Enhanced recovery protocols benefit perioperative care of patients with Crohn’s disease
SAN DIEGO — Patients with Crohn’s disease who were perioperatively managed with an enhanced recovery protocol experienced a reduction in length of stay and faster recovery without an increase in adverse events, according to a study presented at Digestive Disease Week.
“The basic goal of enhanced recovery protocols is to reduce the length of hospital stay and accelerate the hospital course while not increasing the risk of complications,” Donald Haering, a third-year medical student at the University of Washington, Seattle, told Healio Gastroenterology. “Enhanced recovery protocols have been used in colorectal surgery in general for quite some time now.”
“The paradigm has been that inflammatory bowel disease is more complicated and some surgeons have felt that perhaps patients with IBD are inappropriate for enhanced recovery protocols,” he added. “Some studies have shown that enhanced recovery protocols lead to less complicated hospital courses, so we wanted to characterize the risks and benefits for Crohn’s disease.”
Patients with Crohn’s disease have often been omitted from such studies because of data that suggests this population has increased odds of longer length of stay and readmission with standard postoperative care, according to the researchers.
Haering and colleagues conducted a retrospective cohort study of patients undergoing surgery for complications of Crohn’s disease between 2012 and 2018 with a historical control. Participants were either managed with the institutional colorectal enhanced recovery protocol (n = 98) or the prior standard of care (n = 53).
The primary outcome was length of stay. Other outcomes included the rate of serious complications, 30-day readmission rates, need for reoperation, return of bowel function, resumption of diet and postoperative pain control.
The researchers assessed continuous outcomes, including length of stay, return of bowel function, tolerance of low-residue diet and postoperative pain control.
Patients in the enhanced recovery protocol cohort had a shorter median length of stay (4 days vs. 5 days; P < .01), faster median return of bowel function (2 days vs. 3 days; P < .01), shorter time to tolerating low-residue diet (2 days vs. 4 days; P < .01) and a faster transition to postoperative pain medications (2 days vs. 4 days; P < .01) than the control cohort.
“In order to achieve oral pain control, a patient needs to be tolerating a low residue diet,” Haering said.
In the multivariate logistic regression analysis, there was a significantly decreased likelihood of prolonged length of stay among patients in the enhanced recovery protocol cohort (OR = 0.37; 95% CI, 0.15-0.88). No differences were observed in the rate of 30-day readmission, rate of serious complications or reoperation.
“Our study was a little underpowered in terms of the complications, but working with what we had, we could not detect any difference in 30-day readmissions, rate of serious complications or reoperation,” Haering said.
Most patients on the ERAS pathway (87.7%) were highly compliant with the protocol (10/13 elements), while the rest (12.3%) were intermediately compliant (6/13 elements). No patients had low compliance with the protocol.
“The dream would be to figure out what elements in particular independently and – more importantly – in concert make the best enhanced recovery protocol,” Haering said. – by Alaina Tedesco
Haering D, et al. Su1939. Presented at: Digestive Disease Week; May 18-21, 2019; San Diego.
Disclosure: The researchers report no relevant financial disclosures.