Lawrence Lee, MD, MSc, Juan Mata, MD, Berson Augustin, Gabriela A Ghitulescu, MD, A S Liberman, MD, Patrick Charlebois, MD, Carol-Ann Vasilevsky, MD, Nancy Morin, MD, Franco Carli, MD, Liane S Feldman, MD. McGill University Health Centre; Sir Mortimer B. Davis Jewish General Hospital.
INTRODUCTION: Enhanced recovery pathways (ERP) for colorectal surgery shorten length of hospitalization and may decrease morbidity, however there is little information about their impact on patient-reported outcomes, especially after hospital discharge. The objective of this study was to estimate the impact of an ERP compared to conventional care (CC) on patient recovery at 4- and 8-weeks after surgery.
METHODS AND PROCEDURES: Consecutive adult patients undergoing elective colorectal surgery at two university-affiliated institutions from Oct 2012 to July 2013 were prospectively enrolled. One centre used an ERP approach while the other did not. Recovery was measured using the SF-6D, a previously validated patient-reported measure of postoperative recovery, which is scored from 0.294 (poorest health) to 1.000 (perfect health). This was administered at baseline (within 2 weeks of surgery), and at 4- and 8-weeks after surgery. Multiple linear regression was used to determine the independent effect of ERP on recovery after adjusting for confounders. Data are presented as mean(SD) or median[IQR].
RESULTS: A total of 124 patients (CC 73, ERP 51) were enrolled. There were no differences in age, gender, body mass index, co-morbidities, malignancy or procedures. More patients in the ERP group underwent a laparoscopic approach compared to the CC group (88% vs. 40%, p<0.001). Total length of stay was lower in the ERP group versus the CC group (5[3-8] vs. 7[4-8], p=0.022), but there were no differences for laparoscopic cases only (ERP 4[3-7] vs. CC 4[4-6], p=0.661). No differences in 60-day complications (ERP 49% vs. CC 42%, p=0.471), emergency visits or readmissions between the two groups were found. Baseline SF-6D values were higher in the ERP compared to CC (0.802 (SD 0.098) vs. 0.750 (SD 0.149), p = 0.022). At 4-weeks, ERP and laparoscopy were independently associated with improved recovery (ERP +0.063 (95% CI 0.005, 0.122); laparoscopy +0.074 (95% CI 0.014, 0.134)), after adjusting for age, gender, co-morbdities, stoma, complications, and baseline SF-6D. However, at 8-weeks, there was no difference in recovery between ERP and CC (mean adjusted difference +0.040 (95% -0.104, 0.185))
CONCLUSIONS: ERPs are associated with improved short-term recovery, independent of laparoscopy, after colorectal surgery.