Enhanced Recovery After Surgery for Noncolorectal Surgery?

A Systematic Review and Meta-analysis of Major Abdominal Surgery

Anthony Visioni, MD; Rupen Shah, MD; Emmanuel Gabriel, MD, PhD; Kristopher Attwood, PhD; Moshim Kukar, MD; Steven Nurkin, MD

Disclosures

Annals of Surgery. 2018;267(1):57-65. 

In This Article

Abstract and Introduction

Abstract

Objective: To evaluate the impact of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures.

Background: ERAS programs have been studied extensively in colorectal surgery and adopted at many centers. Several studies testing such protocols have shown promising results in improving postoperative outcomes across various surgical procedures. However, surgeons performing major abdominal procedures have been slower to adopt these ERAS protocols.

Methods: A systematic review was performed using "enhanced recovery after surgery" or "fast track" as search terms and excluded studies of colorectal procedures. Primary endpoints for the meta-analysis include length of stay (LOS) and complication rate. Secondary endpoints were time to first flatus, readmission rate, and costs.

Results: A total of 39 studies (6511 patients) met inclusion and exclusion criteria. Among them 14 studies were randomized trials, and the remaining 25 studies were cohort studies. Meta-analysis showed a decrease in LOS of 2.5 days (95% confidence interval, CI: 1.8–3.2, P < 0.001) and a complication rate of 0.70 (95% CI: 0.56–0.86, P = 0.001) for patient treated in ERAS programs. There was also a significant reduction in time to first flatus of 0.8 days (95% CI: 0.4–1.1, P < 0.001) and cost reduction of $5109.10 (95% CI: $4365.80–$5852.40, P < 0.001). There was no significant increase in readmission rate (OR 1.03, 95% CI: 0.84–1.26, P = 0.80) in our analysis.

Conclusions: ERAS protocols decreased length of stay and cost by not increasing complications or readmission rates. This study adds to the evidence that ERAS protocols are safe to implement and are beneficial to surgical patients and the healthcare system across multiple abdominal procedures.

Introduction

Nearly 20 years ago, Henrik Kehlet asked "why a technically successful operation, whether a colonic resection, hip replacement, or cardiac operation, should result in an unsuccessful outcome."[1] He eloquently described the multifactorial surgical stress response and interventions that could possibly mitigate or modify this deleterious response thus improving outcomes. This premise became the foundation for enhanced recovery after surgery (ERAS) pathways, which seek to promote rapid recovery of patients undergoing major surgery. These programs address patient recovery preoperatively, intraoperatively, and postoperatively with a variety of interventions. Preoperative interventions include: organized counseling regarding procedure and recovery, carbohydrate loading before procedure, no prolonged fasting before procedure, no or selective bowel preparation, appropriate antimicrobial prophylaxis, deep vein thrombosis (DVT) prophylaxis, and avoiding long acting preanesthesia anxiolytics. Intraoperative interventions include: use of short acting anesthetics, use of regional and epidural anesthesia, minimal use of drains and nasogastric tubes, avoiding of salt and fluid overload, maintaining normal body temperature, and preventing postoperative nausea/vomiting. Postoperative interventions include: avoiding salt and fluid overload, early Foley catheter removal, early enteral nutrition, minimizing use of opioid analgesics, early and organized mobilization, and stimulation of the gut to avoid ileus.

Extensive research has been performed in the field of colorectal surgery, and many centers now have ERAS programs in place. However, ERAS programs have not yet gained widespread adoption in other abdominal surgeries. This may be because of multiple studies showing mixed results regarding decreased length of stay and decreased complication rates.[2–5] Till date, 3 Cochrane reviews (in colorectal, gynecological surgery, and upper gastrointestinal/liver/pancreas) have been performed to evaluated ERAS protocols.[6–8] The review in colorectal surgery included 4 randomized trials and did show a decrease in length of stay (LOS) and complications. However, the authors concluded that it could not be recommended as the standard of care because of poor quality of the trials and lack of sufficient other outcome measures.[6] A review in upper gastrointestinal, liver, and pancreas surgery included 9 randomized trials and, once again, demonstrated a decrease in LOS. However, the authors concluded that because of the low quality of evidence and risks of bias more randomized trials were needed.[8] Finally, a review in gynecological cancer patients did not identify any studies that met inclusion criteria.[7] Studies continue to be performed in many subspecialties of surgery other than colorectal, including: liver, pancreas, stomach, esophagus, urology, and gynecology. Irrespective of the type of surgery, however, these ERAS protocols are all founded on the principles set forth by Kehlet, which is to minimize the surgical stress response to improve outcomes. This underscores the idea that these pathways aim to counteract the traumatic nature of surgery itself and are not necessarily specific to a particular operation. We, therefore, hypothesized that ERAS protocols applied across a variety of abdominal procedures would result in a decrease in length of hospital stay without increasing complications.

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