An enhanced recovery after surgery pathway in pediatric colorectal surgery improves patient outcomes

IntroductionEnhanced recovery after surgery (ERAS) pathways in adult colorectal surgery are known to reduce complications, readmissions, and length of stay (LOS). However, there is a paucity of ERAS data for pediatric colorectal surgery.MethodsA 2014–2018 single-institution, retrospective cohort study was performed on pediatric colorectal surgery patients (2–18 years) pre- and post-ERAS pathway implementation. Bivariate analysis and linear regression were used to determine if ERAS pathway implementation reduced total morphine milligram equivalents per kilogram (MME/kg), LOS, and time to oral intake.Results98 (70.5%) and 41 (29.5%) patients were managed with ERAS and non-ERAS pathways, respectively. There was no statistical difference in age, sex, diagnosis, or use of laparoscopic technique between cohorts. The ERAS cohort experienced a significant reduction in total MME/kg, Foley duration, time to oral intake, and LOS with no increase in complications. The presence of an ERAS pathway reduced the total MME/kg (? 0.071, 95% CI ? 0.10, ? 0.043) when controlling for covariates.ConclusionThe use of an ERAS pathway reduces opioid utilization, which is associated with a reduction in LOS and expedites the initiation of oral intake, in colorectal pediatric surgery patients. Pediatric ERAS pathways should be incorporated into the care of pediatric patients undergoing colorectal surgery.Level of evidenceLevel III evidence.Type of studyRetrospective cohort study.     

Enhanced recovery after surgery (ERAS) improves return of physiological function in frail patients undergoing one- to two-level TLIFs: an observational retrospective cohort study

Background contextThe enhanced recovery after surgery (ERAS) protocol is a multimodal approach which has been shown to facilitate recovery of physiological function, and reduce early post-operative pain, complications, and length of stay (LOS) in open one- to two-level TLIF. The benefit of ERAS in specifically frail patients undergoing TLIF has not been demonstrated. Frailty is clinically defined as a syndrome of physiological decline that can predispose patients undergoing surgery to poor outcomes.PurposeThis study primarily evaluated the benefit of an ERAS protocol in frail patients undergoing one- or two-level open TLIF compared to frail patients without ERAS. Secondarily, we assessed whether outcomes in frail patients with ERAS approximated those seen in nonfrail patients with ERAS.Study DesignRetrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status.Patient SampleConsecutive patients that underwent one- or two-level open TLIF for degenerative disease from August, 2015 to July, 2021 by a single surgeon. ERAS was implemented in December 2018.Outcome MeasuresPrimary outcome measure was return of postoperative physiological function defined as the summation of first day to ambulate, first day to bowel movement, and first day to void. Additional outcome measures included LOS, daily average pain scores, opioid use, discharge disposition, 30-day readmission rate, and reoperation.MethodsA retrospective analysis of frail patients > 65 years of age undergoing one- to two-level open TLIF post-ERAS were compared to propensity matched frail pre-ERAS patients. Frailty was assessed using the Fried phenotype classification (score >1). Patient demographics, LOS, first-day-to-ambulate (A1), first-day-to-bowel movement (B1), first-day-to-void (V1) were collected. Return of physiological function was defined as A1+B1+V1. Primary analysis was a comparison of frail patients pre-ERAS versus post-ERAS to determine effect of ERAS on return of physiologic function with frailty. Secondary analysis was a comparison of post-ERAS frail versus post-ERAS nonfrail patients to determine if return of physiologic function in frail patients with ERAS approximates that of nonfrail patients.ResultsIn the primary analysis, 32 frail patients were included with mean age ± standard deviation of 72.8±4.4 years, mean BMI 28.8±5.5, 65.6% were male, 15 pre-ERAS and 17 post-ERAS. Patient characteristics were similar between groups. After ERAS implementation, return of physiological function improved by a mean 3.2 days overall (post-ERAS 3.4 vs. pre-ERAS 6.7 days) (p<.0001), indicating a positive effect of ERAS in frail patients. Additionally, length of stay improved by 1 day (4.8±1.6 vs. 3.8±1.9 days, p<.0001). Total daily intravenous morphine milligram equivalent (MME) as well as average daily pain scores were similar between groups. Secondarily, 26 nonfrail patients post ERAS were used as a comparison group with the 17 post-ERAS frail cohort. Mean age of this cohort was 73.4±4.6 years, mean BMI 27.4±4.9, and 61.9% were male. Return of physiologic function was similar between cohorts (post-ERAS nonfrail 3.5 vs. post-ERAS frail 3.4 days) (p=.938), indicating the benefit with ERAS in frail patients approximates that of nonfrail patients.ConclusionsERAS significantly improves return of physiologic function and length of stay in patients with frailty after one- to two-level TLIF, and approximates improved outcomes seen in non-frail patients.     

Enhanced recovery after surgery (ERAS) for open transforaminal lumbar interbody fusion: a retrospective propensity-matched cohort study

BACKGROUNDThe enhanced recovery after surgery (ERAS) protocol is a multidisciplinary, multimodal approach which has been shown to facilitate recovery of physiological function, and reduce postoperative pain, complication rates, and length of stay without adversely affecting readmission rates. Design and implementation of ERAS protocols in the recent spine surgery literature has primarily focused on patients undergoing minimally invasive lumbar surgery. However, conventional open transforaminal lumbar interbody fusion (TLIF) remains a common procedure and to date there are no studies assessing an ERAS protocol in this patient population.PURPOSEThis study presents a single surgeon experience implementing an ERAS protocol in patients undergoing 1- or 2-level open TLIF.STUDY DESIGN/SETTINGRetrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status.PATIENT SAMPLEConsecutive patients that underwent 1- or 2-level open TLIF for degenerative disease from 12/2018 – 02/2021 and controls from 12/2011-12/2017 by a single surgeon. ERAS was implemented in December 2018.OUTCOME MEASURESPrimary: length of stay; Secondary: first day to ambulate, first day to bowel movement, first day to void, daily average and maximum pain scores, opioid use, discharge disposition, 30-day readmission rate, and re-operations.METHODSDemographic, perioperative, clinical, radiographic data were collected. Multivariate mixed-linear regression models were developed for length of stay, physiological function, pain scales, and opiate use.RESULTSThere were 114 patients included with 57 in each cohort. After propensity matching, patient characteristics were similar between groups. Operative time decreased significantly after institution of ERAS (170±44 vs. 141±37 minutes, p <.0001) as did length of stay (4.6±1.7 vs. 3.6±1.6 days, p<.0001). First day of ambulation, bowel movement, and bladder voiding improved by 0.8 (p<.0001), 0.7 (p=.008), and 0.8 (p<.0001) days, respectively, in the ERAS cohort. Total daily intravenous morphine milligram equivalent (MME) (8±9 vs. 36±38, p<0.0001) and total 72-hour MME consumption (53±33 vs. 68±48, p<.0001) was significantly lower in the ERAS cohort; however, 72-hour MME consumption was not found to be significantly different in a sensitivity analysis controlling for preoperative MME. Average daily pain scores were similar between groups.CONCLUSIONSConsistent with other studies demonstrating benefit of an ERAS protocol for minimally invasive spine procedures, ERAS was associated with decreased operative time, reduced length of stay, decrease in IV opioid consumption, and improved physiological outcomes for open 1- and 2-level TLIF. ERAS can be a potentially effective strategy for improving patient outcome and efficiency of healthcare resources for common conventional spinal surgeries such as open TLIF.     

Feasibility and benefits of an enhanced recovery after surgery protocol for patients undergoing cytoreductive surgery and heated intraperitoneal chemotharpy: A single institution experience

BackgroundCytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is reported to have a prolonged length of stay (LOS). We incorporated an enhanced recovery after surgery (ERAS) protocol to examine whether we could reduce our LOS.MethodsPatients were identified who underwent CRS/HIPEC from 2015 to 2018 before and after initiation of ERAS protocol. The protocol included pre-operative, peri-operative and post-operative interventions. Primary end point was LOS. Secondary endpoints were morbidity and mortality.ResultsForty patients were identified, thirty-one of which underwent CRS/HIPEC: 16 before and 15 after ERAS. The median LOS prior to ERAS was 11 days (5–20) and 7 days (5–27) after ERAS (P < 0.05). There was no significant difference in 30-day morbidity (Clavien-Dindo ≥3) or mortality between the groups.ConclusionsAn ERAS protocol can safely be implemented in patients undergoing CRS/HIPEC with earlier return of bowel function and decrease in LOS without increasing morbidity or mortality.     

Effects of general anesthesia with and without thoracic epidural block on length of stay after open spine surgery: a single-blinded randomized controlled trial

BACKGROUND CONTEXTLength of hospital stay (LOS) is an important concern in all types of surgery, and the enhanced recovery after surgery (ERAS) protocol has been developed to improve perioperative management and outcomes, which require multidisciplinary management. In terms of pain control, intraoperative regional anesthesia and postoperative opioid-sparing analgesia are recommended. For open spine surgery, we aimed to combine thoracic epidural analgesia to reduce pain and opioid-related side effects, thereby hastening recovery.PURPOSEThis study aimed to compare the length of hospital stay after open complete laminectomy with fusion between general anesthesia and combined general anesthesia involving a single thoracic epidural injection.DESIGNA randomized single-blinded controlled study.PATIENT SAMPLEThirty-eight patients scheduled for elective open laminectomy with fusion between I and III levels were selected.OUTCOME MEASURESLOS, postoperative pain, patient-controlled morphine consumption at 24 hours, patient satisfaction score, and other opioid-related side effects were recorded.METHODSPatients were randomly selected to receive standard general anesthesia (GA) or GA combined with a single-shot thoracic epidural at T11–T12 or T12–L1, a block with 10 mL of 0.25% bupivacaine, and 4 mg of morphine.RESULTSThere were no significant differences in the demographic variables between groups. LOS was significantly lower in the combined epidural and/or GA than in the control group (3.78±0.81 [mean±standard deviation] and 4.79±1.51 days, respectively; p=.017). Numeric rating score (at rest) at the post-anesthesia care unit, 24 hours postoperative morphine consumption (mg), operating time, and blood loss were significantly lower in the epidural group. Patients who received combined epidural and/or GA were more likely to report higher patient satisfaction (p=.008). However, the incidence of intraoperative hypotension was significantly higher in the epidural group (72.2% vs. 21.1%, p=.003). The incidences of adverse events and surgical field rating scores did not differ between the 2 patient groups.CONCLUSIONSCombined lower thoracic epidural and/or GA in patients undergoing elective lumbar spine surgery was associated with decreased LOS.     

How much narcotics are really needed after bariatric surgery: results of a prospective study

BackgroundTo mitigate the opioid crisis, physicians are reevaluating opioid prescribing patterns.ObjectivesTo evaluate outcomes of maximal opioid reduction on top of an existing Enhanced Recovery after Surgery (ERAS) pathway in our The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited bariatric surgery program.SettingAcademic tertiary care hospital, United States.MethodsPatients undergoing primary bariatric operation were studied from July 2017 to April 2019, (standard ERAS cohort), and compared to patients from April 2019 to February 2021 (standard ERAS with Sparing Opioid Use Postoperatively protocol) (SOUP cohort). The primary endpoint was reduction of perioperative opioid use.ResultsOf 367 patients, 212 (57.8%) and 155 (42.2%) were in the ERAS and SOUP cohorts, respectively. Roux-en-Y gastric bypass was 48.6% (n = 103) versus 54.2% (n = 84) and sleeve gastrectomy was 51.4% (n = 109) versus 45.8% (n = 71) for ERAS versus SOUP, respectively (P = .29).The SOUP cohort of patients required a low median inpatient morphine equivalent dose of 4 mg [0–6.2]. The ERAS cohort was discharged on a higher morphine equivalent dose than the SOUP cohort at 186.7 mg ± 92.9 versus 37.6 ± 32.3 (P < .05), and median consumption of the standard 5 mg oxycodone tablet was 1.5 tablets [0–4]. The SOUP cohort patients rated their pain satisfaction score on a scale of 1 to 10 at 9.1 points (standard deviation ± 1.8). The SOUP cohort had a shorter length of stay (P < .05), with comparable readmission rates.ConclusionsAn opioid-sparing protocol can be implemented after bariatric surgery with high overall satisfaction with pain control.     

Development of a five point enhanced recovery protocol for pectus excavatum surgery

PurposeWe implemented and evaluated an Enhanced Recovery after Surgery (ERAS) protocol for Nuss procedures consisting of patient education, bowel management, pre/post-operative transitional pain service involvement, serratus anterior plane blocks and intercostal nerve cryoablation.MethodsA 5-point ERAS protocol was implemented using multiple plan-do-study-act (PDSA) cycles. Data was collected prospectively for patients in the full ERAS protocol and retrospectively for previous patients. The primary outcome was length of stay (LOS). Secondary outcomes were opioid consumption, pain scores, protocol compliance and patient satisfaction. The impact of PDSA cycles and the ERAS protocol was quantified using statistical process control charts and Mann Whitney U test.ResultsA total of 53 patients were identified, 13 within the ERAS protocol and 40 prior to introduction. There was no difference in age, sex, or Haller index between the two cohorts. The median LOS was decreased by 3 days in the ERAS cohort (P = 0.00001). There was decreased opioid consumption on post-operative day 1 (1.47 vs 1.96 MME/kg, p = 0.009) and overall (3.12 vs 6.35 MME/kg, p = 0.0042) in the ERAS cohort. Median pain scores did not differ between cohorts. ERAS bundle element compliance was: education 92%, bowel management 100%, transitional pain involvement 100%, serratus block 100% and cryoablation 100%. The 1-month survey revealed that 92% of patients were satisfied with their experience.ConclusionOur results demonstrate significant reduction in LOS and a trend to decreasing opioid consumption in hospital following ERAS protocol implementation and support the further application of ERAS protocols in pediatrics.Level of evidence:III – Retrospective comparative study.     

Opioid use and length of stay following minimally invasive pectus excavatum repair in 436 patients – Benefits of an enhanced recovery pathway

PurposeThe purpose of this study was to determine outcomes of an enhanced recovery pathway (ERP) for minimally invasive repair of pectus excavatum (MIRPE) at a high volume center, hypothesizing it is associated with decreased opioid requirement and shorter hospital stay.MethodsPatients were categorized into pre-ERP (1998–2006), transition (2007–2011), and ERP (2012–2017) cohorts. Data were abstracted from medical records. Univariate and multivariable analyses compared opioid utilization, length of stay (LOS), and complications between cohorts. Opioids were converted to morphine daily dose per kilogram (MEDD/kg).ResultsOf 436 patients, 186 were ERP, 104 were transition, and 146 were pre-ERP. ERP was associated with decreased hospital opioid utilization (mean MEDD/kg 0.5 ± 0.2 vs 0.7 ± 0.4 vs 0.7 ± 0.8 p < .001) and shorter median LOS (3 vs 4 vs 5 days, p < .001) despite equivalent pain scores at discharge (2.7 ± 0.1 vs 2.8 ± 0.2 vs 2.9 ± 0.3, p = .73). Most ERP patients (76%) had LOS ≤ 3 days. Differences in LOS between ERP, transition, and pre-ERP persisted on multivariable analysis after adjusting for confounding factors. Post-operative complications were rare and not different between groups (p > .05).ConclusionsImplementation of our ERP was associated with decreased opioid requirement and shorter hospital stay. ERPs are a valuable tool in pediatric surgery given the current emphasis on optimizing opioid and resource utilization.Levels of EvidenceLevel III (Retrospective comparative study).     

Influences on length of stay in an enhanced recovery programme after colonic surgery

Aim Enhanced recovery after surgery (ERAS) programmes have been shown to accelerate and enhance functional recovery after colonic surgery. We analysed prospectively collected data to investigate potentially modifiable factors that may influence the length of stay (LOS) in the ERAS setting at a single institution. Method Between October 2005 and November 2008, prospective data were collected on consecutive patients who underwent elective colonic surgery without a stoma. Patients with rectal cancer, those unable to participate in preoperative ERAS components because of their inability to communicate effectively in English, those with cognitive impairment and those with an American Society of Anesthesiologists (ASA) grade of ≥4 were excluded. Statistical analyses were performed using the Mann–Whitney U‐test and Cox regression modelling. Results A total of 100 (79 malignancies) patients underwent elective colon resection during the study period. There were 57 right‐sided, 41 left‐sided and two total colectomies. The median age of the patients was 67.5 (range 31–92) years and the median day stay was 4 (range 3–46) days. Factors with significant correlations for reduced LOS were female gender, the surgeon, operative severity, high‐dependency unit (HDU) admission and incision type favouring laparoscopic and transverse approaches. Age, operation site, indication for surgery and body mass index were not significant predictors of hospital stay. Gender, operative severity, HDU admission and surgeon did not have any independent correlation with LOS; in contrast to the ASA score and the type of incision, which did. Conclusion Lower ASA score, transverse incision laparotomy and laparoscopy correlated independently with reduced postoperative LOS within the ERAS setting.     

An enhanced recovery after surgery protocol in children who undergo nephrectomy for Wilms tumor safely shortens hospital stay

BackgroundPediatric unilateral renal tumors in the US are treated with upfront nephrectomy and surgical staging. We applied enhanced recovery after surgery (ERAS) principles in care of children after Wilms nephrectomy.MethodsWe reviewed records of pediatric unilateral nephrectomies for Wilms tumors, and analyzed tumor stage, surgical approach, length of operation, use of anesthesia adjuncts and catheters, diet advancement, hospital length of stay (LOS), and complications. Our ERAS protocol includes: parental education regarding discharge criteria and anticipated LOS, avoiding thoraco abdominal incisions, avoiding routine nasogastric tubes, clear liquids starting day of surgery, minimizing opiates, routine IV ketorolac use, and avoiding routine ICU stay. We examined the effects of our protocol on postoperative hospital LOS and complication rates.ResultsSixty six children (31 boys, mean age 3.8y, range 0–11.9) underwent unilateral total nephrectomy for Wilms tumor. Mean nephrectomy duration was 2.7 h. Post operatively, seven (11%) had temporary gastric tubes and 24 (36%) had epidural catheters. Ten (15%) recovered in the ICU. Patients were given regular diets mean of 1.9 days post op. Mean LOS was 3.7 days, with 56% of patients being discharged within 2–3 days. Presence of tumor thrombus, longer epidural catheter duration, delayed diet advancement, and total IV narcotic usage were associated with longer LOS. Routine use of IV ketorolac was associated with shorter LOS.ConclusionsUse of an ERAS protocol in children undergoing nephrectomy for Wilms tumor is safe, resulting in rapid return to regular diet and compared to the published literature, shorter postoperative LOS without an increase in complications or return to ED/OR.Level of evidenceLevel III     

Length of stay,readmission, and mortality after primary surgery for pediatric spinal deformities: a 10-year nationwide cohort study

BACKGROUND CONTEXTExtended length of stay (extLOS) and unplanned readmissions after first time pediatric spinal deformity surgery are a considerable challenge to both the patient and the health-care system. To our knowledge, only a limited number of nationwide studies reporting short-term comorbidity with complete follow-up exist.PURPOSEThe purpose of this study was to identify the postoperative complications leading to extLOS, readmissions, and mortality within 90 days after surgery. Furthermore, to identify risk factors for readmission.DESIGNRetrospective national cohort study.PATIENT SAMPLEA nationwide registry study including all pediatric spinal deformity patients (≤21 years of age) undergoing primary surgery during 2006–2015 (n=1,310).OUTCOME MEASURESReasons for extLOS and 90-day readmissions as well as mortality risk.METHODSPatients were identified by procedure and diagnosis codes in the Danish National Patient Registry (DNPR). Data on length of stay (LOS), readmissions, and mortality within 90 days were retrieved from the DNPR. Patients were categorized in six groups according to etiology. Reasons for extLOS and readmission were collected from medical records and discharge summaries.RESULTSFor the 1,310 patients, the median LOS was 8 days (interquartile range 7–9). Etiologies were idiopathic deformity (53%), neuromuscular deformity (23%), congenital/structural deformity (9%), spondylolisthesis (7%), Scheuermann kyphosis (5%), and syndromic deformity (3%). A total of 274 (21%) patients had extLOS and the most common reason was pain/mobilization issues but with considerable variation between etiologies; Scheuermann kyphosis (91%), idiopathic (59%), syndromic (44%), spondylolisthesis (38%), and congenital (30%). Pulmonary complications were the primary reason for extLOS in the neuromuscular group (22%). The 90-day readmission rate was 6%; 67% of readmissions were medical, mainly infections unrelated to the surgical site (23%); 33% of readmissions were surgical and 14% of patients required revision surgery. Neuromuscular deformity, spondylolisthesis, Scheuermann kyphosis, and LOS >9 days were independent risk factors for readmission; odds ratio (OR) 4.4 (95% confidence interval: 2.2–9.1, p<.01), OR 3.0 (1.1–8.0, p=.03), OR 4.9 (1.7–13.6, p<.01), and OR 1.8 (1.0–3.1, p=.04), respectively. The 90-day mortality risk was 0.4%.CONCLUSIONSIn this nationwide cohort, pain/mobilization issues are the most common reason for extLOS. The most common reason for readmission is infection unrelated to the surgical site. Readmission after pediatric spinal surgery is related to the etiology and increased focus on patients operated for neuromuscular deformity, spondylolisthesis and Scheuermann kyphosis is warranted.     

Enhanced recovery after surgery pathways benefit patients with soft pancreatic texture following pancreaticoduodenectomy

BackgroundWe aimed to compare the enhanced recovery after surgery pathway with the standard perioperative care protocol concerning complications, postoperative length of stay and 1-year survival rate.MethodsUsing a before–after cohort study design, data from patients with pancreatic head cancer, who consecutively underwent pancreaticoduodenectomy, were retrospectively collected.ResultsCompared to the control group, patients with soft pancreas in the enhanced recovery after surgery group had a lower incidence of delayed gastric emptying (36.7% vs 13.3%, P = 0.026) and respiratory complications (46.7% vs 20.0%, P = 0.028), and shorter postoperative length of stay (All: 10.9 ± 3.4 d vs13.5 ± 3.8 d, P = 0.002; Soft: 11.2 ± 3.8 d vs14.0 ± 4.5 d, P = 0.001). The 1-year survival rates were similar between the groups.ConclusionThe enhanced recovery after surgery pathways can significantly reduce the incidence of certain surgical complications and decrease the postoperative length of stay. It does not affect 1-year survival.     

Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery

BackgroundDespite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions.MethodsAn ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ).ResultsWe included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ± 24.1 vs 46.1 ± 37.0 MMEQ, P <0.001) and in per-day postoperative opioid consumption (10.9 ± 8.7 vs 15.1 ± 10.3 MMEQ, P <0.001), lower peak pain scores (7 [5–9] vs 8 [7–9], P=0.007) and a shorter hospital length of stay (2.5 ± 0.5 vs 2.9 ± 1.2 days, P <0.001) were found after the introduction of the ERAS protocol.ConclusionsImplementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.     

Structured Synchronous Implementation of an Enhanced Recovery Program in Elective Colonic Surgery in 33 Hospitals in The Netherlands

Background

It has been clearly shown that after elective colorectal surgery patients benefit from multimodal perioperative care programs. The Dutch Institute for Health Care Improvement started a breakthrough project to implement a multimodal perioperative care program of enhanced recovery after surgery (ERAS). This pre/post noncontrolled study evaluated the success of large-scale implementation of the ERAS program for elective colonic surgery using the breakthrough series.

Methods

A total of 33 hospitals participated in this breakthrough project during 2005–2009. Each hospital performed a retrospective chart review to gather information on traditionally treated patients (pre-ERAS group, n = 1,451). During the subsequent year patients were treated according to the ERAS program (ERAS group, n = 1 034). Outcomes were length of stay (LOS), functional recovery, adherence to the protocol, and determinants of reduced LOS.

Results

Median LOS decreased significantly from 9 to 6 days (p < 0.001). In the ERAS group, functional recovery was reached within 3 days. Adherence to the protocol elements was high during the preoperative and perioperative phases but slightly lower during the postoperative phase. Younger age, female sex, American Society of Anesthesiologists grades I/II, and laparoscopic surgery were associated with decreased LOS. Care elements that positively influenced LOS were cessation of intravenous fluids and mobilization on postoperative day 1 and administration of laxatives postoperatively.

Conclusions

The ERAS program was successfully implemented in one-third of all Dutch hospitals using the breakthrough series. Participating hospitals reduced the LOS by a median 3 days and were able to improve their standard of care in elective colonic surgery.     

Enhanced recovery after surgery (ERAS) for craniotomies in the treatment of brain tumors: A systematic review

IntroductionPostoperative complications after craniotomy for brain tumors include pain, nausea/vomiting, and infection. A standardized enhanced recovery after surgery (ERAS) protocol is not widely accepted for this common neurosurgical procedure. Few studies have explored its application.MethodsA literature search of PubMed, Cochrane, and Google Scholar databases was performed between January 1992 and March 2023. Original studies that implemented an ERAS protocol for patients that underwent craniotomy for brain tumors were included. The following variables were evaluated: hospital length of stay (LOS), postoperative pain, postoperative nausea and vomiting (PONV) prophylaxis, non-opioid analgesia, and quality of life (QOL).ResultsTwelve studies with a total of 1309 patients met inclusion criteria, including ten randomized controlled trials, one nonrandomized controlled trial, and one quality control study. Most frequently assessed metrics included hospital LOS, PONV prophylaxis, and non-opioid analgesia. A significant reduction in postoperative LOS was observed in 7 studies with ERAS or ERAS components. ERAS was significantly associated with pain reduction on the visual analog scale and verbal numerical rating scale (n = 8). Non-opioid analgesia in ERAS improved postoperative pain control (n = 4) and decreased the duration of pain (n = 1). Three of six studies found no difference in PONV in ERAS vs. control. No studies reported an increase in postoperative complications using ERAS vs. control. One study showed greater patient satisfaction at 30-day follow-up with improved QOL.ConclusionImplementing ERAS protocol may enhance outcomes and quality of life in patients with moderate evidence for improved recovery in those undergoing craniotomy for brain tumors.     

Positive effects of the enhanced recovery after surgery (ERAS) protocol in DIEP flap breast reconstruction

BackgroundEnhanced recovery after surgery protocols are successfully implemented in different surgical specialties, but a specific protocol for autologous breast reconstruction is missing. The aim of this study was to determine whether an enhanced recovery after surgery (ERAS) protocol contributes to a reduced length of stay without an increase in postoperative complications for patients undergoing a DIEP flap breast reconstruction.Materials en methodsThe effect of the ERAS protocol was examined using a single-center patient-control study comparing two groups of patients. Patients who underwent surgery between November 2017 and November 2018 using the ERAS protocol were compared with a historical control group (pre-ERAS) who underwent surgery between November 2016 and November 2017. The primary outcome measure was hospital length of stay. Secondary outcome measures were postoperative pain and postoperative complications.Results152 patients were included (ERAS group, n = 73; control group, n = 79). Mean hospital length of stay was significantly shorter in the ERAS group than in the control group (5 vs. 6 days, p < 0.001). The average pain score was 1.73 in de the ERAS group compared to 2.17 in the control group (p = 0.032). There were no significant differences between the groups in postoperative complications. The ERAS group experienced less constipation (41 vs. 25 patients, p = 0.028).ConclusionAn enhanced recovery after surgery protocol contributes an accelerated postoperative recovery of patients undergoing a DIEP flap breast reconstruction. In this study a significant decrease was found in hospital length of stay, patient-reported pain score and adverse health issues.     

Can the introduction of Enhanced Recovery After Surgery (ERAS) reduce the variation in length of stay after total ankle replacement surgery?

BackgroundEnhanced Recovery After Surgery (ERAS) has been successfully adopted across a range of procedures. This study explores whether there is scope to improve length of stay (LOS) for total ankle replacement surgery (TAR) in the UK by implementing ERAS pathways.MethodsHospital Episode Statistics (HES) data (April 2015/March 2016) on LOS for TAR were analysed. A literature search was then carried out to examine whether there were any publications on outpatient TAR and/or the use of ERAS protocols.ResultsMean observed LOS was 3.3 days (range 0–17.3) days. Case mix-adjusted expected LOS range was 2.0–5.7 days. It is likely that the wide observed LOS range is due to differences in local processes and pathways. Two papers were found by the literature search.ConclusionsTAR should aim to be outpatient surgery as the literature, and data demonstrating scope for improvement in LOS, suggest this should be possible.     

Ambulatory latissimus dorsi flap breast reconstruction: A prospective cohort study of an enhanced recovery after surgery (ERAS) protocol

PurposeEnhanced recovery after surgery (ERAS) protocols improve quality of recovery and decrease length of stay for patients undergoing both alloplastic and autologous breast reconstruction. Their use in latissimus dorsi (LD) flap reconstruction has not been well established. The purpose of this study was to compare postoperative outcomes, length of stay, and total costs in a prospectively enrolled group of patients who underwent LD flap breast reconstruction using an ERAS protocol to those of a retrospective cohort of patients who were treated with a traditional recovery after surgery (TRAS) protocol.MethodsIn a prospective cohort study conducted from 2016 to 2019, an ERAS protocol was implemented for patients undergoing LD flap breast reconstruction. The primary outcome was 24-h discharge, and secondary outcomes were readmission rate, complications, and quality of recovery. Outcomes of patients who underwent LD flap reconstruction with the ERAS protocol were compared with those of a retrospective cohort of patients who underwent LD flap reconstruction with TRAS protocols.ResultsTwenty patients enrolled in the ERAS group were compared with 58 patients in the TRAS group. Postoperatively, 100% of ERAS patients were discharged within 24 h (60% on the same day) as compared to 21% (9% on the same day) in the TRAS group (p<0.0001). Minor and major complication rates were similar (30% ERAS vs. 33% TRAS and 20% ERAS vs. 10% TRAS, respectively, p > 0.05). There was significant reduction in length of stay and total cost between the two groups (6.4 h vs. 58.5 h (p = 0.003) and $5,666.80 vs. $8890.25 (p = 0.0003), respectively).ConclusionsBreast reconstruction with the LD flap can be performed safely and effectively in the ambulatory setting. The implementation of an ERAS protocol was successful in discharging all patients home within 24 h, and the expedited discharge was associated with an acceptable complication rate, reduced length of stay, and excellent quality of recovery. Conversion from TRAS to ERAS protocols was associated with $3,223.45 cost savings per patient.     

Usefulness of an enhanced recovery after surgery protocol for perioperative management following open repair of an abdominal aortic aneurysm

Purpose

To achieve early recovery and early discharge from the hospital by applying an enhanced recovery after surgery (ERAS) protocol, which is mainly used with colonic surgery, for the perioperative management of open AAA surgery.

Method

One hundred twenty-seven open AAA surgery cases successfully carried out between 2003 and 2011 were included in this study. The ERAS protocol was used for the cases from April 2008 onward, and we performed a comparison of the conventionally treated cases with ERAS cases regarding the start of postoperative oral consumption, the postoperative hospital stay, and hospitalization medical costs.

Results

The time to restarting oral consumption and the postoperative hospital stay were significantly shorter for the ERAS group (n?=?52) compared to the conventionally managed group (n?=?75); with values of 59?±?15 and 93?±?25?h (p?=?0.021), 9?±?3 and 16?±?5?days (p?=?0.001), respectively. The medical costs for the ERAS group were 92?% of the costs of the conventionally managed group.

Conclusion

Use of the ERAS protocol for the perioperative management of open AAA surgery shortened the time before recommencing oral consumption, the postoperative hospital stay, and reduced the medical costs compared to the conventional approach.