1. Home
  2. Vol 4, No 4 (2022)
  3. Karachentsev

Implementation of Enhanced Recovery After Surgery Protocol in a Second-level Hospital

Sergiy Karachentsev

Abstract


Background: Enhanced recovery after surgery (ERAS) became standard perioperative care in the western world. However, little is known about the implementation of fast-track pathways (FTP) in developing countries. The objectives of the study were to assess the feasibility of the FTP program and adherence to the ERAS protocol in general surgery patients implemented in low-resource setting. Methods: In this retrospective, observational study, we evaluated perioperative care for elective and emergency surgical population changed in accordance with the ERAS program in a second-level hospital in Zambia. Ninety-eight patients aged two weeks to 87 years (median 32 years) with a male to female ratio of 2.3:1 and categorised by the American Society of Anaesthesiologists (ASA) in classes I to IV were included. Outcomes of interest were functional recovery, postoperative complications, length of hospital stay, and compliance with the protocol. Results: All elements of the ERAS protocol, including minimal access surgery (through mini-laparotomy incisions) and accelerated postoperative care, were employed. A successful recovery with discharge home by day 4 after the operation and the absence of complications and readmissions was achieved in 45.5% of patients. The postoperative period was complicated in 18.8% of cases, with a total mortality rate of 6.3%. The overall adherence level to the protocol was 72.2%. The highest levels of adaptation (≥95%) were reported for preoperative stratification, antimicrobial prophylaxis, modification of preanaesthetic medications, and prevention of intraoperative hypothermia. The poor compliance to the program was recorded for fasting and carbohydrate loading before surgery and postoperative thromboprophylaxis (17.9% and 21.4%, respectively). Conclusion: The study indicates that the employment of the ERAS program for the general surgery population at a second-level hospital is feasible and safe. It is possible to achieve a high level of adherence to the ERAS pathway in a resource-limited environment. A reasonable modification of the protocol can bring additional clinical benefits. Integrating elements of FTP into perioperative care and including the ERAS program in postgraduate education in developing nations is recommended. Further studies are needed, first, to frame ERAS pathways for application in emergency general surgery, and second, to present the local initiatives and identify barriers to the implementation of FTP in low-income countries.

 

Doi: 10.28991/SciMedJ-2022-04-04-04

Full Text: PDF


Keywords


Enhanced Recovery After Surgery (ERAS); General Surgery; Fast-track Pathways (FTP).

References


Hajibandeh, S., Hajibandeh, S., Bill, V., & Satyadas, T. (2020). Meta-analysis of Enhanced Recovery After Surgery (ERAS) Protocols in Emergency Abdominal Surgery. World Journal of Surgery, 44(5), 1336–1348. doi:10.1007/s00268-019-05357-5.

Peden, C. J., Aggarwal, G., Aitken, R. J., Anderson, I. D., Bang Foss, …, Scott, M. (2021). Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1—Preoperative: Diagnosis, Rapid Assessment and Optimization. World Journal of Surgery, 45(5), 1272–1290. doi:10.1007/s00268-021-05994-9.

Wijk, L., Udumyan, R., Pache, B., Altman, A. D., Williams, L. L., Elias, K. M., McGee, J., …, Dowdy, S. C., & Nelson, G. (2019). International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery. American Journal of Obstetrics and Gynecology, 221(3), 237.e1-237.e11. doi:10.1016/j.ajog.2019.04.028.

Roberts, K., Brindle, M., & McLuckie, D. (2020). Enhanced recovery after surgery in paediatrics: a review of the literature. BJA Education, 20(7), 235–241. doi:10.1016/j.bjae.2020.03.004.

Malik, K., Poletto, G., Musto, L., Giustiniano, E., Cecconi, M., & Civilini, E. (2021). Implementation of a perioperative protocol to enhance open aortic repair. Journal of Vascular Surgery, 74(2), 434-441. doi:10.1016/j.jvs.2020.12.102.

Rodríguez-Laiz, G. P., Melgar-Requena, P., Alcázar-López, C. F., Franco-Campello, M., Villodre-Tudela, C., Pascual-Bartolomé, S., …, Lluís-Casajuana, F., & Ramia-Ãngel, J. M. (2021). Fast-Track Liver Transplantation: Six-year Prospective Cohort Study with an Enhanced Recovery After Surgery (ERAS) Protocol. World Journal of Surgery, 45(5), 1262–1271. doi:10.1007/s00268-021-05963-2.

Feldheiser, A., Aziz, O., Baldini, G., Cox, B. P. B. W., Fearon, K. C. H., Feldman, L. S., Gan, T. J., Kennedy, R. H., Ljungqvist, O., Lobo, D. N., Miller, T., Radtke, F. F., Ruiz Garces, T., Schricker, T., Scott, M. J., Thacker, J. K., Ytrebø, L. M., & Carli, F. (2016). Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: Consensus statement for anaesthesia practice. Acta Anaesthesiologica Scandinavica, 60(3), 289–334. doi:10.1111/aas.12651.

Nelson, G., Kiyang, L. N., Crumley, E. T., Chuck, A., Nguyen, T., Faris, P., Wasylak, T., Basualdo-Hammond, C., McKay, S., Ljungqvist, O., & Gramlich, L. M. (2016). Implementation of Enhanced Recovery after Surgery (ERAS) Across a Provincial Healthcare System: The ERAS Alberta Colorectal Surgery Experience. World Journal of Surgery, 40(5), 1092–1103. doi:10.1007/s00268-016-3472-7.

Aarts, M.-A., Rotstein, O. D., Pearsall, E. A., Victor, J. C., Okrainec, A., McKenzie, M., McCluskey, S. A., Conn, L. G., & McLeod, R. S. (2018). Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery. Annals of Surgery, 267(6), 992–997. doi:10.1097/sla.0000000000002632.

Feng, J., Li, K., Xu, R., Feng, H., Han, Q., Ye, H., & Li, F. (2022). Association between compliance with enhanced recovery after surgery (ERAS) protocols and postoperative outcome in patients with primary liver cancer undergoing hepatic resection. Journal of Cancer Research and Clinical Oncology, 148(11), 3047–3059. doi:10.1007/s00432-021-03891-1.

Tanious, M. K., Ljungqvist, O., & Urman, R. D. (2017). Enhanced Recovery after Surgery: History, Evolution, Guidelines, and Future Directions. International Anesthesiology Clinics, 55(4), 1–11. doi:10.1097/AIA.0000000000000167.

Fawcett, W. J., Mythen, M. G., & Scott, M. J. (2021). Enhanced recovery: joining the dots. British Journal of Anaesthesia, 126(4), 751–755. doi:10.1016/j.bja.2020.12.027.

Mukhopadhyay, S., Lin, Y., Mwaba, P., Kachimba, J., Makasa, E., Lishimpi, K., Silverstein, A., Afshar, S., & Meara, J. G. (2017). Implementing World Health Assembly Resolution 68.15: National surgical, obstetric, and anesthesia strategic plan development--the Zambian experience. Bulletin of the American College of Surgeons, 102(6), 28–35.

Kooistra, B., Dijkman, B., Einhorn, T. A., & Bhandari, M. (2009). How to Design a Good Case Series. Journal of Bone and Joint Surgery, 91(Supplement_3), 21–26. doi:10.2106/jbjs.h.01573.

Horvath, B., Kloesel, B., Todd, M. M., Cole, D. J., & Prielipp, R. C. (2021). The Evolution, Current Value, and Future of the American Society of Anesthesiologists Physical Status Classification System. Anesthesiology, 135(5), 904–919. doi:10.1097/ALN.0000000000003947.

NHSN. (2022). Surgical Site Infection Event (SSI): Center for Disease Control (CDC), National Healthcare Safety Network. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. Updated Jan 2015. (accessed on October 2022).

Pecorelli, N., Hershorn, O., Baldini, G., Fiore, J. F., Stein, B. L., Liberman, A. S., Charlebois, P., Carli, F., & Feldman, L. S. (2017). Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program. Surgical Endoscopy, 31(4), 1760–1771. doi:10.1007/s00464-016-5169-2.

Dindo, D., Demartines, N., & Clavien, P. A. (2004). Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery, 240(2), 205–213. doi:10.1097/01.sla.0000133083.54934.ae.

Alves, A., Panis, Y., Lelong, B., Dousset, B., Benoist, S., & Vicaut, E. (2008). Randomized clinical trial of early versus delayed temporary stoma closure after proctectomy. British Journal of Surgery, 95(6), 693–698. doi:10.1002/bjs.6212.

Jansson Timan, T., Hagberg, G., Sernert, N., Karlsson, O., & Prytz, M. (2021). Mortality following emergency laparotomy: a Swedish cohort study. BMC Surgery, 21(1), 322. doi:10.1186/s12893-021-01319-8.

Ariyaratnam, R., Palmqvist, C. L., Hider, P., Laing, G. L., Stupart, D., Wilson, L., Clarke, D. L., Hagander, L., Watters, D. A., & Gruen, R. L. (2015). Toward a standard approach to measurement and reporting of perioperative mortality rate as a global indicator for surgery. Surgery, 158(1), 17–26. doi:10.1016/j.surg.2015.03.024.

Watters, D. A., & Wilson, L. (2021). The Comparability and Utility of Perioperative Mortality Rates in Global Health. Current Anesthesiology Reports, 11(1), 48–58. doi:10.1007/s40140-020-00432-3.

World Alliance for Patient Safety. (2008). Global patient safety challenge: Safe Surgery Saves Lives. World Health Organisation (WHO), Geneva, Switzerland.

Elias, K. M., Stone, A. B., McGinigle, K., Tankou, J. I., Scott, M. J., Fawcett, W. J., Demartines, N., Lobo, D. N., Ljungqvist, O., & Urman, R. D. (2018). The Reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) Checklist: A Joint Statement by the ERAS® and ERAS® USA Societies. World Journal of Surgery, 43(1), 1–8. doi:10.1007/s00268-018-4753-0.

Patel, J., Tolppa, T., Biccard, B. M., Fazzini, B., Haniffa, R., Marletta, D., Moonesinghe, R., Pearse, R., Vengadasalam, S., Stephens, T. J., & Vindrola-Padros, C. (2022). Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis. World Journal of Surgery, 46(9), 2102–2113. doi:10.1007/s00268-022-06621-x.

Baluku, M., Bajunirwe, F., Ngonzi, J., Kiwanuka, J., & Ttendo, S. (2020). A Randomized Controlled Trial of Enhanced Recovery after Surgery Versus Standard of Care Recovery for Emergency Cesarean Deliveries at Mbarara Hospital, Uganda. Anesthesia and Analgesia, 130(3), 769–776. doi:10.1213/ANE.0000000000004495.

Moydien, M. R., Oodit, R., Chowdhury, S., Edu, S., Nicol, A. J., & Navsaria, P. H. (2016). Enhanced recovery after surgery (ERAS) in penetrating abdominal trauma: A prospective single-center pilot study. South African Journal of Surgery, 54(4), 7–10.

Loots, E., Sartorius, B., Paruk, I. M., & Clarke, D. L. (2018). The Successful Implementation of a Modified Enhanced Recovery After Surgery (ERAS) Program for Bariatric Surgery in a South African Teaching Hospital. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques, 28(1), 26–29. doi:10.1097/SLE.0000000000000488.

Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. American Journal of Community Psychology, 41(3–4), 327–350. doi:10.1007/s10464-008-9165-0.

Ugarte-Sierra, B., Landaluce-Olavarria, A., Cabrera-Serna, I., Viñas-Trullen, X., Brugiotti, C., Ramírez-Rodríguez, J. M., & Arroyo, A. (2021). Enhanced Recovery After Emergency Surgery: Utopia or Reality? Cirugia Espanola, 99(4), 258–266. doi:10.1016/j.ciresp.2020.04.017.

Balasubramanian, A., Cheddie, S., Naidoo, N. M., & Singh, B. (2018). An evaluation of mini-laparotomy cholecystectomy in the laparoscopic era: A rural experience. South African Journal of Surgery, 56(2), 36–40. doi:10.17159/2078-5151/2018/v56n2a2287.

Zhao, J. J., Syn, N. L., Chong, C., Tan, H. L., Ng, J. Y. X., Yap, A., Kabir, T., & Goh, B. K. P. (2021). Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients. Surgery (United States), 170(4), 994–1003. doi:10.1016/j.surg.2021.04.004.

Bugada, D., Bellini, V., Fanelli, A., Marchesini, M., Compagnone, C., Baciarello, M., Allegri, M., & Fanelli, G. (2016). Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach. Surgery Research and Practice, 2016, 1–6. doi:10.1155/2016/3561249.

Currie, A., Burch, J., Jenkins, J. T., Faiz, O., Kennedy, R. H., Ljungqvist, O., Demartines, N., Hjern, F., Norderval, S., Lassen, …, Fearon, K. (2015). The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: Results from an international registry. Annals of Surgery, 261(6), 1153–1159. doi:10.1097/SLA.0000000000001029.

MacFie, J. (2016). Enhanced Recovery After Surgery Is Obsolete. Diseases of the Colon & Rectum, 59(10), 1002–1003. doi:10.1097/dcr.0000000000000622.

Hartman, A., Leonard, D., Trefois, C., Remue, C., Bachmann, R., Abbes Orabi, N., Lupu, I., Robu, B., Steyaert, A., & Kartheuser, A. (2020). Good compliance to enhanced recovery program improves outcome after colorectal surgery. Surgical Endoscopy, 35(8), 4214–4221. doi:10.1007/s00464-020-07903-y.

Delaney, C. P., Zutshi, M., Senagore, A. J., Remzi, F. H., Hammel, J., & Fazio, V. W. (2003). Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Diseases of the Colon and Rectum, 46(7), 851–859. doi:10.1007/s10350-004-6672-4.

Chestovich, P. J., Lin, A. Y., & Yoo, J. (2013). Fast-Track Pathways in Colorectal Surgery. Surgical Clinics of North America, 93(1), 21–32. doi:10.1016/j.suc.2012.09.003.

Boukili, I. E., Flaris, A. N., Mercier, F., Cotte, E., Kepenekian, V., Vaudoyer, D., Glehen, O., & Passot, G. (2022). Prehabilitation before major abdominal surgery: Evaluation of the impact of a perioperative clinical pathway, a pilot study. Scandinavian Journal of Surgery, 111(2), 1–9. doi:10.1177/14574969221083394.

Salvo, G., & Ramirez, P. T. (2020). Tubes and Drains: Current Updates on Evidence on Their Role within Recovery. Enhanced Recovery After Surgery. Springer, Cham, Switzerland. doi:10.1007/978-3-030-33443-7_20.

GlobalSurg Collaborative. (2016). Mortality of emergency abdominal surgery in high-, middle and low-income countries. British Journal of Surgery, 103, 971-988. doi:10.1002/bjs.10151.

Oodit, R., & McQueen, K. (2020). ERAS for Low- and Middle-Income Countries. Enhanced Recovery After Surgery. Springer, Cham, Switzerland. doi:10.1007/978-3-030-33443-7_64.

Vashistha, N., Singhal, D., Budhiraja, S., Aggarwal, B., Tobin, R., & Fotedar, K. (2018). Outcomes of Emergency Laparotomy (EL) Care Protocol at Tertiary Care Center from Low–Middle-Income Country (LMIC). World Journal of Surgery, 42(5), 1278–1284. doi:10.1007/s00268-017-4333-8.

Sethi, A., Debbarma, M., Narang, N., Saxena, A., Mahobia, M., & Tomar, G. (2018). Impact of targeted preoperative optimization on clinical outcome in emergency abdominal surgeries: A prospective randomized trial. Anesthesia: Essays and Researches, 12(1), 149. doi:10.4103/aer.aer_190_17.

Diaper, J., Schiffer, E., Barcelos, G. K., Luise, S., Schorer, R., Ellenberger, C., & Licker, M. (2021). Goal-directed hemodynamic therapy versus restrictive normovolemic therapy in major open abdominal surgery: A randomized controlled trial. Surgery (United States), 169(5), 1164–1174. doi:10.1016/j.surg.2020.09.035.

EuroSurg Collaborative. (2018). Ileus management international (IMAGINE): protocol for a multicentre, observational study of ileus after colorectal surgery. Colorectal Diseases, 20, O17-O25. doi:10.1111/codi.13976.

He, F., Lin, X., Xie, F., Huang, Y., & Yuan, R. (2015). The effect of enhanced recovery program for patients undergoing partial laparoscopic hepatectomy of liver cancer. Clinical and Translational Oncology, 17(9), 694–701. doi:10.1007/s12094-015-1296-9.

Mythen, M. G., Swart, M., Acheson, N., Crawford, R., Jones, K., Kuper, M., McGrath, J. S., & Horgan, A. (2012). Perioperative fluid management: Consensus statement from the enhanced recovery partnership. Perioperative Medicine, 1(1), 2. doi:10.1186/2047-0525-1-2.

Martin, C., Cortegiani, A., Gregoretti, C., Martin-Loeches, I., Ichai, C., Leone, M., Marx, G., & Einav, S. (2018). Choice of fluids in critically ill patients. BMC Anesthesiology, 18(1). doi:10.1186/s12871-018-0669-3.

Delaney, C. P. (2008). Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery. Diseases of the Colon & Rectum, 51(2), 181–185. doi:10.1007/s10350-007-9126-y.

Sarin, A., Litonius, E. S., Naidu, R., Yost, C. S., Varma, M. G., & Chen, L. lynn. (2016). Successful implementation of an Enhanced Recovery After Surgery program shortens length of stay and improves postoperative pain, and bowel and bladder function after colorectal surgery. BMC Anesthesiology, 16(1). doi:10.1186/s12871-016-0223-0.

Iyer, S., & Kareem, Z. (2019). Fast-track protocol versus conventional protocol on patient outcome: A randomized clinical trial. Nigerian Journal of Surgery, 25(1), 36. doi:10.4103/njs.njs_34_17.

Pooya, S., Johnston, K., Estakhri, P., & Fathi, A. (2021). Successful Implementation of Enhanced Recovery After Surgery Program in a Safety-Net Hospital: Barriers and Facilitators. Journal of Perianesthesia Nursing, 36(5), 468–472. doi:10.1016/j.jopan.2020.12.011.

Meyenfeldt, E. M. V., Van Nassau, F., De Betue, C. T. I., Barberio, L., Schreurs, W. H., Marres, G. M. H., Bonjer, H. J., & Anema, J. (2022). Implementing an enhanced recovery after thoracic surgery programme in the Netherlands: A qualitative study investigating facilitators and barriers for implementation. BMJ Open, 12(1), 51513. doi:10.1136/bmjopen-2021-051513.

Stone, A. B., Yuan, C. T., Rosen, M. A., Grant, M. C., Benishek, L. E., Hanahan, E., Lubomski, L. H., Ko, C., & Wick, E. C. (2018). Barriers to and facilitators of implementing enhanced recovery pathways using an implementation framework: A systematic review. JAMA Surgery, 153(3), 270–278. doi:10.1001/jamasurg.2017.5565.

Slieker, J., Hübner, M., Addor, V., Duvoisin, C., Demartines, N., & Hahnloser, D. (2018). Application of an enhanced recovery pathway for ileostomy closure: a case–control trial with surprising results. Techniques in Coloproctology, 22(4), 295–300. doi:10.1007/s10151-018-1778-1.

Herbert, G., Sutton, E., Burden, S., Lewis, S., Thomas, S., Ness, A., & Atkinson, C. (2017). Healthcare professionals’ views of the enhanced recovery after surgery programme: A qualitative investigation. BMC Health Services Research, 17(1), 617. doi:10.1186/s12913-017-2547-y.

Meara, J. G., Leather, A. J. M., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Mérisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L. M., Grimes, C. E., Gruen, R. L., Ismail, E. A., … Yip, W. (2015). Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. The Lancet, 386(9993), 569–624. doi:10.1016/S0140-6736(15)60160-X.

Oodit, R., Biccard, B. M., Panieri, E., Alvarez, A. O., Sioson, M. R. S., Maswime, S., Thomas, V., Kluyts, H. L., Peden, C. J., de Boer, H. D., Brindle, M., Francis, N. K., Nelson, G., Gustafsson, U. O., & Ljungqvist, O. (2022). Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low–Middle-Income Countries (LMIC’s): Enhanced Recovery After Surgery (ERAS) Society Recommendation. World Journal of Surgery, 46(8), 1826–1843. doi:10.1007/s00268-022-06587-w.


Full Text: PDF

DOI: 10.28991/SciMedJ-2022-04-04-04

Refbacks

  • There are currently no refbacks.


Copyright (c) 2022 Sergiy Karachentsev