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Original Article
ERAS
 Impact of an Enhanced Recovery After Surgery (ERAS) program on the management of complications after laparoscopic or robotic colectomy for cancer
Victoria Weetsorcid, Hélène Meillatorcid, Jacques Emmanuel Saadounorcid, Marie Dazzaorcid, Cécile de Chaisemartinorcid, Bernard Lelongorcid
Annals of Coloproctology 2024;40(5):440-450.
DOI: https://doi.org/10.3393/ac.2023.00850.0121
Published online: September 20, 2024

Department of Digestive Surgical Oncology, Institute Paoli-Calmettes, Marseille, France

Correspondence to: Hélène Meillat, MD Department of Digestive Surgical Oncology, Institute Paoli-Calmettes, 232 Blvd Sainte Marguerite, Marseille 13009, France Email: meillath@ipc.unicancer.fr
• Received: November 29, 2023   • Revised: January 19, 2024   • Accepted: January 23, 2024

© 2024 The Korean Society of Coloproctology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • Purpose
    Enhanced Recovery After Surgery (ERAS) reduces postoperative complications (POCs) after colorectal surgery; however, its impact on the management of POCs remains unclear. This study compared the diagnosis and management of POCs before and after implementing our ERAS protocol after laparoscopic or robotic colectomy for cancer and examined the short- and mid-term oncologic impacts.
  • Methods
    This single-center, retrospective study evaluated all consecutive patients who underwent laparoscopic or robotic colectomy for cancer between 2012 and 2021, focusing on the incidence of POCs within 90 days. We compared outcomes before (standard group) and after (ERAS group) the implementation of our ERAS protocol in January 2016.
  • Results
    Significantly fewer patients in the ERAS group developed POCs (standard vs. ERAS, 136 of 380 patients [35.8%] vs.136 of 660 patients [20.6%]; P<0.01). The ERAS group had a significantly shorter mean total length of stay after POCs (13.1 days vs. 11.4 days, P=0.04), and the rates of life-threatening complications (6.7% vs. 0.7%) and 1-year mortality (7.4% vs. 1.5%) were significantly lower in the ERAS group than in the standard group. Among patients with anastomotic complications, laparoscopic reoperation was significantly more common in the ERAS group than in the standard group (8.3% vs. 75.0%, P<0.01). Among patients with postoperative ileus, the diagnosis and recovery times were significantly shorter in the ERAS group than in the standard group, resulting in a shorter total length of stay (13.5 days vs. 10 days, P<0.01).
  • Conclusion
    The implementation of an ERAS protocol did not eliminate all POCs, but it did accelerate their diagnosis and management and improved patient outcomes.
  • Keywords: Enhanced Recovery After Surgery; Postoperative complications; Colonic neoplasms
Enhanced Recovery After Surgery (ERAS) protocols have been developed to optimize perioperative patient management and minimize surgical stress. These protocols involve a multidisciplinary team and the implementation of standardized perioperative management practices, with a strong emphasis on patient education to encourage active participation in their own care [1, 2]. Following colectomy, ERAS protocols have been shown to reduce postoperative morbidity, leading to shorter hospital stays without increasing readmission rates or unscheduled postoperative visits [3–5]. In our previously published series, the observed reduction in overall morbidity following the adoption of an ERAS protocol was primarily due to a decrease in minor morbidity, and to a lesser extent, a reduction in the rate of reintervention [3]. However, postoperative complications (POCs) are an inherent risk of any surgical procedure, and some are unavoidable. The complication rate following colectomy for colorectal cancer is between 15% and 20%, with the majority of these complications being surgical [6]. Consequently, prompt diagnosis and treatment of these POCs are crucial. POCs are often viewed as a failure of the ERAS protocol because they can lead to prolonged hospital stays [7]. However, to our knowledge, the influence of ERAS protocols on the detection and management of POCs following laparoscopic or robotic cancer colectomy has not been studied. As such, it remains unclear whether patients who experience POCs still derive benefits from an ERAS protocol. The rapid demedicalization associated with early mobilization, deperfusion, and feeding, as recommended by ERAS [1], may facilitate the early identification of any clinical deviations, thereby enabling the more rapid detection of POCs. However, early discharge could potentially delay the diagnosis of POCs that occur at home, resulting in missed opportunities for timely treatment.
This study aimed to analyze the impact of ERAS protocol implementation on the incidence of POCs in patients undergoing colon cancer surgery, considering their diagnosis, management methods, and oncological impact.
Ethics statement
The study was conducted in accordance with the 1989 World Medical Association Declaration of Helsinki. The study was approved by the Institutional Review Board of the Paoli Calmettes Institute (No. IPC 2022-24). The requirement for obtaining informed consent was waived owing to the retrospective nature of the study.
Study design
We extracted data from all patients who underwent laparoscopic or robotic colectomy for cancer between January 2011 and December 2021 at our institution from a prospectively maintained institutional database (ClinicalTrials.gov identifier: NCT02869503). We excluded patients who underwent emergency surgery or needed a permanent or temporary stoma and patients scheduled for total colectomy. In January 2016, a standardized ERAS protocol was implemented in the department for colonic surgery [3] and applied systematically. Therefore, patients who underwent colectomy after the implementation of this protocol were included in the ERAS group. Patients who underwent colectomy between January 2012 and December 2015 (before the ERAS protocol implementation) constituted the control group (standard group).
Outcomes
We analyzed the diagnosis and treatment modalities of all complications that occurred within 90 days after laparoscopic or robotic colonic cancer surgery. Morbidity at 30 and 90 days was reported according to the Clavien-Dindo classification [8] and the Comprehensive Complication Index (CCI) [9]. Anastomotic complications included anastomotic leakage (AL), defined as a communication between the digestive lumen and the peritoneal cavity and/or intra-abdominal abscesses [10].
Postoperative ileus (POI) was defined by the presence of at least 2 of the following criteria from postoperative day 2: nausea or vomiting, solid food intolerance, abdominal distension, no passage of gas during the previous 24 hours, and radiological evidence of ileus on computed tomography (CT) [11]. Cases of secondary POI related to intra-abdominal complications [12] were not considered. The resolution of POI or recovery time was defined as the return to a normal diet, first flatus, and termination of intravenous fluid infusion [13].
The other analyzed data included the initial length of stay (LOS), total LOS, readmission rate, and unscheduled postoperative consultations. The initial LOS was defined as the number of nights spent in the hospital after surgery, and the total LOS was defined as the number of nights spent in the hospital, including nights after readmission within 30 days after surgery. Any hospitalization of a patient within 30 days after discharge to the patient’s home or a convalescent center was considered a readmission.
Patient management

Preoperative optimization

During the preoperative consultation in both groups, the following risk factors for POCs were screened and corrected as appropriate: (1) anemia, defined as hemoglobin <12 g/dL in women and <13 g/dL in men or ferritin <30 mg/L; and (2) malnutrition, defined as weight loss >5% in 1 month or >10% in 6 months; body mass index (BMI) < 18.5 kg/m2 if the patient was aged ≥70 years or BMI < 21 kg/m2 if the patient was aged <70 years.
In the ERAS group, we also conducted systematic screening for fragility using the G8 score in all patients aged >75 years, and an oncogeriatric consultation was provided if the score was <14 [14].

Perioperative care protocols

The patient management protocols before and after the implementation of our ERAS protocol are summarized in Table 1.

Discharge criteria and modalities

The discharge criteria were as follows: adequate pain control with nonopioid oral analgesics, well-tolerated solid food intake, resumption of gas passage, no signs of infection, return to preoperative mobility level, and patient consent to discharge. No C-reactive protein monitoring was performed in the department. A blood test was routinely conducted on postoperative day 2; thereafter, if judged necessary, additional tests were performed based on clinical signs.

Postoperative surveillance

Patients in both groups were followed up 7 to 10 days after discharge and then every 3 months during the first 2 years postoperatively. One-year mortality was defined as death from any cause within 1 year after surgery. Patients who died within 90 days after surgery were excluded from this analysis.
Statistical analysis
Statistical analyses were performed with the pvalue.io software (Medistica). The threshold for statistical significance was set at P<0.05. Descriptive data are presented as number (%) for categorical variables and mean±standard deviation for quantitative variables. Continuous data were compared using the Mann-Whitney U-test, and categorical data were compared using the Fisher exact test or the chi-square test, as appropriate.
Population
During the study period, 1,040 patients underwent laparoscopic or robotic colon cancer surgery in our department, of whom 272 developed POCs. The 90-day morbidity rate was significantly lower in the ERAS group than in the standard group (136 of 380 patients [35.8%] vs. 136 of 660 patients [20.6%], P<0.01).
The characteristics of patients in both groups who developed complications are presented in Table 2. The 2 groups were comparable in terms of sex, American Society of Anesthesiologists (ASA) physical status, BMI, administration of neoadjuvant therapy, and type of surgical procedure. In the ERAS group, the mean overall compliance rate per patient was 90.3%. Supplementary Table 1 summarizes the results for each item.
The mean initial LOS (12.2 days vs. 8.8 days, P<0.01) and total LOS (13.1 days vs. 11.4 days, P=0.04) after POCs were significantly shorter in the ERAS group than in the standard group. The reintervention rate for all POCs was higher in the ERAS group than in the standard group, but the difference was not significant (14.7% vs. 23.5%, P=0.08). The rates of readmission and nonscheduled consultation were comparable between the 2 groups. Twelve patients died within 1 year after surgery (10 in the standard group and 2 in the ERAS group, P=0.03). Details of the complications encountered are given in Supplementary Table 2.
The histopathological analysis of the operative specimens is summarized in Supplementary Table 3. No significant difference in pathological findings was observed between the 2 groups.
Anastomotic complications
In the entire population, the rates of anastomotic complications were comparable before and after ERAS implementation (14 of 380 patients [3.7%] vs. 21 of 660 patients [3.2%], P=0.84). Among patients who developed anastomotic complications (Table 3), the diagnostic and reintervention times were shorter in the ERAS group than in the standard group (diagnostic: 5.3 days vs. 3.8 days, P=0.06; reintervention: 7.1 days vs. 4.1 days, P=0.07) without reaching significance. Reoperations were performed laparoscopically significantly more often in the ERAS group than in the standard group (8.3% vs 75.0%, P<0.01), with a tendency for more conservative surgery (suture and protective stoma). Additionally, the total LOS among patients with anastomotic complications was significantly shorter in the ERAS group than in the standard group (25.1 days vs. 14.8 days, P<0.01). Six patients in the standard group and one in the ERAS group developed life-threatening complications (Clavien-Dindo grade IV, P=0.03), and the mean CCI was higher in the standard group than in the ERAS group (43.1 vs. 33.1, P=0.03). Adjuvant chemotherapy among patients with anastomotic complications was more often performed in the ERAS group than in the standard group (20% vs. 100%, P<0.01).
Postoperative ileus
In the entire population, the POI rate was significantly higher before ERAS implementation (47 of 380 patients [12.4%] vs. 49 of 660 patients [7.4%], P<0.01). Among patients who developed POI (Table 4), the diagnosis was established earlier in the ERAS group than in the standard group (3.8 days vs. 2.9 days, P<0.01), and the recovery time was significantly shorter in the ERAS group, resulting in a shorter total LOS (13.5 days vs. 10 days, P<0.01). Complications associated with POI were 3 times more frequent in the standard group than in the ERAS group, particularly ionic disorders and/or renal failure (25.5% vs. 10.7%), as reflected by a significantly higher CCI (17.7 vs. 14.2, P<0.01). One patient with heart failure in the ERAS group died due to acute coronary syndrome following aspiration pneumonia. The rate of adjuvant chemotherapy administration among patients with POI was approximately 90% in both groups.
Readmissions
In the entire population, readmission rates were comparable before and after ERAS implementation (15 of 380 patients [3.9%] vs. 26 of 660 patients [3.9%], P>0.99). Among patients requiring readmission (Table 5), 10 patients in each group (66.7% in the standard group and 38.5% in the ERAS group, P=0.11) developed POCs during the initial stay. The severity of POCs requiring readmission was comparable between the 2 groups (P=0.37), with only 1 life-threatening complication in the standard group (hemorrhagic shock due to duodenal hematoma after right colectomy). The mean total LOS was 3 days shorter in the ERAS group than in the standard group, but without reaching significance (15.4 days vs. 18.3 days, P=0.57).
Numerous studies have shown that ERAS protocols improve the quality of care following colorectal surgery [15, 16]. These protocols expedite postoperative recovery, reduce the LOS, and decrease the rates of POCs. Consequently, POCs are often viewed as an indication of protocol failure. In our study, we examined the diagnosis and management of POCs at our center before and after implementing an ERAS protocol. We found that both the initial and total LOS were significantly shorter across all types of POCs in the ERAS group, without an increase in readmission rates. Despite the diversity of POCs, we noted an overall enhancement in their management post-ERAS implementation, as indicated by a marked reduction in life-threatening complications and a halving of associated complications. Even in patients who experienced complications, we propose that ERAS protocols mitigate the stress response and help preserve physiological functions. This may contribute to the observed uptick in chemotherapy administration rates and the significant drop in 1-year mortality. Additionally, we investigated practice changes in managing the primary complications following laparoscopic or robotic colectomy: POI and anastomotic complications. In both scenarios, earlier diagnosis and intervention were significantly more common in the ERAS group, leading to a shortened LOS. For patients with POI, a trend was observed wherein nasogastric tube placement was more frequent in the ERAS group, yet recovery times were significantly reduced, and occurrences of ionic and renal disorders, as well as severe-associated complications, were less common. Our findings, therefore, endorse the notion that prompt and accurate assessment of intake and output facilitates improved supportive care.
Concerning anastomotic complications, we noted a trend towards a shorter time to surgical revision in the ERAS group compared to the standard group (7.1 days vs. 4.1 days, P=0.07). Additionally, only 1 patient in 5 was able to receive CT when it was required after AL in the standard group, whereas all patients in the ERAS group underwent CT. In the ERAS group, immediate laparoscopic exploration was carried out in all patients who exhibited early signs of concern (abdominal pain resistant to level 2 analgesics and/or fever, food intolerance, or abnormal clinical examination) within the first 72 hours, without waiting for CT results. Indeed, the diagnostic value of fluid effusion or residual pneumoperitoneum on a CT scan so soon after laparoscopic surgery may be questionable. On the other hand, laparoscopy can become challenging in the presence of ileus caused by an AL or any other intra-abdominal complication, due to the dilated and fragile small intestine. All immediate laparoscopic explorations identified surgical complications, and thanks to early diagnosis [17], over half of the patients in the ERAS group received a “conservative” treatment, which included lavage of an infected hematoma (n=2) or repair of a small pinhole leak (n=8), along with the creation of a systematic diverting stoma and proper drainage [18]. In cases of severe anastomotic disruption and/or diffuse postoperative peritonitis, we removed the anastomosis and created an end colostomy. In the standard group, 4 patients (36.3%) underwent abdominal cavity lavage-drainage via laparotomy, likely due to delayed diagnosis. We attribute this shift in practice to the implementation of ERAS.
First, some ERAS measures induce a reduction in the postoperative inflammatory response to surgery [19], which could obscure the early signs of infectious POCs. Additionally, the early “demedicalization” of the patient facilitates a more accurate clinical evaluation. For instance, abdominal pain is more easily assessed in a patient who is ambulatory and eating normally, without the presence of a drain and the influence of morphine. Second, the standardization of perioperative care results in improved training for medical and paramedical teams in the detection of these complications. Indeed, the management of complications is just as crucial as their prevention. This explains why postoperative outcomes are superior in so-called “high-volume” hospitals [20, 21]; although the rate of complications may not be lower, the teams are more adept at recognizing and addressing POCs.
This standardization also facilitates better patient education by providing appropriate information before, during, and after hospitalization. Achieving early discharge is a key challenge when implementing an ERAS protocol. We did not perform systematic biological tests; instead, we conducted a twice-daily clinical assessment using a logbook maintained by the patient with assistance from a home care nurse. The nurse was also given relevant information prior to the patient's hospitalization. Enhanced patient education and improved collaboration between the city and hospital enabled us to streamline the process for patients returning to the hospital if POC developed at home. In fact, we noted a tendency for earlier readmission in the ERAS group (9.7 days vs. 5.6 days after discharge, P=0.17) and a 3-day reduction in total LOS (P=0.57). The LOS and severity of complications during readmission were comparable between the 2 groups, indicating that there was no disadvantage for patients experiencing POC at home.
To the best of our knowledge, no validated tool currently exists to assess the impact of ERAS and POCs on oncologic prognosis [22–24]. A retrospective study has indicated that both POCs and lower adherence to the ERAS protocol independently contribute to worse survival outcomes following laparoscopic colorectal resection for non-metastatic cancer [25]. The underlying mechanism of this association remains elusive; however, we propose that POCs provoke a significant systemic inflammatory response, which in turn leads to immune system dysregulation and a sustained decline in the patient's physical condition. This adverse effect appears to be particularly pronounced in the presence of infectious complications, such as AL and intra-abdominal abscesses [23, 26], and/or severe complications classified as Clavien-Dindo grades III and IV [24, 27]. This is supported by the observed reduction in 5-year survival rates following surgical intervention for digestive cancers.
The retrospective design of our study did not allow sufficient follow-up for patients in the ERAS group to compare long-term survival. Nevertheless, we observed better rehabilitation, reflected by the absence of life-threatening complications (Clavien-Dindo grade IV) and lower 1-year mortality, in the ERAS group. Among the 12 patients who died in the 1st postoperative year, only 1 had a severe complication within 90 days, and 2 had nonsevere infectious complications (1 urinary tract infection and 1 parietal abscess). These data are insufficient to assess the effect of ERAS on oncological outcomes.
This study has other limitations that should be noted. The number of patients in the 2 groups was small, which limited our ability to perform subgroup analyses, but the study includes all patients who presented with POCs among a large sample of patients without exclusion criteria. This was a historical comparative study, not a randomized study, but the study period was short enough to avoid changes in surgical techniques. The single-center nature of the study limited its external validity, but enabled optimal compliance with the ERAS protocol and ensured homogeneity in complication management, thus reducing many biases in interpretation. Multicenter studies that evaluate the impact of ERAS on patients with POCs with a larger population should be performed to confirm our results and examine the oncological impact of ERAS implementation.
Our results suggest that POCs after laparoscopic or robotic colectomy for cancer should not be considered a failure of the ERAS protocol. Above all, we contend that the most critical factor in improving patient management is the standardization of practices via the creation of a predefined, standardized perioperative care pathway. Enhanced coordination among care teams and better patient education are vital for facilitating early diagnosis and swift treatment. These measures are imperative to prevent organ failure and to improve outcomes for patients experiencing POCs.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: HM, CdC, BL; Data curation: VW, MD, JS; Formal analysis: HM; Writing–original draft: HM, VW, MD; Writing–review & editing: CdC, BL, JS. All authors read and approved the final manuscript.

Supplementary Table 1.

ERAS protocol and compliance in the ERAS group (n=136)
ac-2023-00850-0121-Supplementary-Table-1.pdf

Supplementary Table 2.

Postoperative morbidity
ac-2023-00850-0121-Supplementary-Table-2.pdf

Supplementary Table 3.

Oncological data
ac-2023-00850-0121-Supplementary-Table-3.pdf
Supplementary materials are available from https://doi.org/10.3393/ac.2023.00850.0121.
ac-2023-00850-0121f1.jpg
Table 1.
Patient management before and after ERAS protocol implementation
Phase ERAS
Before After
Preoperative phase
 Information Standard information Specific information with nurse and informed consent
 Immunonutrition Yes Yes
 Bowel preparation Not systematic No
 Limited fasting Fasting at midnight the day before Last meal 6 hr before surgery
Clear liquids until 2 hr before surgery
 Carbohydrate loading No 400 mL the evening before surgery and 2 hr before surgery
 Premedication Alprazolam 0.5 mg the evening before Only for anxiety
Perioperative phase
 Antibioprophylaxis Yes Yes
 Zero fluid balanced No Yes
 Corticosteroid No Dexamethasone 8 mg at induction
 Prevention of PONV Nonsystematic Prophylactic use of ondansetron 4 mg
 Normothermia Yes Yes
 Locoregional analgesia Nonsystematic TAP block or incisional infiltration (lidocaine)
 Abdominal drain Nonsystematic Nonsystematic
Postoperative phase
 Nasogastric tube 24 hr postoperation for right colectomy No
 Thromboprophylaxis Yes Yes
 Opioid-sparing multimodal analgesia No (systematic patient-controlled morphine pump) Ketoprofen 100 mg×2/day for 2 days
Paracetamol 1,000 mg + opium 25 mg×4/day
Opioid 5 mg only if VAS >4
 Removal of IV fluid After resumption of transit and normal feeding On POD 1 in the absence of PONV
 Early feeding Progressive after resumption of transit Semisolid meal on the evening of the intervention
Normal diet on POD 1
 Early mobilization No Out of bed 1 hr on POD 0
Walking and chair >4 hr/day from POD 1
 Urinary catheter Systematic and removal on POD 2 Removal on POD1
 Postdischarge Dedicated emergency telephone number Logbook containing postoperative instructions for early detection of POCs at home
No systematic blood test apart from platelet counts during anticoagulant treatment Telephone interviews on days 1, 7, and 30 after discharge to record all medical problems and to ensure patient’s satisfaction with return home and nursing care
No systematic blood test

ERAS, Enhanced Recovery After Surgery; PONV, postoperative nausea and vomiting; TAP, transverse abdominal plane; VAS, visual analog scale; IV, intravenous; POD: postoperative day; POC, postoperative complication.

Table 2.
Comparison of characteristics of patients who developed complications (n=272)
Characteristic Standard group (n=136) ERAS group (n=136) P-value
Sex 0.47
 Male 70 (51.5) 76 (55.9)
 Female 66 (48.5) 60 (44.1)
Age (yr) 68.3±12.4 67.8±13.6 0.75
ASA physical status 0.35
 I, II 91 (66.9) 99 (72.8)
 III, IV 45 (33.1) 37 (27.2)
Comorbidity
 Diabetes mellitus 15 (11.0) 19 (14.0) 0.45
 Pulmonary 13 (9.6) 29 (21.3) <0.01
 Cardiac 17 (12.5) 12 (8.8) 0.34
 Tobacco use 41 (30.1) 56 (41.2) 0.05
Body mass index (kg/m2) 25.6±4.3 25.9±5.0 0.62
Malnutrition 14 (10.3) 26 (19.1) 0.04
Preoperative anemia 51 (37.5) 43 (31.6) 0.33
Neoadjuvant chemotherapy 20 (14.7) 34 (25.0) 0.04
Surgical procedure 0.66
 Right colectomy 79 (58.1) 86 (63.2)
 Left colectomy 57 (41.9) 50 (36.8)
Surgical approach <0.01
 Robotic 0 (0) 37 (27.2)
 Laparoscopy 136 (100) 99 (72.8)
Conversion 10 (7.4) 9 (6.7) >0.99
Length of stay (day)
 Initial 12.2±7.7 8.8±5.7 <0.01
 Total 13.1±8.7 11.4±6.7 0.04
ICU admission 51 (37.5) 43 (31.6) 0.37
90-day Clavien-Dindo grade <0.01
 I 66 (48.5) 64 (47.1)
 II 43 (31.6) 27 (19.9)
 III 17 (12.5) 43 (31.6)
 IV 9 (6.7) 1 (0.7)
 V 1 (0.7) 1 (0.7)
Life-threatening complication 9 (6.7) 1 (0.7) 0.01
Reoperation 20 (14.7) 32 (23.5) 0.08
Indication for adjuvant chemotherapy 53 (39.0) 23 (16.9) <0.01
Adjuvant chemotherapy performed 40/53 (75.5) 22/23 (95.7) 0.05
1-yr Mortality 10 (7.4) 2 (1.5) 0.03

Values are presented as number (%), mean±standard deviation, or mean.

ERAS, Enhanced Recovery After Surgery; ASA, American Society of Anesthesiologists; ICU, intensive care unit.

Table 3.
Comparison of characteristics of patients with postoperative anastomotic complications
Characteristic Standard group (n=14) ERAS group (n=21) P-value
Proportion in the overall population 14/380 (3.7) 21/660 (3.2) 0.84
Type of complication >0.99
 Abscess 3 (21.4) 7 (33.3)
 Anastomotic leakage 11 (78.6) 14 (66.7)
Type of surgery >0.99
 Left colectomy 7 (50.0) 12 (57.1)
 Right colectomy 7 (50.0) 9 (42.9)
Time of diagnostic 0.25
 Initial stay 12 (85.7) 15 (71.4)
 Readmission 2 (14.3) 6 (28.6)
Diagnostic delay (day) 5.3±1.9 3.8±1.2 0.06
Diagnostic CT scan 14 (100) 16 (76.2) 0.06
Treatment 0.49
 Antibiotic alone 0 (0) 3 (14.3)
 Radiological drainage 2 (14.3) 3 (14.3)
 Surgical treatment 12 (85.7) 16 (76.2)
Time to surgery (day) 7.1±4.2 4.1±1.9 0.07
Surgical approach during reoperation <0.01
 Laparotomy 11/12 (91.7) 2/16 (12.5)
 Laparoscopy 1/12 (8.3) 12/16 (75.0)
 Conversion to open 0/12 (0) 2/16 (12.5)
Surgical procedure <0.01
 Take-down anastomosis + end stoma 7/12 (58.3) 6/16 (37.5)
 Suture + diverting stoma 1/12 (8.4) 10/16 (62.5)
 Peritoneal lavage and drainage 4/12 (33.3) 0/16 (0)
ICU admission 7 (50.0) 10 (47.6) 0.89
 ICU stay (day) 13.9±7.9 6.4±3.6
Associated complication 9 (64.3) 7 (33.3) 0.07
 Ionic and/or renal disorders 5 (35.7) 2 (9.5)
 Delirium 3 (21.4) 1 (4.8)
 Transfusion 4 (28.6) 4 (19)
 Cardiac decompensation 1 (7.1) 0 (0)
 Aspiration pneumonia 1 (7.1) 0 (0)
 Respiratory distress 2 (14.3) 1 (4.8)
 Hemodynamic instability 3 (21.4) 1 (4.8)
90-day Morbidity (Clavien-Dindo grade) 0.03
 II 0 (0) 3 (14.3)
 III 8 (57.1) 17 (80.9)
 IV 6 (42.9) 1 (4.8)
Comprehensive Complication Index 43.1±12.8 33.1±6.0 0.03
Length of stay (day)
 Initial 23.3±12.5 10.9±7.9 <0.01
 During readmission 6.0±7.3 10.2±7.3 0.18
 Total 25.1±11.5 14.8±7.4 <0.01
Stoma closure 6/8 (75.0) 15/16 (93.8) 0.24
Time to stoma closure (wk) 17.8±5.3 13.1±4.6 0.08
Indication for adjuvant chemotherapy 5 (35.7) 8 (38.1) >0.99
Adjuvant chemotherapy performed 1/5 (20.0) 8/8 (100) <0.01
1-yr Mortality 0 (0) 0 (0) -

Values are presented as number (%) or mean±standard deviation.

ERAS, Enhanced Recovery After Surgery; CT, computed tomography; ICU, intensive care unit.

Table 4.
Comparison of characteristics of patients with postoperative ileus
Characteristic Standard group (n=47) ERAS group (n=49) P-value
Proportion in the overall population 47/380 (12.4) 49/660 (7.4) 0.01
Type of surgery 0.13
 Left colectomy 13 (27.7) 7 (14.3)
 Right colectomy 34 (72.3) 42 (85.7)
Time of diagnosis (day) 3.8±1.3 2.9±0.9 <0.01
 Initial stay 46 (97.9) 45 (91.8)
 Readmission 1 (2.1) 4 (8.2)
Diagnostic CT scan 20 (42.6) 20 (40.8) >0.99
Time to CT scan (day) 6.3±3.1 4.0±1.6 <0.01
Maintenance of postoperative NGT 21 (44.7) 3 (6.1) <0.01
Insertion of NGT 27 (57.4) 34 (69.4) 0.20
NGT duration (day) 4.5±2.2 3.4±1.4 0.13
Recovery time (day) 8.5±4.4 6.6±2.6 0.02
Infusion duration (day) 7.7±4.6 6.1±3.1 0.07
First gas (day) 4.9±2.1 3.3±2.1 <0.01
First feces (day) 6.7±2.4 5.2±2.4 <0.01
ICU admission 5 (10.6) 3 (6.1) 0.48
Length of stay (day)
 Initial 13.3±6.9 9.5±3.8 <0.01
 During readmission 6.0 4.6±2.6 -
 Total 13.5±7.0 10.0±3.3 <0.01
Associated complication 17 (36.2) 6 (12.2) <0.01
 Ionic and/or renal disorder 12 (25.5) 4 (8.2)
 Confusion 4 (8.5) 1 (2.0)
 Cardiac decompensation 2 (4.3) 1 (2.0)
 Aspiration pneumonia 4 (8.5) 3 (6.1)
90-day Morbidity (Clavien-Dindo grade) 0.38
 I–II 44 (93.6) 47 (96.0)
 III 1 (2.1) 1 (2.0)
 IV 2 (4.3) 0 (0)
 V 0 (0) 1 (2.0)
Comprehensive Complication Index 17.7±10.4 14.2±13.9 <0.01
Indication for adjuvant chemotherapy 27 (57.4) 24 (49.0) 0.41
Adjuvant chemotherapy performed 23/27 (85.2) 22/24 (91.7) 0.67
1-yr Mortality 4 (8.5) 1 (2.0) 0.20

Values are presented as number (%) or mean±standard deviation.

ERAS, Enhanced Recovery After Surgery; CT, computed tomography; NGT, nasogastric tube; ICU, intensive care unit.

Table 5.
Comparison of characteristics of patients who were readmitted
Characteristic Standard group (n=15) ERAS group (n=26) P-value
Proportion in the overall population 15/380 (3.9) 26/660 (3.9) >0.99
Delay surgery-readmission (day) 17.9±10.5 10.4±8.9 0.01
Delay discharge-readmission (day) 9.7±8.9 5.6±6.4 0.17
Initial LOS before readmission (day) 10.1±6.9 7.2±5.3 0.01
LOS during readmission (day) 8.3±12.9 8.2±6.7 0.35
POC during initial stay 10 (66.7) 10 (38.5) 0.11
ICU admission 5 (33.3) 3 (11.5) 0.12
Total LOS (day) 18.3±13.1 15.4±8.0 0.57
Main cause of readmission -
 Dehydration 1 (6.7) 2 (7.7)
 Parietal abscess or hematoma 4 (26.7) 4 (15.4)
 Ileus 2 (13.3) 4 (15.4)
 Intestinal bleeding 2 (13.3) 3 (11.5)
 Intra-abdominal abscess 5 (33.3) 4 (15.4)
 Anastomotic leakage 1 (6.7) 4 (15.4)
 Acute urinary retention 0 (0) 1 (3.8)
 Clostridium difficile colitis 0 (0) 1 (3.8)
 Chyloperitoneum 0 (0) 1 (3.8)
 Ascites 0 (0) 1 (3.8)
Clavien-Dindo grade during readmission 0.37
 I–II 7 (46.7) 11 (42.3)
 III 7 (46.7) 15 (57.7)
 IV 1 (6.7) 0 (0)
Indication for adjuvant chemotherapy 7 (46.7) 11 (42.3) >0.99
Adjuvant chemotherapy performed 6/7 (85.7) 11/11 (100) 0.39
1-yr Mortality 3 (20.0) 0 (0) -

Values are presented as number (%) or mean±standard deviation. Percentages may not total 100 due to rounding.

ERAS, Enhanced Recovery After Surgery; LOS, length of stay; POC, postoperative complication; ICU, intensive care unit.

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Figure & Data

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      Impact of an Enhanced Recovery After Surgery (ERAS) program on the management of complications after laparoscopic or robotic colectomy for cancer
      Ann Coloproctol. 2024;40(5):440-450.   Published online September 20, 2024
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    Impact of an Enhanced Recovery After Surgery (ERAS) program on the management of complications after laparoscopic or robotic colectomy for cancer
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    Graphical abstract

    Impact of an Enhanced Recovery After Surgery (ERAS) program on the management of complications after laparoscopic or robotic colectomy for cancer
    Phase ERAS
    Before After
    Preoperative phase
     Information Standard information Specific information with nurse and informed consent
     Immunonutrition Yes Yes
     Bowel preparation Not systematic No
     Limited fasting Fasting at midnight the day before Last meal 6 hr before surgery
    Clear liquids until 2 hr before surgery
     Carbohydrate loading No 400 mL the evening before surgery and 2 hr before surgery
     Premedication Alprazolam 0.5 mg the evening before Only for anxiety
    Perioperative phase
     Antibioprophylaxis Yes Yes
     Zero fluid balanced No Yes
     Corticosteroid No Dexamethasone 8 mg at induction
     Prevention of PONV Nonsystematic Prophylactic use of ondansetron 4 mg
     Normothermia Yes Yes
     Locoregional analgesia Nonsystematic TAP block or incisional infiltration (lidocaine)
     Abdominal drain Nonsystematic Nonsystematic
    Postoperative phase
     Nasogastric tube 24 hr postoperation for right colectomy No
     Thromboprophylaxis Yes Yes
     Opioid-sparing multimodal analgesia No (systematic patient-controlled morphine pump) Ketoprofen 100 mg×2/day for 2 days
    Paracetamol 1,000 mg + opium 25 mg×4/day
    Opioid 5 mg only if VAS >4
     Removal of IV fluid After resumption of transit and normal feeding On POD 1 in the absence of PONV
     Early feeding Progressive after resumption of transit Semisolid meal on the evening of the intervention
    Normal diet on POD 1
     Early mobilization No Out of bed 1 hr on POD 0
    Walking and chair >4 hr/day from POD 1
     Urinary catheter Systematic and removal on POD 2 Removal on POD1
     Postdischarge Dedicated emergency telephone number Logbook containing postoperative instructions for early detection of POCs at home
    No systematic blood test apart from platelet counts during anticoagulant treatment Telephone interviews on days 1, 7, and 30 after discharge to record all medical problems and to ensure patient’s satisfaction with return home and nursing care
    No systematic blood test
    Characteristic Standard group (n=136) ERAS group (n=136) P-value
    Sex 0.47
     Male 70 (51.5) 76 (55.9)
     Female 66 (48.5) 60 (44.1)
    Age (yr) 68.3±12.4 67.8±13.6 0.75
    ASA physical status 0.35
     I, II 91 (66.9) 99 (72.8)
     III, IV 45 (33.1) 37 (27.2)
    Comorbidity
     Diabetes mellitus 15 (11.0) 19 (14.0) 0.45
     Pulmonary 13 (9.6) 29 (21.3) <0.01
     Cardiac 17 (12.5) 12 (8.8) 0.34
     Tobacco use 41 (30.1) 56 (41.2) 0.05
    Body mass index (kg/m2) 25.6±4.3 25.9±5.0 0.62
    Malnutrition 14 (10.3) 26 (19.1) 0.04
    Preoperative anemia 51 (37.5) 43 (31.6) 0.33
    Neoadjuvant chemotherapy 20 (14.7) 34 (25.0) 0.04
    Surgical procedure 0.66
     Right colectomy 79 (58.1) 86 (63.2)
     Left colectomy 57 (41.9) 50 (36.8)
    Surgical approach <0.01
     Robotic 0 (0) 37 (27.2)
     Laparoscopy 136 (100) 99 (72.8)
    Conversion 10 (7.4) 9 (6.7) >0.99
    Length of stay (day)
     Initial 12.2±7.7 8.8±5.7 <0.01
     Total 13.1±8.7 11.4±6.7 0.04
    ICU admission 51 (37.5) 43 (31.6) 0.37
    90-day Clavien-Dindo grade <0.01
     I 66 (48.5) 64 (47.1)
     II 43 (31.6) 27 (19.9)
     III 17 (12.5) 43 (31.6)
     IV 9 (6.7) 1 (0.7)
     V 1 (0.7) 1 (0.7)
    Life-threatening complication 9 (6.7) 1 (0.7) 0.01
    Reoperation 20 (14.7) 32 (23.5) 0.08
    Indication for adjuvant chemotherapy 53 (39.0) 23 (16.9) <0.01
    Adjuvant chemotherapy performed 40/53 (75.5) 22/23 (95.7) 0.05
    1-yr Mortality 10 (7.4) 2 (1.5) 0.03
    Characteristic Standard group (n=14) ERAS group (n=21) P-value
    Proportion in the overall population 14/380 (3.7) 21/660 (3.2) 0.84
    Type of complication >0.99
     Abscess 3 (21.4) 7 (33.3)
     Anastomotic leakage 11 (78.6) 14 (66.7)
    Type of surgery >0.99
     Left colectomy 7 (50.0) 12 (57.1)
     Right colectomy 7 (50.0) 9 (42.9)
    Time of diagnostic 0.25
     Initial stay 12 (85.7) 15 (71.4)
     Readmission 2 (14.3) 6 (28.6)
    Diagnostic delay (day) 5.3±1.9 3.8±1.2 0.06
    Diagnostic CT scan 14 (100) 16 (76.2) 0.06
    Treatment 0.49
     Antibiotic alone 0 (0) 3 (14.3)
     Radiological drainage 2 (14.3) 3 (14.3)
     Surgical treatment 12 (85.7) 16 (76.2)
    Time to surgery (day) 7.1±4.2 4.1±1.9 0.07
    Surgical approach during reoperation <0.01
     Laparotomy 11/12 (91.7) 2/16 (12.5)
     Laparoscopy 1/12 (8.3) 12/16 (75.0)
     Conversion to open 0/12 (0) 2/16 (12.5)
    Surgical procedure <0.01
     Take-down anastomosis + end stoma 7/12 (58.3) 6/16 (37.5)
     Suture + diverting stoma 1/12 (8.4) 10/16 (62.5)
     Peritoneal lavage and drainage 4/12 (33.3) 0/16 (0)
    ICU admission 7 (50.0) 10 (47.6) 0.89
     ICU stay (day) 13.9±7.9 6.4±3.6
    Associated complication 9 (64.3) 7 (33.3) 0.07
     Ionic and/or renal disorders 5 (35.7) 2 (9.5)
     Delirium 3 (21.4) 1 (4.8)
     Transfusion 4 (28.6) 4 (19)
     Cardiac decompensation 1 (7.1) 0 (0)
     Aspiration pneumonia 1 (7.1) 0 (0)
     Respiratory distress 2 (14.3) 1 (4.8)
     Hemodynamic instability 3 (21.4) 1 (4.8)
    90-day Morbidity (Clavien-Dindo grade) 0.03
     II 0 (0) 3 (14.3)
     III 8 (57.1) 17 (80.9)
     IV 6 (42.9) 1 (4.8)
    Comprehensive Complication Index 43.1±12.8 33.1±6.0 0.03
    Length of stay (day)
     Initial 23.3±12.5 10.9±7.9 <0.01
     During readmission 6.0±7.3 10.2±7.3 0.18
     Total 25.1±11.5 14.8±7.4 <0.01
    Stoma closure 6/8 (75.0) 15/16 (93.8) 0.24
    Time to stoma closure (wk) 17.8±5.3 13.1±4.6 0.08
    Indication for adjuvant chemotherapy 5 (35.7) 8 (38.1) >0.99
    Adjuvant chemotherapy performed 1/5 (20.0) 8/8 (100) <0.01
    1-yr Mortality 0 (0) 0 (0) -
    Characteristic Standard group (n=47) ERAS group (n=49) P-value
    Proportion in the overall population 47/380 (12.4) 49/660 (7.4) 0.01
    Type of surgery 0.13
     Left colectomy 13 (27.7) 7 (14.3)
     Right colectomy 34 (72.3) 42 (85.7)
    Time of diagnosis (day) 3.8±1.3 2.9±0.9 <0.01
     Initial stay 46 (97.9) 45 (91.8)
     Readmission 1 (2.1) 4 (8.2)
    Diagnostic CT scan 20 (42.6) 20 (40.8) >0.99
    Time to CT scan (day) 6.3±3.1 4.0±1.6 <0.01
    Maintenance of postoperative NGT 21 (44.7) 3 (6.1) <0.01
    Insertion of NGT 27 (57.4) 34 (69.4) 0.20
    NGT duration (day) 4.5±2.2 3.4±1.4 0.13
    Recovery time (day) 8.5±4.4 6.6±2.6 0.02
    Infusion duration (day) 7.7±4.6 6.1±3.1 0.07
    First gas (day) 4.9±2.1 3.3±2.1 <0.01
    First feces (day) 6.7±2.4 5.2±2.4 <0.01
    ICU admission 5 (10.6) 3 (6.1) 0.48
    Length of stay (day)
     Initial 13.3±6.9 9.5±3.8 <0.01
     During readmission 6.0 4.6±2.6 -
     Total 13.5±7.0 10.0±3.3 <0.01
    Associated complication 17 (36.2) 6 (12.2) <0.01
     Ionic and/or renal disorder 12 (25.5) 4 (8.2)
     Confusion 4 (8.5) 1 (2.0)
     Cardiac decompensation 2 (4.3) 1 (2.0)
     Aspiration pneumonia 4 (8.5) 3 (6.1)
    90-day Morbidity (Clavien-Dindo grade) 0.38
     I–II 44 (93.6) 47 (96.0)
     III 1 (2.1) 1 (2.0)
     IV 2 (4.3) 0 (0)
     V 0 (0) 1 (2.0)
    Comprehensive Complication Index 17.7±10.4 14.2±13.9 <0.01
    Indication for adjuvant chemotherapy 27 (57.4) 24 (49.0) 0.41
    Adjuvant chemotherapy performed 23/27 (85.2) 22/24 (91.7) 0.67
    1-yr Mortality 4 (8.5) 1 (2.0) 0.20
    Characteristic Standard group (n=15) ERAS group (n=26) P-value
    Proportion in the overall population 15/380 (3.9) 26/660 (3.9) >0.99
    Delay surgery-readmission (day) 17.9±10.5 10.4±8.9 0.01
    Delay discharge-readmission (day) 9.7±8.9 5.6±6.4 0.17
    Initial LOS before readmission (day) 10.1±6.9 7.2±5.3 0.01
    LOS during readmission (day) 8.3±12.9 8.2±6.7 0.35
    POC during initial stay 10 (66.7) 10 (38.5) 0.11
    ICU admission 5 (33.3) 3 (11.5) 0.12
    Total LOS (day) 18.3±13.1 15.4±8.0 0.57
    Main cause of readmission -
     Dehydration 1 (6.7) 2 (7.7)
     Parietal abscess or hematoma 4 (26.7) 4 (15.4)
     Ileus 2 (13.3) 4 (15.4)
     Intestinal bleeding 2 (13.3) 3 (11.5)
     Intra-abdominal abscess 5 (33.3) 4 (15.4)
     Anastomotic leakage 1 (6.7) 4 (15.4)
     Acute urinary retention 0 (0) 1 (3.8)
     Clostridium difficile colitis 0 (0) 1 (3.8)
     Chyloperitoneum 0 (0) 1 (3.8)
     Ascites 0 (0) 1 (3.8)
    Clavien-Dindo grade during readmission 0.37
     I–II 7 (46.7) 11 (42.3)
     III 7 (46.7) 15 (57.7)
     IV 1 (6.7) 0 (0)
    Indication for adjuvant chemotherapy 7 (46.7) 11 (42.3) >0.99
    Adjuvant chemotherapy performed 6/7 (85.7) 11/11 (100) 0.39
    1-yr Mortality 3 (20.0) 0 (0) -
    Table 1. Patient management before and after ERAS protocol implementation

    ERAS, Enhanced Recovery After Surgery; PONV, postoperative nausea and vomiting; TAP, transverse abdominal plane; VAS, visual analog scale; IV, intravenous; POD: postoperative day; POC, postoperative complication.

    Table 2. Comparison of characteristics of patients who developed complications (n=272)

    Values are presented as number (%), mean±standard deviation, or mean.

    ERAS, Enhanced Recovery After Surgery; ASA, American Society of Anesthesiologists; ICU, intensive care unit.

    Table 3. Comparison of characteristics of patients with postoperative anastomotic complications

    Values are presented as number (%) or mean±standard deviation.

    ERAS, Enhanced Recovery After Surgery; CT, computed tomography; ICU, intensive care unit.

    Table 4. Comparison of characteristics of patients with postoperative ileus

    Values are presented as number (%) or mean±standard deviation.

    ERAS, Enhanced Recovery After Surgery; CT, computed tomography; NGT, nasogastric tube; ICU, intensive care unit.

    Table 5. Comparison of characteristics of patients who were readmitted

    Values are presented as number (%) or mean±standard deviation. Percentages may not total 100 due to rounding.

    ERAS, Enhanced Recovery After Surgery; LOS, length of stay; POC, postoperative complication; ICU, intensive care unit.

    Table 1.

    Table 2.

    Table 3.

    Table 4.

    Table 5.

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