In the current study we evaluated the clinical outcome in patients who underwent elective colorectal resection in a single institution serving a wide low densely populated rural and fishing area before, retrospectively, and after, prospectively, the adoption of a colorectal ERP. Implementing the protocol in such an area, allowed to improve safely patient’s convalescence by reducing time to functional recovery, lowering by half the duration of hospital LoS, and decreasing by almost one third postoperative complications, with no increase in mortality and 30-day re-admissions. Finally, following a traditional perioperative care protocol was the only factor we found to be associated to a prolonged postoperative hospital LoS.
The application of an ERP may be particularly difficult in rural hospitals serving wide areas, as it may be hindered by multiple factors affecting both health care professionals and patients such as: 1) lack of strong scientific evidence supporting the real efficacy outside urban areas and tertiary or academic hospitals, 2) fear of complications due to decrease resources to manage postoperative complications, 3) more difficult access to medical care by the patients, 4) decreased health literacy as ERP principles may not be intuitive, 5) higher medical and nursing staff turnover and shortage, 5) poor familiarity with some elements of ERP protocol by medical and nursing staffs, 6) lack of time and commitment by health care professionals to constitute a multidisciplinary team, 7) limited hospital resources, 8) lower case-volume, 9) patient perplexity about earlier hospital discharge.
Introduction of ERP into clinical practice has been pioneered as fast-track surgery by Henrik Kehlet and colleagues in the mid-1990s , with the principal objective to optimize postoperative outcomes of the surgical patients. This protocol was initially used in urban and academic tertiary care centers and many hospitals began to adopt it, with a slow progressive dissemination from Northern Europe and North America throughout the world. The core guidelines established by Kehlet were delineated by consensus review , until the birth of the Enhanced Recovery After Surgery (ERAS) society in 2010 . The safety and efficacy of colorectal ERP has been established in a few randomized studies and meta-analysis of randomized studies conducted in urban and academic hospitals [12-14]. Until today, however, the evidence regarding the adoption and feasibility of such a program in rural contexts is quite limited [3-8], which may be perceived as a barrier to ERP implementation in those area. Very few experiences from North American rural and community hospitals [6-8] as well as European rural contexts [3-5] have been published in the last decade. Tebala GD et al.  found age and laparoscopic approach as independent prognostic factors significantly associated with early discharge with a readmission rate of 9.1%. Moreover, they analyzed the influence of the operation day of the week on postoperative recovery: in their study, interestingly, oncologic results were slightly better and postoperative complications were lower in patients operated on Mondays to Wednesdays . Marres CCM et al.  also found a significant reduction of major post-operative complications and mortality after implementing a quality improvement program in colorectal surgery. Geltzeiler CB et al.  analyzed the evolution of implementing colorectal ERP from 2009 to 2012 and they found a significant decrease of hospital LoS (6.7 days vs 3.7 days) with a remarkable estimated cost-saving for patients. Archibald LH et al.  investigated the introduction of a comprehensive care process for enhanced recovery after colon surgery in eight community hospitals and they concluded that ERP represents the most important factor, more than laparoscopic approach, in decreasing length of stay.
As evidenced from the literature, there is a strong relationship between the adherence to the elements of the protocol and the complete recovery of patients with a remarkable reduction in hospital LoS [15-17]. The median adherence to ERP protocol in our study was 68%. Two important items were not fulfilled: the amount of intra-operative fluids administration and early mobilization after surgery. Concerning the first element, although the amount of intra-operative fluids was reduced with the adoption of the program versus control, the target infusion was not reached, which was probably related to the habits of anesthetists. Early mobilization was probably affected by advanced patients’ age [77 years-old (69-83)] as well as the high nurse to patient ratio (1:12 am, 1:12 pm) and limited physiotherapists available for support. However, despite the reduced compliance with these elements, the median time to functional recovery was significantly reduced and the duration of hospital LoS was half among ERP patients (5 days) versus controls (10 days). Furthermore, considering the last quartile of patients in the ERP group (N=20), a further decrease of 1 day in the hospital LoS (4 days) was detected, suggesting that mastering the implementation of ERP improves the outcome.
Another remarkable achievement with the ERP was patient hospital discharge as soon as recovery was complete according to predefined standardized criteria (i.e., fit for discharge), while control patients left the hospital a median of one day after they were fit for discharge.
It could be argued that the improved outcome among ERP patients could be due to the use of laparoscopy (95%) as opposed to open surgery among control patients. Certainly, the laparoscopic approach is a key stress reducing element that should be integrated in ERP to obtain the greatest improvement in recovery . The global peri-operative patient care, however, is fundamental to improve the postoperative outcome regardless of the approach used . A meta-analysis of randomized trials on open colorectal resections showed a significant reduction of hospital LoS by following ERP . Finally, it should be noticed that being on traditional rather than enhanced recovery care was the only independent predictor of prolonged hospital LoS in our study population (N=160).
An interesting point of debate could be the higher postoperative ICU admission rate observed in ERP group (47%) compared to the Pre-ERP group (20%), although the duration of ICU LoS was half [1 (1-1) vs. 2 (1-4), p=0.001]. This reflects, however, the institution of a sub-intensive care unit (SICU) in 2016 to care for the elderly as well as the advanced age in our study population.
Another important aspect of ERP perioperative care is related to health cost-saving. Previous studies show hospital LoS reduction yielding significant cost savings per patient with ERP in colorectal surgery [6,8,17]. Moreover, a prospective study underlined the benefits of an ERP in a North American community hospital in terms of overall wound complications rates . Although not evaluated in our investigation, the decrease in postoperative complications (31%) and duration of hospital LoS (5 days shorter) among patients on enhanced recovery may well suggest a reduction for institutional costs with the ERP.
Strength and limitations
This is a single center prospective study with a historical control group used for comparison and, therefore, the results must be interpreted with caution.
Due to profound organizational changes in the unit and the time of implementation of the program there is a two-year interval between the study periods. Also, two different surgeons operated in the ERP group and pre-ERP group, respectively.
Patients in the ERP group may have benefited from the laparoscopic approach as opposed to the open one adopted in the Pre-ERP group. Minimally invasive approaches, however, are an important component of ERPs to reduce the postoperative surgical stress response. Furthermore, at multivariate analysis, being on a traditional perioperative program was the only factor associated to prolonged hospital LoS.
Nonetheless, given the weakness and paucity of scientific evidence about implementation of ERP in colorectal surgery, this study is very useful as it clearly demonstrates the reproducibility of a safe and effective colorectal ERP within a wide agricultural area with a low-density population.