Learning curve of enhanced recovery after surgery program in open colorectal surgery

Table 1 Enhanced recovery after surgery protocol for open colorectal surgery

Preadmission

1 Cessation of smoking and intake of alcohol; 2 Nutrition assessment and nutrition support as needed; 3 Medical optimization of chronic disease

Preoperative

4 Structured preoperative counseling to patients and their relatives; 5 No mechanical bowel preparation; 6 Administration of appropriate prophylactic antibiotics; 7 Prophylaxis of postoperative nausea and vomiting

Intraoperative

8 Use of epidural anesthesia; 9 Use of atraumatic O-ring wound retractor/protector; 10 Avoid hypothermia; 11 Maintaining fluid balance and vasopressors to support blood pressure control; 12 No intraabdominal or pelvic drain

Postoperative

13 Early intake of oral fluids and semi-solid foods (day of surgery); 14 Early ambulation (postoperative day 1); 15 Multimodal approach to opioid-sparing pain control; 16 Removal of urinary catheter by postoperative day 3; 17 Discontinuous intravenous fluid infusion by postoperative day 3

Table 2 Patients’ characteristics and operative details

	Overall	1st quintile	2nd quintile	3rd quintile	4th quintile	5th quintile	P value
	(n = 380)	(n = 76)	(n = 76)	(n = 76)	(n = 76)	(n = 76)
Age (yr)	62.8 ± 12.7	60.9 ± 14.8	65.2 ± 11.2	63.7 ± 12.4	61.6 ± 12.9	62.4 ± 11.5	0.227
Male	206 (54)	43 (57)	40 (53)	41 (54)	44 (51)	38 (50)	0.877
BMI (kg/m2)	23.0 ± 4.1	23.7 ± 4.5	23.0 ± 3.8	23.2 ± 3.8	22.3 ± 4.2	23.1 ± 3.9	0.371
ASA classification ≥ 3	75 (20)	9 (12)	19 (25)	20 (26)	13 (17)	14 (18)	0.146
CR-POSSUM	1.80	1.77	1.88	1.75	1.80	1.90	0.675
Predicting mortality	(1.00-2.58)	(0.96-2.58)	(0.98-3.18)	(0.95-2.58)	(1.30-3.28)	(1.30-2.50)
Hematocrit (%)	36.8 ± 5.4	36.6 ± 5.5	36.1 ± 5.1	37.3 ± 5.5	37.4 ± 5.6	36.5 ± 5.3	0.548
Cancer surgery	347 (91)	70 (92)	68 (90)	69 (91)	71 (93)	69 (91)	0.930
Rectal surgery	165 (43)	34 (45)	30 (40)	39 (38)	40 (53)	32 (42)	0.397
Stoma formation	82 (22)	19 (25)	20 (26)	13 (17)	20 (26)	10 (13)	0.157
Multi-organ Resection1	36 (10)	9 (12)	10 (13)	5 (7)	9 (12)	3 (4)	0.227
Blood loss (mL)	150 (73-300)	200 (100-425)	200 (100-400)	150 (90-300)	150 (55-385)	140 (55-200)	0.067

Data are presented as mean ± SD, median (IQR) or number (percentage).

¹Multi-organ resection excluded the resection of appendix, gallbladder, ovaries and fallopian tubes, small bowel, and part of urinary bladder (partial cystectomy). ASA: American Society of Anesthesiologists; BMI: Body mass index; CR-POSSUM: ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity.

Table 3 Surgical outcomes

	Overall	1st quintile	2nd quintile	3rd quintile	4th quintile	5th quintile	P value
	(n = 380)	(n = 76)	(n = 76)	(n = 76)	(n = 76)	(n = 76)
Time to resume normal diet (d)	2 (1-3)	2 (1-3)	1 (0-2)a	2 (0-2.8)	2 (1-3)	2 (1-2)	< 0.001a
Time to first bowel movement (d)	3 (2-3)	3 (2-3)	3 (2-3)	3 (2-3)	2 (2-4)	3 (2-3)	0.848
Overall complication	83 (21.8)	18 (23.7)	20 (26.3)	16 (21.1)	18 (23.7)	11 (14.5)	0.457
Major complication1	11 (2.9)	1 (1.3)	3 (3.9)	2 (2.6)	3 (3.9)	2 (2.6)	0.860
Hospital stay (d)	4 (4-5)	5 (4-7)b	4 (4-5)	4 (4-5)	5 (4-5.8)	4 (3-5)	0.015a
Hospital stay >5 d	86 (22.6)	31 (40.8)c	12 (15.8)	15 (18.4)	19 (25.0)	10 (13.2)	< 0.001a
30-d readmission	9 (2.4)	1 (1.3)	0	5 (6.6)	2 (2.6)	1 (1.3)	0.077
30-d mortality	1 (0.3)	0	1 (1.3)	0	0	0	0.405
ERAS compliance %	73.5 ± 11.8	68.6 ± 16d	75.4 ± 11.1	73.7 ± 9.9	74.3 ± 10.2	75.5 ± 9.5	< 0.001 a
Optimal recovery2	288 (75.0)	44 (57.9)e	64 (84.2)	57 (75.0)	55 (72.4)	65 (85.5)	< 0.001 a

Data are presented as mean ± standard deviation, median (IQR) or number (percentage).

^aP < 0.05. 2^nd quintile had a shorter period of time to resume normal diet than 1^st and 4^th quintile; 1^st quintile had a longer length of postoperative stay than 5^th quintile; 1^st quintile had a higher number of patients discharged after postoperative day 5 than the others; 1^st quintile had a lower compliance rate of ERAS protocol than 2^nd, 4^th and 5^th quintile; 1^st quintile had a higher rate of composite unfavorable outcomes than 2^nd, 4^th and 5^th quintile.

¹Clavien-Dindo grade ≥ III (the most severe complication was registered for patients with more than one complication);

²Optimal recovery was defined as no major postoperative complication, discharge by postoperative day 5, and no 30-d readmission.

ERAS: Enhanced recovery after surgery.