title: Eight years of experience with Enhanced Recovery After Surgery in patients with colon cancer: Impact of measures to improve adherence. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection The influence of an Enhanced Recovery Programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer Implementation of laparoscopic colectomy with fast-track care in an academic medical center: benefits of a fully ascended learning curve and specialty expertise. Implementation of a Fast-Track Clinical Pathway Decreases Postoperative Length of Stay and Hospital Charges for Liver Resection The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection Enhanced Recovery After Surgery (ERAS) Program Attenuates Stress and Accelerates Recovery in Patients After Radical Resection for Colorectal Cancer: A Prospective Randomized Controlled Trial Prospective study of colorectal enhanced recovery after surgery in a community hospital. Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia. Laparoscopy in Combination with Fast Track Multimodal Management is the Best Perioperative Strategy in Patients Undergoing Colonic Surgery: A Randomized Clinical Trial (LAFA-study) Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis. The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer Enhanced Recovery After Surgery Protocols Are Valuable in Pancreas Surgery Patients. Cost-effectiveness of Enhanced Recovery Versus Conventional Perioperative Management for Colorectal Surgery Impact of a fast‐track surgery programme for pancreaticoduodenectomy
abstract: BACKGROUND Perioperative treatment of patients with colorectal cancer according to the Enhanced Recovery After Surgery ( ERAS ) protocol has proven to reduce complications and duration of stay . However , strict adherence remains a challenge and the benefits may decrease with lower adherence . In this study , we report on 8 years of adherence to the ERAS protocol and its effect on postoperative outcome in patients with colon cancer . METHODS In 2006 , the ERAS protocol was introduced for treatment of colon cancer patients in the Medical Center Alkmaar , a large teaching hospital . Patients scheduled for elective colon cancer resection were included in this study . Adherence to ERAS items was monitored and along with clinical data prospect ively gathered in a data base . In 2011 , several measures to improve adherence were implemented . RESULTS In total , 816 patients were included .  Mean adherence rate was 73 % in 2006 and 2007 , 66 % in 2008 and 2009 , 63 % in 2010 and 2011 , and 82 % in 2012 and 2013 . There was a shorter duration of stay in the years with high adherence ( 5.7 days ) compared with the years with low adherence ( 7.3 days ; P < .001 ) . The ERAS items that were the strongest predictors for a shorter duration of stay were no nasogastric tube , early mobilization , early oral nutrition , early removal of epidural , early removal of catheter , and nonopioid oral analgesia . CONCLUSION It is possible to improve adherence to the ERAS protocol and related outcomes with specific measures . Adherence to the ERAS protocol was related inversely to duration of stay . Only postoperative items of the ERAS protocol were predictive for a shorter duration of stay . Keeping adherence optimal remains an ongoing challenge that requires repeated training and dedicated personnel The aim of this trial was to compare  multimodal optimization  with  conventional perioperative management  in a consecutive series of patients undergoing a wide range of colorectal procedures Objective Optimizing peri‐operative care using an enhanced recovery programme improves short‐term outcomes following colonic resection . This study compared a prospect i ve group of patients undergoing resection of colorectal cancer within an enhanced recovery programme , with a prospect ively studied historic cohort receiving conventional care BACKGROUND There are few data describing successful institutional " conversion " from open colectomy/st and ard care techniques to laparoscopic colectomy/fast-track care . PURPOSE To assess the benefits of transitioning an institution from open to laparoscopic colectomy with fast-track care while avoiding a learning curve . METHOD Twenty consecutive laparoscopic colorectal resections ( LCRs ) performed by a colorectal surgeon were compared with 20 matched open colorectal resections ( OCRs ) performed by general surgeons before the arrival of the colorectal surgeon . RESULTS Surgical procedures were as follows : sigmoidectomy : OCR 16 and LCR 11 ; right colectomy : OCR 3 and LCR 8 ; and total colectomy : OCR 1 and LCR 1 . The mean operative time for sigmoidectomy was 250 and 109 minutes for OCR and LCR , respectively , and for right colectomy 181 and 97 minutes for OCR and LCR , respectively ( P < .001 ) . Morbidity was OCR 45 % versus LCR 25 % . There was no mortality .  LCR showed significantly lower length of stay and direct cost ( 3.6 vs. 8.3 days ; 4,993 dollars vs. 11,383 dollars ; both P < .001 ) . CONCLUSIONS The data clearly show an institutional benefit for the implementation of specialty-based advanced laparoscopic procedures A fast-track clinical pathway is design ed to streamline patient care delivery and maximize cost effectiveness . It has decreased postoperative length of stay ( LOS ) and hospital charges for many surgical procedures . However , data on clinical pathways after liver surgery are sparse . This study examined whether use of a fast-track clinical pathway for patients undergoing elective liver resection affected postoperative LOS and hospital charges . A fast-track clinical pathway was developed and implemented by a multidisciplinary team for patients undergoing liver resection . Between July , 2007 and May , 2008 , a total of 117 patients underwent elective liver resection :  the fast-track clinical pathway ( education of patients and families , earlier oral feeding , earlier discontinuation of intravenous fluid , no drains or nasogastric tubes , early ambulation , use of a urinary catheter for less than 24 h and planned discharge 6 days after surgery ) was studied prospect ively in 56 patients ( postpathway group ) . These patients were compared with the remainder who had usual care ( prepathway group ) . Outcome measures were postoperative LOS , perioperative hospital charges , intraoperative and postoperative complications , mortality , and readmission rate .  Among all patients , 69 ( 59 % ) had complicating diseases and /or a history of surgery and 24 patients belonged to American Society of Anesthesiologists grade III – IV . Compared with the prepathway group , the postpathway group had a significantly shorter postoperative LOS ( 7 vs. 11 days , P < 0.01 ) . The average perioperative hospital charges were RMB 26,626 for patients in the prepathway group and only RMB 21,004 for those in the postpathway group ( P < 0.05 ) , with no differences in intraoperative and postoperative complications ( P = 0.814 ) , mortality ( P = 0.606 ) , and readmission rate ( P = 0.424 ) . Implementation of the fast-track clinical pathway is an effective and safe method for reducing postoperative LOS and hospital charges for high-risk patients undergoing elective liver resection . The result supports the further development of fast-track clinical pathways for liver surgical procedures OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity Enhanced recovery after surgery ( ERAS ) pathways have been associated with improved perioperative outcomes following several surgical procedures . Less is known , however , regarding their use following hepatic surgery Background The aim of this trial was to compare the Enhanced Recovery After Surgery ( ERAS ) program with conventional perioperative management in patients who underwent radical resection for colorectal cancer . Methods A combination of evidence -based and consensus methodology was used to develop the ERAS protocol . Five hundred ninety-seven consecutive patients who underwent elective colorectal resection were r and omized to either the ERAS ( n = 299 ) or the  control group ( n = 298 ) . Outcomes relating to nutrition and metabolism index , stress index , and recovery index were measured and recorded . Results Demographic and operative data were similar between the two groups . Patients in the ERAS group showed improved nutritional status when compared with those of the control group . On postoperative day ( POD ) 1 , the HOMA-IR ( insulin resistance index ) of the ERAS group was lower than that of the control group ( p < 0.001 ) . The cortisol level of the control group was elevated on both POD 1 ( p = 0.007 ) and POD 5 ( p = 0.002 ) compared to the preoperative level . However , the cortisol level of the ERAS group was not increased until POD 5 ( p = 0.001 ) . Reduced levels of TNF-α , IL-1β , IL-6 , and IFN-γ in the ERAS group indicated less postoperative stress responses . In addition , ERAS was associated with accelerated recovery of gastrointestinal function . The postoperative length of stay ( p < 0.001 ) and expense ( p < 0.001 ) for the ERAS group were reduced in comparison to the controls . Twenty-eight cases in the control group and twenty-nine in the ERAS group suffered complications , which was not significantly different . Conclusion The ERAS protocol attenuates the surgical stress response and accelerates postoperative recovery without compromising patient safety IMPORTANCE Enhanced recovery after surgery ( ERAS ) colorectal programs have shown to be successful at reducing length of stay in many international and academic centers ; however , their efficacy in a community hospital setting remains unclear . OBJECTIVE To determine if favorable results could be reproduced in a community hospital setting using our ERAS program , which was developed using core ERAS guidelines with the goal of accelerated recovery while also addressing other important outcomes affecting patient experience and safety . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve study of ERAS program , a multidisciplinary effort involving anesthesia , preadmission staff , nursing , and surgery staff at a community hospital . The program was initiated in 2010 and was in full practice by 2011 . We assessed practice patterns and patient outcomes for all elective colon and rectal resection cases performed in 2009 ( prior to ERAS implementation ) , 2011 , and 2012 . MAIN OUTCOMES AND MEASURES Laparoscopic approach , narcotic use , length of stay , 30-day readmission , ileus ( defined as reinsertion of nasogastric tube ) , and intra-abdominal infection and association between colorectal cancer ( CRC ) diagnosis and these outcomes . RESULTS From 2009 to 2012 , the use of laparoscopy increased from 57.4 % to 88.8 % ( P < .001 ) . Length of stay decreased significantly ( 6.7 days vs 3.7 days , P < .001 ) , without an increase in 30-day readmission rate ( 17.6 % vs 12.5 % , P = .49 ) . Use of patient-controlled narcotic analgesia and duration of use decreased ( 63.2 % of patients vs 15 % , P < .001 ; 67.8 hours vs 47.1 hours , P = .02 ) . Ileus rate decreased from 13.2 % to 2.5 % ( P = .02 ) . Intra-abdominal infection decreased from 7.4 % to 2.5 % ( P = .24 ) . When comparing laparoscopic cases alone , similar results were observed . Following regression analysis , there were no statistically significant differences between CRC diagnosis and LOS , 30-day readmission rates , ileus , and intra-abdominal infection ( all P 's > .05 ) . Length of stay reductions result ed in an estimated cost savings of $ 3202 per patient ( 2011 ) and $ 4803 per patient ( 2012 ) . CONCLUSIONS AND RELEVANCE Implementation of this patient care-directed enhanced recovery program is feasible in a community hospital setting , and it is associated with decreased LOS without increased readmission or morbidity , as well as significant decreases in narcotic use and cost . Improved outcomes are independent of the laparoscopic approach and CRC diagnosis PURPOSE Patients with pneumonia often remain hospitalized after becoming clinical ly stable , without demonstrated benefits on outcome . The purpose s of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia . SUBJECTS AND METHODS As part of a prospect i ve study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals , daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital 's Medicare cost reports . RESULTS The median total cost of hospitalization for all 982 in patients was $ 5 , 942 , with a median daily cost of $ 836 , including $ 491 ( 59 % ) for room and $ 345 ( 41 % ) for non-room costs . Average daily non-room costs were 282 % greater on the first hospital day , 59 % greater on the second day , and 19 % greater on the third day than the average daily cost throughout the hospitalization ( all P < 0.05 ) , and were 14 % to 72 % lower on the last 3 days of hospitalization . Average daily room costs remained relatively constant throughout the hospital stay , with the exception of the day of discharge . A projected mean savings of $ 680 was associated with a 1-day reduction in length of stay . CONCLUSIONS Despite institutional differences in total costs , patterns of daily re source use throughout hospitalization were similar at all institutions . A 1-day reduction in length of stay might yield substantial cost-savings Objective : To investigate which perioperative treatment , ie , laparoscopic or open surgery combined with fast track ( FT ) or st and ard care , is the optimal approach for patients undergoing segmental resection for colon cancer . Summary Background Data : Important developments in elective colorectal surgery are the introduction of laparoscopy and implementation of FT care , both focusing on faster recovery . Methods : In a 9-center trial , patients eligible for segmental colectomy were r and omized to laparoscopic or open colectomy , and to FT or st and ard care  , result ing in 4 treatment groups . Primary outcome was total postoperative hospital stay ( THS ) . Secondary outcomes were postoperative hospital stay ( PHS ) , morbidity , reoperation rate , readmission rate , in-hospital mortality , quality of life at 2 and 4 weeks , patient satisfaction and in-hospital costs .  Four hundred patients were required to find a minimum difference of 1 day in hospital stay . Results : Median THS in the laparoscopic/FT group was 5 ( interquar-tile range : 4–8 ) days ; open/FT 7 ( 5–11 ) days ; laparoscopic/st and ard 6 ( 4.5–9.5 ) days , and open/st and ard 7 ( 6–13 ) days ( P < 0.001 ) . Median PHS in the laparoscopic/FT group was 5 ( 4–7 ) days ; open/FT 6 ( 4.5–10 ) days ; laparoscopic/st and ard 6 ( 4–8.5 ) days and open/st and ard 7 ( 6–10.5 ) days ( P < 0.001 ) . Secondary outcomes did not differ significantly among the groups . Regression analysis showed that laparoscopy was the only independent predictive factor to reduce hospital stay and morbidity . Conclusions : Optimal perioperative treatment for patients requiring segmental colectomy for colon cancer is laparoscopic resection embedded in a FT program . If open surgery is applied , it is preferentially done in FT care . This study was registered under NTR222 ( www.trialregister.nl ) BACKGROUND Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient population s ; however , little prospect i ve data are available to support their use . This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis , a complex procedure in which we had extensive practical experience , affected hospital charges or length of stay ( LOS ) . METHODS A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis .  All operations were performed by two attending physicians ( J.E.F. , M.S.N. ) . Before implementation , 10 pilot patients were prospect ively monitored to ensure that hospital charges were accurately generated . In addition , charge audits were performed by an outside agency to verify the accuracy of the hospital bills . The pathway was then implemented , and 14 patients were prospect ively analyzed . RESULTS In all patients the principal diagnosis was ulcerative colitis , with the exception of three patients with familial polyposis .  Mean external audit charges were within 2 % of the hospital bills ; therefore the hospital bills were used in all calculations . The mean LOS decreased from 10.3 days to 7.5 days ( p = 0.046 ) for patients on the pathway versus pilot patients . Mean hospital charges also decreased significantly , from $ 21,650 to $ 17,958 per patient ( p = 0.005 ) . CONCLUSIONS Implementation of a clinical pathway , even for an operation in which the surgeon has much experience , is an effective method for reducing LOS and charges for patients . This is likely the result of interdisciplinary cooperation , elimination of unnecessary interventions , and streamlined involvement of ancillary services . These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care . In addition , the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure Objective To analyze the results after the introduction of enhanced recovery after surgery ( ERAS ) protocol s , a r and omized study was performed to compare the outcomes of laparoscopic hepatectomy under ERAS or traditional care . Methods Patients undergoing laparoscopic hepatectomy from April 2014 to October 2014 were included and r and omly divided into Control group ( CG ) and ERAS . Primary outcome was quality of life ( QoL ) and length of hospital stay ( LOS ) . Secondary endpoints were percentage readmission , mortality , duration to first flatus , complications , hospital costs , conversions and blood loss . Results Thirteen patients withdrew after r and omization . Eighty-six patients completed the study , 48 ERAS and 38 CG . Postoperative LOS was significantly reduced in ERAS [ 6 ( 4–8 ) versus 10 ( 7–15 ) days , P = 0.04 ] . First flatus occurred earlier in ERAS than CG [ 2(1–4 ) versus 3(2–5 ) days , P = 0.02 ] . The average perioperative charges were 9470 ± 1540 in CG and only 7742 ± 1200 in ERAS ( P = 0.03 ) , with no differences in readmission rate , blood loss , conversions to open surgery , mortality or surgical complications . The median AUC ( area under a curve ) of QoL was considerably improved in ERAS ( P = 0.04 ) . Conclusions This study suggests that ERAS is feasible and safe for laparoscopic hepatectomy BACKGROUND There is increasing interest in implementing comprehensive perioperative protocol s , including preoperative optimization and education , perioperative goal -directed fluid management , and postoperative fast tracking , to enhance recovery after surgery . Data on the outcomes of these protocol s in pancreatic surgery , however , are limited . STUDY DESIGN A retrospective review of a prospect ively maintained pancreas surgery data base at a single institution from August 2012 to April 2015 was undertaken . An enhanced recovery protocol was initiated in October 2014 , and patients were divided into groups according to pre protocol or post protocol implementation . Preoperative , intraoperative , and postoperative data were tabulated . Statistical analysis was performed with Student 's t-test and Fisher 's exact tests , as well as e quality of variances where appropriate , using SAS System software ( SAS Institute ) . RESULTS Three hundred and seventy-eight patients ( 181 men , mean age 54 years , BMI 28 kg/m(2 ) ) underwent elective pancreatic surgery during the study period , 297 patients pre protocol and 81 post protocol . There were no significant differences in preoperative or intraoperative characteristics . Mean postoperative length of stay was significantly lower in the Enhanced Recovery After Surgery group ( 7.4 vs 9.2 days ; p < 0.0001 ) . Hospital costs were similarly lower in the Enhanced Recovery After Surgery group ( $ 23,307.90 vs $ 27,387.80 ; p < 0.0001 ) . Readmission ( 29 % vs 32 % ) and pancreatic fistula ( 26 % vs 28 % ) rates were similar between groups . Delayed gastric emptying was lower in the Enhanced Recovery After Surgery group ( 26 % vs 13 % ; p = 0.03 ) . CONCLUSIONS Implementation of an enhanced recovery after pancreatic surgery protocol significantly decreased length of stay and hospital cost without increasing readmission or morbidity . Despite patient complexity and the potential need for individualization of care , enhanced recovery protocol s can be valuable and effective in high-risk patient population s , including pancreatic surgery patients Objective : To determine the cost-effectiveness of enhanced recovery pathways ( ERPs ) versus conventional care for patients undergoing elective colorectal surgery . Background : ERPs for colorectal surgery are clinical ly effective , but their cost-effectiveness is unknown . Methods : A multi-institutional prospect i ve cohort cost-effectiveness analysis was performed . Adult patients undergoing elective colorectal resection at 2 university-affiliated institutions from October 2012 to October 2013 were enrolled . One center used an ERP , whereas the other did not . Postoperative outcomes were recorded up to 60 days . Total costs were reported in 2013 Canadian dollars . Effectiveness was measured using the SF-6D , a health utility measure vali date d for postoperative recovery . Uncertainty was expressed using bootstrapped estimates ( 10,000 repetitions ) . Results : A total of 180 patients were included  ( conventional care : n = 95 ; ERP : n = 95 ) . There were no differences in patient characteristics except for a higher proportion of laparoscopy in the ERP group . Mean length of stay was shorter in the ERP group ( 6.5 vs 9.8 days ; P = 0.017 ) , but there were no differences in complications or readmissions . Patients in the ERP group returned to work quicker and had less caregiver burden . There was no difference in quality of life between the 2 groups . The cost of the ERP program was $ 153 per patient . Overall societal costs were lower in the ERP group ( mean difference = −2985 ; 95 % confidence interval , −5753 to −373 ) . The ERP had a greater than 99 % probability of cost-effectiveness . The results were insensitive to a range of assumptions and subgroups . Conclusions : Enhanced recovery is cost-effective compared with conventional perioperative management for elective colorectal resection Fast‐track ( FT ) programmes are multimodal , evidence ‐based approaches to optimize patient outcome after surgery . The aim of this study was to evaluate the safety , clinical outcome and patients ' experience of a FT programme after pancreaticoduodenectomy ( PD ) in a high‐volume institution in Sweden
target: The present systematic review suggests that ERPs in colorectal and pancreas surgery are associated with cost savings compared to conventional perioperative management .
background: Enhanced recovery programs ( ERPs ) have been shown to improve postoperative outcomes after abdominal surgery .
  This study aim ed to review the current literature to assess if ERPs in colorectal , pancreas , and liver surgery induce cost savings .