THE ROLE OF ENHANCED RECOVERY PROTOCOLS IN THE PERIOPERATIVE CARE OF PATIENTS WITH CROHN'S DISEASE
Donald Haering*1, Linda Ferrari3, Alessandro Fichera2, Mukta K. Krane1
1Surgery, University of Washington, Seattle, WA; 2Surgery, University of North Carolina, Chapel Hill, NC; 3Surgery, Sant'Andrea, Rome, Italy
Background: Enhanced Recovery Protocols (ERPs) are associated with decreased hospital length of stay (LOS) and complications. However, patients with Crohn's Disease (CD) have largely been excluded from these studies due to data suggesting that under traditional post-operative care this population has higher odds of prolonged LOS and readmission. The aim of this study is to determine if ERPs are beneficial in the perioperative management of patients undergoing surgery for CD.
Methods: Retrospective cohort study of patients undergoing colorectal surgery for complications of CD from 2012-2018 with a historical control. Post-operative outcomes for patients managed on the institutional colorectal ERP are compared with the prior standard of care. The primary outcome of interest is LOS. Additional outcomes include rate of serious complications, 30-day readmission, reoperation, return of bowel function (ROBF), resumption of diet, and PO pain control. Mann-Whitney U test was used to analyze continuous outcomes, including LOS and days to ROBF, tolerance of low residue diet (LRD), and PO pain control. Unadjusted analyses of prolonged length of stay and 30-day readmission were performed using Χ2. Rate of reoperation and serious complications were analyzed using Fisher exact test due to low incidence. Adjusted analysis for prolonged length of stay to control for demographic and procedural variables was determined using multivariate logistic regression with forward progression, with entry p < 0.05. Patient demographic and procedural variables were compared between cohorts using Χ2 analysis or Mann-Whitney U test as appropriate. ERAS pathway compliance was determined per ACS NSQIP standards as high (≥10/13 elements), intermediate (≥6/13), or low (< 6/13).
Results: Analysis included 98 patients managed on ERP and 53 on the historical control. The ERP cohort had a shortened median LOS (4 vs 5 days, p < 0.01), accelerated return of bowel function (med = 2 vs 3 days, p < 0.01), shortened time to tolerating LRD (2 vs 4 days, p < 0.01), and more rapid transition to PO pain medications (2 vs 4 days p < 0.01) than the historical control. Multivariate logistic regression showed that patients in the ERP cohort were significantly less likely to have a prolonged LOS, when simultaneously controlling for ASA Class and procedure duration (OR = 0.37, 95% CI = 0.15-0.88, p = 0.02). No difference was seen in the rate of 30-day readmission (p = 0.73), rate of serious complications (p = 0.58) or reoperation (p = 0.42). Among patients on ERAS pathway, 87.7% were highly compliant with the protocol (≥10/13 elements), 12.3% were intermediately compliant (≥6/13 elements), and zero had low compliance with the protocol.
Conclusion: Compared with traditional management, CD patients on ERP had accelerated hospital outcomes, reduction in LOS, and no detectable increase in adverse events.
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