The purpose of this study was to evaluate the results of the implementation of a simplified accelerated recovery protocol (SARP) in patients submitted to laparascopic colorectal surgery and to identify possible factors related to implementation failure. Only postoperative measures were adopted, as they were considered the most important and because many pre- and perioperative measures, already shown to be beneficial, had been adopted in our department previously, and it was not considered ethical to not adopt them in one of the groups.
The results obtained with regard to the length of hospital stay, the conversion rate, morbidity, and mortality are all comparable to those of other studies14,15.
The median length of hospital stay in the SARP group was significantly lower, and patients started walking, expelling gas, and tolerating a diet sooner, confirming the main advantages of the several accelerated postoperative recovery programs. Complication and rehospitalization rates, as well as returns to the emergency room, were not different between groups. Therefore, we conclude that the implementation of an accelerated recovery protocol, even if simplified (SARP), was beneficial and safe for patients, as it shortened hospital stays without increasing the risk of complications or rehospitalizations10,16.
In addition, the present study was able to demonstrate a 60% acceptance rate for SARP, which matches the rates described in the literature, despite the wide variation observed. Some pilot studies describe more than 90% acceptance8, while others observe very low rates of adherence to accelerated recovery programs17. Nygren et al. reported the importance of maximizing adherence to ERAS™ protocols, but this adherence is often hampered by their complexity7,14. The present study, as is the case with a few others described in the literature,18,19 aims to simplify the protocol, adapting it to the actual circumstances of our institution. In this way, a simplified protocol was adopted (Table 1) and, even though it counted only seven items, the success rate remained at 60%. This result demonstrates that four out of ten patients did not benefit from SARP, making it clear that it is still possible to improve the cost-benefit ratio by increasing the acceptance rate of these protocols. The identification of these patients, as well as the reasons for non-tolerance, certainly makes it possible to achieve even better results in the future.
In univariate analysis, by comparing patients who tolerated SARP with those who did not, we demonstrated that the development of postoperative complications, the need for ostomy, a prolonged operative time, and the performance of proctectomies were the variables associated with non-tolerance to the program. In multivariate analysis, development of complications, the need for ostomy, and a prolonged operative time, but not the type of surgery performed, influenced the non-acceptance of the protocol.
Of the patients who had complications, 81% did not tolerate SARP (p < 0.0001). The possible reasons associated with non-tolerance to the program are a long hospital stay, immobilization over an extended period, greater difficulty in accepting a diet due to a longer ileum recovery, and uncertainty of being discharged after the complication.
Patients who required ostomy had a significantly higher failure rate. Only 14.3% of patients with ostomy tolerated SARP (p < 0.0001), which matches the results from other studies that analyzed this finding20,21. According to Delaney et al22, the need for ostomy is an independent risk factor for prolonging hospital stay after colorectal surgery. Some studies have shown that setting up an educational program prior to discharge, with guidelines on how to care for the stoma, can shorten the hospital stay. These educational programs are even more effective if performed in the preoperative period, particularly with the involvement of a specialized physician or a stomatherapist23,24,25. Therefore, educational programs are an excellent investment of resources, in order to optimize the acceptance of accelerated postoperative recovery protocols.
Prolonged operative time was another factor that influenced the acceptance of SARP. The mean surgical time in the group that tolerated SARP was significantly lower than the mean in the group that did not. Adoption of measures that reduce surgery length, such as the strict standardization of the surgical technique and the participation of a senior surgeon in surgeries during the learning period, can not only contribute to reducing surgery time, but may also positively influence the implementation of SARPs.
In univariate analysis, another factor that significantly influenced the acceptance of the program was the type of surgery: patients who underwent rectal surgeries had worse tolerance to the program than those who underwent colectomies. In patients who underwent colectomies, the acceptance rate of SARP was 78.6%, while in patients who underwent proctectomies, the acceptance rate decreased to 14.3%. The ERAS Compliance Group26 also reported poor results in patients who underwent rectal surgery, with a lower rate of adherence to the protocol, longer hospital stays, and higher readmission rates.
However, as demonstrated by multivariate analysis, the type of surgery itself was not statistically related to tolerance or non-tolerance to the implementation of the program. Nevertheless, patients who underwent rectal resections had longer surgeries and more complications and required ostomies more frequently; these variables were significant in multivariate analysis. Accordingly, proctectomy is a procedure more likely to result in non-tolerance to SARP. In other words, proctectomies in the present study met the conditions for worse acceptance of SARP and should be investigated by the team, in search of better results.
Other variables that were analyzed, such as age, BMI, sex, and type of disease (whether benign or malignant), did not influence the acceptance of SARP. These data demonstrate that SARPs can be adopted even in elderly patients and in those with high BMI, as demonstrated previously by the study of the ERAS Compliance Group26, which found no differences between these variables in the acceptance of the ERAS protocol.
The ERAS™ philosophy has gained wider acceptance in the scientific community. Recently, the ERAS Society16, as well as the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons, published the guidelines for clinical practice for enhanced recovery after surgery in colorectal surgery27. In a meta-analysis of sixteen randomized, controlled studies, Greco et al.28 demonstrated that hospital stays were shortened by 2.28 days and that the complication rate decreased by 40% with the adoption of accelerated postoperative recovery programs. Moreover, Lee et al.,4 among other authors,29,30, found that ERAS™ allowed patients to get back to work sooner and to be less dependent on caregivers, without impairing quality of life.
In Brazil, in a study with over 5,000 patients who underwent large abdominal surgeries, Bicudo-Salomão et al.31 demonstrated that operation costs, length of hospital stay, and complication rates were reduced in patients submitted to the ACERTO™ accelerated recovery protocol, compared to patients submitted to conventional postoperative care.
However, for the programs to succeed, it is essential that measures be well-tolerated by the patients32. In that regard, this study was able to identify variables that negatively influence patients’ acceptance of SARPs.