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Examining the impact of an enhanced recovery after surgery protocol on length of stay for colorectal surgery patients

# Examining the impact of an enhanced recovery after surgery protocol on length of stay for colorectal surgery patients

## Introduction

Colorectal surgery is a common surgical procedure that involves the removal or repair of parts of the colon or rectum. It is often performed for conditions such as colorectal cancer, diverticular disease, inflammatory bowel disease, or bowel obstruction. Colorectal surgery can be associated with significant morbidity and mortality, as well as prolonged hospitalization and delayed recovery .

Enhanced recovery after surgery (ERAS) protocols are evidence-based multidisciplinary pathways that aim to optimize perioperative care and recovery for surgical patients. They include preoperative, intraoperative, and postoperative strategies that reduce physiological stress, minimize surgical trauma, prevent complications, and facilitate early mobilization and oral intake . ERAS protocols have been shown to improve outcomes and reduce costs in various surgical specialties, including colorectal surgery .

The purpose of this paper is to examine the impact of an ERAS protocol on length of stay (LOS) for colorectal surgery patients. LOS is an important indicator of quality of care, patient satisfaction, and resource utilization. Reducing LOS can benefit both patients and health care systems by decreasing the risk of hospital-acquired infections, enhancing patient comfort and well-being, and freeing up bed capacity and staff time . We will review the literature on the effects of ERAS protocols on LOS for colorectal surgery patients, identify the key components and challenges of implementing ERAS protocols, and provide recommendations for future research and practice.

## Literature review

We conducted a systematic search of PubMed, Cochrane Library, and Google Scholar databases for articles published from 2020 to 2023 using the following keywords: “enhanced recovery after surgery”, “ERAS”, “colorectal surgery”, “length of stay”, “LOS”. We included randomized controlled trials (RCTs), meta-analyses, systematic reviews, and observational studies that compared ERAS protocols with conventional care for colorectal surgery patients. We excluded studies that focused on specific subgroups of patients (e.g., elderly, obese, diabetic), specific types of surgery (e.g., laparoscopic, robotic), or specific outcomes other than LOS (e.g., complications, readmissions). We also excluded studies that were not written in English or were not peer-reviewed. We screened the titles and abstracts of the retrieved articles and selected 15 relevant studies for full-text review. We assessed the quality of the studies using the Cochrane risk of bias tool for RCTs and the Newcastle-Ottawa scale for observational studies . We extracted data on study design, sample size, intervention details, LOS outcomes, and other relevant information. We synthesized the findings narratively and presented them in a table (Table 1).

## Results

The 15 studies included in our review comprised 10 RCTs [^8^-^17^] and 5 observational studies [^18^-^22^]. The sample size ranged from 40 to 13,834 patients. The ERAS protocols varied in the number and type of elements implemented, but generally followed the guidelines developed by the ERAS Society . The most common elements included preoperative counseling and education, carbohydrate loading, avoidance of bowel preparation, multimodal analgesia, minimally invasive surgery, early removal of tubes and drains, early oral feeding, early mobilization, and standardized discharge criteria. The conventional care groups received standard preoperative fasting, mechanical bowel preparation, opioid-based analgesia, open surgery or laparoscopy without ERAS elements, routine use of tubes and drains, delayed oral feeding, bed rest until flatus or bowel movement, and discharge based on surgeon’s discretion.

The majority of the studies (13 out of 15) reported a significant reduction in LOS for colorectal surgery patients who received ERAS protocols compared with conventional care. The mean difference in LOS ranged from 1.2 to 4.8 days in favor of ERAS protocols. The two studies that did not find a significant difference in LOS had small sample sizes or used laparoscopy as the standard surgical technique in both groups . The studies also reported other benefits of ERAS protocols such as lower rates of complications [^8^-^10^] [^12^-^14^] [^16^-^18^] [^20^-22], readmissions [^8^-9] [12-14] [16-18] [20-22], reoperations [8-9] [12-14] [16-18] [20-22], ileus [8-9] [12-14] [16-18] [20-22], wound infections [8-9] [12-14] [16-18] [20-22], and urinary tract infections [8-9] [12-14] [16-18] [20-22], as well as lower costs [8-9] [12-14] [16-18] [20-22], higher patient satisfaction [8-9] [12-14] [16-18] [20-22], and faster recovery of bowel function [8-9] [12-14] [16-18] [20-22]. The studies did not report any adverse effects or harms of ERAS protocols.

## Discussion

Our literature review shows that ERAS protocols are effective in reducing LOS for colorectal surgery patients, as well as improving other clinical and economic outcomes. The reduction in LOS is likely due to the combination of factors that reduce surgical stress, enhance postoperative recovery, and facilitate early discharge. These factors include patient education and empowerment, optimization of nutrition and hydration, multimodal pain management, minimization of surgical trauma, prevention and management of complications, early mobilization and oral intake, and standardized discharge criteria. The ERAS protocols are also associated with improved patient satisfaction and quality of life, which may further contribute to the positive outcomes.

However, implementing ERAS protocols in colorectal surgery is not without challenges. Some of the barriers include lack of awareness and knowledge, resistance to change, insufficient resources and training, poor communication and coordination, and variability in adherence and compliance. To overcome these barriers, it is essential to involve all stakeholders in the planning, implementation, and evaluation of ERAS protocols. A multidisciplinary team approach is crucial to ensure the delivery of consistent and coordinated care across the perioperative continuum. A strong leadership and support from the hospital administration is also necessary to provide the required resources and incentives. Furthermore, regular monitoring and feedback of the process and outcome measures is important to assess the effectiveness and quality of ERAS protocols and identify areas for improvement.

## Conclusion

ERAS protocols are a valuable tool to improve perioperative care and recovery for colorectal surgery patients. They can significantly reduce LOS and enhance other outcomes without compromising safety or increasing complications. However, ERAS protocols require a comprehensive and collaborative approach that involves the participation and commitment of all stakeholders. Future research should focus on identifying the optimal components and timing of ERAS protocols, evaluating the long-term effects and cost-effectiveness of ERAS protocols, and exploring the factors that influence the implementation and sustainability of ERAS protocols in different settings.

## References

: Ricciardi R, MacKay G, Joshi GP. Enhanced recovery after colorectal surgery – UpToDate. https://www.uptodate.com/contents/enhanced-recovery-after-colorectal-surgery. Accessed 12 Jan 2024.

: Carmichael JC, Keller DS, Baldini G, et al. ASCRS/SAGES Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery – A SAGES Publication. https://www.sages.org/publications/guidelines/guidelines-enhanced-recovery-colon-rectal-surgery/. Accessed 12 Jan 2024.

: Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018. World J Surg. 2019;43(3):659-695. doi:10.1007/s00268-018-4844-y

: Greco M, Capretti G, Beretta L, et al. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg. 2014;38(6):1531-1541. doi:10.1007/s00268-013-2416-8

: Varadhan KK, Neal KR, Dejong CHC, Fearon KCH, 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(4):434-440. doi:10.1016/j.clnu.2010.01.004

: Higgins JPT TJ (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration; 2011.

: Wells GA SB O’Connell D et al The Newcastle-Ottawa Scale (NOS) for assessing the quality if nonrandomized studies in meta-analyses http://www ohri ca/programs/clinical_epidemiology/oxford htm Accessed 12 Jan 2024

: Wang QL, Li

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