FormalPara Main novel aspects

  • This is the first study focused on ERAS in elderly patients from the Czech Republic.

  • This paper brings further evidence that the ERAS protocol is beneficial both clinically and financially in elderly patients undergoing colorectal surgery.

Introduction

Kehlet et al. introduced the enhanced recovery after surgery (ERAS) protocol for perioperative care in 1997 as a way to accelerate recovery after surgery [1]. This protocol has been shown in various randomised controlled clinical trials, systematic reviews and meta-analyses to decrease length of hospitalisation, postoperative morbidity and to reduce treatment costs [2,3,4,5,6,7,8]. The ERAS protocol rapidly gained international recognition and been implemented in many colorectal centres worldwide and is expanding into other surgical disciplines [9]. Although it has been shown to be beneficial to patients in the general population, less is known about its benefit in elderly patients. A systematic review on the effect of the ERAS protocol in elderly patients concluded that the protocol is safe, yet further studies should be performed to evaluate adherence and clinical benefit in this subset of patients [10]. Even though the majority of new cases of CRC occur in patients over the age of 65, there are few studies focused solely on this age group and as far as we know there have been no published cost–benefit analyses in this specific subgroup of patients [11]. Elderly patients have more comorbidities, are frailer and have a higher risk of surgical complications than younger patients [12, 13]. Thus, the extent to which elderly patients can adhere to and benefit from ERAS programs is not certain [10]. The goal of this study was to evaluate whether elderly patients can achieve high adherence to ERAS protocols and whether these protocols are clinically and financially beneficial when compared to standard perioperative care.

Methods

Patient selection

Patients undergoing colorectal resection at the department of surgery of the Motol University Hospital in Prague between January 2015 and August 2017 were assessed for eligibility to be included in the study. After a trial period of 3 months, the ERAS protocol was fully implemented in July 2016. Patients in the ERAS group underwent surgery between July 2016 and August 2017. The control group consisted of patients who underwent colorectal surgery before implementation of ERAS. We selected patients who underwent colorectal surgery between January 2015 and March 2016 to create the control group. All patient information was recorded in a prospectively managed database. Inclusion criteria were age above 65 years, informed consent and open colorectal resection. Exclusion criteria were multivisceral resection, transanal resection, postoperative intensive care. The study was approved by the institutional ethical board (reference no. EK-760/18).

Outcome measures

All data were collected prospectively in a computerised database. Outcome measures consisted of recovery parameters, hospitalisation length, readmission within the first 30 days after discharge, 30-day postoperative morbidity and mortality, and treatment costs. Recovery parameters recorded were postoperative nausea and vomiting occurring within the first 24 hours after surgery, full mobilization on the first postoperative day, tolerance of solid diet by the fourth postoperative day, amount of intravenous fluids received on the day of surgery and administration of parenteral nutrition. Paralytic postoperative ileus was diagnosed if any two of the following items were met on or after the third postoperative day: nausea or vomiting, intolerance of solid or semisolid food, abdominal distension, absence of bowel movements or flatulence, or radiological evidence of ileus. 30-day postoperative morbidity and mortality were defined according to the Clavien–Dindo classification. Minor complications were defined as Clavien–Dindo grades I and II, major complications as Clavien–Dindo grades III and IV, and deaths as Clavien–Dindo grade V.

Cost of treatment was defined as the sum of the cost of hospital bed stay, interventions and medical materials. Costs of treatment were calculated from administrative data compiled from hospital claims reported to health funds. Both costs of hospital bed stay and interventions were assigned using the list of procedures and reimbursement decree issued annually by the Ministry of Health. Costs of medical materials were assigned using the list of reimbursed materials and pharmaceuticals issued annually by the main public health insurance company of the Czech Republic and the State Institute for Drug Control.

ERAS protocol

The ERAS protocol consisted of 16 items divided into three groups: preoperative, perioperative and postoperative periods. A list of all the items and the adherence to each item are shown in Table 1. Mechanical bowel preparation was used for left-sided and rectal resection and when intraoperative colonoscopy was indicated. Goal-directed fluid therapy was performed using the LiDCORapidTM (LiDCO, London, United Kingdom) hemodynamic monitoring. Thermoregulation was achieved by intraoperative patient warming using a convective air warming system (Bair Hugger; 3M-Switzerland, Rüschlikon, Switzerland) and warming intravenous fluids (Biegler Fluid Warmer; Biegler GmbH, Mauerbach, Austria) (Fig. 1). Epidural catheters were removed by the first 72 hours after surgery. Abdominal drains were not used in colonic resection, and when used in rectal surgery, they were removed within the first 72 hours. A nasogastric tube was not used during surgery or removed immediately at the end of the surgery. Multimodal opioid-sparing analgesia consisted of a combination of paracetamol with nonsteroidal anti-inflammatory drugs; this item was considered fulfilled when patients received no more than one dose of opioids per day. When following the protocol, we expected to discharge patients within the first 9 days after surgery. When patient discharge was delayed longer than 9 days the reasons for delayed discharge were recorded.

Table 1 Adherence to the ERAS protocol
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Fig. 1
figure 1

Goal-directed fluid therapy (LiDCORapidTM, LiDCO, London, United Kingdom) and intraoperative patient warming. Triangle arrow hemodynamic monitoring system, dashed arrow convective air warming system, unbroken arrow fluid warmer

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Statistical analysis

Statistics were performed in the program R (R core team 2018). Categorical variables were compared using Fisher’s test and continuous variables were quantile normalised and compared using t‑tests. P-values of less than 0.05 were taken to be statistically significant.

Results

Patient and surgical characteristics

Seventy-four patients were included in the ERAS group and sixty-one in the control group. Patient and surgical characteristics were similar in the two groups. Details can be seen in Table 2.

Table 2 Patient and surgical characteristics
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Protocol adherence

A high overall adherence to the ERAS protocol was achieved; the average adherence was 83.8% with a standard deviation of 9.5. Full adherence was achieved in antithrombotic and antibiotic prophylaxis, intraoperative thermoregulation and avoidance of nasogastric tubes. The items with the lowest adherences were early removal of Foley catheters (23.0%), not using abdominal drains (48.6%), early removal of epidural catheters (50.0%) and preoperative fasting (64.9%). Adherence of over 80% was achieved in all other items.

Outcome measures

Outcome measures are shown in Table 3. A significant improvement in all recovery parameters apart from postoperative nausea and vomiting was achieved. Length of hospital stay was reduced by the ERAS protocol (P < 0.001) while readmission rate remained unchanged. The total length of hospital stay was reduced by 1.6 days; the length of stay in the intermediate care unit by 1.1 days and in the standard department by 0.5 days. Our target of discharging patients within the first postoperative 9 days was reached in 48 patients (64.9%). Delayed discharges were most often due to minor complications and social reasons (see Table 4). There were no significant differences in morbidity and mortality.

Table 3 Outcome measures
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Table 4 Reasons for delayed discharges in ERAS
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Cost–benefit analysis

The cost–benefit analysis revealed that ERAS reduced the total treatment costs per patient by an average of €1187 (Table 5). Significant cost reductions were seen in cost of hospital bed stay (P = 0.008), both in the intermediate care unit (P = 0.018) and on the ward (P = 0.049), laboratory tests (P = 0.033) and parenteral nutrition (P < 0.01). The use of hemodynamic monitoring and intraoperative thermoregulation naturally resulted in increased cost in the ERAS group, but did not increase the overall treatment costs.

Table 5 Cost impact of implementation of the ERAS protocol
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Discussion

We showed that our enhanced recovery after colorectal surgery protocol in elderly patients is feasible, effective and safe; we achieved an adherence rate of more than 80%, improved recovery parameters and shortened LOS without increasing readmission rate, morbidity or mortality. The ERAS protocol was associated with a reduction in treatment costs. However, probably due to the small study size, this reduction was not statistically significant.

Total adherence in our study was 83.8%, with a range between 23 and 100%, which fares well when compared to other studies. Venara et al. reported a range of adherence to the ERAS items from 25 to 100% [14]. In a multicentre study, from Gonzales et al., the total adherence to an ERAS protocol in elderly patients was 56% [15]. When comparing these studies and others, there seems to be no correlation between low adherence and specific ERAS protocol items [14,15,16]. We believe low adherence is more likely due to resistance to change in standard practise than patient intolerance.

Our target of dismissal within the first 9 days after surgery was achieved in 64.9%. When compared to young patients, social reasons for delaying discharge, such as lack of space in nursing homes and rehabilitation centres, are much more predominant. Additionally, minor complications, which may be managed in an outpatient setting in younger patients, may require lengthened hospitalisation in elderly patients [16]. Indeed, in our cohort, hospital discharge was delayed due to social reasons in 9 patients and due to minor complications in 13 patients. Despite the length of hospital stay being potentially prolonged for non-surgical reasons, we believe these patients can still benefit from the accelerated recovery and should be included in ERAS protocols.

To the best of our knowledge, this is the first study on the cost–benefit analysis of elderly patients undergoing colorectal resections in an ERAS protocol. Cost–benefit analyses have been performed in the general population and have positive results. Our results show that, despite the fact certain aspects of the ERAS protocol increased treatment costs, particular hemodynamic monitoring and intraoperative thermoregulation, the overall average cost was reduced by €1187 per patient. As this result was not proven to be statistically significant, further larger studies and meta-analyses on this topic should be performed.

Limitations of the study

The study was limited by its non-randomized single-centre design and small study size. The cost analysis was limited by using a cost model based on administrative data from claims, rather than real costs. However, the results show a decrease in the use of resources, which indicates a decline in real costs.

Conclusion

We have demonstrated successful integration of ERAS for elective colorectal surgery in elderly patients. A high rate of adherence to the protocol was achieved and length of hospital stay was reduced, while readmission rate, morbidity and mortality remained unchanged and the cost of treatments were reduced.