J. S. Colvin1, M. Rosen1, S. Rosenblatt1, A. Prabhu1, D. Krpata1 1Cleveland Clinic,General Sugery,Cleveland, OH, USA
Introduction: Enhanced Recovery After Surgery (ERAS) pathways represent a multi-modal approach to post-operative care, with the goal of improved recovery, outcomes, and value. Patients undergoing abdominal wall reconstruction have lengths of stay of six days on average. We hypothesized that implementation of an ERAS pathway for abdominal wall reconstruction would result in faster recovery and decreased length of stay (LOS).
Methods: A universal ERAS protocol for patients undergoing elective abdominal wall reconstruction at the Cleveland Clinic was implemented. The protocol consisted of multi-modal analgesia with transversus abdominis plane (TAP) blocks in addition to both narcotic and non-narcotic oral pain medications. Early feeding and diet advancement as well as goal-directed intravenous fluids were implemented. Bowel regimen, routine labs, and use of drains were also standardized. One hundred consecutive patients undergoing abdominal wall reconstruction with use of our ERAS pathway were compared to a historical cohort. Groups were compared on demographics and clinical characteristics using chi-square, Fisher’s exact, and two sample t-tests.
Results: The average LOS was not significantly different after implementation of the ERAS protocol (6.0 ± 8.3 vs 6.0 ± 11.5 days, p=0.96). Time to regular diet was also not significantly different (3.43 ± 2.2 vs 3.6 ± 7.9 days, p=0.57). There was decrease in time to discontinuation of intravenous or epidural patient-controlled analgesia (3.8 ± 6.0 days vs 3.2 ± 4.7 days, p=0.05). There was no increase in readmission rates. In a sub-group analysis, factors associated with a LOS<4 days were hernia width ≤9.5 ± 7.2 cm (p=0.009), operative time ≤2.5 ± 0.85 hours (p=0.001), and pre-operative quality-of-life (HerQles) score ≥59.5 ± 11.7 (p=0.008).
Conclusion: Our study is one of the largest to investigate ERAS protocols for complex ventral hernia repairs. In this cohort, ERAS failed to reduce LOS. We were able to identify predictors of a shorter LOS, which included smaller hernia defects, shorter operative times, and higher baseline quality of life scores. This demonstrates which subset of patients may have greater benefit from an ERAS pathway within our practice.