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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 151-154

Experience of implementation of enhanced recovery after surgery in colorectal surgeries in rashid hospital


Departement of General Surgery, Rashid Hospital, Dubai Health Authority, Dubai, United Arab Emirates

Date of Submission13-Feb-2022
Date of Decision25-Mar-2022
Date of Acceptance25-Mar-2022
Date of Web Publication21-Sep-2022

Correspondence Address:
Abdulaziz AlBaroudi
Rashid Hospital, Dubai Health Authority, Dubai
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_21_22

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  Abstract 


Background: Enhanced Recovery After Surgery guidelines in colorectal surgery state that there is improvement in general post-operative outcomes including reduction in operative complications and 30 days readmission rates. These recommendations were originating from high flow, excellence and academic centers. Aim and objectives: Demonstrating the feasibility of ERAS protocols application in low-flow centres as our hospital is the aim of this study. Materials and Method: A retrospective cohort study was performed at a tertiary hospital. A total of 99 patients were included over a period of 6 years from January 2014 till January 2020 for all elective colorectal cases after being filtered through inclusion and exclusion criteria. They were divided into two groups Pre-ERAS (n=29) and ERAS group (n=70) starting from August 2016 the date of beginning implementation of the local protocol. Results: It was observed that there was statistical significance in reducing the length of hospital stay from an average of 13 days in Pre-ERAS to average of 8 days in the ERAS group and a decrease in day 1 post-operative pain score were achieved without adverse impact in surgery related morbidities or readmission rate. Conclusion: ERAS protocol can be applied to improve surgical outcomes in colorectal surgery without increased risk of complications.

Keywords: Colectomy, colon cancer, enhanced recovery after surgery, surgery


How to cite this article:
AlBaroudi A, AlZarooni N, AlOzabi L, Hejazi NA. Experience of implementation of enhanced recovery after surgery in colorectal surgeries in rashid hospital. Hamdan Med J 2022;15:151-4

How to cite this URL:
AlBaroudi A, AlZarooni N, AlOzabi L, Hejazi NA. Experience of implementation of enhanced recovery after surgery in colorectal surgeries in rashid hospital. Hamdan Med J [serial online] 2022 [cited 2022 Oct 7];15:151-4. Available from: http://www.hamdanjournal.org/text.asp?2022/15/3/151/356438




  Introduction Top


Colorectal surgery is considered one of the major pillars of general surgery. These surgeries are often associated with long lengths of stay, an average of 8 days,[1] high rates of surgical site infection approaching 20%[2] and readmission rates have been noted as high as 35.4%.[3]

A multidisciplinary, evidence-based perioperative approach known as enhanced recovery after surgery (ERAS pathway) was developed with the aim to reduce post-operative stress, metabolic response and organ dysfunction thereby accelerating recovery.[4]

The protocol depends on applying measures such as reducing intraoperative fluid use, omitting opioids from the given analgesia, introducing laparoscopic techniques, early mobilisation and starting oral diet.

Executing the ERAS pathway showed improved outcomes; however, literature reporting results from ERAS programmes mostly originate from international or specialised academic centres.[5],[6],[7] Keeping in mind the population variation in this region compared to developed countries, the feasibility and efficacy of ERAS protocol implementation in regional centres need to be tested.


  Methods Top


Rashid Hospital is a tertiary specialised academic institution in the Emirate of Dubai, United Arab Emirates. As such, ERAS concept was introduced based on literature review and professional meetings. By July 2016, the ERAS protocol was adopted in full practice as shown in [Table 1]. A retrospective cohort study was conducted; ethical approval of the study was obtained from the institutional ethical committee (DSREC/RRP/2020/09). Cases were studied between the dates January 2014 and January 2020 with a total number of 99 patients. The inclusion criteria were any elective case with a patient aged above 18 years and had colorectal pathology. Emergency surgeries, patients' ages below the age of 18 years and American Society of Anaesthesiology score 5 and 6 were the exclusion criteria used during conducting the study.
Table 1: Institutional ERAS protocol elements

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Analysis was carried out between two groups defined as the pre-ERAS group (n = 29) and the ERAS group (n = 70) based on the date of implementation of the protocol which took place in August 2016.

Mean, range and frequencies were reported as descriptive statistics. Mann–Whitney U test was used. The Chi-square/Fisher's exact test was used for categorical variables, and the data were presented as numbers (percentages) as appropriate. P < 0.05 was considered significant. SPSS software was used for statistical analysis.

Length of hospital stay, pain score, readmission rate and operation-related morbidity were compared between both groups to determine if the ERAS protocol was effective.


  Results Top


From January 2014 to January 2020, a total number of 99 patients were included in the study. The number of patients in the pre-ERAS group was 29 patients, whereas 70 patients were in the ERAS group. Analysis was done between the two groups as shown in [Figure 1].
Figure 1: Sample Groups

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The mean age group was 54.6 years for the pre-ERA'S group, whereas the ERAS group's mean age was 57.8 years. Furthermore, the male-to-female ratio was comparable between the two groups. Diagnoses of operated cases were a mixture of benign and malignant disease with 72% of the cases operated throughout the given period being cancer cases. The above-mentioned demographic variables were not statistically significant, reflecting the similarity of demography between the two groups. However, the difference in the number of surgeries and use of laparoscopy between the pre-ERAS and ERAS groups showed a statistically significant increase. In the control group, 3 patients out of 29 were operated on laparoscopically, whereas in the ERAS group, 51 patients out of 70 underwent minimally invasive surgery.

The demography and type of surgeries are illustrated in [Table 2].
Table 2: Demographics and types of surgery

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Patients included in the study had a wide range of co-morbidities. However, diabetes mellitus and hypertension were the most frequent diseases [Figure 2].
Figure 2: Percentage of comorbidities

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There was a statistically significant difference in length of hospital stay (pre-ERAS group 13.2 days versus ERAS group 7.7 days) with P < 0.01. It was noted that the 30-day readmission rate was more in the ERAS group n = 2 versus pre-ERAS group n = 0. However, there was no statistically significant difference P = 0.35 shown in [Table 3].
Table 3: Length of hospital stay

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When comparing the presence of post-operative complications in both groups, it was found to be less in the ERAS group as 29% of patients had complications, whereas the pre-ERAS group had 41% of patients with complications.

Rates of ileus, surgical site infection, leak and reoperation were not statistically significant between the two groups (P = 0.21), as illustrated in [Table 4].
Table 4: Complications

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Pain score was low on the 1st post-operative day in the ERAS group which is statistically significant (P = 0.04). The pain score during the remaining days showed no statistical difference, as shown in [Table 5].
Table 5: Pain score

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For all of the patients in the study, a correlation was found between the side of surgery and the length of hospital stay as well as the existence of complications. There was no statistically significant difference with regard to any of the aforementioned factors (P = 0.37), (P = 0.32).


  Discussion Top


In the study, it was found that the implementation of ERAS protocol showed a statistically significant decrease in the number of days of hospital stays after surgery with an improvement in the level of pain during the 1st post-operative day.

When comparing our results with referenced studies and guidelines, there was a similarity in the final results. There was no obvious difference in the post-operative complications between the two groups seen in our results and this can possibly be attributed to the percentage adherence to the protocol applied for each patient, underreporting of complications and the low number of complications to be compared between the two groups.

The mean hospital stay was 13 days in the pre-ERAS group, whereas the period declined to 8 days in the ERAS group. When compared to the literature, the decrease was found to be 3 days on average. Regarding the average pain score on the 1st-day post-surgery, the mild was more prevalent than moderate and severe scores with statistical significance. There was no statically significant difference in the pain score in the remainder of the days which is different to that of the reference literature.

Searching throughout the literature, we found a study[8] that has similarities to our hospital with regard to the level of service offered as both the hospitals are classified as community hospitals and not academic/excellence centres. There were similarities in the reduction of hospital stay and pain score, but our results differed when it came to the number of co-morbidities or readmission rates.

We believe that better outcomes can be achieved by adding more elements from the guidelines to our protocol with stricter adherence brought about by further training of all staff involved in the care of surgical patients.

Looking into the study population, there was no statistical difference in regard to sex, age and colorectal diseases that lead to their enrolment in the study with our patient enrolment having a wider demographic than others referenced, especially when it came to the ages of the patients.

Going through the number of cases that were readmitted during 30 days from surgery, in our study, it was noticed that only two cases from the ERAS group were readmitted but without statistical significance and that could possibly be attributed to a low number of patients in the pre-ERAS group.


  Conclusion Top


It is evident in our study that the application of ERAS protocol effectively enhances the recovery course without increasing the post-operative morbidity or readmission rates in a community hospital with an effective reduction in length of hospital stay and pain score.

Ethical clearance

Ethical approval was obtained from Dubai Scientific Research Ethical Committee (DSREC/RRP/2020/09).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kang CY, Chaudhry OO, Halabi WJ, Nguyen V, Carmichael JC, Stamos MJ, et al. Outcomes of laparoscopic colorectal surgery: Data from the Nationwide Inpatient Sample 2009. Am J Surg 2012;204:952-7.  Back to cited text no. 1
    
2.
Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, McMurry TL, et al. Standardization of care: Impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg 2015;220:430-43.  Back to cited text no. 2
    
3.
Nagle D, Pare T, Keenan E, Marcet K, Tizio S, Poylin V. Ileostomy pathway virtually eliminates readmissions for dehydration in new ostomates. Dis Colon Rectum 2012;55:1266-72.  Back to cited text no. 3
    
4.
Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: A review. JAMA Surg 2017;152:292-8.  Back to cited text no. 4
    
5.
Basse L, Thorbøl JE, Løssl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004;47:271-7.  Back to cited text no. 5
    
6.
Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 2003;46:851-9.  Back to cited text no. 6
    
7.
Wind J, Polle SW, Fung Kon Jin PH, Dejong CH, von Meyenfeldt MF, Ubbink DT, et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006;93:800-9.  Back to cited text no. 7
    
8.
Geltzeiler CB, Rotramel A, Wilson C, Deng L, Whiteford MH, Frankhouse J. Prospective study of colorectal enhanced recovery after surgery in a community hospital. JAMA Surg 2014;149:955-61.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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