Wound complications had been reported as the risk factors for prolonged LOS and more hospitalization cost[2, 9, 16]. In addition to avoiding implant device-associated infections, perioperative management and nutritional support were also important to minimize wound complications. In present study, we identified that our ERAS pathway was associated with a lower incidence of wound complications including SSI, wound dehiscence and persist wound drainage. Additionally, we found that patients receiving the ERAS care had a lower rate of sever postoperative hypoalbuminemia without increasing the albumin transfusion. Patients in ERAS group had shorter LOS and a lower rate of readmission, this result was consistent with previous studies.
Despite great advances in antibiotics and surgical instruments over the past few decades, wound healing following PLF surgery still remains a challenging clinical problem. Many studies were conducted to discuss the risk factors and treatment for postoperative SSI[7, 13], however, few literature reporting other wound problem including wound drainage and wound dehiscence which might also contribute to a reduction of satisfaction were found. In present study, the rates of wound dehiscence and persist wound drainage were 4.5% and 6.7%, which was higher than the rate of postoperative SSI. Persist wound drainage and wound dehiscence might be early symptom of infection and they could create a humid environment for the growth of bacteria. Equal attention should be pay to patients with non-infection wound complications.
As a multidisciplinary and multifaceted perioperative care pathway, ERAS protocol consists of preoperative, intraoperative and postoperative interventions which may help to reduce the effect of those risk factors on adverse events[12, 17]. To the best of our knowledge, this is the first study to evaluate the impact of ERAS pathway on wound complications in Asian patients. Although no significant difference was observed in SSI and wound drainage, we found that the implement of ERAS was beneficial in reducing the incidence of wound complications in patients underwent PLF surgery, especially wound dehiscence.
Several possible reasons may explain our finding. First, previous studies had proved that perioperative malnutrition and hypoalbuminemia were independent risk factors for postoperative SSI and nutrition is a key player at each of the wound healing steps (haemostasis, inflammatory, proliferative and remodelling phase)[5, 18], in present study, the patients in ERAS group had a lower incidence of server postoperative hypoalbuminemia which may result from the nutrition support and early rehabilitation of digestive function. Xu et al. conducted a prospective randomized controlled trial and also found that perioperative multimodal nutritional management effectively reduced albumin infusion and incidence of wound drainage.Second, preoperative education on smoking and optimization of chronic disease may contribute to the reduction of wound complications. Pirkle et al. retrospectively reviewed an PearlDiver national insurance claims database of 12519 patients undergoing lumbar fusion surgery and found that diabetes was an independent factor for wound infection after single and multi-level fusion surgery. In a systematic review and meta-analysis of 107 studies, preoperative smoking was found to be associated with an increased risk of the wound complications. More efforts were needed to identify the effect of preoperative interventions on postoperative complications by conducting prospective randomized controlled studies. At last, prolonged drain duration also was proved to be associated with higher incidence of wound infection in patients with lumbar spinal fusion surgery. In present study, patients in EARS group were recommended to remove drain on postoperative day 1and postoperative day 2.
With regard to other complications, a high rate of postoperative hypoalbuminemia was observed in our study population, with nearly one in every two patients had postoperative hypoalbuminemia or server hypoalbuminemia, a lower rate of server hypoalbuminemia was observed in ERAS group compared with non-ERAS group. Avoiding mechanical bowel preparation and early postoperative enteral nutrition relieve irritation of the gastrointestinal tract and facilitate the recovery of gastrointestinal motility[21, 22], These measures may help to improve nutrition and less patients developed server hypoalbuminemia(serum albumin <30g/L) in ERAS group. However, the incidence of hypoalbuminemia(serum albumin <35g/L)was similar between groups, more effective perioperative nutritional support protocol was needed to improve nutritional status. Additionally, a trend toward the lower rate of urinary tract infection in ERAS group was observed(p=0.07), although there was no statistical significance, the potential association may be detected in a long-term studies with larger sample sizes. Moreover, the implement of ERAS pathway did not increase the risk of cardiovascular complications, acute cerebral infarction and local haematoma, which were consistent with previous studies on ERAS pathway[23, 24].
In present study, although the preoperative LOS was similar between two groups, the postoperative LOS decreased from 9.5 days in the non-ERAS group to 8.0 days in the ERAS group. We did not evaluate the effect of ERAS on postoperative LOS for short-segment and long-segment fusion surgery separately, but previous studies had reported that patients in the ERAS group had significantly shorter LOS compared with non-ERAS group after short lumbar fusion and long segment deformity surgery[17, 25]. A lower rate of 90-day readmission was also observed in ERAS group, this result was consistent with previous retrospective study of 124 patients conducted by Adeyemo et al.Postoperative multidisciplinary care and multimodal pain control may contribute the lower incidence of readmission for postoperative complications and transferring to rehabilitation center.
However, this study had several limitations. First, it was a single-center study so that patients included in our study were only from our institution, and the variables data were only acquired from our electronic medical records, we couldn’t avoid the loss of part information, for example, the total costs and patient satisfaction. Also, the primary outcome of our study was the incidence of wound complications within 90-day, despite our efforts to identify wound problems, some minor wound complications may still be overlooked. Moreover, the compliance with ERAS protocol was associated with postoperative outcomes, but due to the lack of standardized perioperative management pathway, it was difficult to evaluate the compliance with ERAS program of patients in non-ERAS group, and efforts are needed to maximize compliance with specific enhanced recovery pathway standards.