Enhanced Recovery After Surgery: Can We Rely on the Key Factors or Do We Need the Bel Ensemble?

World J Surg. 2017 Oct;41(10):2464-2470. doi: 10.1007/s00268-017-4054-z.


Background: The success of enhanced recovery (ERAS) pathways depends on the actual application of the intended protocol (adherence), but its full implementation remains challenging. In order to potentially streamline the pathway, it is indispensable to know the impact of individual items and the entire protocol on clinical outcomes.

Methods: Retrospective analysis including all consecutive colorectal ERAS patients since implementation (May 2011) until February 2014; demographics, adherence and outcomes were retrieved from a prospectively maintained database. Primary outcome was the impact of individual item and of the entire protocol on complications (overall and major) and length of hospital stay. Statistical analysis included logistic multivariate regression and adjustment for confounding factors.

Results: There were 328 patients with complete data sets analyzed. A minimally invasive approach [odd ratio (OR) 0.62; confidence interval (CI) 0.4-0.9] was significantly associated with less overall complications. In contrast, the use of prophylactic nasogastric tubes (OR 3.18; CI 1.4-7.4), prophylactic abdominal and pelvic drains (OR 1.96; 1.2-3.2) and intraoperative thoracic epidural analgesia (OR 1.76; CI 1.3-2.4) were associated with more overall complications. Minimal invasive approach was further associated with reduced hospital stay (OR 0.5; CI 0.4-0.7) and less major complications (OR 0.58; CI 0.4-0.8). Higher adherence to the entire ERAS protocol was associated with significantly less complications (P < 0.001) and shorter hospital stay (P < 0.001).

Conclusions: Minimally invasive surgery was the single most important component of the ERAS pathway while nasogastric tubes, drains and epidurals should be avoided. Overall, increasing adherence with the protocol was associated with better outcomes and should be the goal.

Keywords: Abdominal Hernia Repair; Minimal Invasive Approach; Perfect Protocol; Segmental Colectomy; Stoma Procedure.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Analgesia, Epidural / adverse effects
  • Clinical Protocols
  • Colon / surgery
  • Digestive System Surgical Procedures* / adverse effects
  • Drainage / adverse effects
  • Female
  • Guideline Adherence
  • Humans
  • Intubation, Gastrointestinal / adverse effects
  • Length of Stay*
  • Logistic Models
  • Male
  • Middle Aged
  • Minimally Invasive Surgical Procedures / adverse effects
  • Perioperative Care / methods*
  • Postoperative Complications / etiology*
  • Postoperative Complications / prevention & control*
  • Recovery of Function
  • Rectum / surgery
  • Retrospective Studies
  • Thoracic Vertebrae