.

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

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.

Association between compliance with enhanced recovery after surgery (ERAS) protocols and postoperative outcome in patients with primary liver cancer undergoing hepatic resection

BackgroundEnhanced recovery after surgery (ERAS) is a multidisciplinary, stress-minimizing approach that is associated with improved postoperative outcomes. However, whether the level of compliance with ERAS protocols impacts the postoperative outcome of patients with primary liver cancer undergoing liver resection is unknown. The study aimed to analyze the association between compliance with ERAS protocols and liver resection outcomes.MethodsThis prospective cohort study consecutively recruited patients with primary liver cancer who were scheduled for elective liver surgery between January 2019 and December 2020 at the Department of Biliary Surgery, West China Hospital of Sichuan University. Twenty individual ERAS items were assessed in all patients. The patients were divided into two groups according to their degree of compliance with the ERAS interventions: an ERAS-compliant (ERAS-C) group of individuals who complied with over 75% of the ERAS components and an ERAS-noncompliant (ERAS-N) group. The primary outcomes were ERAS compliance, occurrence of major complications within 30 days postoperatively, and length of postoperative hospital stay. The secondary outcomes were 30-day readmissions, reoperations and other rehabilitation indicators. The study was registered at www.chictr.org.cn (identity number ChiCTR2000040021).ResultsOverall, 436 patients were enrolled; their mean age was 54 years (interquartile range [IQR], 47–66). Of these patients, 206 were allocated to the ERAS-C group, and the other 230 patients comprised the ERAS-N group. The overall compliance rate was 70% (IQR, 65%-80%). The ERAS-C group had higher compliance rates [80.00% (IQR, 75.00–85.00%)] than the ERAS-N group [65.00% (IQR, 65.00–70.00%)], P < 0.001). The ERAS-C group had significantly fewer major complications (7.77% vs. 15.65%, OR, 0.449, 95% CI, 0.241–0.836, P = 0.012) and shorter postoperative hospital stays (5 days [IQR, 4–6] vs. 6 days [IQR, 5–7], P < 0.001) than the ERAS-N group. Subgroup analysis indicated that compliance rates greater than 80%, between 65 and 80%, and lower than 65% were associated with decreased major complication rates (6.25%, 8.48% and 22.83%, respectively) and shorter postoperative hospital stays. However, the rates of ICU stay, readmission, reoperation and mortality within 30 days after surgery were not different between groups (P > 0.05).ConclusionThe results of this study suggest that higher compliance with ERAS components is associated with a lower incidence of major postoperative complications and a shorter postoperative hospital stay.

Implementation and improvement of Enhanced Recovery After Surgery protocols for colorectal cancer surgery.

PurposeEnhanced Recovery After Surgery (ERAS) reduces postoperative complications and shortens hospital stays. We aimed to describe the implementation and improvement of ERAS protocols in our institution through a multidisciplinary team approach.MethodsA multidisciplinary team comprised of colorectal surgeons, anesthesiologists, nurses, pharmacists, nutritionists, and a performance improvement team was launched to develop the ERAS protocol. The ERAS protocol was followed in patients who underwent colonic and rectal surgery between January and November 2017. The ERAS protocol comprised 22 elements in the preoperative, intraoperative, and postoperative phases. After the initial application, ERAS compliance was monitored and audited every 4–6 months and improvements made as necessary.ResultsThe length of hospital stay significantly decreased after the application of the ERAS protocols for colon cancer in 2017 and 2018. And there was no significant difference in the duration of hospital stay after applying the rectal cancer ERAS protocol. Moreover, after starting the colon ERAS, there was a significant decrease in the complication rate. Since December 2017, there was a continuous increase in the colorectal ERAS clinical pathway application rate, which remained high (>90%). The patient compliance rate significantly increased between 2017 and 2018, but slightly decreased again in 2019.ConclusionThe application and continual improvement of an ERAS protocol are crucial. Improving compliance may result in better clinical outcomes. Additionally, the basic guidelines of ERAS must be applied and developed according to each hospital’s situation based on the team approach.

Early Postoperative ERAS Compliance is Associated with Decreased Length of Stay and Complications Following Liver Resection

Introduction: Enhanced recovery after surgery (ERAS) criteria for hepatectomy lack standardization and compliance. We evaluated our ERAS protocol and describe the association of postoperative ERAS compliance with length of stay (LOS) and complications.

Observations from Implementation of the ERAS Protocol after DIEP Flap Breast Reconstruction.

The Enhanced Recovery After Surgery (ERAS) protocol is a multivariate intervention requiring the help of several departments, including anesthesia, nursing, and surgery. This study seeks to observe ERAS compliance rates and obstacles for its implementation at a single academic institution. This is a retrospective study looking at patients who underwent deep inferior epigastric perforator (DIEP) flap breast reconstruction from January 2016 to September 2019. The ERAS protocol was implemented on select patients early 2017, with patients from 2016 acting as a control. Thirteen points from the protocol were identified and gathered from the patient's electronic medical record (EMR) to evaluate compliance. Two hundred and six patients were eligible for the study, with 67 on the control group. An average of 6.97 components were met in the pre-ERAS group. This number rose to 8.33 by the end of 2017. Compliance peaked with 10.53 components met at the beginning of 2019. The interventions most responsible for this increase were administration of preoperative medications, goal-oriented intraoperative fluid management, and administration of scheduled gabapentin postoperatively. The least met criterion was intraoperative ketamine goal of >0.2 mg/kg/h, with a maximum compliance rate of 8.69% of the time. The introduction of new protocols can take over a year for full implementation. This is especially true for protocols as complex as an ERAS pathway. Even after years of consistent use, compliance gaps remain. Staff-, patient-, or resource-related issues are responsible for these discrepancies. It is important to identify these issues to address them and optimize patient outcomes.

Risk of venous thromboembolism for ovarian cancer patients during first-line therapy after implementation of an Enhanced Recovery After Surgery (ERAS) protocol

<h3>Objectives:</h3> Patients with ovarian cancer have been shown to have high rates of venous thromboembolism (VTE), with previous studies reporting an up to 16% overall incidence of symptomatic VTE, and a 7.5% cumulative incidence of VTE within the first 30 days after surgery. The goal of this study is to determine the updated incidence and risk factors for VTE for patients with advanced epithelial ovarian cancer undergoing first-line therapy, including cytoreductive surgery, on an Enhanced Recovery After Surgery (ERAS) protocol. <h3>Methods:</h3> Medical records were reviewed for all patients with FIGO stage IIIA-IVB epithelial ovarian, fallopian tube, or primary peritoneal cancer undergoing primary or interval cytoreductive surgery from March 2017 through September 2019 at a single institution. All patients were enrolled on an ERAS protocol, including 28-day postoperative VTE prophylaxis. Demographic information, past medical history, perioperative characteristics, and ERAS compliance were collected and evaluated using univariate and multivariate Cox proportional hazards models. <h3>Results:</h3> Of 230 patients undergoing cytoreductive surgery via laparotomy, 155 received neoadjuvant chemotherapy and 75 received primary cytoreduction. 38 patients had a VTE during the study period. 13 events (5.7%) were identified at time of diagnosis, 6 (3.9%) during neoadjuvant chemotherapy, 5 (2.2%) within 30 days after surgery, 5 (2.2%) between 30 days and 6 months after surgery, and 9 (3.9%) after the 6-month window. The cumulative incidence of VTE was 6.1% (95% CI, 4.3-8.8%) within 6 months after diagnosis and 8.5% (6.2-11.4%) within 1 year after diagnosis. Estimated blood loss (adjusted HR 1.22 [95% CI, 1.09-1.36], p=0.001) and history of VTE (7.06 [2.34-21.29], p=0.001) were independently associated with VTE. <h3>Conclusions:</h3> With implementation of an ERAS protocol and 28-day postoperative VTE prophylaxis, only 1 in 46 patients experienced a VTE within 30 days after surgery, a rate markedly lower than historically reported for cytoreductive procedures. However, overall VTE occurred in 1 in 16 patients during first-line therapy. Half of the venous thromboembolic events occurred prior to surgery and 36.8% occurred more than 30 days after surgery. Strategies to further reduce VTE risk, especially during neoadjuvant chemotherapy and surveillance, should be investigated.

Importance of Enhanced Recovery After Surgery (ERAS) Protocol Compliance for Length of Stay in Ovarian Cancer Surgery.

Enhanced Recovery After Surgery (ERAS) programs include multiple perioperative care elements, which when implemented together are designed to improve recovery after surgery with subsequent reduction in hospital length of stay (LOS). The aim of this study is to examine the impact of ERAS protocol compliance on LOS in patients undergoing advanced ovarian cancer surgery within the context of a randomized clinical trial. Patients were enrolled in a prospective, consecutive, interventional randomized clinical trial between June 2014 and March 2018. Women with either suspected or confirmed advanced ovarian cancer with International Federation of Gynecology and Obstetrics (FIGO) stages IIB-IVA and recurrent ovarian cancer, who underwent cytoreduction surgery, were randomly assigned to either a conventional management (CM) protocol or an ERAS protocol. Demographic items, preoperative clinical data, and surgical characteristics of patients were recorded, as were LOS and ERAS protocol compliance. Negative binomial regression was used to model the relation between length of stay and ERAS protocol compliance. We included 49 patients in the CM group and 50 patients in the ERAS group. The overall rate of ERAS compliance was 92%. We observed that increasing ERAS protocol compliance was associated with shorter median LOS, and in patients who underwent higher complex surgeries, the length of stay reduction was greater. This study identifies a correlation between increasing ERAS protocol compliance and decreasing LOS in ovarian cancer surgery. This finding underlines the necessity to implement as many ERAS protocol elements as possible to achieve optimal clinical outcome improvements.

Risk of venous thromboembolism for ovarian cancer patients during first-line therapy after implementation of an Enhanced Recovery After Surgery (ERAS) protocol

ObjectiveTo determine incidence and risk factors for VTE for patients with advanced epithelial ovarian cancer undergoing first-line therapy, including cytoreductive surgery, on an Enhanced Recovery After Surgery (ERAS) protocol. MethodsMedical records were reviewed for patients with FIGO stage IIIA-IVB epithelial ovarian, fallopian tube, or primary peritoneal cancer undergoing primary or interval cytoreductive surgery from March 2017 through September 2019. All patients were enrolled on an ERAS protocol, including 28-day postoperative VTE prophylaxis. Demographic information, medical history, perioperative characteristics, and ERAS compliance were evaluated using univariate and multivariate models. ResultsOf 230 patients undergoing cytoreductive surgery via laparotomy, 155 received neoadjuvant chemotherapy and 75 received primary cytoreduction. 38 patients had a VTE during the study period. 13 events (5.7%) were identified at time of diagnosis, 6 (3.9%) during neoadjuvant chemotherapy, 5 (2.2%) within 30 days after surgery, 5 (2.2%) between 30 days and 6 months after surgery, and 9 (3.9%) after the 6-month window. The cumulative incidence of VTE was 6.1% (95% CI, 4.3–8.8%) within 6 months after diagnosis and 8.5% (6.2–11.4%) within 1 year after diagnosis. Estimated blood loss (adjusted HR 1.22 [95% CI, 1.09–1.36], p = 0.001) and history of VTE (7.06 [2.34–21.29], p = 0.001) were independently associated with VTE. ConclusionWith implementation of an ERAS protocol, only 1 in 46 patients experienced a VTE within 30 days after surgery. However, overall VTE occurred in 1 in 16 patients during first-line therapy. Strategies to further reduce VTE risk, especially during neoadjuvant chemotherapy and surveillance, should be investigated.