What are the risk factors for delayed discharge within an ERAS programme?

Pędziwiatr M, Pisarska M, Kisielewski M, Matłok M,Major P, Wierdak M, Budzyński A, Ljungqvist O. Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery? Med Oncol. 2016 Mar;33(3):25.

What is already known:

ERAS programmes are well known to reduce length of stay, however the reasons for a prolonged stay are not as well studied. In this Swedish pilot study which included the ERAS society chairman in its authorship, aimed to assess what influences delayed discharge within an ERAS program for laparoscopic colorectal surgery.

What this paper adds:

Length of stay did not seem to be affected by traditional patient risk factors eg ASA grade, co-morbidities or cancer stage but simply by compliance of the ERAS protocol. The exact reason why a patient did not follow the protocol fully remains to be answered, and may well be tricky to address but a key question to answer in the future. Chris Jones, Guildford.


Risk of anastomotic leak after NSAID use within an ERAS programme

Bakker N, Deelder JD, Richir MC, Cakir H, Doodeman HJ, Schreurs WH, Houdijk AP. Risk of anastomotic leakage with nonsteroidal anti-inflammatory drugs within an enhanced recovery program. J Gastrointest Surg. 2016 Apr;20(4):776-82.

What is already known:

Anastomotic leakage is a much feared complication after colorectal resection. The incidence is higher in low rectal resections (up to 13%) than with colonic resections (3%). It can have a profoundly negative impact on length of stay, morbidity and mortality, and possibly on longer term oncological outcome. It is thought that NSAID’s can increase this risk.

What this paper adds:

In this single centre observational study the use of diclofenac was associated with a higher rate of anastomtic leakage in both colonic and rectal resections. Interestingly the other NSAIDS – Ibuprofen and Mebutan used in this study had no association.

Chris Jones, Guildford.


Regional anaesthesia and ERAS

Carli F, Clemente A. Regional anesthesia and enhanced recovery after surgery. Minerva Anestesiol. 2014 Nov;80(11):1228-33

Comments

This paper written by one of the board members of the ERAS society explores the role of regional anaesthesia within an ERAS program and how it can affect postoperative outcomes.

Chris Jones, Guildford.


Enhanced Recovery After Surgery: A Review 

Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surgery. Epub January 11th 2017.

Comments

This review, written by three members of the ERAS® executive committee, provides a great overview of how fast track or Enhanced Recovery has evolved. The rationale of ERAS® is discussed, its elements and the concept of multimodal care, with synergy between the individual elements of care, as well as the interplay between caregivers: surgeons, physicians, nurses, physiotherapists and dieticians.

The paper addresses how ERAS programmes are set up in individual institutions, underpinned by evidence based, procedure specific, guidelines and continuous audit. The ERAS® Society been at the forefront of worldwide implementation of ERAS®.

Whilst length of hospital stay may have been an early goal for patients treated within ERAS® programmes, we are now seeing other benefits in particular a reduction in complications and readmissions across a range of surgeries. This has resulted in considerable cost savings per patient. Excitingly, long term benefits of ERAS® are becoming evident in both orthopaedics and patients with colorectal cancer.

Since this prestigious review was written for JAMA Surgery, our friend, colleague and mentor, Professor Ken Fearon died, and this review provides a fitting testimony to his outstanding efforts, intellect and enthusiasm for the ERAS® programme.

Bill Fawcett, UK.


ERAS and the impact of sarcopenia on outcomes

Pędziwiatr M, Pisarska M, Major P, Grochowska A, Matłok M, Przęczek K, Stefura T, Budzyński A, Kłęk S. Laparoscopic colorectal cancer surgery combined with enhanced recovery aftersurgery protocol (ERAS) reduces the negative impact of sarcopenia on short-termoutcomes. Eur J Surg Oncol. 2016 Jun;42(6):779-87.

What is already known:

The presence of sarcopenia (loss of skeletal muscle mass) or myosteatosis (fat infiltration in skeletal muscle) can lead to increased rates of morbidity and mortality in colorectal surgery. However the majority of studies are in open surgery.

What this paper adds:

This study of 124 patients undergoing laparoscopic colorectal surgery demonstrated that a comprehensive ERAS program can minimise the negative impact of sarcopenia and myosteatosis on all post-operative outcomes in colorectal cancer surgery.

Chris Jones, Guildford.


The importance of high compliance with all ERAS elements.

Gustafsson U; Hausel J; Thorell A; Ljungqvist O; Soop M; Nygren J; Enhanced Recovery After Surgery Study Group. Adherence to the Enhanced Recovery After Surgery Protocol and Outcomes After Colorectal Cancer Surgery. Arch Surg. 2011;146(5):571-577.

What is already known:

This is now a relatively old paper but it was one of the first large studies to highlight the importance of adherence to all the ERAS elements.

What this paper adds:

This is a large prospective cohort study from a single centre. It compared an earlier phase (2002-5) during which ERAS was poorly implemented with a more recent period (2005-7) during which the ERAS programme was reinforced and as such achieved significantly higher compliance with the protocol. They demonstrated fewer major complications, fewer debilitating postoperative symptoms and shorter length of stay. Multivariate analysis showed that preoperative carbohydrate loading and perioperative fluid restriction were independent predictors of postoperative outcomes.

Chris Jones, Guildford


High compliance with ERAS elements can have huge long-term benefits.  

Gustafsson UO, Oppelstrup H, Thorell A, Nygren J, Ljungqvist O. Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery: A Retrospective Cohort Study. World J Surg. 2016 Jul;40(7):1741-7.

What is already known:

ERAS protocols have mostly focused on the short-term outcomes such as length of hospital stay, morbidity or hospital costs. This is one of the few papers that have started to look at longer term outcomes. We know from Khuri et al in 2005, that perioperative complications can have a dramatic effect on long term survival (in both cancer and non-cancer surgery). We know that ERAS pathways can reduce morbidity but we don’t know what long-term effect this reduction of morbidity can have.

What this paper adds:

This is potentially a hugely important paper. In this Swedish single centre study with over 900 patients, they compared adherence of ERAS elements with 5-year overall and cancer specific survival. They found that patients with >70% adherence the risk of 5-year cancer-specific survival was lowered by 42%. And importantly avoiding fluid overload and early oral intake were shown as independent predictors of increased 5-year survival.

Chris Jones, Guildford