A Better Approach to Colorectal Surgery

By Jane Farrell

Hospital stays for colorectal-surgery patients can be cut by two days via a practice known as “enhanced recovery,” according to researchers from Duke University Hospital. The practice also reduced readmission rates.

The process, the researchers said, involves a team approach.  "Enhanced recovery is about change management,” said senior author Tong J. Gan, M.D., MHS, professor of anesthesiology at Duke. “It’s getting the team together, including nurses, anesthesiologists, surgeons and patients, with everyone understanding the expectations of how to do things differently and improve patient care.”

The findings were published in the journal Anesthesia & Analgesia.

Gan and his colleagues analyzed statistics from 241 patients at Duke University Hospital who were undergoing open or laparoscopic colorectal surgery during two time periods: before the enhanced recovery approach was implemented, and after. Ninety-nine patients were studied in the traditional approach, and 142 using enhanced recovery.

The researchers found that the enhanced recovery approach (ERAS) used for colorectal surgery cut hospital admissions from an average seven days to five, and reduced the rate of readmissions by half.

In care provided before surgery, patients are usually told to fast and undergo laxative treatments, and aren’t not given food or drink after surgery until bowel sounds are restored, sometimes several days later. Additionally, traditional perioperative care includes a variety of different anesthesia regimens, fluid management and pain control.

Under traditional perioperative care, patients who experience pain, stress, immobilization, and postoperative constipation can remain in the hospital for 10 days or more, with complication rates of up to 48 percent. Such complications can be expensive, estimated at an average of $10,000.

In the Duke study, patients in the ERAS group were educated about what they should expect. Routine bowel preparation was not performed, and patients were allowed to drink clear fluids until 3 hours before their surgeries.

All of the ERAS patients received an epidural as well as non-opioid painkillers to reduce opioid side effects such as nausea, vomiting, constipation, urinary retention and drowsiness. They then underwent general anesthesia. After surgery, the patients transitioned to oral acetaminophen or other NSAIDs, plus oral opioids, if necessary, after about 72 hours. Patients were also encouraged to drink liquids and get out of bed on the day of surgery, and for at least six hours every subsequent day.

“We have shown that providing care within an ERAS pathway, we are increasing the quality of care for patients while at the same time reducing complications and medical costs,” said lead author Timothy Miller, assistant professor of anesthesiology at Duke. “I believe that going forward, enhanced recovery care could become the new standard for best practice.”