Effect of implementation of enhanced recovery after surgery (ERAS) protocol and risk factors on 3-year survival after colorectal surgery for cancer-a retrospective cohort of 1001 patients

Impact of the enhanced recovery after surgery (ERAS) protocol on 3-year survival and outcomes following esophagectomy: a retrospective cohort study of 124 patients

INTRODUCTION

The benefits of the enhanced recovery after surgery (ERAS) protocol across surgeries are well documented, but its impact on esophageal cancer surgery remains understudied. This study compared the 3-year survival rates of esophagectomy patients treated with and without ERAS at a tertiary care hospital.

METHODS

A retrospective analysis of 124 elective esophagectomy patients (Jan 2017-Jan 2022) was conducted. Patients with distant metastasis or had concurrent hypopharynx cancer that needed pharyngectomy were excluded from analysis. Patients treated before April 2019 received standard care, while those treated from April 2019 followed the ERAS protocol. Multivariate Cox regression analysis identified potential prognostic factors for overall survival. Survival associations were determined using the Kaplan-Meier(K-M) method and log-rank tests. The primary outcome was 3-year overall survival, and the secondary outcomes were postoperative intensive care unit (ICU) stay, hospital length of stay (LOS), and complications.

RESULTS

We analyzed 58 patients in the control group and 66 patients in the ERAS group. The ERAS group demonstrated significantly lower 3-year overall mortality compared to the control group in multivariate Cox regression (adjusted hazard ratio: 0.44, 95% CI: 0.22-0.88, p = 0.020). Advanced pathologic cancer stage and neoadjuvant chemoradiation therapy (CCRT) were independent negative prognostic factors (adjusted hazard ratio for advanced pathological stage: 2.91, 95% CI: 1.27-6.66, p = 0.011; for neoadjuvant CCRT: 2.73, 95% CI: 1.23-6.08, p = 0.013). Kaplan-Meier survival analysis showed a significantly higher 3-year survival rate in the ERAS group compared to the control group (70.2% vs. 47.4%, p = 0.043). Subgroup analysis revealed significant survival benefits of ERAS in patients with preoperative albumin concentration < 4 g/dl, advanced pathological stage and aged < 65 years. Additionally, the ERAS group had significantly shorter ICU stays (mean difference: -2.3 days, p < 0.001), shorter hospital LOSs (mean difference: -4.9 days, p < 0.001), while postoperative complication rates were comparable between two groups.

CONCLUSIONS

The ERAS protocol in esophagectomy patients was associated with shorter ICU and hospital stays and emerged as an independent positive prognostic factor for 3-year overall survival. These results suggest ERAS might indirectly improve long-term survival by accelerating recovery, thereby enabling patients to better tolerate and complete essential postoperative oncological treatments. Nevertheless, larger prospective studies are required to validate this interpretation conclusively.

Five-year oncological outcomes after enhanced recovery after surgery (ERAS) compared to conventional care for colorectal cancer: a retrospective cohort of 981 patients

BACKGROUND

The enhanced recovery after surgery (ERAS) protocol has been introduced over the past three decades for patients undergoing colorectal surgery. However, the effect of this program on long-term survival is poorly studied. We evaluated the effect of ERAS on 5-year overall survival (OS) and recurrence-free survival (RFS) after colorectal cancer surgery, and identified risk factors.

METHODS

This retrospective study used data from the comparison of oncological outcomes at 3 years after ERAS or conventional care (pre-ERAS), conducted in our department between 2005 and 2017, and published in 2022. A total of 981 patients were included (ERAS, n = 486; pre-ERAS, n = 495).

RESULTS

The 5-year OS and RFS rates were similar in the ERAS and pre-ERAS groups, respectively (63.3% [58.9; 67.4] vs 57.7% [53.2; 61.9]; p = 0.055) and (69.5% [65.2; 73.4] vs 70.9% [66.6; 74.8]; p = 0.365). The 5-year OS result was confirmed by a propensity score analysis (HR 0.98 [0.71; 1.37], p = 0.911). Analysis of 5-year survival by a multivariate Cox model identified age (HR 1.28 [1.15; 1.43]), BMI < 18.5 (HR 1.62 [1.08; 2.45]), smoking (HR 1.68 [1.26; 2.24]), ASA score > 2 (HR 1.56 [1.22; 1.98]), and laparotomy interventions (HR 2.06 [1.61; 2.63]) as risk factors for death. Regarding RFS, multivariate analysis adjusted on the ERAS group identified age as a protective factor with a reduction of 10% in the risk of recurrence (HR 0.90 [0.81-0.99]). In contrast patients treated with neoadjuvant chemotherapy had a higher risk of recurrence (HR 1.41 [1.07-1.85]).

CONCLUSION

This study failed to demonstrate any advantage of the ERAS program in improving 5-year OS and RFS after colorectal cancer surgery. Age, undernutrition, smoking, ASA score > 2, and laparotomy interventions are independently associated with early mortality.

Suprapubic versus transurethral catheterization for bladder drainage in male rectal cancer surgery (GRECCAR10), a randomized clinical trial

BACKGROUND

Bladder drainage is systematically used in rectal cancer surgery; however, the optimal type of drainage, transurethral catheterization (TUC) or suprapubic catheterization (SPC), is still controversial. The aim was to compare the rates of urinary tract infection on the fourth postoperative day (POD4) between TUC and SPC, after rectal cancer surgery regardless of the day of removal of the urinary drain.

METHODS

This randomized clinical trial in 19 expert colorectal surgery centers in France and Belgium was performed between October 2016 and October 2019 and included 240 men (with normal or subnormal voiding function) undergoing mesorectal excision with low anastomosis for rectal cancer. Patients were followed at postoperative days 4, 30, and 180.

RESULTS

In 208 patients (median age 66 years [IQR 58-71]) randomized to TUC (n = 99) or SPC (n = 109), the rate of urinary infection at POD4 was not significantly different whatever the type of drainage (11/99 (11.1%) vs. 8/109 (7.3%), 95% CI, - 4.2% to 11.7%; p = 0.35). There was significantly more pyuria in the TUC group (79/99 (79.0%) vs. (60/109 (60.9%), 95% CI, 5.7-30.0%; p = 0.004). No difference in bacteriuria was observed between the groups. Patients in the TUC group had a shorter duration of catheterization (median 4 [2-5] vs. 4 [3-5] days; p = 0.002). Drainage complications were more frequent in the SPC group at all followup visits.

CONCLUSIONS

TUC should be preferred over SPC in male patients undergoing surgery for mid and/or lower rectal cancers, owing to the lower rate of complications and shorter duration of catheterization.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT02922647.

Enhanced recovery after surgery protocols following emergency intra-abdominal surgery: a systematic review and meta-analysis

PURPOSE

The aim of this systematic review and meta-analysis was to evaluate whether Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing emergency intra-abdominal surgery improve postoperative outcomes as compared to conventional care.

METHODS

MEDLINE, EMBASE, WoS, CENTRAL, and Pubmed were searched from inception to December 2022. Articles were eligible if they were randomized controlled trials (RCT) or non-randomized studies comparing ERAS protocols to conventional care for patients undergoing emergency intra-abdominal surgery. The outcomes included postoperative length of stay (LOS), postoperative morbidity, prolonged postoperative ileus (PPOI), and readmission. An inverse variance random effects meta-analysis was performed. A risk of bias was assessed with Cochrane tools. Certainty of evidence was assessed with GRADE.

RESULTS

After screening 1018 citations, 20 studies with 1615 patients in ERAS programs and 1933 patients receiving conventional care were included. There was a reduction in postoperative LOS in the ERAS group for patients undergoing upper gastrointestinal (GI) surgery (MD3.35, 95% CI 2.52-4.17, p < 0.00001) and lower GI surgery (MD2.80, 95% CI 2.62-2.99, p < 0.00001). There was a reduction in postoperative morbidity in the ERAS group for patients undergoing upper GI surgery (RR0.56, 95% CI 0.30-1.02, p = 0.06) and lower GI surgery (RR 0.66, 95%CI 0.52-0.85, p = 0.001). In the upper and lower GI subgroup, there were nonsignificant reductions in PPOI in the ERAS groups (RR0.59, 95% CI 0.30-1.17, p = 0.13; RR0.49, 95% CI 0.21-1.14, p = 0.10). There was a nonsignificant increased risk of readmission in the ERAS group (RR1.60, 95% CI 0.57-4.50, p = 0.50).

CONCLUSION

There is low-to-very-low certainty evidence supporting the use ERAS protocols for patients undergoing emergency intra-abdominal surgery. The currently available data are limited by imprecision.

The implementation of an inflammatory bowel disease-specific enhanced recovery after surgery protocol: an observational cohort study

BACKGROUND

The implementation of Enhanced Recovery After Surgery (ERAS) protocols has resulted in improved postoperative outcomes in colorectal cancer surgery. The evidence regarding feasibility and impact on outcomes in surgery for inflammatory bowel disease (IBD) is limited.

METHODS

We performed a retrospective observational cohort study, comparing patient trajectories before and after implementing an IBD-specific ERAS protocol at Zealand University Hospital. We assessed the occurrence of serious postoperative complications of Clavien-Dindo grade 3 or higher as our primary outcome, with postoperative length of stay in days and rate of readmissions as secondary outcomes, using χ2, Mann-Whitney test, and odds ratios adjusted for sex and age.

RESULTS

From 2017 to 2023, 394 patients were operated on for IBD and included in our study. In the ERAS cohort, 39/250 patients experienced a postoperative complication of Clavien-Dindo grade 3 or higher compared to 27/144 patients in the non-ERAS cohort (15.6% vs. 18.8%, p = 0.420) with an adjusted odds ratio of 0.73 (95% CI 0.42-1.28). There was a significantly shorter postoperative length of stay (median 4 vs. 6 days, p < 0.001) in the ERAS cohort compared to the non-ERAS cohort. Readmission rates remained similar (22.4% vs. 16.0%, p = 0.125).

CONCLUSIONS

ERAS in IBD surgery was associated with faster patient recovery, but without an impact on the occurrence of serious postoperative complications and rate of readmissions.

Abdominal massage to prevent ileus after colorectal surgery. A single-center, prospective, randomized clinical trial: the MATRAC Trial

BACKGROUND

There is scarce literature on the effect of mechanical abdominal massage on the duration of ileus after colectomy, particularly in the era of enhanced recovery after surgery (ERAS). The aim of this study was to determine whether abdominal massage after colorectal surgery with anastomosis and no stoma helps toward a faster return of intestinal transit.

METHODS

This study was a superiority trial and designed as a prospective open-label, single-center, randomized controlled clinical trial with two parallel groups. Patients scheduled to undergo intestinal resection and follow an ERAS protocol were randomly assigned to either the standard ERAS group or the ERAS plus massage group. The primary endpoint was the return of intestinal transit, defined as the first passage of flatus following the operation. Secondary endpoints included time of the first bowel motion, maximal pain, 30 day complications, complications due to massage, anxiety score given by the Hospital Anxiety and Depression (HAD) questionnaire, and quality of life assessed by the EQ-5D-3L questionnaire.

RESULTS

Between July 2020 and June 2021, 36 patients were randomly assigned to the ERAS group or the ERAS plus massage group (n = 19). Patients characteristics were comparable. There was no significant difference in time to passage of the first flatus between the ERAS group and the ERAS plus abdominal massage group (1065 versus 1389 min, p = 0.274). No statistically significant intergroup difference was noted for the secondary endpoints.

CONCLUSION

Our study, despite its limitations, failed to demonstrate any advantage of abdominal massage to prevent or even reduce symptoms of postoperative ileus after colorectal surgery.

TRIAL REGISTRATION NUMBER

38RC20.021.

Association between Enhanced Recovery After Surgery (ERAS) protocol, risk factors and 3-year survival after colorectal surgery for cancer in the elderly

INTRODUCTION

As life expectancy is currently growing, more elderly and fragile patients need colorectal resection for cancer. We sought to assess the link between enhanced rehabilitation after surgery (ERAS), risk factors and overall survival at 3 years, in patients aged 65 and over.

METHODS

Between 2005 and 2017, all patients undergoing colorectal resection for cancer were included. Overall survival at 3 years was compared for patients treated in following ERAS guidelines compared to conventional treatment (pre-ERAS).

RESULTS

661 patients were included (ERAS, n = 325; pre-ERAS, n = 336). The 3-year overall survival rate was significantly better regardless of age for ERAS vs pre-ERAS patients (73.1% vs 64.4%; p = 0.016). With overall survival rates of 83.2% vs 73.8%, 65.4% vs 62.8% and 59.6% vs 40% for the age bands 65-74, 75-84 and ≥ 85 years. The analysis of survival at 3 years by a multivariate Cox model identified ERAS as a protective factor with a reduction in the risk of death of 30% (HR = 0.70 [0.50-0.94], p = 0017) independently of other identified risk factors: age bands, ASA score > 2, smoking, atrial fibrillation and abdominal surgery. This result is confirmed by an analysis of the propensity score (HR = 0.67 [0.47-0.97], p = 0.032).

CONCLUSIONS

Our study shows that ERAS is associated with better 3-year survival in patients undergoing colorectal resection for cancer, independent of risk factors. The practice of ERAS is effective and should be offered to patients aged 65 and over.