Impact of an Enhanced Recovery Program (ERP) on Clinical Outcomes and Institutional Costs in Elective Laparoscopic Colorectal Resections.

Carlo V. Feo, MD, FACS1, Mattia Portinari, MD1, Simona Ascanelli, MD1, Simone Targa1, Maria Elisabete Dos Santos Valgode, RN1, Barbara Bonvento2, Emidia Vagnoni2, Stefano Camerani3, Marco Verri, MD3, Carlo Alberto Volta3. 1Department of Surgery, University of Ferrara, Ferrara, Italy, 2Department of Economy, University of Ferrara, Ferrara, Italy, 3Department of Anesthesiology, University of Ferrara, Ferrara, Italy

Objectives: To determine the impact on postoperative recovery and cost-effectiveness of a standardized enhanced recovery program (ERP) for  colorectal surgery. 
Methods: A prospective series of patients (N=76) undergoing elective colorectal resection completing a standardized ERP in 2013-2015 (ERP group) was compared to patients (N=74) operated on at the same academic hospital in 2010-2011 (conventional group), before the introduction of the ERP methodology. The exclusion criteria for both groups were: age>80 years old, ASA score IV, TNM stage IV, and inflammatory bowel disease. Functional recovery time, morbidity and mortality, hospital length of stay (LOS), and readmission rate in-between groups were compared. Direct costs related to the preoperative phase and hospitalization, and implementation of the ERP were collected. Data were analyzed using chi-square, t-Student, log-rank tests, and Cox regression analysis.
Results: Age, gender, and BMI were comparable in-between groups. Outcome variables and institutional costs are shown in the table. After adjusting for potential confounders, following a conventional perioperative protocol was the only factor associated to prolonged hospital LOS (P<0.001). 
Conclusion: Implementing an ERP in elective colorectal surgery: 1) significantly reduced time to functional recovery and postoperative hospital LOS; 2) did not increase morbidity, mortality, and 30-day readmissions; and 3) significantly decreased institutional costs.

Study funded by the Italian Ministry of Health.


Conventional Group(N=74)

ERP Group(N=76)

Time to solid food(days)*5(5-6)3(2-3)<0.001
Time to bowel movements(days)*5(4-6)3(2-4)<0.001
Pain control on oral analgesic(days)*4(3-5)3(3-4)0.019
Postoperative complications (Clavien-Dindo)  0.549
Grade I3(4.0)7(9.2) 
Grade II12(16.2)15(19.7) 
Grade IIIa1(1.4)0 
Grade IIIb1(1.4)1(1.3) 
30 days mortality00 
Hospital length of stay(days)*8(7-9)4(4-6)<0.001
30 days re-admission3(4.0)1(1.3)0.363
Total institutional costs per patient(USD)§8.893,36±5.708,835.756,24±1.735,300.001














*Median(Interquartile range 25-75);N(%),Mean ± Standard Deviation;§Currency on September 23, 2015.



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