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Implementation of an enhanced recovery after surgery (ERAS) program: The MD Anderson Cancer Center experience
Abstracts / Clinical Nutrition ESPEN 19 (2017) 73e99
the impact of ERAS programme in our institution on patient outcomes after elective major colorectal surgery. Methods: 180 consecutive patients who underwent elective colorectal surgery under the ERAS Programme from March to Dec 2016 were analyzed from a prospectively-maintained database. They were compared with retrospective data of 335 elective colorectal surgery patients who received standard care, from January 2015 e May 2016. The primary outcome measure was post-operative length of hospital stay. Secondary outcome measures included post-operative complications, readmission rates, and compliance to ERAS guidelines. Results: For patients in the ERAS group, the median age is 69. 42 (23.3%) hemicolectomies, 69 (38.3%) sigmoid colectomies, 58 (32.2%) anterior resections, 4 (2.2%) abdominoperineal resections and 7 (3.9%) other major resections were performed. Patients who received standard care have similar demographics. Median length of stay decreased from 7 days to 6 days in ERAS group (p¼0.025). Paralytic ileus rates also improved from 23.6% to 15% (p¼0.022). Surgical complications rates decreased from 26.9% in the standard care group to 17.2% in ERAS group (p¼0.017). Re-admission rates were 7% in both groups. Compliance to ERAS guidelines has increased from 42.4% to 65.6% since its implementation. Conclusion: Implementation of ERAS Programme is associated with significantly shorter duration of post-operative hospital stay and lower rates of paralytic ileus and overall surgical complications rates. There is no significant difference in hospital re-admissions rates. The difficulties in implementing the full ERAS programme and achieving a high level of compliance were multifactorial. Despite these challenges, the adoption of ERAS protocol can result in improved patient outcomes and should be considered as standard of care in this group of patients. Disclosure of interest: None declared. P061 IMPLEMENTATION OF AN ENHANCED RECOVERY AFTER SURGERY (ERAS) PROGRAM: THE MD ANDERSON CANCER CENTER EXPERIENCE Gloria Salvo 1, Larissa A. Meyer 1, Javier Lasala 2, Maria D. Iniesta 1, Nipa Sheth 1, Mark F. Munsell 3, Andrea Rodriguez-Restrepo 2, Camila Corzo 1, Karen H. Lu 1, Pedro T. Ramirez 1, *. 1 Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, United States; 2 Department of Anesthesia, MD Anderson Cancer Center, Houston, United States; 3 Department of Biostatistics, MD Anderson Cancer Center, Houston, United States * Corresponding author.
Objectives: To evaluate perioperative outcomes of patients undergoing exploratory laparotomy for gynecologic indications in an Enhance Recovery after Surgery (ERAS) program and compare to those receiving traditional perioperative care (pre-ERAS). Methods: All consecutive patients managed under an ERAS program undergoing exploratory laparotomy between 11/3/2014 and 10/26/2016 were compared to historical controls (May to October, 2014). Interventions included, but not limited to, allowing oral intake of fluids up to 2 hours before induction of anesthesia; pre-, intra-, and post-operative euvolemia as well as opioid-sparing analgesia (total intravenous anesthesia); and ambulation and regular diet on the day of surgery. Wilcoxon rank-sum and Fisher’s exact tests were used for comparisons Results: A total of 518 enhanced recovery patients were compared with 74 patients in the control group (pre-ERAS). ERAS resulted in a 73.6% reduction in median postoperative morphine equivalents during the first 3 days after surgery with no significant difference in mean pain scores between the pre- and post ERAS cohorts. Thus far, ERAS has resulted in a 1-day reduction in hospital stay (median LOS pre-ERAS: 4 days [range, 2-27] vs. ERAS: 3 days [range, 1-43], p<0.01) with stable readmission rates (preERAS: 14.1% vs. ERAS: 12.9%, p¼0.85). No differences were observed in postoperative complications between pre-ERAS and ERAS groups respectively (29.6% vs. 25.7%, p¼0.47; GU: 21.1% vs. 18.3%, p¼0.63; Hematologic: 16.9% vs. 11.8%, p¼0.25). Median percentage compliance to the enhance recovery components for the ERAS group was 70% (range, 40-85%)
POD0 POD1 POD2 POD3 MED/Day
99
Pre-ERAS Median (range)
ERAS Median (range)
% Reduction
P-value
49.0 50.0 32.0 22.0 28.4
7.5 9.4 7.5 7.5 7.5
84.7% 81.2% 76.6% 65.9% 73.6%
<0.001 <0.001 <0.001 <0.001 <0.001
(4.0-637.5) (0.0-843.0) (1.0-752.6) (0.0-481.0) (1.5-253.5)
(0-101.3) (0-200.0) (0-225.0) (0-205.0) (0-107.0)
Conclusion: Implementation of an ERAS program was associated with reduced length of stay with stable readmission and perioperative complication rates and reduced overall opioid consumption. Further study is warranted to determine impact on progression free survival. Disclosure of interest: None declared. P062 ADHERENCE TO THE ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL AND OUTCOMES AFTER COLORECTAL CANCER SURGERY IN NORTH ESTONIA MEDICAL CENTRE €rma 1, *, Indrek Seire 2, Anni Laas 2, Sander Kütner 2. 1 Department of Eve Ha Anaesthesiology North Estonia Medical Center, Tallinn, Estonia; 2 Department of Surgery, North Estonia Medical Center, Tallinn, Estonia * Corresponding author.
Objectives: In 2015 the Enhanced Recovery After Surgery (ERAS) protocol for management of the colorectal cancer patients was implemented in North Estonia Medical Centre (NEMC). A multidisciplinary team including a colorectal surgeon, anaesthetist, ERAS dedicated nurse, pain management nurse and physiotherapist was formed. The team launched hospital specific guidelines and introduced the programme among all the specialities involved. The aim of this audit was to evaluate the impact of different adherence levels of ERAS protocol to the outcome after major colorectal procedure. Methods: The data of 53 patients who underwent radical colorectal cancer surgery between September 2015 and May 2016 was collected retrospectively and analysed. According to the recent literature 11 most important ERAS elements such as using preoperative carbohydrate drinks, selective bowel preparation, early mobilisation and oral intake, avoiding premedication and fluid overload etc., were selected and measured. Based on the completion of 11 ERAS elements, the patients were divided in to 5 groups (>90%; 80-89%; 70-79%; 60-69%; <60% of elements completed respectively). The primary endpoint (postoperative complications, e.g. postoperative ileus, anastomotic leakage, wound infection or dehiscence etc.) and secondary endpoints such as length of hospital stay (LOS), readmissions and 30-day mortality were measured between the different groups. Results: The overall adherence to the ERAS protocol in NEMC is well above average. The overall procedure related complication rate was 28%, most common complications being wound infection (28%), wound dehiscence (11%), anastomotic complications (11%), intraabdominal abscess (11%), postoperative ileus (17%) and more rare being sepsis, pulmonary complications, acute kidney injury and gastric ulcer perforation (22% in total). 3 patients were reoperated due to complications. 9 patients (17%) were readmitted to the hospital for various reasons, infection being most common (56%). The patients with lower adherence to ERAS protocol had longer LOS. Conclusion: The patients who underwent major colorectal surgery and were treated with higher adherence to ERAS protocol had significantly lower rate of postoperative complications and readmissions as well as reduced LOS. There were no changes in the 30- day mortality rate between the groups according to this audit. Disclosure of interest: None declared.
the impact of ERAS programme in our institution on patient outcomes after elective major colorectal surgery. Methods: 180 consecutive patients who underwent elective colorectal surgery under the ERAS Programme from March to Dec 2016 were analyzed from a prospectively-maintained database. They were compared with retrospective data of 335 elective colorectal surgery patients who received standard care, from January 2015 e May 2016. The primary outcome measure was post-operative length of hospital stay. Secondary outcome measures included post-operative complications, readmission rates, and compliance to ERAS guidelines. Results: For patients in the ERAS group, the median age is 69. 42 (23.3%) hemicolectomies, 69 (38.3%) sigmoid colectomies, 58 (32.2%) anterior resections, 4 (2.2%) abdominoperineal resections and 7 (3.9%) other major resections were performed. Patients who received standard care have similar demographics. Median length of stay decreased from 7 days to 6 days in ERAS group (p¼0.025). Paralytic ileus rates also improved from 23.6% to 15% (p¼0.022). Surgical complications rates decreased from 26.9% in the standard care group to 17.2% in ERAS group (p¼0.017). Re-admission rates were 7% in both groups. Compliance to ERAS guidelines has increased from 42.4% to 65.6% since its implementation. Conclusion: Implementation of ERAS Programme is associated with significantly shorter duration of post-operative hospital stay and lower rates of paralytic ileus and overall surgical complications rates. There is no significant difference in hospital re-admissions rates. The difficulties in implementing the full ERAS programme and achieving a high level of compliance were multifactorial. Despite these challenges, the adoption of ERAS protocol can result in improved patient outcomes and should be considered as standard of care in this group of patients. Disclosure of interest: None declared. P061 IMPLEMENTATION OF AN ENHANCED RECOVERY AFTER SURGERY (ERAS) PROGRAM: THE MD ANDERSON CANCER CENTER EXPERIENCE Gloria Salvo 1, Larissa A. Meyer 1, Javier Lasala 2, Maria D. Iniesta 1, Nipa Sheth 1, Mark F. Munsell 3, Andrea Rodriguez-Restrepo 2, Camila Corzo 1, Karen H. Lu 1, Pedro T. Ramirez 1, *. 1 Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, United States; 2 Department of Anesthesia, MD Anderson Cancer Center, Houston, United States; 3 Department of Biostatistics, MD Anderson Cancer Center, Houston, United States * Corresponding author.
Objectives: To evaluate perioperative outcomes of patients undergoing exploratory laparotomy for gynecologic indications in an Enhance Recovery after Surgery (ERAS) program and compare to those receiving traditional perioperative care (pre-ERAS). Methods: All consecutive patients managed under an ERAS program undergoing exploratory laparotomy between 11/3/2014 and 10/26/2016 were compared to historical controls (May to October, 2014). Interventions included, but not limited to, allowing oral intake of fluids up to 2 hours before induction of anesthesia; pre-, intra-, and post-operative euvolemia as well as opioid-sparing analgesia (total intravenous anesthesia); and ambulation and regular diet on the day of surgery. Wilcoxon rank-sum and Fisher’s exact tests were used for comparisons Results: A total of 518 enhanced recovery patients were compared with 74 patients in the control group (pre-ERAS). ERAS resulted in a 73.6% reduction in median postoperative morphine equivalents during the first 3 days after surgery with no significant difference in mean pain scores between the pre- and post ERAS cohorts. Thus far, ERAS has resulted in a 1-day reduction in hospital stay (median LOS pre-ERAS: 4 days [range, 2-27] vs. ERAS: 3 days [range, 1-43], p<0.01) with stable readmission rates (preERAS: 14.1% vs. ERAS: 12.9%, p¼0.85). No differences were observed in postoperative complications between pre-ERAS and ERAS groups respectively (29.6% vs. 25.7%, p¼0.47; GU: 21.1% vs. 18.3%, p¼0.63; Hematologic: 16.9% vs. 11.8%, p¼0.25). Median percentage compliance to the enhance recovery components for the ERAS group was 70% (range, 40-85%)
POD0 POD1 POD2 POD3 MED/Day
99
Pre-ERAS Median (range)
ERAS Median (range)
% Reduction
P-value
49.0 50.0 32.0 22.0 28.4
7.5 9.4 7.5 7.5 7.5
84.7% 81.2% 76.6% 65.9% 73.6%
<0.001 <0.001 <0.001 <0.001 <0.001
(4.0-637.5) (0.0-843.0) (1.0-752.6) (0.0-481.0) (1.5-253.5)
(0-101.3) (0-200.0) (0-225.0) (0-205.0) (0-107.0)
Conclusion: Implementation of an ERAS program was associated with reduced length of stay with stable readmission and perioperative complication rates and reduced overall opioid consumption. Further study is warranted to determine impact on progression free survival. Disclosure of interest: None declared. P062 ADHERENCE TO THE ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL AND OUTCOMES AFTER COLORECTAL CANCER SURGERY IN NORTH ESTONIA MEDICAL CENTRE €rma 1, *, Indrek Seire 2, Anni Laas 2, Sander Kütner 2. 1 Department of Eve Ha Anaesthesiology North Estonia Medical Center, Tallinn, Estonia; 2 Department of Surgery, North Estonia Medical Center, Tallinn, Estonia * Corresponding author.
Objectives: In 2015 the Enhanced Recovery After Surgery (ERAS) protocol for management of the colorectal cancer patients was implemented in North Estonia Medical Centre (NEMC). A multidisciplinary team including a colorectal surgeon, anaesthetist, ERAS dedicated nurse, pain management nurse and physiotherapist was formed. The team launched hospital specific guidelines and introduced the programme among all the specialities involved. The aim of this audit was to evaluate the impact of different adherence levels of ERAS protocol to the outcome after major colorectal procedure. Methods: The data of 53 patients who underwent radical colorectal cancer surgery between September 2015 and May 2016 was collected retrospectively and analysed. According to the recent literature 11 most important ERAS elements such as using preoperative carbohydrate drinks, selective bowel preparation, early mobilisation and oral intake, avoiding premedication and fluid overload etc., were selected and measured. Based on the completion of 11 ERAS elements, the patients were divided in to 5 groups (>90%; 80-89%; 70-79%; 60-69%; <60% of elements completed respectively). The primary endpoint (postoperative complications, e.g. postoperative ileus, anastomotic leakage, wound infection or dehiscence etc.) and secondary endpoints such as length of hospital stay (LOS), readmissions and 30-day mortality were measured between the different groups. Results: The overall adherence to the ERAS protocol in NEMC is well above average. The overall procedure related complication rate was 28%, most common complications being wound infection (28%), wound dehiscence (11%), anastomotic complications (11%), intraabdominal abscess (11%), postoperative ileus (17%) and more rare being sepsis, pulmonary complications, acute kidney injury and gastric ulcer perforation (22% in total). 3 patients were reoperated due to complications. 9 patients (17%) were readmitted to the hospital for various reasons, infection being most common (56%). The patients with lower adherence to ERAS protocol had longer LOS. Conclusion: The patients who underwent major colorectal surgery and were treated with higher adherence to ERAS protocol had significantly lower rate of postoperative complications and readmissions as well as reduced LOS. There were no changes in the 30- day mortality rate between the groups according to this audit. Disclosure of interest: None declared.