Nicolò Pecorelli, MD, Saba Balvardi, A. Sender Liberman, MD, Patrick Charlebois, MD, Barry Stein, MD, Franco Carli, MD, MPhil, Liane Feldman, MD, Julio Flavio Fiore Jr., PT, MSc, PhD. McGill University Health Centre
INTRODUCTION: Adherence to perioperative care elements is pivotal for the successful implementation of enhanced recovery programs(ERPs). In colorectal surgery, increased adherence is associated with improved recovery as measured by traditional clinical outcomes (i.e. morbidity, length of stay). However, the impact of adherence on patient reported outcome measures (PROMs) has not been studied. The objective of this study was to evaluate the extent to which adherence to ERP elements is associated with patient reported recovery.
METHODS AND PROCEDURES: We analyzed secondary data from a recently completed RCT assessing the impact of facilitated postoperative mobilization on recovery after colorectal resection. Adherence was assessed for 20 ERP elements (from preoperative to POD 2). Multivariable linear regression adjusted for confounding factors evaluated the association of adherence with PROMs assessing early recovery (Abdominal Surgery Impact Scale (ASIS) and Multidimensional Fatigue Inventory (MFI) on POD2), and late recovery (Duke Activity Status Index, RAND-36 Physical and Mental Summary Scores, Life-Space Mobility Assessment at 4-weeks after surgery). Missing data were addressed using multiple imputation.
RESULTS: 100 patients were included (57 male, median age 63(IQR 50-71) years, 81 laparoscopic, 37 rectal surgery). Patients were adherent to median 16/20 elements (80%, IQR 14-18). For early recovery (POD2), there was a positive association between overall adherence and ASIS score (4% increase for each additional element, 95%CI 1-8%; p=0.018), while no association was found for any of the MFI domains. Adherence to PONV prophylaxis (34% increase, 95%CI 5-63%; p=0.023) and early solid food (20% increase, 95%CI 5-35%; p=0.009), along with occurrence of postoperative morbidity(34% decrease, 95%CI -48 to -20%; p<0.001), were independently associated with ASIS scores. Adherence to PONV prophylaxis(36% decrease, 95%CI -64 to -8%; p=0.014) and occurrence of postoperative morbidity(20% increase, 95%CI 5-35%; p=0.011) were also associated with MFI-General fatigue domain scores. For late recovery (4 weeks after surgery), overall adherence to ERP elements was not associated with PROM scores. Postoperative complications were consistently associated with worse scores for PROMs involving the physical domain (ASIS, MFI general, physical and activity subscales, Duke, LSM, RAND-36 Physical). New stoma formation was significantly associated with reduced LSM and RAND-36 Mental scores at 4 weeks.
CONCLUSION: Overall adherence to perioperative care elements was associated with early recovery post-surgery, while no association was found between adherence and late recovery as measured by PROMs. The occurrence of postoperative complications is the strongest factor influencing patient reported recovery after colorectal surgery in the context of an ERP.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86818
Program Number: S126
Presentation Session: ERAS Session
Presentation Type: Podium