Perioperative Care in Colorectal Cancer Surgery before a Structured Implementation Program of the ERAS Protocol in a Regional Network. The Piemonte EASY-NET Project

Abstract

Background: In 2019, the Enhanced Recovery After Surgery (ERAS) protocol for colorectal cancer surgery was adopted by a minority of hospitals in Piemonte (4.3 million inhabitants, north-west Italy). The present analysis aims to compare the level of application of the ERAS protocol between hospitals already adopting it (ERAS, N = 3) with the rest of the regional hospitals (non-ERAS, N = 28) and to identify possible obstacles to its application. Methods: All patients surgically treated for a newly diagnosed colorectal cancer during September–November 2019, representing the baseline period of a randomized controlled trial with a cluster stepped-wedge design, were included. Indicators of compliance to the ERAS items were calculated overall and for groups of items (preoperative, intraoperative and postoperative) and analyzed with a multilevel linear model adjusting for patients’ characteristics, considering centers as random effects. Results: Overall, the average level of compliance to the ERAS protocol was 56% among non-ERAS centers (N = 364 patients) and 80% among ERAS ones (N = 79), with a difference of 24% (95% CI: −41.4; −7.3, p = 0.0053). For both groups of centers, the lowest level of compliance was recorded for postoperative items (42% and 66%). Sex, age, presence of comorbidities and American Society of Anesthesiologists (ASA) score were not associated with a different probability of compliance to the ERAS protocol. Conclusions: Several items of the ERAS protocol were poorly adopted in colorectal surgery units in the Piemonte region in the baseline period of the ERAS Colon-Rectum Piemonte study and in the ERAS group. No relevant obstacles to the ERAS protocol implementation were identified at patient level.

A retrospective study on the efficacy of the ERAS protocol in patients who underwent laparoscopic left and right colectomy surgeries

“…Compared to open surgery, laparoscopic surgery results in a significantly shorter median post-operative stay and much less postoperative morbidity and pain. As reported in multiple randomized controlled trials, this is due to less surgical stress response (14,15). And it is also found in several randomized studies evaluating the effect of ERAS protocols on the outcomes of elective colorectal surgery that the implementation of ERAS helps reduce complications and median post-operative stay and accelerate postoperative recovery (16,17).…”

Implementation of an enhanced recovery after surgery protocol for colorectal cancer in a regional hospital network supported by audit and feedback: a stepped wedge, cluster randomised trial

“…After the fourth updated version of the ERAS protocol in colorectal cancer, 1 only three selected hospitals, particularly open to change, have adopted this approach in routine care in Piemonte, an Italian region of around 4.2 million inhabitants. 5 The Piemonte region has a large network of medium-small public-funded hospitals treating colorectal cancer, referring to the Piemonte e Valle d’Aosta Cancer Network ( http://www.reteoncologica.it/ ). Initiatives to improve the quality of cancer care within the network were mainly based on the adaptation and implementation of regional clinical guidelines ( https://next.cpo.it/it/publications ) and their monitoring with administrative data.…”