Implications of Practice Variability: Comment.

Effect of Multimodal Analgesia on Opioid Use After Open Ventral Hernia Repair

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

Cost analysis of enhanced recovery after surgery in microvascular breast reconstruction

(Objectives) The Enhanced Recovery After Surgery (ERAS) protocols are standardized and multimodal perioperative care pathways designed to improve surgical outcomes by minimizing stress response and inflammation following surgery. First adopted in colorectal surgery, ERAS is now being employed in various other types of surgeries, most recently in patients undergoing radical cystectomy (RC). Implementation of ERAS protocols resulted in reductions in perioperative complication rates and length of hospital stay (LOS). However, information on the adoption of ERAS in patients undergoing RC in Japan is limited. The objective of this study was to evaluate the safety and efficacy of ERAS implemented in the Toyohashi Municipal Hospital in 2017 for the management of patients with RC. (Patients and methods) This was a retrospective study of 103 patients who underwent RC and urinary diversion from January 2012 to March 2019. Of the 103 patients, 71 underwent surgery prior to the introduction of the ERAS were allocated to the 'traditional' group, while 32 were exposed to the ERAS protocol were allocated to the 'ERAS' group. In this study, ERAS included no bowel preparation, preoperative carbohydrate loading, preoperative fluid reduction, preoperative fasting, reduced drainage use, no nasogastric intubation, and early postoperative drinking and eating. A comparative analysis was performed to evaluate LOS and postoperative complication rate (Clavien classification ≥2) after RC between the 'traditional' and 'ERAS' groups. (Results) Patient characteristics and intraoperative variables such as median age, sex, body mass index, clinical and pathological cancer stage, amount of bleeding, need for transfusion, and technique of urinary diversion did not differ between groups. However, duration of surgery was significantly shorter in the ERAS group than in the traditional group (402 min vs. 470 min; P = 0.03). Further, rate of complication was significantly lower (43.8% vs. 67.6%; P=0.03) and LOS after RC was significantly shorter (21 days vs. 28 days; P<0.001) in the ERAS group compared to the traditional group. Moreover, ERAS was an independent factor affecting shorter LOS after RC (OR, 5.22; 95% CI, 1.52-17.90; P = 0.009) in multivariate analyses. (Conclusions) It is possible that the ERAS protocol adopted in this study reduced the LOS and postoperative complication rate after RC at this site in Japan.

BackgroundDistal radius fractures (DRF) account for one in five bony injuries in both primary and secondary trauma care. Enhanced recovery after surgery (ERAS) has been adopted successfully to improve clinical outcomes in multiple surgical disciplines; however, no study has investigated the effect of different degrees of compliance with ERAS protocol on short-term outcomes following distal radius surgery. We aimed to analyze whether different degrees of compliance with the ERAS pathway are associated with clinical improvement following surgery for DRF.MethodsWe retrospectively analyzed all consecutive patients with ERAS who underwent surgery for DRF at our department between May 2019 and October 2022. Their pre-, peri-, and post-operative compliance with the 22 elements of the ERAS program were assessed. We compared parameters between low- (< 68.1%) and high-compliance (> 68.1%) groups, including patient complications, total length of hospitalization, discharge time after surgery, hospital costs, time taken to return to preinjury level performance level, number of visual analogue scale (VAS) pain scores > 3 points during hospitalization, disabilities of the arm, shoulder and hand (DASH) scores. We performed multiple linear regression analyses to assess the impact of ERAS compliance on the postoperative function level (DASH scores).ResultsNo significant differences were detected between the high- and low-compliance groups with respect to demographics, including sex, age, body mass index (BMI), and comorbidities (P > 0.05). We observed significant differences between the high- and low-compliance groups in terms of the DASH score (32.25 ± 9.97 vs. 40.50 ± 15.65, p < 0.05) at 6 months postoperatively, the discharge time after surgery (2.45 ± 1.46 vs. 3.14 ± 1.50, p < 0.05), and number of times when the VAS pain score was > 3 points during hospitalization (0.88, [0.44, 1.31], p < 0.05). Our study demonstrated a significant negative association between ERAS compliance and the function level of patients postoperatively (DASH scores) when adjusted for age, comorbidity, sex, and BMI.ConclusionsThis study provided a realistic evaluation and comparison of the ERAS protocol among patients with DRF and can guide clinical decision making. The ERAS protocol may improve outcomes after surgery, with high postoperative function levels and reduced pain and discharge time after surgery, without increased complication rates or hospital costs.

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.

Identification of core items in the enhanced recovery pathway

To compare enhanced recovery after surgery (ERAS) with traditional recovery after surgery (TRAS) for patients undergoing alloplastic breast reconstruction. A retrospective chart review of 2 patient groups (ERAS and TRAS) undergoing alloplastic breast reconstruction was performed. Data were collected from 2012 to 2013 (TRAS) and from 2013 to 2016 (ERAS). The ERAS protocol included day surgery, multimodal analgesia, and preoperative anti-emetic. The TRAS pathway involved overnight admission, narcotic-based analgesia, and no preoperative anti-emetic. Demographics, operative variables, and complications were compared between groups. Seventy-eight ERAS patients and 78 TRAS patients were included. Length of stay was shorter for ERAS patients (0.38 nights ERAS and 1.45 nights TRAS; P < .001). The ERAS patients underwent significantly more bilateral surgery (80.8% ERAS and 55.1% TRAS; P < .001), immediate reconstruction (98.6% ERAS and 89.3% TRAS; P = .004), and had more implants versus expanders placed (66% [93/141] ERAS and 24.8% TRAS; P < .001). There were no differences in the number of post-operative emergency department visits (8% ERAS and 14% TRAS; P = .2) and readmissions (8% ERAS and 3.8% TRAS; P = .3) between the groups. There was no difference in the rate of hematoma (0.7% ERAS and 0% TRAS; P = .35), infection requiring explantation (1.4% ERAS and 0.8% TRAS; P = .65), infection requiring outpatient IV antibiotics (1.4% ERAS and 2.5% TRAS; P = .53), and infection requiring IV antibiotics and readmission (2.1% ERAS and 1.7% TRAS; P = .78) between the groups. There were no differences in the number of minor complications (22% ERAS and 23% TRAS; P = .82). The ERAS protocol for alloplastic breast reconstruction is safe, without increased readmission or complication rates compared to TRAS, and significantly decreased length of stay.

This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery. This retrospective cohort study was performed in a tertiary care hospital. A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck HospitalofUniversity of Southern California (USC), California, USA, from 2016 to 2020 were included in this study. The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared towarda satisfactory, safe, and expeditious discharge. The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block. The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.

The impact of an enhanced recovery after surgery (ERAS) programme in emergency colorectal surgery has not yet been reported. The objective of this study was to evaluate the feasibility and the results of patients included in an ERAS protocol following emergency colon surgery for left colon perforation. For this purpose, patients with a low to moderate risk of mortality, according to a Peritonitis Severity Score (PSS), and treated with an ERAS protocol (ERAS group) after emergency surgery for left colon perforation were compared for a period of 40 months (March 2014–June 2017) with a control group of patients treated with conventional care (CC group) during the 38 months prior to implementation of the new ERAS protocol (January 2011–February 2014). The main endpoint was 90-day postoperative morbidity according to the Clavien–Dindo classification. Secondary endpoints included length of postoperative hospital stay, 90-day readmission rate, protocol compliance and mortality. Fifty patients were included in the study, 29 in the ERAS group and 21 in the CC group. There were no significant differences between the groups in the demographic data or in the operative characteristics. A reduction in the incidence of postoperative complications (20.7% vs. 38%; p > 0.05) and in the postoperative hospital stay (7.7 + /- 3.85 vs. 10.9 + /- 5.6 days; p = 0.009) were observed in the ERAS group. The 90-day readmission rate did not differ significantly between the two groups (2 vs. 1). No 90-day mortality was observed in either group. The ERAS group showed better results than the CC group in protocol compliance. We conclude that ERAS protocols are feasible and help to reduce morbidity and length of hospital stay without adversely affecting the rate of readmission or mortality.

Objective To assess the efficacy of microvascular decompression (MVD) for hemifacial spasm with an enhanced recovery after surgery (ERAS) protocol. Methods 984 hemifacial spasm patients who underwent MVD from Jan 2017 to Dec 2017 were analyzed. They were divided into the conventional treatment group (control; n = 453) and the later ERAS group (n = 531). The multimodal ERAS protocol consists of 23 perioperative elements. Time to feeding, mobilization, and urinary catheter removal, wound pain, postoperative nausea and vomiting (PONV), and total, preoperative, and perioperative hospital length of stay (LOS), along with outcomes and complications, were analyzed. Results The patients in both groups had similar clinical characteristics. Patients in the ERAS group had significantly higher rates of early feeding (469 [88.5%], ERAS, vs. 183 [40.6%], control; p < 0.05), early mobilization (497 [93.7%], ERAS, vs. 215 [47.7%], control; p < 0.05), and early removal of urinary catheter (458 [86.4%], ERAS, vs. 175 [38.8%], control; p < 0.05). The ERAS group also had a significantly lower incidence of wound pain (135 [25.5%], ERAS, vs. 348 [77.2%], control) and PONV (173 [32.6%], ERAS, vs. 251 (55.7%), control) (p < 0.05) and significantly shorter preoperative (0.9 ± 0.3 d, ERAS, vs. 2.3 ± 0.6 d, control), postoperative (4.1 ± 0.4 d, ERAS, vs. 5.8 ± 0.7 d, control), and total LOS (5.2 ± 0.3 d, ERAS, vs. 8.8 ± 0.6 d, control) (p < 0.05). There was no significant difference in outcomes or surgical complication rates between two groups. Conclusions Implementation of the ERAS protocol for patients undergoing MVD procedures for the treatment of HFS improved the quality of perioperative care without an increase in adverse events.

PD51-11 REPORTING RADICAL CYSTECTOMY OUTCOMES FOLLOWING IMPLEMENTATION OF ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOLS

Enhanced recovery after surgery (ERAS) implementation has proven to reduce complication rate and length of hospital stay. Little is known about the sustainability of these results over time. The study aim was to assess the application of ERAS pathway over the first 4years after initial implementation. This retrospective study analyzed data collected prospectively from 482 consecutive elective colorectal patients operated in 2011 during the ERAS implementation process (n=66), and after initial implementation in 2012 (n=136), 2013 (n=152), and 2014 (n=128). Auditing ERAS was appraised from different perspectives: adherence with the ERAS protocol, clinical outcomes, and functional recovery. Patients were compared by year. The groups were similar in terms of demographics and surgical strategies. Length of stay remained stable at 7days without significant variation over time (p=0.741). The 30-day complications and readmission rates were not statistically different (respectively p=0.068 and p=0.639). There was also no difference in functional recovery, more particularly, first flatus occurred at day 2 (p=0.177), pain was adequately controlled with oral analgesics at day 2 (p=0.111), and patients were mobilized more than 4h the first postoperative day in more than 60% of cases (p=0.343). Overall adherence with the ERAS pathway was 73% during implementation and, respectively, 73 and 77% for 2012 and 2013 after initial implementation (p=0.614). A significant decrease between 2013 (77%) and 2014 (73%) was observed (p=0.032). Application of the institutional ERAS pathway could be maintained in the first 4years after implementation leading to sustained improved functional recovery and clinical outcome.

The Enhanced Recovery After Surgery (ERAS) pathway promotes an early recovery after surgery using an evidence-based multidisciplinary approach. The ERAS protocol is aimed at standardizing care to improve patient outcomes. There is consistent evidence that ERAS pathways reduce hospital length of stay (LOS) and readmission rates, decrease healthcare costs, and improve patient satisfaction and outcomes. By attenuating the surgical stress response and supporting the return of physiological function, the ERAS pathway achieves its effectiveness. This scholarly project aimed to evaluate how ERAS improves patient outcomes in gynecology patients at a county hospital. A standardized method for improving patient recovery was not in place at the institution prior to the implementation of the ERAS pathway. ERAS-boarded gynecology surgery patients were reviewed retrospectively as part of this quality improvement project. Through this quality improvement project, hospital LOS was reduced without increasing readmissions or complications. There were no significant relationships between readmission rate and categorical extraneous variables. However, two significant relationships were found among LOS and the categorical extraneous variables. Hispanics had a shorter LOS and women who had an open procedure had longer LOS. As a result of the evaluation of this pathway, modifications may be made to the implementation of ERAS to ensure the high level of success of the program and enhance its expansion to other surgical specialties.

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