Background and Aims: Enhanced recovery after surgery (ERAS) has been shown to improve outcomes for patients following gastrointestinal surgery. Data on protocol adherence and how this impacts on outcome are limited. This study examines how protocol adherence changes over time and determines how this impacts on outcome across a large-volume gastrointestinal surgical service. Materials and Methods: A prospective review of patients eligible for colorectal, liver and oesophagogastric ERAS over two 3-month periods in 2010 and 2011 was performed. End points included: length of stay (LOS), overall protocol adherence, individual modality adherence, reason for pathway deviation and patient outcomes. Results: 172 patients (110 colorectal, 31 liver and 31 oesophagogastric) were evaluated. For each sub-speciality, the introduction of ERAS led to significant reductions in LOS that were sustained for the duration of the study. Adherence was achieved across 60% (colorectal), 75% (liver) and 88% (oesophagogastric) of individual pathway modalities. The major causes of pathway deviation were: post-operative nausea and vomiting (colorectal), pain (liver) and pulmonary complications (oesophagogastric). Conclusions: Large-scale implementation of ERAS at a high-volume centre is feasible and offers many of the benefits demonstrated in controlled trials, but adherence may diminish over time.

Keywords:
Enhanced recovery after surgery, Fast-track surgery, Adherence, Compliance
1.
Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al: Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466-477.
2.
Kehlet H: Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997;78:606-617.
3.
Department of Health National Cancer Action Team, NHS Institute: Enhanced Recovery Partnership Project Report. 2011.
4.
Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N, Group ZFTS: A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009;136:842-847.
5.
Varadhan KK, Neal KR, Dejong CH, Fearon KC, Ljungqvist O, Lobo DN: The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010;29:434-440.
6.
Sammour T, Kahokehr A, Chan S, Booth RJ, Hill AG: The humoral response after laparoscopic versus open colorectal surgery: a meta-analysis. J Surg Res 2010;164:28-37.
7.
Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, et al: Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 2011;254:675-868.
8.
Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N: A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009;136:842-847.e1.
9.
van Dam RM, Hendry PO, Coolsen MM, Bemelmans MH, Lassen K, Revhaug A, et al: Initial experience with a multimodal enhanced recovery programme in patients undergoing liver resection. Br J Surg 2008;95:969-975.
10.
Hendry PO, van Dam RM, Bukkems SF, McKeown DW, Parks RW, Preston T, et al: Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery protocol following liver resection. Br J Surg 2010;97:1198-1206.
11.
Coolsen MME, Wong-Lun-Hing EM, van Dam RM, van der Wilt AA, Slim K, Lassen K, et al: A systematic review of outcomes in patients undergoing liver surgery in an enhanced recovery after surgery pathways. HPB 2012;15:245-251.
12.
Stoot JH, van Dam RM, Busch OR, van Hillegersberg R, De Boer M, Olde Damink SW, et al: The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study. HPB (Oxford) 2009;11:140-144.
13.
Munitiz V, Martinez-de-Haro LF, Ortiz A, Ruiz-de-Angulo D, Pastor P, Parrilla P: Effectiveness of a written clinical pathway for enhanced recovery after transthoracic (Ivor Lewis) oesophagectomy. Br J Surg 2010;97:714-718.
14.
Cerfolio RJ, Bryant AS, Bass CS, Alexander JR, Bartolucci AA: Fast tracking after Ivor Lewis esophagogastrectomy. Chest 2004;126:1187-1194.
15.
Low DE, Kunz S, Schembre D, Otero H, Malpass T, Hsi A, et al: Esophagectomy - it's not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg 2007;11:1395-1402; discussion 1402.
16.
Tang J, Humes DJ, Gemmil E, Welch NT, Parsons SL, Catton JA: Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages. Ann R Coll Surg Engl 2013;95:323-328.
17.
Li C, Ferri LE, Mulder DS, Ncuti A, Neville A, Lee L, et al: An enhanced recovery pathway decreases duration of stay after esophagectomy. Surgery 2012;152:606-616.
18.
Gustafsson UO, Hausel J, Thorell A, et al: Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011;146:571-577.
19.
Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J: Enhanced recovery after surgery protocols - compliance and variations in practice during routine colorectal surgery. Colorectal Dis 2012;14:1045-1051.
20.
Feroci F, Lenzi E, Baraghini M, Garzi A, Vannucchi A, Cantafio S, et al: Fast-track colorectal surgery: protocol adherence influences postoperative outcomes. Int J Colorectal Dis 2013;28:103-109.
21.
Dindo D, Demartines N, Clavien PA: Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-213.
22.
Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, et al: Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 2013;37:259-284.
23.
Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, et al: Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2013;37:285-305.
24.
Guidelines for the Management of Colorectal Cancer, ed 3. London, Association of Coloproctology of Great Britain and Ireland, 2007.
© 2014 S. Karger AG, Basel
2014
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.