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Original Investigation
May 8, 2019

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Colorectal Surgery: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study

Author Affiliations
  • 1Department of Anaesthesia and Critical Care, Infanta Leonor University Hospital, Madrid, Spain
  • 2Universidad Complutense de Madrid, Madrid, Spain
  • 3Spanish Perioperative Audit and Research Network, Zaragoza, Spain
  • 4Grupo Español de Rehabilitación Multimodal. Enhanced Recovery After Surgery Spain Chapter, Zaragoza, Spain
  • 5Department of General Surgery, Lozano Blesa University Hospital, Zaragoza, Spain
  • 6Department of Anaesthesia and Perioperative Medicine. Lozano Blesa University Hospital, Zaragoza, Spain
  • 7Department of Anaesthesia and Perioperative Medicine, Río Hortega University Hospital, Valladolid, Spain
  • 8Department of Anaesthesia and Perioperative Medicine, Alava University Hospital, Alava, Spain
  • 9Blood and Tissue Bank of Navarra, Servicio Navarro de Salud-Osasunbidea, Pamplona, Navarra, Spain
  • 10Anemia Working Group Spain, Barcelona, Spain
  • 11Department of Anaesthesia and Critical Care, Vall d´Hebrón University Hospital, Barcelona, Spain
  • 12Department of Anaesthesia and Perioperative Medicine, Hospital Clínic Universitat de Barcelona, Barcelona, Spain
  • 13Department of Anaesthesia and Critical Care, La Paz University Hospital, Madrid, Spain
  • 14Department of Anaesthesia and Critical Care, Hospital Universitario Central de Asturias, Oviedo, Spain
  • 15Department of Anaesthesia and Perioperative Medicine, Hospital de Sant Joan Despí Moisès Broggi, Consorci Sanitari Integral, Barcelona, Spain
  • 16Department of Anaesthesia and Critical Care, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
JAMA Surg. 2019;154(8):725-736. doi:10.1001/jamasurg.2019.0995
Key Points

Question  Are the complications after colorectal surgery frequent and are the complications associated with Enhanced Recovery After Surgery protocols?

Findings  In this cohort study of 2084 patients, 566 patients presented with moderate to severe complications. Patients receiving care at a facility that had greater adherence to the Enhanced Recovery After Surgery items had a lower number of postoperative complications, regardless of whether the center had an established Enhanced Recovery After Surgery protocol.

Meaning  An increase in adherence to the Enhanced Recovery After Surgery protocol appeared to be associated with a decrease in postoperative complications; thus, a high adherence rate to the Enhanced Recovery After Surgery protocol is recommended in the management of care for patients undergoing colorectal surgery.

Abstract

Importance  Enhanced Recovery After Surgery (ERAS) care has been reported to be associated with improvements in outcomes after colorectal surgery compared with traditional care.

Objective  To determine the association between ERAS protocols and outcomes in patients undergoing elective colorectal surgery.

Design, Setting, and Participants  The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study is a multicenter, prospective cohort study of 2084 consecutive adults scheduled for elective colorectal surgery who received or did not receive care in a self-declared ERAS center. Patients were recruited from 80 Spanish centers between September 15 and December 15, 2017. All patients included in this analysis had 1 month of follow-up.

Exposures  Colorectal surgery and perioperative management were the exposures. Twenty-two individual ERAS items were assessed in all patients, regardless of whether they were included in an established ERAS protocol.

Main Outcomes and Measures  The primary study outcome was moderate to severe postoperative complications within 30 days after surgery. Secondary outcomes included ERAS adherence, mortality, readmissions, reoperation rates, and hospital length of stay.

Results  Between September 15 and December 15, 2017, 2084 patients were included in the study. Of these, 1286 individuals (61.7%) were men; mean age was 68 years (interquartile range [IQR], 59-77). A total of 879 patients (42.2%) presented with postoperative complications and 566 patients (27.2%) developed moderate to severe complications. The number of patients with moderate or severe complications was lower in the ERAS group (25.2% vs 30.3%; odds ratio [OR], 0.77; 95% CI, 0.63-0.94; P = .01). The overall rate of adherence to the ERAS protocol was 63.6% (IQR, 54.5%-77.3%), and the rate for patients from hospitals self-declared as ERAS was 72.7% (IQR, 59.1%-81.8%) vs non-ERAS institutions, which was 59.1% (IQR, 50.0%-63.6%; P < .001). Adherence quartiles among patients receiving the highest and lowest ERAS components showed that the patients with the highest adherence rates had fewer moderate to severe complications (OR, 0.34; 95% CI, 0.25-0.46; P < .001), overall complications (OR, 0.33; 95% CI, 0.26-0.43; P < .001), and mortality (OR, 0.27; 95% CI, 0.07-0.97; P = .06) compared with those who had the lowest adherence rates.

Conclusions and Relevance  An increase in ERAS adherence appears to be associated with a decrease in postoperative complications.

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