Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Colorectal Surgery: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study

Abstract

Importance: Enhanced Recovery After Surgery (ERAS) care has been reported to be associated with improvements in outcomes after colorectal surgery compared with traditional care.

Objective: To determine the association between ERAS protocols and outcomes in patients undergoing elective colorectal surgery.

Design, setting, and participants: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study is a multicenter, prospective cohort study of 2084 consecutive adults scheduled for elective colorectal surgery who received or did not receive care in a self-declared ERAS center. Patients were recruited from 80 Spanish centers between September 15 and December 15, 2017. All patients included in this analysis had 1 month of follow-up.

Exposures: Colorectal surgery and perioperative management were the exposures. Twenty-two individual ERAS items were assessed in all patients, regardless of whether they were included in an established ERAS protocol.

Main outcomes and measures: The primary study outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS adherence, mortality, readmissions, reoperation rates, and hospital length of stay.

Results: Between September 15 and December 15, 2017, 2084 patients were included in the study. Of these, 1286 individuals (61.7%) were men; mean age was 68 years (interquartile range [IQR], 59-77). A total of 879 patients (42.2%) presented with postoperative complications and 566 patients (27.2%) developed moderate to severe complications. The number of patients with moderate or severe complications was lower in the ERAS group (25.2% vs 30.3%; odds ratio [OR], 0.77; 95% CI, 0.63-0.94; P = .01). The overall rate of adherence to the ERAS protocol was 63.6% (IQR, 54.5%-77.3%), and the rate for patients from hospitals self-declared as ERAS was 72.7% (IQR, 59.1%-81.8%) vs non-ERAS institutions, which was 59.1% (IQR, 50.0%-63.6%; P < .001). Adherence quartiles among patients receiving the highest and lowest ERAS components showed that the patients with the highest adherence rates had fewer moderate to severe complications (OR, 0.34; 95% CI, 0.25-0.46; P < .001), overall complications (OR, 0.33; 95% CI, 0.26-0.43; P < .001), and mortality (OR, 0.27; 95% CI, 0.07-0.97; P = .06) compared with those who had the lowest adherence rates.

Conclusions and relevance: An increase in ERAS adherence appears to be associated with a decrease in postoperative complications.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Ripollés-Melchor reports personal fees from Edwards Lifesciences and Fresenius Kabi outside the submitted work. Dr García-Erce reports personal fees from Alexion, Amgen, Braun, Celgene, Ferrer, GSK, Inmucor, Jansen, Novartis, Octapharma, Sanofi, Sandoz, Terumo and Zambon; and personal fees and nonfinancial support from Vifor Pharma outside the submitted work. Dr Suarez de la Rica reports personal fees from Baxter and MSD outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. STROBE Flow Diagram for Included Patients

Figure 2.. Postoperative Outcomes

Moderate or severe complications and type of complication in all included patients and in patients with and without the Enhanced Recovery After Surgery (ERAS) protocol. aStatistically significant.

Figure 3.. Postoperative Outcomes and Enhanced Recovery After Surgery (ERAS) Adherence

Postoperative moderate to severe complications in all included patients depending on the quartile (Q) of adherence to the ERAS protocol. aStatistically significant.

Figure 4.. Moderate to Severe Complications by Enhanced Recovery After Surgery (ERAS Items)

PONV indicates postoperative nausea and vomiting. aStatistically significant.