P. Vinsard3, A. C. Spaulding2, J. M. Naessens2, Z. Li5, A. Merchea1, J. E. Crook5, D. W. Larson4, R. G. Landmann1, D. T. Colibaseanu1,2 1Mayo Clinic,Department Of General Surgery,Jacksonville, FL, USA 2Mayo Clinic,Center For The Science Of Health Care Delivery,Rochester, MN, USA 3University Of Connecticut,Department Of Surgery,Farmington, CT, USA 4Mayo Clinic,Division Of Colorectal Surgery,Rochester, MN, USA 5Mayo Clinic,Department Of Health Sciences Research,Jacksonville, FL, USA
Introduction: Enhanced Recovery after Surgery (ERAS) has been shown to decrease length of stay, postoperative pain, morbidity, and cost of care. Implementation of the various elements of ERAS is variable, and limited data exists regarding protocol validation. We aim to describe the implementation and validation of a previously described ERAS protocol.
Methods: A retrospective review with propensity score matching of all patients undergoing elective colorectal surgery from 2009 – 2016 was undertaken. Patient demographics, length of stay (LOS), pain scores, and perioperative morbidity (30-day readmissions, unplanned reoperations, surgical site infections, anastomotic leaks and bleeding) are described. Patients enrolled in the ERAS protocol and those undergoing standard of care were compared for the above outcomes.
Results:From the initial 1,556 patients identified in the initial, nonmatched cohort, 1398 were propensity matched, 698 in each group. After propensity matching, there was no significant difference in age, Charlson Comorbidity Index, American Society of Anaesthesiologists (ASA) score, Body Mass Index (BMI), sex, operative approach (minimally invasive or open), and surgery duration. Overall postoperative complications were the same in both groups, with postoperative bleeding slightly lower in the ERAS group. The median LOS in ERAS and non-ERAS groups was 3 vs 5 days, respectively (p <0.001). From the time of implementation, the 2-day decrease in LOS stabilized after approximately 6 months. Mean pain scores were always lower in the ERAS group, measured at discharge from post anesthesia unit (4.8 vs 3.4; p<0.0001), on Post Operative Day (POD)1 (3.8 vs 3.3; p 0.002) , and on POD 2 (3.1 vs 2.8; p 0.024), but were the same on discharge (2.0).
Conclusion:This ERAS protocol was successfully validated at our institution, using the same protocol and a similar population of patients as the institution that developed the protocol. The primary outcome, LOS, decreased by 2 days as at the original institution. In this study, the time to achieve a 2-day decrease in LOS from the moment of implementation was 6 months. Secondary outcomes were also very similar as the original institution; in particular pain scores were observed to be statistically significant and lower in the ERAS group. Different than most other retrospective studies was the use of propensity matching which ensured that – to the best of the authors’ ability- the groups are as evenly matched as possible. This study adds to the body of literature showing that ERAS is beneficial to the patients, but is the only validation ERAS study in a propensity matched cohort of patients undergoing elective colorectal surgery. Limitations of this study include the retrospective design and that this is a single institution experience, reliant on its surgical mix and electronic clinical systems to capture some of the outcomes described. Further validation from other institutions would be beneficial.