Question

What are the effects of applying an enhanced recovery after surgery (ERAS) program in laparoscopic resection or open resection of colorectal cancer?

Recommendation

An ERAS program should be used for optimal perioperative care in elective colorectal resections.

Introduction

It is generally accepted that the optimization of perioperative care is crucial to the outcome of care. This concept is designed within ERAS programs. Within ERAS the perioperative care is standardized to 20 items, with the aim of accelerating the recovery and reduce complications. Reduction of stress response, early repair of bowel function and the maintenance of immunological function are important for accelerated recovery after minimally invasive surgery in combination with ERAS (1; 8). Within ERAS clear targets (discharge criteria) are defined to be achieved postoperatively.

This module examines the immediate perioperative care as defined in ERAS programs. For optimal preparation to an outpatient elective colorectal resection and outpatient aftercare please refer to the module supportive care, which, among others, refers to optimizing the preoperative nutritional status.

Conclusions

Using an ERAS program for elective colorectal surgery leads to a reduction of the duration of the post-operative hospital stay after open surgery (0.9 to 5.7 days).
Level 1: A1 Cochrane 2011; A2 Ren 2012 (6); Vlug, 2011 (9)

Using an ERAS program for elective colorectal surgery leads to a reduction of the duration of the post-operative hospital stay after laparoscopic surgery (1-1.5 days).
Level 2: A2 Vlug 2011 (9); B Wang G 2012 (10); Wang Q 2012 (11)

Using an ERAS program for elective colorectal surgery leads to a reduction of minor complications, but not of major complications.
Level 1: A1 Cochrane 2011

Application of an ERAS program does not increase the number of readmissions
Level 1: A1 Cochrane 2011, A2 Vlug 2011 (9), B Yang in 2012 (12); Wang G 2012 (13); Wang G 2011 (10)

There is no difference in postoperative mortality between ERAS and conventional perioperative care.
Level 1: A1 Cochrane 2011, A2 Vlug 2011 (9), B Yang in 2012 (12); Wang G 2012 (13); Wang G 2011 (10)

There are indications that ERAS might be cost effective by reducing the use of resources in the postoperative period compared with conventional perioperative care.
Level 3: B Sammour 2010 (7)

 

Literature summary

There has been much focus on implementation of ERAS within the elective colorectal surgery in the Netherlands. A breakthrough project between 2005 and 2009 in 33 hospitals showed a significant decrease in the recording time of 9 to 6 days (3).

Probably not all items within ERAS are equally important for the outcome. ERAS items that were independently associated in multivariate analysis with a shorter hospital stay in the LAFA study were normal postoperative diet (HR 1.87 (1.46 to 2.38)) and early mobilization (HR 1.72 (1.34 to 2 , 20)) (9). In the Dutch breakthrough project the elements that were found to affect hospital stay were mobilizing on day 1, postoperative laxatives and postoperative stopping intravenous fluid administration (3).

British studies have shown that type analgesia and individualized moisture policies are critical (4). In a randomized study, epidural analgesia, spinal analgesia and PCA (patient controlled analgesia) were compared to laparoscopic colorectal surgery (4). In comparison to the epidural analgesia, functional recovery was significantly faster in the spinal analgesia and PCA groups.

Omission of bowel preparation and continuation of water or carbohydrate-enriched drink up to 2 hours before surgery prevents dehydration. Individualized fluid management during surgery and avoiding excessive NaCl infusion postoperatively promotes recovery of bowel function (4).

The literature search was based on both clinical effectiveness and expediency of ERAS in both open and laparoscopic colorectal surgery.

Clinical effectiveness
For assessing the effectiveness of ERAS regarding hospitalization, complications, readmissions, mortality and quality of life compared to conventional perioperative care after his selection a Cochrane review from 2011 and subsequently published six RCTs were included. The RCT of Vlug was a 4-arm study, which for this purpose is divided into two parts based on the surgical approach (open / laparoscopic) (9). Table 1 shows the main results.

All studies found a significant reduction in postoperative hospital stay with a reduction ranging between 1 and 6 days. In 2 of the 3 RCTs in which patients had laparoscopic surgery this difference was 1 day and in the third RCT 0.5 days. With the exception of 2 RCTs a significant reduction was found in the total number of complications. The Cochrane review showed a significant difference based on the reduction of minor complications (such as wound infection), while there was no difference in major complications (such as anastomotic leakage). In none of the studies, significant differences were found for the number of readmissions or postoperative mortality.

One study used quality of life as an outcome measure, measured by the Short-Form 36 and Gastro-Intestinal Quality of Life Index (GIQLI) (9). At both scales, at any measuring point, a significant difference between the 4 groups could be found.

Expediency
For the determination of expediency of ERAS one economic evaluation was included (7). This concerned a prospective cohort study that was compared with an individually matched historical control group. It concerned elective open colon surgery. The costs included in the evaluation were related to program development, educational materials, medication, care, complications, readmissions and outpatient costs. No sensitivity analysis was performed. Costs were clearly broken down into units of health care utilization, cost per unit care use and total costs of health care use.

The total cost and the cost per patient were lower in the ERAS group than in the control group. The cost per patient of the ERAS program were approximately € 10.000, - and the control group approximately € 14.500,-. The greatest differences were found in the cost of complications and intra- and postoperative fluid use.

Two RCTs included costs, but these weren’t full economic evaluations. In the study by Ren postoperative cost per patient in the ERAS group were $ 548.40 (±$ 223.10) and $ 804.00 (± $ 288.70) in the control group (p <0.001) (6) without any difference in preoperative and surgical costs. Vlug didn’t find a difference in costs between the four groups (lap / ERAS vs. open / ERAS vs. lap / conventional vs. open / conventional) (9).

Considerations

Composition
It is unclear to what extent each individual item of the ERAS program contributes to improved outcomes of care. Also, in some studies some ERAS items already became part of the conventional care. The composition of the ERAS program is also shifting. A high thoracic epidural was initially part of ERAS, but in laparoscopic surgery increasingly replaced by PCA with opioids. In addition, NSAIDs are more and more avoided because of possible increased risk of anastomotic leakage (2). Also, new items are being studied like the effects of chewing gum and coffee on postoperative recovery of bowel function.

The applicability of ERAS for specific patients is not well studied. Certain elements within ERAS for an individual patient may not be feasible or perhaps even desirable. Examples are potentially adverse effects of direct normal oral intake after omentum plastic surgery or multivisceral resection with high probability of gastroparesis. General targets within ERAS programs may not be feasible or perhaps even counterproductive for older frail patients.

Compliance
Compliance is important. In the LAFA study compliance was an average of 75% (9). It appears that the gains seen after implementation of an ERAS program in time can be lost. Therefore continuing to monitor after implementation is important.

Functional recovery versus hospitalization
Time to functional recovery is actually a better endpoint for evaluation of ERAS than the duration of post-operative hospital stay. After the operation a check is necessary to determine if the patient meets predetermined discharge criteria. In the Dutch study of Vlug, there was a difference of 0.5 to 1.5 days between following the discharge criteria and the actual discharge (9). Expectations and other patient-related factors as well as socio-cultural factors may explain the length of stay may be longer than the time to functional recovery. Also this explains differences in length of stay in the literature.

For high-risk groups or older, fragile patients, individual adjustments to an ERAS program can be considered, such extensive surgery (multivisceral resection / omentum plastic surgery) although no data are available on the applicability and generalizability of ERAS for specific subgroups of patients.

 

Authorization date and validity

Last review : 16-04-2014

Last authorization : 16-04-2014

The validity of this guideline and its associated modules is five years. For various reasons, it may be necessary to edit modules sooner than intended. The National Working Group on Gastrointestinal Cancers therefore annually assesses the content of the guideline and its associated modules. By 2016 it is decided whether a new multidisciplinary working group should be installed to revise the entire guideline.

Initiative and authorization

Initiative : Nederlandse Vereniging voor Radiotherapie en Oncologie

Authorized by:
  • Nederlandse Internisten Vereniging
  • Nederlandse Vereniging voor Klinische Geriatrie
  • Nederlandse Vereniging van Maag-Darm-Leverartsen
  • Nederlandse Vereniging voor Nucleaire geneeskunde
  • Nederlandse Vereniging voor Radiotherapie en Oncologie
  • Nederlandse Vereniging voor Heelkunde
  • Nederlandse Vereniging voor Pathologie
  • Nederlandse Vereniging voor Radiologie
  • Vereniging Klinische Genetica Nederland

General details

All members were mandated by a scientific, professional or patient association. In the composition of the working group we tried to take national distribution, input from participants from both academic and general hospitals and representatives of various disciplines into account. Patients are also represented by delegation into the working group, as well as a focus group meeting.

Scope and target group

Goal

This guideline and its associated modules are - as much as possible - based on scientific research and / or consensus. It is a document with recommendations to support the daily practice of health care professionals involved in patients with (possible) colon cancer, rectal cancer or colorectal liver or lung metastases. It provides recommendations for diagnosis, treatment, follow-up and organization of care. The guideline and its associated modules are thus seeking to improve the quality of care, to increase transparency of choice for treatment and reduce diversity.

 

Target population

Each year colorectal cancer is identified in approximately 13,000 new patients. Rectal carcinoma occurs in about 1 in 3 patients of this. In the Netherlands, the colorectal cancer in both men and women rank third place in incidence of oncological diseases. The expected number of patients diagnosed with colorectal cancer are increased in 2020 to about 17,000, reflecting a slight increase in incidence (especially in men), population growth and aging.

Colorectal cancer is slightly more common in men than in women and ninety percent of patients 55 years or older. More information about the Dutch population can be found at the Netherlands Cancer Registry: www.cijfersoverkanker.nl

This guideline is applicable to all adult patients with (suspected) a primary colorectal carcinoma and patients with metastatic disease. Particular attention is given to the elderly. A separate guideline is available for adult patients with an increased risk of hereditary colon cancer.

Target Audience

This guideline and its associated modules are intended for all professionals involved in the diagnosis, treatment and rehabilitation of patients with (metastatic) colorectal cancer, such as surgeons, general practitioners, consultants, internists, gastroenterologists, (specialist) nurses, clinical geneticists, paramedics, pathologists, radiologists and radiotherapists. The complete guideline is used to develop a patient education text from the Dutch patients Consumer Federation (NPCF).

 

Members of the guideline panel

Name

Function

Hospital

Mandated

Mw. prof. dr. C.A.M. Marijnen chair

Radiotherapist

LUMC Leiden

NVRO

Mw. prof. dr. R.G.H. Beets-Tan

Radiologist

MUMC Maastricht

NVVR

Mw. S. de Bruijn

Specialist nurse

Renier de Graaf hospital Delft

V&VN

Mw. dr. A. Cats

Gastroenterologist

NKI-AVL Amsterdam

NVMDL

Prof. dr. E.F.I. Comans

Nuclear doctor

VUMC Amsterdam

NVNG

Dr. A.R. van Erkel

Intervention radiologist

LUMC Leiden

NVVR

Mw. dr. M.A.M. Frasa

Clinical chemist

Groene Hart hospitalGouda

NVKC

Mw. C. Gielen

Specialist nurse

MUMC Maastricht

V&VN

Dr. E.J.R. de Graaf

Surgeon

IJsselland hospital Capelle a/d IJssel

NVVH

Mw. dr. M. Hamaker

Geriatrician

Diakonessenhuis Utrecht

NVKG

Mw. dr. J.E. van Hooft

Gastroenterologist

AMC Amsterdam

NVMDL

Mw. H.J.A.M.. Kunneman

Researcher

LUMC Leiden

n.v.t.

Mw. dr. M.E. van Leerdam

Gastroenterologist

NKI-AVL Amsterdam

NVMDL

Dr. H. Martijn

Radiotherapist

Catharina-hospital Eindhoven

NVRO

Mw. dr. A.M. Mendez

Romero

Radiotherapist

EMC Cancer Insititute Rotterdam

NVRO

Mw. prof. dr. I.D. Nagtegaal

Pathologist

UMCN St Radboud Nijmegen

NVVP

Dr. L.A. Noorduyn

Pathologist

Lab. Voor Pathologie Dordrecht e.o.

NVVP

Mw. A. Ormeling

Patient

Stomavereniging

NFK

Drs. T.A.M. van Os

Klinisch Geneticus

AMC Amsterdam

VKGN

Dr. F.T.M. Peters

Gastroenterologist

UMCG Groningen

NVMDL

Mw. J. Pon

Patient

NFK/SPKS

NFK

Mw. dr. J.E.A. Portielje

Medical oncologist

Haga hospital Den Haag

Gerionne

Prof. dr. C.J.A. Punt

Medical oncologist

AMC Amsterdam

NIV

Mw. dr. H. Rütten

Radiotherapist

UMCN Radboud Nijmegen

NVRO

Prof. dr. H.J.T. Rutten

Surgeon

Catharina-hospitalEindhoven

NVVH

Prof. dr. J. Stoker

Radiologist

AMC Amsterdam

NVVR

Dr. P.J. Tanis

Surgeon

AMC Amsterdam

NVVH

Dr. J.H. von der Thüsen

Pathologist

MC Haaglanden Den Haag

NVVP

Prof. dr. H.M.W. Verheul

Medical oncologist

VUMC Amsterdam

NIV

Prof. dr. C. Verhoef

Surgeon

EMC Cancer Insititute Rotterdam

NVVH

Dr. Tj. Wiersma

General practitioner

NHG

NHG

 

 

Name

Function

Location

Mw. drs. A.Y. Steutel

process manager

Utrecht

Drs. T. van Vegchel

process manager

Amsterdam

Mw. S. Janssen-van Dijk

secretary

Rotterdam

M.P.  van den Berg

Researcher

Bilthoven

P.F. van Gils

Researcher

Bilthoven

Mw. J. Robays

Methodologist

Brussels

Mw. drs. Y Smit

Methodologist

Germany

Mw. A. Suijkerbuijk

Researcher

Bilthoven

Mw. dr. L. Veerbeek

Methodologist

Groningen

Mw. dr. L. Verheye

Methodologist

Brussels

Mw. dr. G.A. de Wit

Researcher

Bilthoven

 

Patient involvement

Two patient experts have been part of the guideline development group. One on behalf of the Dutch Ostomy Association and on behalf of SPKS/NFK. Based on a focus group meeting experiences of patients regarding care were collected. The guideline also has been used to develop a patient education text for the Dutch patients Consumer Federation (NPCF).

Method of development

Evidence based

Implementation

Promoting the use of recommendations begins with a broad (digital) distribution of the guideline, using direct mailing and an article published in the Dutch Journal of Oncology. In other journals or training sessions, for example, the guideline is brought to the attention. An implementation plan for this guideline contains the key recommendations and an overview of barriers and facilitators for implementation.

Methods and proces

The working group met in July 2012 for the first time. Based on an initial list of problems by working group members a survey among professionals involved in patients with colorectal carcinoma was held. Through this survey, sixty professionals supplied and prioritized possible subjects for revision. Also, a focus group meeting was held, collection patients' experiences. The eleven most relevant questions were answered, and translated into English. Also, alle recommendations were translated into English.

 

Each clinical question was andwered by a subgroup within the development group. External methodologists provided the literature search, review, critical assessment, evidence tables and a draft literature review. Workgroup members suggested other considerations and recommendations.

Responsibility

The Comprehensive Cancer Organisation the Netherlands (IKNL) promotes that people with cancer and their families have access to a consistent and qualitatively adequate care as close to home as possible. IKNL was established to improve treatment, care and clinical research in oncology. It also has a role in setting up and supporting networks for palliative care. IKNL supports multidisciplinary guideline development for oncology and palliative care and facilitates the maintenance, management, implementation and evaluation of these guidelines.

AGREE was used to check the methodological quality of the guideline.

Search strategy

Searches are available upon request. Please contact the Richtlijnendatabase.