By Monica J. Smith

Enhanced recovery after surgery protocols are associated with reduced hospital length of stay, fewer complications and lower costs, but one institution found no improvement in outcomes and higher costs after implementing an ERAS protocol.

“ERAS has been widely studied and accepted; however, more recent data have contradictory findings, calling into question the true impact of the protocol’s benefit,” said Miles Landry, MBBS, the academic chief resident at the University of Tennessee Medical Center, in Knoxville. “We wanted to look at the impact on outcomes and cost, and to further investigate if site of resection had an influence on these results.”

Dr. Landry and his colleagues evaluated data on 598 patients undergoing elective colon resection, 100 before the implementation of an ERAS protocol in 2014, and 498 between implementation and 2017. Before implementation, the most frequently performed surgery was right colectomy; after implementation, sigmoidectomy was most commonly performed. (Less commonly performed were left colectomy, transverse colectomy and low anterior resection).

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They found a general cost increase that was statistically significant for every site of resection except transverse colectomy. “That did have a more than $2,000 increase, but with the low number of procedures, it failed to reach statistical significance,” Dr. Landry said.

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There was a smaller difference in the cost increase with the frequently performed right colectomy and sigmoidectomy procedures, “which suggests we’re gaining some level of efficiency from doing those more regularly,” Dr. Landry said.

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Hospital length of stay, averaging 4.5 days for open procedures and 3.5 days for minimally invasive procedures prior to the protocol, improved initially in the laparoscopic surgery cohort, but then returned to average.

“Is this a worthwhile thing to do? I think if we can truly establish the preoperative and perioperative factors that identify patients who would be in the hospital for five to seven days rather than two to three, we’ll be able to see the real benefit of the ERAS protocol,” Dr. Landry said.

He presented his study at the 2020 Southeastern Surgical Congress (abstract 67).

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Russell Farmer, MD, an assistant professor of colon and rectal surgery at the University of Louisville, in Kentucky, congratulated the authors for examining a topic that is becoming a standard of care in minimally invasive colectomy. “Many accrediting bodies outside the [United States] include ERAS protocol components as a mandatory part of their board examination,” he said.

Dr. Farmer asked if the shift from right colectomy to sigmoidectomy might have affected the researchers’ findings.

“I do think that hints at the idea that the expected outcomes for patients would have been different as we included more difficult patients, but we didn’t design the database that way. That’s a key component that we’ll include in future evaluations,” Dr. Landry said.

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“I do think there is a population that will benefit from this protocol; being able to customize our medical care is a goal of this process,” he added.