Aspects of ERAS-care pathways within colo-rectal surgery

Abstract

Almost half of all in-patients in Sweden are treated with surgery. Fast postoperative recovery is important not only for each patient undergoing surgery but also from a health economical perspective. Within traditional care, the rate of postoperative recovery after major abdominal surgery has been slow with high morbidity and long hospital stays. The enhanced recovery program (ERAS) designed to reduce surgical metabolic stress through a multimodal approach, has enabled a fundamental shift in terms of perioperative care. The aim with this thesis was to evaluate certain aspects of the ERAS-program.

The objective in paper I was to study the impact of different adherence levels to the ERAS-protocol and the effect of various ERAS-elements on outcomes following major surgery. In a single-centre prospective cohort study of 953 consecutive colo-rectal cancer patients at a colo-rectal surgical ERAS unit, patients treated in 2002-2004 were compared to patients treated in 2005-2007, i.e. before and after reinforcement of an ERAS-protocol. All clinical data, 114 variables, were prospectively recorded. All patients were also analysed across periods. Following an overall increase in adherence to the ERAS-protocol, postoperative complications as well as symptoms, declined significantly. Restriction of perioperative intravenous fluid volumes and the use of a preoperative carbohydrate drink were found to be major independent predictors for postoperative outcomes. Across periods, the proportion of adverse postoperative outcomes (30-day morbidity, symptoms delaying discharge, and readmissions) was significantly reduced with increasing adherence to the ERASprotocol.

In paper II the objective was to study pre- and postoperative glucose control in patients undergoing colorectal surgery and whether preoperative HbA1c could predict hyperglycaemia and/or adverse outcomes. In this prospective cohort study, 120 patients without known diabetes underwent major colorectal surgery within an enhanced-recovery protocol. HbA1c was measured at admission and 4 weeks postoperatively. Postoperative plasma glucose was monitored five times daily. Patients were stratified according to preoperative levels of HbA1c above normal range (>6.0) and within normal range (6.0). We found that 26% of the patients had a preoperative value above the normal range. Among these, postoperative glucose and CRP concentrations were higher and complications were more common, compared to patients with HbA1c within normal range.

In paper III, the objective was to study if patients with Type 2 diabetes can be treated with a preoperative carbohydrate drink (one of the ERAS-elements) without effects on preoperative glycaemia and gastric emptying. Twenty-five patients with Type 2 diabetes and 10 healthy control subjects were studied. A carbohydrate-rich drink was given with paracetamol for determination of gastric emptying. It was found that glucose concentrations after intake of the drink were normalized after 180 vs. 120 minutes in diabetic patients and healthy subjects, respectively. After two hours, for both groups, approximately 10% of the paracetamol remained in the stomach.

The objective of paper IV, was to study the association between type of surgical approach (laparoscopic vs. open surgery), compliance to the ERAS-protocol and outcome from surgery in an ERAS environment. Between January 2007- December 2009, 96 consecutive patients underwent high anterior resection with laparoscopic-assisted (n=49) or open resection (n=47). All clinical data (114 variables) were prospectively recorded. We found no significant difference with regards to overall adherence to the preoperative ERAS-protocol between the laparoscopic and open surgery groups. Neither was there any significant difference between groups in terms of postoperative complications, overall postoperative symptoms delaying recovery or median hospital stay. The proportion of patients within target length of stay ≤3 days was however larger in the laparoscopic group, and some of the recovery parameters were also better following laparoscopy compared to open surgery.

In conclusion, it appears that one should strive to achieve highest possible adherence to the elements of the ERASprotocol in order to improve surgical outcomes. Also, certain ERAS elements may be more important than others for beneficial outcomes. Unsatisfactory glucose control, as indicated by elevated HbA1c, is common in patients scheduled for colorectal surgery. Furthermore, postoperative hyperglycaemia appears to be prevalent even among patients with no history of diabetes and this may be even more important in patients with elevated HbA1c before surgery. It may be safe, within the current fasting guidelines, to administer a preoperative carbohydrate drink to patients with uncomplicated Type 2 diabetes preoperatively. Early recovery can be achieved after both laparoscopic and open resection using the ERAS program. There was some indication of improved recovery following laparoscopic resection compared to open surgery. Modification of the ERAS-protocol to achieve further improvements in association with laparoscopic technique may be warranted.