Comparison of adapted enhanced recovery after surgery (ERAS) pathway versus standard care in patients undergoing emergency abdominal surgery – A randomized controlled trial.

Implementation of a urogynecology-specific enhanced recovery after surgery (ERAS) pathway

Introduction There is established evidence on the role of enhanced recovery after surgery (ERAS) protocols in elective surgeries but its effectiveness in emergency surgeries has been nominally studied. We aimed at studying the feasibility and effectiveness of ERAS protocols in patients undergoing emergency abdominal surgery for intestinal perforation and small bowel obstruction and compare their surgical outcomes with conventional care. Materials and methods This prospective randomized study was performed for a period of 16 months. A total of 100 patients presenting either with intestinal perforation or acute small bowel obstruction were recruited; 50 each in the ERAS and the conventional care groups. The primary outcomes studied were the postoperative length of stay and 30-day morbidity and mortality. Results It was seen that the median (interquartile range) of the duration of hospital stay in the ERAS group was 4 (1) days while it was 7 (3) days in the conventional care group, which was statistically significant (W = 323.000, p ≤ 0.001). Similarly, postoperative morbidities like a chest infection and surgical site infections) were significant in the conventional care group. Conclusion The ERAS protocols are safe and effective in emergency surgeries and result in a better postoperative outcome.

Enhanced recovery after surgery (ERAS) pathways are widely used in elective surgical procedures. The objective of this study was to evaluate the feasibility and efficacy of ERAS pathways in patients undergoing emergency surgery for perforated peptic ulcer (PPU). The single-centre prospective study was conducted in patients with PPU undergoing emergency open simple closure with Graham’s patch technique were randomized into 42 patients in ERAS group and 43 patients in standard care group in the ratio 1:1. Patients with refractory shock, ASA ≥ 3 and multiple perforation and size > 1 cm were excluded. The outcomes were studied with length of hospitalization (LOH), functional recovery parameters and postoperative morbidity. LOH in ERAS group was significantly shorter (mean difference of 5.31 ± 1.102 days; p < 0.001). Patients in ERAS group had a significantly early functional recovery (days) for the time to first fluid diet (1.904 ± 0.72; p < 0.001), and first semi-solid diet (3.1 ± 0.48; p < 0.001), first stool (3.81 ± 0.76; p < 0.001) and removal of drain (2.19 ± 0.39: p < 0.001). There was a significant reduction in postoperative morbidity rate in ERAS group compared with standard care group. The application of enhanced recovery pathways in patients with perforated peptic ulcer undergoing emergency surgery is safe and feasible.

BackgroundEmergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.ObjectivesThe objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis.DesignThis was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals.SettingThe trial was set in acute surgical services of 93 NHS hospitals.ParticipantsPatients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible.InterventionThe intervention was a QI programme to implement an evidence-based care pathway.Main outcome measuresThe primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years.Data sourcesData were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires.ResultsOf 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon.LimitationsSubstantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery and the mortality rate was lower than anticipated.ConclusionsThere was no survival benefit from a QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. The modest impact of the intervention on process measures, despite good clinician engagement, may have been limited by the time and resources needed to improve patient care.Future workFuture QI programmes must balance intervention complexity with the practical realities of NHS services to ensure that such programmes can be delivered with the resources available.Trial registrationCurrent Controlled Trials ISRCTN80682973 andThe Lancetprotocol 13PRT/7655.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 7, No. 32. See the NIHR Journals Library website for further project information.

Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.

Implications of Practice Variability: Comment.

Introduction: Enhanced recovery after surgery (ERAS) pathways strive to minimize surgical stress and restore normal physiological function through the implementation of standardized and streamlined protocols. ERAS pathways have shown benefits in many surgical populations including cardiac, colorectal, urology and general surgery by aiming to accelerate recovery and reduce post-operative morbidity. As microsurgical breast reconstruction continues to become more popular, study objectives aim to determine possible benefits of ERAS pathway implementation during abdominal-based free flap breast reconstruction related to post-operative narcotic use and health-care resource utilization. Methods: A retrospective analysis of consecutive patients undergoing abdominal-based free flap breast reconstruction from Nov 2015 to April 2018 was performed. Study populations were defined relative to uniform implementation of an ERAS pathway, which included preoperative counseling, optimization of nutrition, perioperative fluid management, early mobilization, and multimodal analgesia. Patient age, medical comorbidities, and BMI were recorded preoperatively. Procedural characteristics and immediate postoperative morbidity were recorded along with length of hospitalization. Utilization of narcotics was standardized for the entire hospitalization by determining morphine milligram equivalents. Results: During the study period, 409 patients met inclusion criteria. The pre-ERAS group was comprised of 205 patients, while 204 patients were managed via ERAS pathway. Mean age, laterality (unilateral vs. bilateral), timing (immediate vs. delayed) of reconstruction, and number of previous abdominal surgeries were similar (p &amp;gt; 0.05) between both groups. Mean BMI (30.4 ± 4.8 vs. 29 ± 5.1) and incidence of autoimmune disease (3.9% vs. 0%) were significantly higher (p &amp;lt; 0.05) in the pre-ERAS group. Mean operative time (minutes) between both groups (450.1 ± 92.7 vs. 440.7 ± 93.5) was similar (p &amp;gt; 0.05). Incidence of vascular thrombosis (6 (2.9%) vs. 5 (2.5%)), hematoma (4 (2%) vs.4 (2%)), flap loss (1 (0.5%) vs. 4 (2.%), or return to OR for any reason (10 (4.9%) vs. 8 (3.9%)) was similar (p &amp;gt; 0.05) between pre-ERAS and ERAS groups, respectively. Mean intra-operative (58.9 ± 32.5 vs. 31.7 ± 23.4) and post-operative (129.5 ± 80.1 vs. 90 ± 93.9) morphine milligram equivalents used were significantly (p &amp;lt; 0.001) higher in the pre-ERAS group. Mean length of stay (days) was significantly (p &amp;lt; 0.001) longer in the pre-ERAS group (4.5 ± 0.8 vs. 3.2 ± 0.6). Bivariate linear regression analysis demonstrates operative time is positively associated with total narcotic requirements [slope (95% CI)=0.217 (0.114, 0.320)], p &amp;lt; 0.001 and length of stay [slope (95% CI) =0.00177 (0.0008, 0.0028)], p &amp;lt; 0.001. Conclusion: Without detrimental effects on operative morbidity, ERAS pathways in microsurgical breast reconstruction promote reduction in intraoperative and postoperative narcotic utilization with concomitant decrease in hospital length of stay. In the current study, patients managed via ERAS pathways required 46% less intraoperative and 31% less postoperative narcotics with a 29% reduction in length of stay. Citation Format: Oscar Ochoa, Meenakshi Rajan, Minas Chrysopoulo, Steven Pisano, Peter Ledoux, Gary Arishita, Ramon Garza III, Chet Nastala. Enhanced recovery after surgery (ERAS) pathway reduces hospital stay and narcotic use in microsurgical breast reconstruction [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD6-2.

(1) Background: The Charlson comorbidity index (CCI) score has been shown to predict 10-year all-cause mortality, but its validity is a matter of debate in surgical patients. We wanted to evaluate CCI on predicting all-cause mortality in elderly patients undergoing emergency abdominal surgery (EAS); (2) Methods: This retrospective single center study included all patients aged 65 years or older consecutively admitted from January 2017 to December 2019, who underwent EAS and were discharged alive. CCI was calculated by using of the International Classification of Diseases, 9th Revision, Clinical Modification codes. Our outcome was all-cause death recorded during the 20.8 ± 8.8 month follow-up; (3) Results: We evaluated 197 patients aged 78.4 ± 7.2 years of whom 47 (23.8%) died. Mortality was higher in patients who underwent open abdominal surgery than in those treated with laparoscopic procedure (74% vs. 26%, p < 0.001), and in those who needed colon, small bowel, and gastric surgery. Mean CCI was 4.98 ± 2.2, and in subjects with CCI ≥ 4 survival was lower. Cox regression analysis showed that CCI (HR 1.132, 95% CI 1.009–1.270, p = 0.035), and open surgery (HR 10.298, 95%CI 1.409–75.285, p = 0.022) were associated with all-cause death independently from age and sex; (4) Conclusions: Calculation of CCI, could help surgeons in the preoperative stratification of risk of death after discharge in subjects aged ≥65 years who need EAS. CCI ≥ 4, increases the risk of all-causes mortality independently from age.

Does compliance with an ERAS protocol for pancreaticoduodenectomy lead to a diffusion effect on compliance for left pancreatectomy?

197. Modest cost reduction associated with initial ERAS implementation in lumbar spine fusion

Extracorporeal membrane oxygenation (ECMO) induces coagulation disorders increasing the risk of bleeding during invasive procedures. We aimed to describe the outcomes of critically ill ECMO patients undergoing emergency abdominal surgery compared to non-ECMO patients. This is a retrospective case-matched single-center study with propensity score analysis in a tertiary ICU. All patients who underwent abdominal surgery were included. From 2006 to 2014, 77 patients admitted in our ICU underwent emergency abdominal surgery, 35 were on ECMO. Surgery indications were comparable for ECMO and non-ECMO patients: mostly intestinal ischemia (42%) and cholecystectomy (25%). Postoperative bleeding was significantly more frequent in ECMO group versus non-ECMO: 77% versus 40% transfused, with medians of 13 (6-22) versus 3 (0-5) packed red blood cell; 9 (3-17) versus 0 (0-4) fresh frozen plasma and 12 (3-22) versus 0 (0-8) platelet units (p < 0.001 for all items). Reintervention for hemorrhage was required in 20% versus 2%, respectively, p = 0.02. At multivariable analysis, ECMO was strongly associated with bleeding (OR, 5.6 [95% CI, 2.0-15.4]; p = 0.001). ICU mortality was higher for ECMO-treated patients (69% vs. 33%; p = 0.003), but perioperative mortality remained comparable between groups (11% vs. 12%, NS). Propensity score-matched analysis confirmed more frequent and severe bleeding in ECMO patients. Abdominal surgery procedures on ECMO-treated patients are associated with a higher risk of hemorrhage compared to non-ECMO ICU patients. Further studies are needed to optimize ECMO patient management during such interventions.

The Enhanced Recovery After Surgery (ERAS) protocol is a comprehensive, multifaceted approach aimed at improving postoperative outcomes. It incorporates a range of strategies to promote early and more effective recovery, including reducing pain, complications, and length of stay, without increasing readmission rate. To date, ERAS for spine surgery patients has been primarily limited to lumbar surgery and anterior cervical decompression and fusion (ACDF). ERAS has not been previously studied for posterior cervical surgery, which may present a greater opportunity for improvement in patient outcomes with ERAS than ACDF. This single-institution, multi-surgeon study assessed the impact of an ERAS protocol in patients undergoing posterior cervical decompression surgery. This study included a retrospective consecutive patient cohort with controls that were propensity matched for age, body mass index, sex, home opioid use, surgical levels, Nurick grade, and smoking status. In addition, consecutive patients who underwent posterior cervical decompression surgery for degenerative disease from December 2014 to December 2021 were included. ERAS was implemented in December 2018. Demographic, perioperative, clinical, and radiographic information was gathered. Regression models were created to evaluate length of stay, physiological function, pain levels, and opioid use. The primary focus was length of stay, with secondary outcomes including timing of ambulation, bowel movement, and voiding; daily pain scores; opioid consumption; discharge status; 30-day readmission rates; and reoperation rates. There were 366 patients included in the study, all of whom were included in multivariate models, and 254 (127 in each cohort) were included on the basis of matching. After propensity matching, patient characteristics, operative procedures, and operative duration were similar between groups. The ERAS cohort had a significantly improved length of stay (3.2 vs 4.7 days, p < 0.0001) and home discharge rate (80% vs 50%, p < 0.001) without an increase in readmission rate. The ERAS cohort had an earlier day of the first ambulation (p = 0.003), bowel movement (p = 0.014), and voiding (p = 0.001). ERAS demonstrated a significantly lower composite complication rate (1.1 vs 1.8, p < 0.0001). ERAS resulted in better maximum pain scores (p = 0.043) and trended toward improved mean pain scores (p = 0.072), although total opioid use was similar. Implementing a novel ERAS protocol significantly improved length of stay, return of physiological function, home discharge, complications, and maximum pain score after posterior cervical surgery.

Enhanced recovery after surgery (ERAS) in one-anastomosis gastric bypass surgery: a matched-cohort study

Enhanced recovery after surgery (ERAS) pathways are multidisciplinary strategies to return patients to their physiologic baseline as efficiently as possible. This study aims to evaluate the feasibility and benefits of an ERAS pathway in children undergoing resection of abdominal neuroblastoma. After IRB approval, all patients greater than 1month old undergoing resection of an abdominal neuroblastoma at one of three children's hospitals between 2020 and 2022 were offered enrollment. A standardized ERAS protocol was utilized at all institutions. Data were prospectively recorded. We compared the prospective cohort to a historic cohort (2014-2020). Fisher's exact and t-tests were used, as appropriate. The study included 23 patients in the ERAS group compared to 24 historic patients. Post-operative nasogastric tube use decreased from 91.7% pre-ERAS to 16.7% in the ERAS cohort. ERAS patients were advanced to regular diets and ambulated 3days earlier than pre-ERAS. Post-operative opioid consumption decreased from 0.54 to 0.21milligram morphine equivalents (MME)mg/kg/day (p = 0.047). All but one patient (23, 96%) in the pre-ERAS cohort experienced at least one post-operative complication, compared to only nine (39.1%) in the ERAS cohort (p < 0.001). Average length of stay was 3.7days with ERAS compared to 6.9days pre-ERAS (p = 0.004). ERAS is associated with improvements in length of stay and a decrease in complications following resection of abdominal neuroblastoma. Children with neuroblastoma stand to benefit considerably from the benefits associated with the use of an ERAS protocol, given their intensive treatment, complex surgeries, and need for expeditious recovery.