The report is a product of the VA/HSR Evidence Synthesis Program.

Enhanced Recovery after Surgery Programs for Patients Undergoing Colorectal Surgery

Enhanced recovery after surgery (ERAS) – also referred to as an enhanced recovery program or fast-track rehabilitation, among similar descriptors – is a multidisciplinary approach to perioperative care. A protocol of components related to preadmission, preoperative, intraoperative, and postoperative care is implemented to:

• Improve patient recovery,
• Facilitate earlier discharge from the hospital, and
• Potentially reduce healthcare costs without increasing complications or hospital readmissions.

Although guidelines for ERAS for elective colorectal (CRC) surgery exist, variation in the number and definition of protocol components contributes to difficulties in determining effectiveness. Little is known about implementation barriers and facilitators, as well as components (or combinations of components), that are key for improved clinical outcomes. In addition, protocol compliance, when reported, may be measured by the percentage of components applied or completed without standardization across components (e.g., timing, regimens, doses, etc.). This report provides a systematic review of randomized controlled trials (RCTs) and controlled clinical trials (CCTs) that examined comparative effectiveness and harms of enhanced recovery protocols for elective colorectal surgery overall – and by type of surgery, colorectal condition, and differentiation from usual care protocols. This review also assessed barriers and facilitators to implementation, and provides a contextual discussion of compliance and outcomes.

Investigators with VA's Evidence-based Synthesis Program Center in Minneapolis, MN searched MEDLINE® and CINAHL for relevant articles published from 2011 to July 2017. After reviewing 1,789 citations, investigators identified 25 trials reported in 27 articles, 10 articles with information about implementation barriers and facilitators, and 13 systematic reviews.

Summary of Findings

• Enhanced recovery protocols significantly reduced length of stay (mean reduction 2.6 days) following elective colorectal surgery compared to usual care protocols (quality of evidence: moderate).
  • Length-of-stay reductions occurred across surgical approach (open and laparoscopic), as well as clinical indications (i.e., colorectal cancer, rectal cancer, a mix of CRC and benign conditions, or benign conditions alone).
• Enhanced recovery protocols significantly reduced overall perioperative morbidity (mean absolute reduction 10%) associated with elective colorectal surgery compared to usual care protocols (quality of evidence: moderate).
  • Reductions due to enhanced recovery protocols did not significantly vary by type of, or clinical indication for surgery.
• Mortality, hospital readmissions, and surgical site infections were similar following colorectal surgery with an enhanced recovery protocol or a usual care protocol (quality of evidence: low).
  • Outcomes were similar across surgical approach and clinical indication for surgery.
• Few studies reported on clinically meaningful differences in pain or quality of life, though most studies noted an improvement in gastrointestinal function (i.e., typically passing flatus or bowel movement).
• Enhanced recovery protocols varied across studies, little information was provided regarding component compliance, and evidence is insufficient regarding key components.
• Commonly reported barriers to implementation include time, resources, and acceptability/feasibility of protocols to clinical staff and patients. Facilitators include organizational support, sufficient staff and electronic medical record resources, clear communication that is receptive to staff and/or patient feedback, and standardized yet adaptable and feasible protocols.

There is no reliable evidence on enhanced recovery components – alone or in combination – that are vital to improving patient outcomes. Therefore, the value of investing time and resources into implementing all of the enhanced recovery components remains largely unknown.

Note: None of the trials and only two of the qualitative studies of barriers to and facilitators of implementation were done in the United States. There is no direct evidence of the effectiveness or harms of an enhanced recovery protocol for colorectal surgery in the U.S. or at VA facilities.

FUTURE RESEARCH
There is a need for data from the United States and, for the purpose of making decisions relevant to Veteran care, RCTs, or quality improvement program processes with real-time evaluation across varying VA healthcare facilities. While investigators found no empiric evidence, their key content experts and consultants suggest that many of the enhanced recovery components have been – or over time are being adopted into standard perioperative care for colorectal surgery. Studies designed to evaluate the benefits and harms of enhanced recovery protocols should provide detailed information describing enhanced recovery components, how they are implemented, and how compliance is assessed in the intervention and control groups. Surgeon experience and surgical volume also should be considered. In addition, outcomes should include patient and/or caregiver experiences.

Reference
Greer N, Sultan S, Shaukat A, Dahm P, Lee A, MacDonald R, McKenzie L, Ercan-Fang D, Wilt, TJ. Enhanced Recovery After Surgery (ERAS) Programs for Patients Undergoing Colorectal Surgery. VA ESP Project #09-009; 2017.

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