Javier Ripollés-Melchor1, Ane Abad-Motos2, Maurizio Cecconi3, Rupert Pearse4, Samir Jaber5, Karem Slim6, Nader Francis7, Antonino Spinelli3, Jean Joris8, Orestis Ioannidis9, Eirini Zarzava10, Nüzhet Mert Şentürk11, Seppe Koopman12, Nicolai Goettel13, Ottokar Stundner14, Tomas Vymazal15, Petr Kocián16, Alaa El-Hussuna17, Michał Pędziwiatr18, Jurate Gudaityte19, Tadas Latkauskas20, Marisa D Santos21, Humberto Machado22, Roman Zahorec23, Ana Cvetković24, Mirjana Miric25, Maria Georgiou26, Yolanda Díez-Remesal27, Ib Jammer28, Gabriel E Mena29, Andrés Zorrilla-Vaca30, Marco V Marino31, Alejandro Suárez-de-la-Rica32, José A García-Erce33, Margarita Logroño-Ejea34, Carlos Ferrando-Ortolá35, María L De-Fuenmayor-Valera36, Bakarne Ugarte-Sierra37, José de Andrés-Ibañez38, Alfredo Abad-Gurumeta36, Gianluca Pellino39, Manuel A Gómez-Ríos40, Gilberto Poggioli41, Albert Menzo-Wolthuis42, Berta Castellano-Paulis43, Patricia Galán-Menéndez44, César Aldecoa45, José M Ramírez-Rodríguez46. 1. Department of Anesthesia and Perioperative Medicine, Infanta Leonor University Hospital, Madrid, Spain; Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Universidad Complutense de Madrid, Madrid, Spain. Electronic address: javier.ripolles@salud.madrid.org. 2. Department of Anesthesia and Perioperative Medicine, Infanta Leonor University Hospital, Madrid, Spain; Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain. 3. Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy; IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy. 4. Barts and the London School of Medicine & Dentistry, Queen Mary University London, EC1M 6BQ, UK. 5. Department of Anesthesiology and Intensive Care, Centre Hospitalier Universitaire de Montpellier, Montpellier, France; The Francophone Group for Enhanced Recovery After Surgery (GRACE), France. 6. The Francophone Group for Enhanced Recovery After Surgery (GRACE), France; Service de Chirurgie Digestive & Unité de Chirurgie Ambulatoire Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France. 7. Department of Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK. 8. The Francophone Group for Enhanced Recovery After Surgery (GRACE), France; Anesthesia and Reanimation CHU de Liège, Université de Liège, Liège, Belgium. 9. Fourth Surgical Department, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece. 10. Department of Anesthesia and Surgical Critical Care, General Hospital "G. Papanikolaou", Thessaloniki, Greece. 11. Department of Anesthesiology, Istanbul University School of Medicine, Istanbul, Turkey. 12. Department of Anesthesiology, Maasstad Hospital, Rotterdam, the Netherlands. 13. Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, USA; Department of Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University of Basel, Basel, Switzerland. 14. Department of Anesthesia and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria. 15. Department of Anesthesiology and Intensive Care, Motol University Hospital, Prague, Czech Republic. 16. Department of Surgery, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic. 17. Department of surgery, Aalborg University Hospital, Aalborg, Denmark; Opensource Research Collaboration, Denmark. 18. 2nd Department of General Surgery, Jagiellonian University Medical College, Kraków, Poland. 19. Department of Anesthesiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania. 20. Department of Surgery, Coloproctology Unit, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania. 21. Colorectal Surgery, Rectal Cancer Reference Center, Centro Hospitalar do Porto, Porto, Portugal. 22. Serviço de Anestesiologia, Centro Hospitalar Universitário do Porto, Porto, Portugal. 23. Anesthesiology and Intensive Medicine, Medical School, Comenius University, Bratislava, Slovakia. 24. Anesthesiology & Intensive Care Medicine, Institute for Oncology and Radiology of Serbia, Clinic of Surgical Oncology, Belgrade, Serbia. 25. Department of Anesthesiology, Reanimatology and Intensive Care, Clinical Hospital Center Zagreb, Zagreb, Croatia. 26. Department of Anesthesiology, Nicosia General Hospital, Nicosia, Cyprus. 27. Anesthesia & Intensive Care Department, Ramón y Cajal University Hospital, Madrid, Spain. 28. Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. 29. Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA. 30. Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. USA. 31. Department of General and Emergency Surgery, Azienda Ospedaliera, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy. 32. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Department of Anesthesiology and Perioperative Medicine, Marqués de Valdecilla University Hospital, Santander, Spain. 33. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Banco de Sangre y Tejidos de Navarra, Servicio Navarro de Salud-Osasunbidea, Pamplona, Spain. 34. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Department of Anesthesiology and Perioperative Medicine, Hospital Universitario de Alava, Alava, Spain. 35. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Department of Anesthesiology and Critical Care, Hospital Clínic, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain. 36. Department of Anesthesia and Perioperative Medicine, Infanta Leonor University Hospital, Madrid, Spain; Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Universidad Complutense de Madrid, Madrid, Spain. 37. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Department of General Surgery, BioCruces Bizkaia Health Research Institute, Hospital Universitario de Galdakao, Galdakao, Vizcaya, Spain. 38. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Department of Anesthesiology and Perioperative Medicine, Hospital General Universitario de Valencia, Valencia, Spain. 39. Department of Advanced Medical and Surgical Sciences, Università degli Studi Della Campania "Luigi Vanvitelli", Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain; Italian Surgical Research Group (ItSURG), Italy. 40. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Anesthesia and Critical Care Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain. 41. Surgery Department, Alma Mater Studiorum University of Bologna, IRCCS Azienda Ospedaliero - Universitaria di Bologna, Bologna, Italy. 42. Surgery Department, University Hospital Leuven, Leuven, Belgium. 43. Anesthesia and Critical Care Department, Hospital Universitario Donostia, Donostia-San Sebastián, Spain. 44. Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Anesthesia and Critical Care Department, Vall d'Hebrón University Hospital, Barcelona, Spain. 45. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Department of Anesthesia and Critical Care, Río Hortega University Hospital, Valladolid, Spain. 46. Spanish Perioperative Audit and Research Network (RedGERM), Zaragoza, Spain; Grupo Español de Rehabilitación Multimodal (GERM), Zaragoza, Spain; Department of General Surgery, Lozano Blesa University Hospital, Zaragoza, Spain; Universidad de Zaragoza, Zaragoza, Spain.
Abstract
STUDY OBJECTIVE: Assess the relationship between the Enhanced Recovery After Surgery (ERAS®) pathway and routine care and 30-day postoperative outcomes. DESIGN: Prospective cohort study. SETTING: European centers (185 hospitals) across 21 countries. PATIENTS: A total of 2841 adult patients undergoing elective colorectal surgery. Each hospital had a 1-month recruitment period between October 2019 and September 2020. INTERVENTIONS: Routine perioperative care. MEASUREMENTS: Twenty-four components of the ERAS pathway were assessed in all patients regardless of whether they were treated in a formal ERAS pathway. A multivariable and multilevel logistic regression model was used to adjust for baseline risk factors, ERAS elements and country-based differences. RESULTS: A total of 1835 patients (65%) received perioperative care at a self-declared ERAS center, 474 (16.7%) developed moderate-to-severe postoperative complications, and 63 patients died (2.2%). There was no difference in the primary outcome between patients who were or were not treated in self-declared ERAS centers (17.1% vs. 16%; OR 1.00; 95%CI, 0.79-1.27; P = 0.986). Hospital stay was shorter among patients treated in self-declared ERAS centers (6 [5-9] vs. 8 [6-10] days; OR 0.82; 95%CI, 0.78-0.87; P < 0.001). Median adherence to 24 ERAS elements was 57% [48%-65%]. Adherence to ERAS-pathway quartiles (≥65% vs. <48%) suggested that patients with the highest adherence rates experienced a lower risk of moderate-to-severe complications (15.9% vs. 17.8%; OR 0.71; 95%CI, 0.53-0.96; P = 0.027), lower risk of death (0.3% vs. 2.9%; OR 0.10; 95%CI, 0.02-0.42; P = 0.002) and shorter hospital stay (6 [4-8] vs. 7 [5-10] days; OR 0.74; 95%CI, 0.69-0.79; P < 0.001). CONCLUSIONS: Treatment in a self-declared ERAS center does not improve outcome after colorectal surgery. Increased adherence to the ERAS pathway is associated with a significant reduction in overall postoperative complications, lower risk of moderate-to-severe complications, shorter length of hospital stay and lower 30-day mortality.
STUDY OBJECTIVE: Assess the relationship between the Enhanced Recovery After Surgery (ERAS®) pathway and routine care and 30-day postoperative outcomes. DESIGN: Prospective cohort study. SETTING: European centers (185 hospitals) across 21 countries. PATIENTS: A total of 2841 adult patients undergoing elective colorectal surgery. Each hospital had a 1-month recruitment period between October 2019 and September 2020. INTERVENTIONS: Routine perioperative care. MEASUREMENTS: Twenty-four components of the ERAS pathway were assessed in all patients regardless of whether they were treated in a formal ERAS pathway. A multivariable and multilevel logistic regression model was used to adjust for baseline risk factors, ERAS elements and country-based differences. RESULTS: A total of 1835 patients (65%) received perioperative care at a self-declared ERAS center, 474 (16.7%) developed moderate-to-severe postoperative complications, and 63 patients died (2.2%). There was no difference in the primary outcome between patients who were or were not treated in self-declared ERAS centers (17.1% vs. 16%; OR 1.00; 95%CI, 0.79-1.27; P = 0.986). Hospital stay was shorter among patients treated in self-declared ERAS centers (6 [5-9] vs. 8 [6-10] days; OR 0.82; 95%CI, 0.78-0.87; P < 0.001). Median adherence to 24 ERAS elements was 57% [48%-65%]. Adherence to ERAS-pathway quartiles (≥65% vs. <48%) suggested that patients with the highest adherence rates experienced a lower risk of moderate-to-severe complications (15.9% vs. 17.8%; OR 0.71; 95%CI, 0.53-0.96; P = 0.027), lower risk of death (0.3% vs. 2.9%; OR 0.10; 95%CI, 0.02-0.42; P = 0.002) and shorter hospital stay (6 [4-8] vs. 7 [5-10] days; OR 0.74; 95%CI, 0.69-0.79; P < 0.001). CONCLUSIONS: Treatment in a self-declared ERAS center does not improve outcome after colorectal surgery. Increased adherence to the ERAS pathway is associated with a significant reduction in overall postoperative complications, lower risk of moderate-to-severe complications, shorter length of hospital stay and lower 30-day mortality.