Protocol adherence enhances outcomes in fast-track colorectal surgery

Outcomes following fast-track colorectal surgery are directly related to adherence to enhanced recovery after surgery (ERAS) protocols, shows an Italian study.

The authors say theirs is the largest study yet to examine the effect of adherence to the protocols, which healthcare teams often find challenging to fully comply with.

"Higher rates of adherence corresponded to a reduction in length of hospital stay, 30-day morbidity, 30-day non-surgical morbidity and, if a full fast-track surgery pathway was followed, a reduction in readmission rates," say Francesco Feroci (Misericordia and Dolce Hospital, Prato, Italy) and colleagues.

The study included 606 patients who underwent elective laparoscopic or open colorectal surgery during a 6-year period. The surgeons followed a 14-point fast-track protocol. The median postoperative stay was 6 days, and the readmission rate was 2.3%.

The authors found that adherence to pre- and intraoperative ERAS criteria was very high. Adherence reached 100% for several items including: preoperative feeding, counseling and bowel preparation, active hypothermia prevention, and antithrombotic and antimicrobial prophylaxis. However, it decreased in the postoperative period.

Reporting in the International Journal of Colorectal Disease, the authors found that the median length of hospital stay, 30-day morbidity, and 30-day nonsurgical morbidity rates were significantly shorter with an increase in the number of ERAS interventions performed. For example, with 100% protocol adherence, the median length of stay was 4 days, and the 30-day morbidity was 12.9%, compared with 10 days, and 40%, respectively with less than 65% protocol adherence.

Readmission rates were also significantly lower in the 100% adherence group compared with 70-80% and the lower than 65% adherence groups (0 vs 2.3, and 3.8%, respectively).

The authors also examined whether the contribution of individual components was measurable by analyzing the relationship between components with less than 100% adherence and postoperative outcomes. They found that length of stay was independently influenced by the majority of ERAS markers, which could indicate that individual components of ERAS programs work in concert with each other to influence outcomes.

ERAS programs can include up to 20 components which can significantly limit adherence outside of clinical trials. Feroci and colleagues found that in their 14-point program adherence to the postoperative components was still poor, which they say is likely due to the increased participation of nursing and junior staff in care, and more complex organization.

However, the authors say that their findings add to the evidence of the benefits of protocol adherence in colorectal surgery in practice. "We observed a clear relationship between the rate of adherence to the ERAS protocol after major colorectal surgery and clinical outcomes, which is similar to the conclusions of the only other similar study," they conclude.

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