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ARE THE SIMPLIFIED VERSIONS OF ENHANCED RECOVERY AFTER SURGERY (ERAS) PROGRAMS RELIABLE?
Maria Luiza V. Olivé, Ana S. Portilho, Rodrigo Moisés d. Leite, Giovana M. Minchillo, Francisco Tustumi
*, Lucas S. Gerbasi, Rafael Vaz Pandini, Lucas C. Stolzemburg, Victor Edmond Seid, Sergio Eduardo Alonso Araujo
Sociedade Beneficente Israelita Brasileira Albert Einstein, Sao Paulo, São Paulo, Brazil
Introduction: Enhanced Recovery After Surgery (ERAS) programs have transformed perioperative care by incorporating evidence-based strategies to improve outcomes and accelerate recovery. However, adherence to all ERAS components can be challenging, and the relative contribution of individual components to improved outcomes remains uncertain. Hence, gaining a more comprehensive understanding of how ERAS protocols influence patient outcomes is of major concern. This study evaluates the impact of ERAS compliance and compares its predictive accuracy with four simplified protocols (Rapid, Basse, Nygren, and Aarts) in patients undergoing colorectal cancer surgery.
Methods: A retrospective cohort study was conducted at Vila Santa Catarina Hospital, São Paulo, Brazil, including patients who underwent elective colorectal resection for adenocarcinoma from 2015 to 2022. ERAS compliance was assessed based on adherence to 22 protocol components and compared with four simplified versions comprising 4 to 12 elements. Outcomes analyzed included being stoma-free, avoiding readmission, absence of postoperative complications, absence of severe complications, and no postoperative mortality. The predictive performance was evaluated by calculating the Area Under the Curve (AUC) derived from Receiver Operating Characteristic (ROC) curves, followed by comparative analyses to identify differences. Statistical significance was set at p<0.05.
Results: The study included 410 patients, with a mean age of 62.3 years (±11.5), and 53.4% female patients. Most procedures were performed laparoscopically (90%), while robotic and open approaches were used in 6.3% and 3.7% of cases, respectively. ASA scores of I/II were noted in 76.1% of patients, and the mean ERAS compliance rate was 75,9% (±9%). Postoperative outcomes showed 66% of patients were stoma-free, 93% avoided readmission, 69% experienced no complications, 86% had no severe complications, and 98% survived without postoperative mortality. The ERAS protocol performed best for predicting the absence of severe complications (AUC: 0.688), with comparable performance to the Nygren protocol (AUC: 0.684). Nygren had the highest AUC (0.697) for stoma-free, followed by ERAS (0.658). For postoperative complications, Nygren again led (AUC: 0.631), with ERAS close behind (0.617). ERAS showed relatively low predictive accuracy for readmission avoidance (AUC: 0.510), and Rapid and Basse outperformed ERAS. ERAS had a similar AUC (p>0.05) for predicting postoperative mortality than the other studied protocols.
Conclusion: Simplified ERAS protocols, such as Nygren and Rapid, demonstrated competitive or even superior predictive performance in certain outcomes, such as stoma-free and avoiding postoperative mortality. While the ERAS protocol remains a robust standard, simplified versions may offer practical alternatives in specific scenarios.
ROC curves illustrating the prediction of outcomes: "free of stoma," "no readmission," "no postoperative complications," "no severe complications," and "no mortality." The areas under curve (AUC) values for compliance with each protocol are displayed alongside p-values for direct comparisons between protocols. Red p-values indicate significant associations (p<0.05).
Area under the curve (AUC) for the ROC curves representing protocol compliance, presented with the corresponding 95% confidence intervals (95% CI). LL: lower limit of the 95% CI; UL: upper limit of the 95% CI.
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