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The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection

Results From an International Registry

 the ERAS Compliance Group

doi: 10.1097/SLA.0000000000001029
Original Articles

Background: The ERAS (enhanced recovery after surgery) care has been shown in randomized clinical trials to improve outcome after colorectal surgery compared to traditional care. The impact of different levels of compliance and specific elements, particularly out with a trial setting, is poorly understood.

Objective: This study evaluated the individual impact of specific patient factors and perioperative enhanced recovery protocol compliance on postoperative outcome after elective primary colorectal cancer resection.

Methods: The international, multicenter ERAS registry data, collected between November 2008 and March 2013, was reviewed. Patient demographics, disease characteristics, and perioperative ERAS protocol compliance were assessed. Linear regression was undertaken for primary admission duration and logistic regression for the development of any postoperative complication.

Findings: A total of 1509 colonic and 843 rectal resections were undertaken in 13 centers from 6 countries. Median length of stay for colorectal resections was 6 days, with readmissions in 216 (9.2%), complications in 948 (40%), and reoperation in 167 (7.1%) of 2352 patients. Laparoscopic surgery was associated with reduced complications [odds ratio (OR) = 0.68; P < 0.001] and length of stay (OR = 0.83, P < 0.001). Increasing ERAS compliance was correlated with fewer complications (OR = 0.69, P < 0.001) and shorter primary hospital admission (OR = 0.88, P < 0.001). Shorter hospital stay was associated with preoperative carbohydrate and fluid loading (OR = 0.89, P = 0.001), and totally intravenous anesthesia (OR = 0.86, P < 0.001); longer stay was associated with intraoperative epidural analgesia (OR = 1.07, P = 0.019). Reduced postoperative complications were associated with restrictive perioperative intravenous fluids (OR = 0.35, P < 0.001).

Conclusions: This analysis has demonstrated that in a large, international cohort of patients, increasing compliance with an ERAS program and the use of laparoscopic surgery independently improve outcome.

The international enhanced recovery registry was analyzed to assess the impact of compliance on outcome after elective colorectal cancer surgery. Increasing compliance and laparoscopic surgery lead to improved outcomes.

*The writing committee comprised the following authors: Andrew Currie, Jennifer Burch, John T. Jenkins, Omar Faiz, and Robin H. Kennedy (Department of Surgery, St Mark's Hospital and Academic Institute, and Imperial College London, London, United Kingdom) and Olle Ljungqvist (Department of Surgery, Örebro University & Örebro University Hospital, Örebro, Sweden). The collaborating committee comprised the following members: Nicolas Demartines (CHUV Lausanne Surgery, Switzerland), Fredrik Hjern (Danderyds Sjukhus, Sweden), Olle Ljungqvist (Örebro Universitetssjukhus/Kirurg, Sweden), Stig Norderval, Kristoffer Lassen, and Arthur Revhaug (University Hospital of North Norway, Tromsö, Norway), Tomas Koczkas (Östersunds Sjukhus, Sweden), Jonas Nygren and Ulf Gustafsson (Ersta Sjukhus, Sweden), Dan Kornfeld (Kirurgkliniken St Göran, Sweden), Karem Slim (University Hospital Clermont-Ferrand, France), Andrew Hill (Middlemore Hospital, Auckland, New Zealand), Mattias Soop (North Shore Hospital, Auckland, New Zealand), Johan Carlander (Västerås Centrallasarett, Sweden), Owe Lundberg (Kirurgkliniken Umeå, Sweden), Ken Fearon (Western General Hospital, Edinburgh, UK), and Robin Kennedy and John T. Jenkins (St Mark's Hospital, London, United Kingdom).

Reprints: Robin Kennedy, St Mark's Hospital and Academic Institute, Watford Road, London, HA1 3UJ, UK. E-mail:

Disclosure: O.L. has received research funding from Nutricia Clinical Care and Fresenius Kabi. O.L. held the patent rights to Nutricia preoperatively (the patent expired in 2011). O.L. serves on an advisory committee for Nutricia AS, The Netherlands, a company that sells clinical nutritional produces. He also owns stock in Encare AB, Sweden, an IT company that manages the ERAS Interactive Audit System used in this study. KCHF has received lecture fees from Fresenius-Kabi and Nutricia and research funding from Fresenius-Kabi. Grant funding. During the period 2008–2013, the ERAS Group and subsequent ERAS Society were supported by unrestricted grants from Nutricia and Fresenius Kabi.* ACC has received research grants from the Barcapel Foundation, the Savvas Regas Foundation, and the Wates Foundation. St Mark's Hospital has received research grants from Ethicon Endosurgery and Olympus. Data collection at the Western General Hospital Edinburgh was supported by a grant from Lothian Hospitals Oncology Endowment Fund (£120K).** But, the authors declare no conflicts of interest.

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