Enhanced recovery after surgery (ERAS) program in patients undergoing major surgery for gastrointestinal cancer: Results of a 6-year clinical study

Abstract

Introduction: Enhanced Recovery After Surgery (ERAS) program is a multimodal perioperative care pathway designed to achieve early recovery after major surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery, without increasing the rate of postoperative complications or readmissions. The key elements of an ERAS protocol include preoperative counseling, optimization of nutrition, standardized analgesic and anesthetic regimes, and early oral feeding and mobilization. The aim of this study was to present the results of our 6-year experience with the application of an ERAS protocol in patients undergoing major surgery for gastrointestinal cancer. Methods: All consecutive patients with an ASA grade < 4 undergoing major surgical procedures for gastrointestinal cancer during a time period of 6 years (Sept. 2010 - Aug. 2016) and treated according to an ERAS regime were prospectively studied and compared with patients treated with the conventional perioperative care during a 6-month period (Sept. 2010 - Febr. 2011). Our ERAS regime consisted of preoperative counseling of the patients regarding the rehabilitation program, bowel preparation only in sigmoid and rectal surgery, thrombotic and antibiotic prophylaxis, use of general anesthesia, removal of the nasogastric tube at the end of the surgical procedure, management of postoperative pain with non-steroid anti-inflammatory drugs, total daily fluid intake< 2.5L, mobilization at the same day of surgery, and early oral feeding from the 1st postoperative day. The outcome measures were incidence of postoperative complications, length of hospital stay, number of relaparotomies, number of readmissions, and mortality within 30 days. The protocol of the study has been approved by the Scientific and Ethical Committee of our hospital and it has been registered through the NIH trials registration system (ClinicalTrials.gov. NCT01400711). Descriptive values are expressed as mean as6SD. Data analysis was done by the use of Fisher's exact test and Mann-Whitney U-test. Results: Seventy two patients (30 men and 42 women, mean age 68.4612.8 years) treated according to the ERAS program were compared with 38 controls that had conventional perioperative care. The two groups were similar with respect to age, gender, ASA grade, type of disease and type of surgery. There was a significantly lower incidence of postoperative complications in the ERAS group compared to the control group (13.3% vs 42.1% respectively, p=0.001). Length of hospital stay was also significantly shorter in the ERAS group compared to the control group (6.163.9 days vs 12.265.9 days respectively, p<0.0001). There was no difference between the ERAS and the control group regarding readmission rate, relaparotomies and mortality. Conclusion: The results of this study suggest that, in selected patients undergoing major surgical procedures for gastrointestinal cancer, the application of an ERAS program is a safe perioperative practice because it does not add more risk in terms of readmissions, relaparotomies and mortality, and lead to significantly lower incidence of postoperative complications and significantly shorter length of hospital stay.