Implementation Of Enhanced Recovery Program Research Articles

Which individual components of a colorectal surgery enhanced recovery program are associated with improved surgical outcomes?

BackgroundEnhanced recovery programs improve surgical outcomes. However, the association of adherence to individual components and outcomes in a comprehensive enhanced recovery program remains unclear. MethodsWe performed a retrospective study of all elective colorectal surgery patients at our institution from 2019 to 2022 (n = 1,175). Data were acquired from our institution’s enhanced recovery program dashboard and American College of Surgeons National Surgical Quality Improvement Program database. Traditional analyses and machine-learning classification trees were used to identify enhanced recovery program components associated with length of stay, readmissions, and complication rates. ResultsThe average length of stay was 5.0 days, readmission rate was 12.3%, and complication rate was 32.6%. On linear regression analysis, adherence to preoperative education, regional analgesia, pre- and postoperative multimodal analgesia, no nasogastric tube, early mobilization, early regular diet, early discontinuation of maintenance intravenous fluids, postoperative venous thromboembolism prophylaxis, and early Foley catheter removal were associated with an decrease in length of stay by 0.7–7.1 days (P < .05). Patients who adhered to no prolonged fasting had a 4.1% decrease in readmission rate (P = .04). Patients who adhered to no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and discontinuation of maintenance intravenous fluids had decreases in complication rates ranging from 7.0 to 28.2% (P < .001). Machine learning demonstrated that no nasogastric tube and discontinuation of maintenance intravenous fluids were significant predictors of shorter length of stay and no nasogastric tube and early mobilization were significant predictors of reduced complication rates. ConclusionsAlthough multiple components were associated outcomes, no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and early discontinuation of maintenance intravenous fluids were associated with more than 1 outcome. Focusing on these components may make enhanced recovery program implementation more feasible for resource-limited hospitals.

Impact of enhanced recovery program on clinical outcomes after elective colorectal surgery in a rural hospital. A single center experience

BackgroundThe main purpose was to determine the impact on postoperative outcomes of a standardized enhanced recovery program (ERP) for elective colorectal surgery in a rural hospital. MethodsA prospective series of patients (N = 80) undergoing elective colorectal resection completing a standardized ERP protocol in 2018–2020 (ERP group) was compared to patients (N = 80) operated at the same rural hospital in 2013–2015 (pre-ERP group), before the implementation of the program. The exclusion criteria for both groups were: ASA score IV, TNM stage IV, inflammatory bowel disease, emergency surgery, and rectal cancer. The primary outcome was hospital length of stay (LoS) which was used as an estimate of functional recovery. Secondary outcomes included 30-day readmission and mortality rates as well as associated factors with both postoperative complications and prolonged hospital LoS. ResultsBaseline characteristics were comparable in both groups. The median adherence to ERP protocol elements was 68 % versus 12 % in the retrospective control group. The median hospital LoS in the ERP-group was significantly lower than in the pre-ERP group (5 vs. 10 days) with no increase in 30-day readmission and mortality rates. The Body Mass Index ≥30 and the traditional peri-operative protocol were the associated factors to postoperative complications, while following a traditional peri-operative protocol was the only factor associated with a prolonged hospital LoS (p < 0.0001). ConclusionsAlthough limited hospital resources are perceived as a barrier to ERP implementation, the current experience demonstrates how adopting an ERP program in a rural area is feasible and effective, despite it requires greater effort.

Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study.

It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP. Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined. Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001). The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.

Clinical Impact of an Enhanced Recovery Program for Lower-extremity Bypass.

To determine the association of Enhanced Recovery Program (ERP) implementation with length of stay (LOS) and perioperative outcomes after lower-extremity bypass (LEB). ERPs have been shown to decrease hospital LOS and improve perioperative outcomes, but their impact on patients undergoing vascular surgery remains unknown. Patients undergoing LEB who received or did not receive care under the ERP were included; pre-ERP (January 1, 2016-May 13, 2018) and ERP (May 14, 2018-July 31, 2022). Clinicopathologic characteristics and perioperative outcomes were analyzed. Of 393 patients who underwent LEB [pre-ERP: n = 161 (41%); ERP: n = 232 (59%)], most were males (n = 254, 64.6%), White (n = 236, 60%), and government-insured (n = 265, 67.4%). Pre-ERP patients had higher Body Mass Index (28.8 ± 6.0 vs 27.4 ± 5.7, P = 0.03) and rates of diabetes (52% vs 36%, P = 0.002). ERP patients had a shorter total [6 (3-13) vs 7 (5-14) days, P = 0.01) and postoperative LOS [5 (3-8) vs 6 (4-8) days, P < 0.001]. Stratified by indication, postoperative LOS was shorter in ERP patients with claudication (3 vs 5 days, P = 0.01), rest pain (5 vs 6 days, P = 0.02), and tissue loss (6 vs 7 days, P = 0.03). ERP patients with rest pain also had a shorter total LOS (6 vs 7 days, P = 0.04) and lower 30-day readmission rates (32%-17%, P = 0.02). After ERP implementation, the average daily oral morphine equivalents decreased [median (interquartile range): 52.5 (26.6-105.0) vs 44.12 (22.2-74.4), P = 0.019], while the rates of direct discharge to home increased (83% vs 69%, P = 0.002). This is the largest single-center cohort study evaluating ERP in LEB, showing that ERP implementation is associated with shorter LOS and improved perioperative outcomes.

PERIOPERATIVE CARE IN DIGESTIVE SURGERY: THE ERAS AND ACERTO PROTOCOLS - BRAZILIAN COLLEGE OF DIGESTIVE SURGERY POSITION PAPER.

The concept introduced by protocols of enhanced recovery after surgery modifies perioperative traditional care in digestive surgery. The integration of these modern recommendations components during the perioperative period is of great importance to ensure fewer postoperative complications, reduced length of hospital stay, and decreased surgical costs. To emphasize the most important points of a multimodal perioperative care protocol. Careful analysis of each recommendation of both ERAS and ACERTO protocols, justifying their inclusion in the multimodal care recommended for digestive surgery patients. Enhanced recovery programs (ERPs) such as ERAS and ACERTO protocols are a cornerstone in modern perioperative care. Nutritional therapy is fundamental in digestive surgery, and thus, both preoperative and postoperative nutrition care are key to ensuring fewer postoperative complications and reducing the length of hospital stay. The concept of prehabilitation is another key element in ERPs. The handling of crystalloid fluids in a perfect balance is vital. Fluid overload can delay the recovery of patients and increase postoperative complications. Abbreviation of preoperative fasting for two hours before anesthesia is now accepted by various guidelines of both surgical and anesthesiology societies. Combined with early postoperative refeeding, these prescriptions are not only safe but can also enhance the recovery of patients undergoing digestive procedures. This position paper from the Brazilian College of Digestive Surgery strongly emphasizes that the implementation of ERPs in digestive surgery represents a paradigm shift in perioperative care, transcending traditional practices and embracing an intelligent approach to patient well-being.

Five-Year Sustained Impact of a Thoracic Enhanced Recovery After Surgery Program

BackgroundOur thoracic enhanced recovery program (ERP) decreased the use of postoperative morphine equivalents and hospital costs 1 year after implementation at our tertiary center. The sustainability and potential increasing benefit of this program were evaluated. MethodsFrom 2015 to 2021, we prospectively analyzed the outcomes of patients who underwent elective pleural, pulmonary, or mediastinal operations at our institution. Patients were separated on the basis of the incision (video-assisted thoracoscopic surgery [VATS] or thoracotomy). The ERP protocol was initiated on May 1, 2016, and includes preoperative education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, protective ventilation, and early ambulation. Outcomes of patients before (2015, pre-VATS and pre-thoracotomy) and after (May 1, 2016, to December 31, 2021, ERP-VATS and ERP-thoracotomy) ERP implementation were compared. ResultsThe cohort included 1079 patients (pre-ERP era, n = 224 [21%]; ERP era, n = 855 [79%]). There was a median reduction of 1.5 hospital days per patient for ERP-thoracotomy and 1 hospital day per patient for ERP-VATS. Median postoperative morphine equivalents decreased in both groups (125 vs 45 mg, in ERP-thoracotomy; 84 vs 23 mg, ERP-VATS; P < .001), as did total admission cost ($32,118 vs $23,775, ERP-thoracotomy; $17,367 vs $11,560, ERP-VATS; P < .001). Median total fluid balance during the hospital stay decreased significantly. Rates of postoperative atrial fibrillation and urinary retention decreased across both subgroups. ConclusionsERP for thoracic surgery is sustainable and has been demonstrated to improve patient outcomes, to decrease opioid use, and to lower hospital costs. Therefore, it has the potential to become the standard of care.

Cardiac Enhanced Recovery Program Implementation and Its Effect on Opioid Administration in Adult Cardiac Surgery

In light of the worsening opioid epidemic and nationwide parenteral opioid shortage, our institution created an enhanced recovery after surgery (ERAS) protocol. Our objective was to evaluate our initial experience transitioning to ERAS in cardiac surgery. An institutional cardiac ERAS protocol was implemented in April 2018, consisting of opioid-sparing analgesia, liberalization of fasting and activity restrictions, and goal-directed standardization of perioperative care. Clinical outcomes, opioid administration, and pain scores of patients undergoing nonemergent cardiac surgery were reviewed from March 2017 to July 2018. Patients were propensity score matched into pre-ERAS and transition-to-ERAS (t-ERAS) cohorts and compared by univariate analysis. Of 467 patients, 236 patients were well-matched (118 per cohort). The transition to ERAS resulted in a 79% reduction in morphine equivalents through postoperative day 1 (359.3 mg pre-ERAS vs 75.4 mg ERAS, P < 0.0001). Despite less opioid utilization, t-ERAS patients reported lower pain scores (median 4.88 vs 4.14, P = 0.011). There was no difference in mortality (2% vs 0%, P = 0.498) or postoperative complications including initial hours ventilated (5.3 vs 5.2 hours, P = 0.380), prolonged ventilation (9.3% vs 6.8%, P = 0.473), renal failure (3.4% vs 2.5%, P = 0.701), and ICU length of stay (58.3 vs 70.4 hours, P = 0.272). The transition to cardiac ERAS resulted in significantly reduced opioid administration and improved patient pain scores while maintaining excellent outcomes. Well-supported, multidisciplinary teams of cardiac surgeons, anesthesiologists, and intensivists can dramatically reduce opioid use without sacrificing pain control or excellent clinical outcomes.

1144 How Much Does Colorectal Enhanced Recovery Program Education Affect Knowledge of Newly Joined Junior Doctors? A General District Hospital Re-Audit

Abstract Aim Aim of the study is closing the audit loop on knowledge of colorectal Enhanced Recovery Program (ERP) among newly joined junior doctors in a general district hospital. Original audit showed shortage of awareness and knowledge among newly joined junior doctors. The recommendation was educating them regarding ERP and re-auditing. Method Education through a 30-minute power point presentation, on colorectal ERP, was done among newly joined junior doctors. This was followed by a 12-point questionnaire for testing the knowledge of colorectal ERP protocol among 5 newly joined junior doctors (Senior House Officers, Foundation year 2 and Foundation year 1) in our surgical department in August 2020. Results The responses showed an increase in doctors’ knowledge to 90 % (re-audit) from 52.9% (original audit). An increase of about 40% in their knowledge. The average score of their knowledge was 10.8/12 (90 %). One doctor (20 %) scored 12 out of 12 (12/12), two (40 %) scored 11/12 and two (40 %) scored 10/12. Conclusions The study showed that education of newly joined junior doctors resulted in a substantial improvement in their level of knowledge of colorectal ERP, almost up to the local hospital guidelines target (100 %). The study recommends this education to be an integral part of their induction program not only locally but also nationwide. It highlights the impact of education on colorectal ERP implementation.

Is an enhanced recovery program (ERP) after rectal surgery as feasible as after colonic surgery? A multicentre Francophone study of 870 rectal resections.

Enhanced recovery program (ERP) is well-established in colorectal surgery. Rectal surgery (RS) is known to be associated with high morbidity and prolonged hospital stay, which might explain why ERPs are less applied in this specific group of patients. The aim of this large-scale study was to assess the feasibility of an ERP in RS compared with colonic surgery. This study was a retrospective analysis of a prospective database including 3740 patients eligible for colorectal resection from February 2014 to January 2017 in 75 European Francophone centres. Patients were divided into two groups (colon group C vs. rectum group R). The main endpoint was compliance with ERP components. A subgroup analysis was performed in patients for whom a defunctioning stoma (DS) was required after RS. A total of 3740 patients were included. There were 2870 patients in group C and 870 patients in group R. The overall compliance rate for ERPs was 81.71% in group C and 79.09% in group R. Patients were significantly less mobilized within 24 h in group R. Specific recommendations for RS concerning bowel preparation and abdominal drainage were significantly less implemented. Overall morbidity was significantly higher in group R. Mean length of stay (LOS) was significantly shorter in group C. In the sub-group analysis, a DS was significantly associated with fewer compliance with early mobilization and early feeding, leading to significantly longer LOS (group R). ERP is safe and effective in RS, despite the well-known higher morbidity and LOS compared with colonic surgery. DS could be a limiting factor in ERP implementation after RS.

Implementing an enhanced recovery program after liver surgery. Lessons from 100 cases

Introduction: Implementing an enhanced recovery program (ERP) requires a coherent sequence starting from the preoperative period in order to improve postoperative outcomes. Compliance to the protocol is paramount to ensure protocol success. In the field of liver surgery, risk factors of compliance failure are poorly reported. Methods: Through an ERP (ERAS) dedicated to liver surgery, all consecutive patients who underwent hepatectomy from June to December 2018 were included (n=53). Perioperative outcomes were compared to 50 patients consecutively operated on before June 2018 (pre-ERAS group). Risk factors for compliance failure were identified. Results: There was no difference regarding patient demographics and hepatectomy extent (Table 1). Consequently to the ERP implementation, anaesthesioly and surgery data have evolved with a decrease in intraoperative vascular filling (p=0.005), estimated blood loss (p=0.082) and intraoperative drain (p<0.001). Postoperative time to deperfusion, oral feeding and bowel function recovery significantly decreased in the ERAS group (p=0.001). Postoperative severe morbidity rate (p=0.087) and inhospital length of stay (p=0.031) reduced significantly in the ERAS group. Compliance failure rate was higher in the postoperative period (48%), as compared to preoperatively (30%) and intraoperatively (20%, p<0.001). Upon univariate analysis, ASA>2, extended hepatectomy, low hemoglobin and albumin levels, high intraoperative vascular filling an estimated blood loss were associated with postoperative compliance failure. Upon multivariable analysis, ASA>2 (OR=4.765, p=0.015) and extended hepatectomy (OR=2.864, p=0.014) were independently associated with postoperative compliance failure. Conclusion: After implementing an ERP for liver surgery, peroperative and intraoperative practices have significantly changed, translating into improved postoperative outcomes. Postoperative compliance to the protocol remains challenging to reach, especially in frail patients and after extended hepatectomy. Prehabilitation to control preoperative factors could help improving outcomes.

Enhanced Recovery Program Implementation Eliminates Disparity for Geriatric Patients

Baker, Samantha MD; Malone, Emily MPH; Gleason, Michael MD; Chu, Daniel I. MD, FACS; Kennedy, Gregory D. MD, PhD, FACS; Yang, George MD, FACS; Morris, Melanie S. MD, FACS Author Information

Enhanced recovery program implementation: an evidence-based review of the art and the science

The benefits of enhanced recovery program (ERP) implementation include patient engagement, improved patient outcomes and satisfaction, better team relationships, lower per episode costs of care, lower public consumption of narcotic prescription pills, and the promise of greater access to quality surgical care. Despite these positive attributes, vast numbers of surgical patients are not treated on ERPs, and many of those considered "on pathway" are unlikely to be exposed to a majority of recommended ERP elements. To explain the gap between ERP knowledge and action, this manuscript reviewed formal implementation strategies, proposed a novel change adoption model and focused on common barriers (and corollary solutions) that are encountered during the journey to a fully implemented and successful ERP. Given the nature of this review, IRB approval was not required/obtained. The information reviewed indicates that implementation of best practice is both a science and an art. What many surgeons have learned is that the "soft" skills of emotional intelligence, leadership, team dynamics, culture, buy-in, motivation, and sustainability are central to a successful ERP implementation. To lead teams toward achievement of pervasive and sustained adherence to best practices, surgeons need to learn new strategies, techniques, and skills.

Gut Dysfunction as Etiology for Prolonged Length of Stay after an Enhanced Recovery Program Implementation

Di Nizo, Daniella M. MD, MPH; Hawkins, Alexander T. MD, MPH; Stokes, John W. MD; Geiger, Timothy M. MD, FACS; Wanderer, Jonathan P. MD, MPhil; McEvoy, Matthew D. MD Author Information

Impact of a colorectal enhanced recovery program implementation on clinical outcomes and institutional costs: A prospective cohort study with retrospective control

BackgroundThe enhanced recovery program for perioperative care of the surgical patient reduces postoperative metabolic response and organ dysfunction, accelerating functional recovery. The aim of this study was to determine the impact on postoperative recovery and cost-effectiveness of implementing a colorectal enhanced recovery program in an Italian academic centre. Materials and methodsA prospective series of consecutive patients (N = 100) undergoing elective colorectal resection completing a standardized enhanced recovery program in 2013–2015 (ERP group) was compared to patients (N = 100) operated at the same institution in 2010–2011 (Pre-ERP group) before introducing the program. The exclusion criteria were: >80 years old, ASA score of IV, a stage IV TNM, and diagnosis of inflammatory bowel disease. The primary outcome was hospital length of stay which was used as a proxy of functional recovery. Secondary outcomes included: postoperative complications, 30-day readmission and mortality, protocol adherence, nursing workload, cost-effectiveness, and factors predicting prolonged hospital stay. The ERP group patient satisfaction was also evaluated. ResultsHospital stay was significantly reduced in the ERP versus the Pre-ERP group (4 versus 8 days) as well as nursing workload, with no increase in postoperative complications, 30-day readmission or mortality. ERP group protocol adherence (81%) and patient satisfaction were high. Conventional perioperative protocol was the only independent predictor of prolonged hospital stay. Total mean direct costs per patient were significantly higher in the Pre-ERP versus the ERP group (6796.76 versus 5339.05 euros). ConclusionsImplementing a colorectal enhanced recovery program is feasible, efficient for functional recovery and hospital stay reduction, safe, and cost-effective. High patient satisfaction and nursing workload reduction may also be expected, but high protocol adherence is necessary.

Labelling as reference Centre of GRACE (Groupe francophone de Réhabilitation Améliorée après ChirurgiE) for colorectal surgery: its impact on the implementation of enhanced recovery programme at the University Hospital of Liège

Background: Enhanced recovery programme (ERP) has been used in our hospital since 2005 for selected colorectal surgeries. Since October 2015, after labelling as GRACE reference centre, we included all patients scheduled for elective colorectal surgery in this programme. We assessed the impact of our labelling on the implementation of ERP.Methods: Results of our first 100 patients entered in the GRACE database were analyzed: length of stay, complications, readmission, adherence to the protocol. These results are compared to those of the last 100 patients undergoing colorectal surgery before our labelling.Results: Patients’ characteristics in both groups were similar. The complications rate was similar in both groups. The global length of hospital stay was 4 [5] days vs. 8.5 [8] (median [IQR]), respectively after and before labelling; p < .001. The duration of hospitalization for the different subgroups (age, surgical approach, types of surgery) were significantly shorter after our labelling (respectively: p < .001, p < .01, and p < .05).Conclusions: Our results demonstrate that labelling as reference centre increases the efficiency of the implementation of ERP. The fact that all subgroups of patients benefit from ERP must encourage inclusion of all patients undergoing elective colorectal surgery in ERP.

Enhanced recovery program (ERP) in major laryngeal surgery: building a protocol and testing its feasibility.

SUMMARYEnhanced recovery programs (ERP) represent a multimodal approach to perioperative patient care. The benefits of ERP are well demonstrated in colorectal surgery and Enhanced Recovery After Surgery (ERAS®) programs, that epitomise the ERP concept, have being introduced in different specialties, including vascular, gastric, pancreatic, urogynecologic and orthopaedic surgery. However, no ERP has been proposed for head and neck surgery. We developed an expert-opinion-based ERP for laryngeal surgery based on the key principles of colorectal surgery ERAS®. Twenty-four patients undergoing major laryngeal surgery (total and partial laryngectomies or surgical removal of oropharyngeal tumour with muscle flap reconstruction) were treated according to such an ERP protocol, which differed under several respects from our previous standard practice (described in 70 consecutive patients who underwent major laryngeal surgery before ERP implementation. The adherence rate to the different ERP items is reported. Adherence to ERP items was high. Nutritional assessment, antibiotic prophylaxis, postoperative nausea and vomit (PONV) prophylaxis and postoperative speech therapy targets were applied as required in 100% of cases. Some ERP items (antibiotic prophylaxis, intraoperative infusion rate, and postoperative speech therapy) were already frequently implemented before ERP adoption. Postoperative medical complications occurred in 8.3% of patients. Our expert opinion-based ERP protocol for major laryngeal surgery proved feasible. The degree of benefit deriving from its implementation has yet to be assessed.

Review of enhanced recovery programs in benign gynecologic surgery

Enhanced recovery programs (ERPs) are evidence-based protocols designed to improve functional rehabilitation after surgery. ERPs have gained widespread acceptance in many surgical disciplines, and their use leads to significant improvements in patient outcomes while reducing hospital length of stay (LOS). There remains a paucity of data on the use of ERPs in benign gynecologic surgery. The purpose of this review was to evaluate current literature on the use of ERP concepts in benign gynecologic surgery. A systematic search of PubMed, CINAHL, Web of Science, and the Cochrane databases was conducted, cross-referencing search terms related to gynecologic surgery and ERP concepts. The search was limited to publications available in English. Studies published prior to 2000, and those involving gynecologic oncology, nonadult patients, and outpatient surgery were excluded. Nine studies were included in the analysis. Due to heterogeneity of the included studies, no statistical pooling was possible and comparison between studies was limited to their respective themes. Primary study outcomes included LOS, postoperative nausea and vomiting (PONV), pain management, patient satisfaction, and hospital costs. Five studies investigated ERPs, two evaluated measures to improve PONV, and four focused on unique aspects of pain management. Across the studies, ERPs that focused on the patients' basic symptoms and recovery were found to have equal, if not better, outcomes than standard practice. This integrative review supports the implementation of ERPs in benign gynecologic surgery. The results showed that the use of ERPs decreased LOS, improved pain scores, and reduced hospital costs, without increasing perioperative complications. We suggest additional randomized controlled trials of ERP concepts in benign gynecologic surgery to support their more widespread use and application.

Are enhanced recovery programs in colorectal surgery feasible and useful in the elderly? A systematic review of the literature

Enhanced recovery programs (ERP) are no longer questionable in the management of patients undergoing surgery. However, there is some doubt as to their feasibility and efficacy in the elderly. Our goal was to systematically review the evidence-based literature concerning the feasibility of ERP in elderly patients undergoing colorectal surgery. The PubMed and Cochrane Database for systematic reviews as well as the "grey" literature between 2000 and 2015 were sought. Articles were selected if they compared ERP in elderly patients to ERP in young patients (feasibility) or compared ERP to traditional post-operative management in the elderly (efficacy). Sixteen articles were identified according to the inclusion criteria. All showed that an ERP was feasible in the elderly although post-operative morbidity was higher compared to younger patients. Compared to traditional management, ERP was effective since it decreased (as in the young) the overall rate of complications and thus the duration of hospital stay. There were not enough data on the degree of implementation of ERP and the medico-economic aspects to come to any formal conclusions. This comprehensive systematic review of the literature showed that ERP was feasible and effective in the elderly undergoing colorectal surgery. Protocols should be adapted to the particular aspects of this population. Future research should target pre-operative evaluation and the place of pre-habilitation in geriatric ERP.

Impact of enhanced recovery program on patients with esophageal cancer in comparison with traditional care.

Enhanced recovery program (ERP) was reported to be beneficial to patients undergoing esophageal surgery. However, evidence for ERP as a new standard perioperative pathway is insufficient. This meta-analysis aims to systematically investigate the differences between ERP and traditional care in terms of postoperative outcomes. Studies comparing ERP with traditional care were searched in Pubmed and Ovid databases and subsequently analyzed. The primary outcome of interest was postoperative length of hospital stay (LOHS), and the secondary outcomes of interest were postoperative morbidity, mortality, and 30-day readmission rates. Statistical analysis was performed using weighted mean difference (WMD) and odds ratio (OR). Review Manager 5.3 was used to generate the eligible data. Thirteen studies with 2358 patients (1182 patients in the ERP group and 1176 patients in the control group) were included in this meta-analysis. The total LOHS (WMD -5.37; 95% confidence interval (CI) -7.74 to -2.99; p<0.00001) was significantly shorter in the ERP group than the control group. No statistically significant difference was found in morbidity (OR 0.78; 95% confidence interval 0.58 to 1.05; p=0.10), mortality (OR 0.76; 95% CI 0.40 to 1.46; p=0.41), and 30-day readmission rates (OR 1.01; 95% CI 0.70 to 1.46; p=0.97). This meta-analysis suggested that the implementation of ERP led to a reduction in LOHS, while morbidity, mortality, and 30-day readmission rates did not increase compared with traditional care in patients undergoing surgery for esophageal cancer.

The effect of an Enhanced Recovery Program in elective retroperitoneal abdominal aortic aneurysm repair

Enhanced Recovery Programs (ERPs) have been introduced to accelerate postoperative recovery and are mainly focused on decreasing the surgical stress response. Limited data are available regarding the implementation of ERPs in patients who undergo abdominal aortic aneurysm (AAA) repair using the retroperitoneal approach. The aims of this study were: (1) to evaluate the implementation of an ERP in patients who underwent elective retroperitoneal AAA repair; and (2) to define independent predictors of prolonged hospital length of stay (LOS) in these patients. This was a retrospective cohort study on 221 patients who underwent elective AAA repair via a retroperitoneal approach from 2005 through 2013 at an Italian university hospital. Patients who received surgery from 2008 through 2013 and enrolled in an ERP (n= 130) were compared with those who received surgery from 2005 through 2007 and managed with traditional perioperative care (n= 91). Patient characteristics were comparable between groups. Intensive care unit admissions were prevalent among patients who received traditional care vs patients in the ERP (P< .01). ERP patients had fewer major (P< .01) and minor (P= .019) complications, and mortality was similar between groups. Complete functional recovery was achieved earlier in ERP patients vs controls (P< .01). Patients in the ERP group left the hospital earlier than controls (P< .01). No readmission ≤30days were reported in the ERP group. Age ≥65years and being in a conventional care protocol were found to be independent predictors of prolonged hospital LOS. The implementation of an ERP after elective AAA repair using a retroperitoneal approach reduced postoperative intensive care unit admission, accelerated functional recovery, and decreased morbidity and LOS with no readmission ≤30days. Age ≥65years and conventional perioperative care were the only independent predictors of prolonged LOS.