Enhanced Recovery After Surgery® (ERAS) in Octogenarians Undergoing HPB Surgery

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

Enhanced recovery after surgery (ERAS) for adolescent idiopathic scoliosis: Standardisation of care improves patient outcomes

PurposeTo compare pain scores (visual analog scale) on postoperative days 1–3 and length of stay after implementing enhanced recovery after surgery (ERAS) in elderly patients undergoing multi-segments lumbar fusion surgery.MethodsWe performed a retrospective analysis of prospectively collected data, patients older than 75 years were enrolled in the study. We selected two periods, before (Pre-ERAS, n =54 patients) and after (ERAS, n =46 patients) implementation of ERAS. Data were collected on patient demographics, operative and perioperative details, 30-day readmission. The primary outcome was the length of stay (LOS), and the secondary outcomes were postoperative mean pain scores on postoperative days (POD) 1–3 and 30-day readmission rates.ResultsA total of 100 patients (46 in ERAS and 54 in pre-ERAS) were enrolled in this study. There were no significant differences in age, sex, body mass index (BMI), smoking and comorbidities between the groups. However, there was a significant difference in pain on postoperative day (POD) 1 (5.31 ± 1.98 vs 4.37 ± 0.85, p = 0.002), while there was no difference in postoperative complications. The mean LOS was significantly shorter in the ERAS than in the pre-ERAS group, it reduced from 12.29 ± 3.93 to 9.45 ± 2.72 days (p < 0.001).ConclusionTo our knowledge, this is the first ERAS protocol used in patients (older than 75 years) undergoing polysegmental lumbar fusion surgery. Pain scores on POD 1 and LOS were significantly lower without increased adverse events after implementation of ERAS. This finding suggests that elderly people (>75 years of age) undergoing polysegmental lumbar fusion surgery could also benefit from ERAS.

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.

Enhanced recovery after surgery (ERAS) pathways have been widely implemented across many surgical practices, including autologous breast reconstruction. However, the benefits of ERAS in the morbidly obese population have yet to be defined.A retrospective chart review of patients undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction at our institution from 2017 to 2022 was performed. Length of stay (LOS), intensive care unit (ICU) utilization, opioid usage, cost, and flap outcomes were analyzed in patients with body mass index greater than 35 before and after ERAS implementation.Thirty-five morbidly obese patients receiving DIEP flap breast reconstruction were identified before ERAS and 18 after ERAS. There were no differences in unilateral versus bilateral or immediate versus delayed reconstruction. LOS decreased with ERAS (3.43 vs. 2.06 days, p < 0.0000001). ICU utilization decreased with ERAS (0.94 vs. 0.0 days, p < 0.0001). Daily and total opioid usage decreased with ERAS (41.8 vs. 17.9 morphine milligram equivalent [MME], p < 0.0001; 190.5 vs. 54.7 MME, p < 0.0001). Financial metrics improved with ERAS, including decreased total cost ($33,454 vs. $25,079, p = 0.0002) and increased cost margin ($4,458 vs. -$8,306, p = 0.004). There were no differences in donor or recipient site outcomes including flap loss, deep venous thrombosis/pulmonary embolism, hernia/bulge, delayed wound healing, revisions, and blood loss.ERAS pathways maintain benefits in the morbidly obese population undergoing abdominally based autologous breast reconstruction, including decreased LOS, ICU utilization, opioid use, and cost while maintaining successful reconstruction outcomes.

Key Findings: This systematic review and metaanalysis assessed studies published on enhanced recovery after surgery (ERAS) in spine surgery across both high-income countries (HICs) and lowmiddle-income countries (LMICs).The researchers were particularly interested in length of stay (LOS) and cost savings with ERAS implementation.The initial search resulted in 1232 articles.After refining the search for those that met the criteria, the analysis included 83 LOS studies and 20 cost comparison studies.A significant reduction in LOS was observed in both HICs (-2.06 days; 95% CI, -2.47 to 1.64) and LMICs (-0.99 days; 95% CI, -1.28 to -0.70).Low-middle-income countries were more likely to implement preoperative optimization measures (OR, 2.14; 95% CI, 1.06 to 4.41) and to study operation time (OR, 3.78; 95% CI, 1.77 to 8.35).Of note, the pooled analysis did not demonstrate statistically significant cost benefits with ERAS implementation. Significance:The analysis showed that ERAS has sustained a global presence in the field of spine surgery, and the number of spine ERAS-related studies published by researchers in LMICs continues to grow.In this meta-analysis, 26 countries were represented, 58% and 42% of which represented HICs and LMICs, respectively.The authors were interested to see how the varying availability of different medication, technology, and resources might influence ERAS adoption in countries of different economic status.This analysis did not reveal any stark differences.In both settings, barriers to ERAS implementation included staff shortages, a lack of metric-tracking infrastructure, and poor communication between multidisciplinary health care providers and between providers and patients.Most of the research was retrospective, had small sample sizes (<500 patients), and primarily focused on adults.Pediatric and older adult patients were largely excluded from most research.Finally, most of the studies assessed minimally invasive procedures as opposed to larger open spinal procedures.The authors noted that there may be a greater need for, and benefit of, ERAS implementation in largesegment spine procedures.

Frailty, Myelopathy, and Enhanced Recovery after Surgery in Patients Undergoing Posterior Cervical Fusion

Background: The Enhanced Recovery After Surgery (ERAS) program is a multimodal, evidence-based perioperative care pathway to improve postoperative recovery. This study evaluates the impact of ERAS implementation on clinical outcomes, with a focus on length of stay (LOS) and postoperative complications in patients undergoing colorectal surgery. Methods: We conducted a retrospective-prospective cohort study involving 231 patients who underwent elective colorectal surgery between 2016 and 2023. Patients were divided into two groups: pre-ERAS (n=84, 2016â?"2019) and ERAS (n=147, 2020 - 2023). The primary outcome was LOS, while secondary outcomes included postoperative complications and blood transfusion requirements. Statistical comparisons were made using the Student's t-test and the chi-square test, with significance defined as p 0.05. Results: ERAS implementation was associated with a significant reduction in LOS - from 10.3 days to 5.5 days (p 0.01). Although the overall complication rate did not differ significantly (p=0.15), fewer patients in the ERAS group experienced complications (10.5% vs 18.1%). No significant differences were found in rates of anastomotic leaks, surgical site infections, or postoperative transfusion. Conclusion: The ERAS protocol significantly reduced hospital stays without increasing postoperative morbidity in colorectal surgery patients. These findings support the clinical value and feasibility of the protocol.

Objectives: The study aims to assess the current state of enhanced recovery after surgery (ERAS) in children across 23 medical institutions in China, providing data to support the management and policy-making of ERAS. Methods: In April 2023, a survey was conducted using convenience sampling among the pediatric surgical units of the National Medical Center's Pediatric Nursing Alliance. Data were collected using a specifically designed pediatric ERAS questionnaire, which included information on hospital demographics, surgical volumes, nurse-to-bed ratios, ERAS implementation status, and the primary challenges and obstacles in implementing ERAS programs. Results: The survey revealed that 21 out of the 23 hospitals (91.3%) had implemented ERAS programs, but only 6 (26.1%) had dedicated ERAS nurses. The challenges faced in implementing ERAS included the lack of ERAS clinical guidelines for specific diseases, the absence of unified quality control plans in hospitals, insufficient understanding of ERAS among medical staff, and the lack of hospital-level policy support. Conclusions: While the implementation of ERAS is a growing trend in pediatric surgical care, there is a significant shortage of specialized ERAS nurses, and various obstacles still hinder the widespread adoption of pediatric ERAS. Future research should focus on developing disease-specific ERAS clinical guidelines and establishing uniform ERAS quality control standards. Hospital administrators should provide policy support following ERAS implementation in their departments to facilitate the progression of ERAS.

Background Perioperative complications are common in kidney transplantation, leading to increased length of stay (LOS) and costs. Enhanced recovery after surgery (ERAS) is well-established as a multimodal perioperative care pathway designed to reduce surgical stress and improve patient experience, however, its effectiveness in kidney transplantation remains largely unknown. Methods Participating centres included consecutive adult renal transplant recipients (live or deceased donors). 30-day follow-up data was prospectively collected. The primary outcome was LOS. Multivariable hierarchical models compared cohorts. Results 213 patients were included in the study period, 15th January - 15th February 2024. 8 centres reported no ERAS protocol, 5 a formal ERAS protocol and 7 delivered informal ERAS care. However, analysis of the perioperative care delivery demonstrated similar patterns irrespective of reported protocols, with a tendency towards ERAS-type care. Between cohorts, the incidence of complications (Clavien-Dindo ≥3) was similar; formal ERAS 14.3%, ERAS informal 17.0%, no ERAS 12.6%; p=0.64. Median LOS was also similar; formal ERAS 6.0 days (5.0-11.5), informal ERAS 7.0 days (5.0-10.5) vs no ERAS 6.0 days (5.0-10.5); p=0.75. Readmissions were comparable; formal ERAS 14.3%, informal ERAS 17.0%, no ERAS 19.4%; p=0.721. Multivariable models confirmed these findings and demonstrated patients with WHO performance status ≥1 had longer LOS &amp; more readmissions. Discussion Most UK renal transplant centres are delivering ERAS care. However, a formal ERAS protocol is not associated with decreased complications, LOS or readmissions. Therefore, efforts to improve perioperative outcomes for recipients should focus on treating frailty and prehabilitation of at-risk groups on the waiting list.

The objective of this study was to evaluate whether an enhanced recovery after surgery (ERAS) protocol was associated with a higher rate of same-day discharge after robot-assisted or laparoscopic sacrocolpopexy and to describe the safety and feasibility of same-day discharge after these procedures. A historical control, retrospective cohort study of women undergoing minimally invasive sacrocolpopexy comparing rates of same-day discharge before and after implementation of an ERAS protocol was conducted. Secondary outcomes were obtained by comparing women discharged the same day with those discharged postoperative day ≥1, including postoperative complications and unplanned postoperative patient encounters within 30 days of surgery. Logistic regression was performed to control for potential confounders. Of the 166 women identified (83 before ERAS implementation; 83 after ERAS implementation), 43 underwent same-day discharge versus 123 admitted overnight. The rate of same-day discharge increased 28 percentage points after ERAS implementation (12% vs 40%, P < 0.01). Compared with women admitted overnight, same-day discharge women had shorter procedures (154 vs 173 minutes, P = 0.01), spent longer time in the postanesthesia care unit (130 vs 106 minutes, P = 0.01), and were more likely to be discharged with a Foley catheter (58% vs 28%, P < 0.01). After multivariable logistic regression analysis, ERAS was associated with increased odds of same-day discharge (odds ratio, 4.91; 95% confidence interval, 2.17-11.09). There were no differences in unplanned postoperative patient contacts or postoperative complications within 30 days between same-day discharge and overnight admission groups. Implementation of an ERAS protocol for minimally invasive sacrocolpopexy was associated with a 3-fold increase in same-day discharge.

Background: Implementation of enhanced recovery after surgery (ERAS) program after pancreatic surgery was associated with decreased length of stay (LOS). However, there were only retrospective uncontrolled before-after study, and care protocols were heterogeneous. We aimed to evaluate the impact of ERAS program on postoperative outcomes after pancreatectomy through a prospective controlled study. Methods: A before/after study with a contemporary control group was undertaken in patients undergoing pancreatectomy. We compared 2 groups: the intervention hospital that implemented ERAS program and the control hospital that performed traditional care; and 2 periods: the preimplementation and the post-implementation period. A difference-in-differences approach was used to evaluate whether implementation of ERAS program was associated with improved LOS and postoperative morbidity. Results: About 97 and 75 patients were included in intervention and control hospital. In multivariate analysis, implementation of ERAS was associated with a significantly shorten LOS (hazard ratio 1.61; 95% CI 1.07–2.44) and higher compliance rate (OR 1.34; 95% CI 1.18–1.53). Difference-in-differences analysis revealed that LOS, morbidity, and readmission did not differ after ERAS implementation. Conclusion: Implementation of ERAS program was safe and effective after pancreatectomy with high compliance rate. LOS was significantly reduced without compromising morbidity

IntroductionThe enhanced recovery after surgery (ERAS) protocol relies on patients’ compliance and their awareness of its principles. Patients’ views on ERAS implementation have never been evaluated in Poland before.AimTo analyse patients’ opinions about this protocol.Material and methodsOne hundred forty consecutive patients undergoing elective laparoscopic procedures in which ERAS was implemented were asked to join the study. Out of them, 120 fulfilled the trial criteria and were surveyed once before and twice after surgery. A 22-question survey about the patient’s perception of ERAS principles was presented upon admission and on the day of discharge. A telephone follow-up was performed 2 weeks after discharge.ResultsPatients reported the need for being counselled by the anaesthetist/surgeon as the most important element of the protocol. Items such as being free of pain, being free of gastrointestinal symptoms, and being free of catheter were rated more highly preoperatively than on the day of discharge, whereas telephone check-up call, being able to drink and eat early after surgery, avoiding bowel preparation, avoiding preoperative fasting and reducing postoperative intravenous fluids were rated more highly on the day of discharge. Pain was still present in over half of patients two weeks after discharge. Only 4.76% of patients admitted in the telephone survey that they were afraid of early discharge. Shortening of the length of hospital stay thanks to ERAS was widely appreciated among all patients who did not find it necessary to spend a longer time in the hospital.ConclusionsPolish patients approve the ERAS protocol as modern perioperative care. Patients emphasize the need for preoperative counselling and painless recovery.

The Impact of an Enhanced Recovery after Surgery (ERAS) Protocol Implementation in a Community-Based Hospital.

There is no consensus on which items of Enhanced Recovery After Surgery (ERAS) should and should not be implemented in radical cystectomy (RC). The aim of this study is to report current practices across European high-volume RC centers involved in ERAS. Based on the recommendations of the ERAS society, we developed a survey with 17 questions that were validated by the Young Academic Urologists-urothelial group. The survey was distributed to European expert centers that implement ERAS for RC. Only one answer per-center was allowed to keep a representative overview of the different centers. 70 surgeons fulfilled the eligibility criteria. Of note, 28.6% of surgeons do not work with a referent anesthesiologist and 25% have not yet assessed the implementation of ERAS in their center. Avoiding bowel preparation, thromboprophylaxis, and removal of the nasogastric tube were widely implemented (> 90%application). On the other hand, preoperative carbohydrate loading, opioid-sparing anesthesia, and audits were less likely to be applied. Common barriers to ERAS implementation were difficulty in changing habits (55%), followed by a lack of communication across surgeons and anesthesiologist (33%). Responders found that performing a regular audit (14%), opioid-sparing anesthesia (14%) and early mobilization (13%) were the most difficult items to implement. In this survey, we identified the ERAS items most and less commonly applied. Collaboration with anesthesiologists as well as regular audits remain a challenge for ERAS implementation. These results support the need to uniform ERAS for RC patients and develop strategies to help departments implement ERAS.