Impact of compliance with an enhanced recovery after surgery pathway on patient outcomes in open gynecologic surgery

Abstract

ObjectiveThe aim of this study was to evaluate if varying levels of compliance with an enhanced recovery after surgery (ERAS) protocol impacted post-operative outcomes (length of stay, complications, readmissions, and re-operations) in gynecologic surgery at a tertiary center.MethodsWe included 584 patients who had open gynecologic surgery between November 1, 2014 and December 31, 2016. Patients were categorized into subgroups according to their date of surgery from the time of the ERAS protocol implementation. Patients were categorized by their per cent compliance into two groups:<80% versus ≥80%. We analyzed compliance with the elements of the protocol over time and its relation with post-operative outcomes, length of stay, post-operative complications, readmission, and re-operations rates. We modeled the probability of having a post-operative complication within 30 days of surgery as a function of overall compliance.ResultsOverall compliance was 72.3%. Patients with compliance ≥80% had significantly less complications (P<0.001) and shorter length of stay (P<0.001). Readmission and re-operation rates were not impacted by compliance (P=0.182, P=0.078, respectively). Avoidance of salt water overload, early mobilization, early oral nutrition, and early removal of Foley catheter were significantly associated with less post-operative complications within 30 days.ConclusionsCompliance with an ERAS pathway exceeding 80% was associated with lower complication rates and shorter length of stay without impacting on re-operations or readmissions.

Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: an international survey of peri-operative practice

“…To date, this is not the case with many studies demonstrating that, with increasing compliance to ERAS, improved outcomes are seen (decreased length of stay and complications) and without increased re-admission rates. [31][32][33] Furthermore, increasing ERAS compliance has been shown to be associated with improved survival in colorectal surgery 34 and orthopedics. 35 The major strength of this study is that it is the first to be conducted on a global scale, including over 454 respondents from 62 countries.…”

Impact of Compliance with an Enhanced Recovery After Surgery Program on the Outcomes Among Elderly Patients Undergoing Lumbar Fusion Surgery

“…Iniesta et al suggested that the constant auditing and analysis of the results are helpful to ensure all or most elements of ERAS program are enforced. 6 What's more, it is easier to maintain compliance when there are strict definitions and standardized elements of the ERAS program. The lack of research on compliance with individual ERAS elements hindered our understanding of their actual contributions.…”

“…5 Enhancing the perioperative management and reducing peri-operative stress can be a cost-effective way to improve the safety in elderly patients. 6 An ERAS program encompasses many elements from initial patient referral through discharge. The overall benefits can be attributed to the aggregation of marginal gains of each components.…”

“…It has been reported that compliance with the ERAS program is strongly associated with prognosis. 6,9 While strict compliance with ERAS protocols is more difficult for all elderly patients in general, it might be particularly challenging for those undergoing lumber fusion surgery. The requirement for active participation in the program may be considered as too aggressive by this patient group.…”

Level I evidence establishes enhanced recovery after surgery as standard of care in gynecologic surgery: now is the time to implement!

“…8e11 To further support this evidence base, several studies (including 1 based on a multicenter international cohort) have established a dose-response relationship whereby higher adherence to the ERAS gynecology guidelines translates to improved clinical outcomes. 12,13 However, some have questioned the validity of ERAS in gynecology as these aforementioned studies are based on cohort-sequential (pre-vs post-) designs, and it has been argued that they are prone to observer bias and the Hawthorne effect. 14 In this issue of the Journal, the article "Validation of an enhanced recovery after surgery protocol in gynecological surgery: an Italian randomized study" 15 provides level I evidence to support the efficacy of ERAS in our specialty.…”