Association between use of enhanced recovery after surgery protocols and postoperative complications in colorectal surgery in Europe:The EuroPOWER international observational study /Javier Ripoll ́es-Melchor, Ane Abad-Motos, Maurizio Cecconi, Rupert Pearse, Samir Jaber, Karem Slim, Nader Francis, Antonino Spinelli, Jean Joris, Orestis Ioannidis, Eirini Zarzava, Nüzhet Mert S ̧ Seppe Koopman, Nicolai Goettel, Ottokar Stundner, Tomas Vymazal, Petr Koci ́an, Alaa El-Hussuna, Michał Pędziwiatr, Jurate Gudaityte, Tadas Latkauskas, Marisa D. Santos, Humberto Machado, Roman Zahorec, Ana Cvetkovi ́c, Mirjana Miric, Maria Georgiou, MD ag, Yolanda Díez-Remesal, PhD ah, Ib Jammer, PhD ai, Gabriel E. Mena, Andr ́es Zorrilla-Vaca, Marco V. Marino, Alejandro Su ́arez-de-la-Rica, Jos ́e A. García-Erce, Margarita Logro ̃no-Ejea, Carlos Ferrando-Ortol ́, María L. De-Fuenmayor-Valera, Bakarne Ugarte-Sierra, Jos ́e de Andr ́es-Iba ̃nez, Alfredo Abad-Gurumeta, Gianluca Pellino, Manuel A. G ́omez-Ríos, Gilberto Poggioli, Albert Menzo-Wolthuis, Berta Castellano-Paulis, Patricia Gal ́an-Men ́endez, C ́esar Aldecoa, Jos ́e M. Ramírez-Rodríguez, on behalf of the EuroPOWER Study Investigators Group, for the Spanish Perioperative Audit and Research Network (RedGERM-SPARN), The Francophone Group for Enhanced Recovery After Surgery

Abstract

STUDY OBJECTIVE: Assess the relationship between the Enhanced Recovery After Surgery (ERAS®) pathway and routine care and 30-day postoperative outcomes. DESIGN: Prospective cohort study. SETTING: European centers (185 hospitals) across 21 countries. PATIENTS: A total of 2841 adult patients undergoing elective colorectal surgery. Each hospital had a 1-month recruitment period between October 2019 and September 2020. INTERVENTIONS: Routine perioperative care. MEASUREMENTS: Twenty-four components of the ERAS pathway were assessed in all patients regardless of whether they were treated in a formal ERAS pathway. A multivariable and multilevel logistic regression model was used to adjust for baseline risk factors, ERAS elements and country-based differences. RESULTS: A total of 1835 patients (65%) received perioperative care at a self-declared ERAS center, 474 (16.7%) developed moderate-to-severe postoperative complications, and 63 patients died (2.2%). There was no difference in the primary outcome between patients who were or were not treated in self-declared ERAS centers (17.1% vs. 16%; OR 1.00; 95%CI, 0.79-1.27; P = 0.986). Hospital stay was shorter among patients treated in self-declared ERAS centers (6 [5-9] vs. 8 [6-10] days; OR 0.82; 95%CI, 0.78-0.87; P < 0.001). Median adherence to 24 ERAS elements was 57% [48%-65%]. Adherence to ERAS-pathway quartiles (≥65% vs. <48%) suggested that patients with the highest adherence rates experienced a lower risk of moderate-to-severe complications (15.9% vs. 17.8%; OR 0.71; 95%CI, 0.53-0.96; P = 0.027), lower risk of death (0.3% vs. 2.9%; OR 0.10; 95%CI, 0.02-0.42; P = 0.002) and shorter hospital stay (6 [4-8] vs. 7 [5-10] days; OR 0.74; 95%CI, 0.69-0.79; P < 0.001). CONCLUSIONS: Treatment in a self-declared ERAS center does not improve outcome after colorectal surgery. Increased adherence to the ERAS pathway is associated with a significant reduction in overall postoperative complications, lower risk of moderate-to-severe complications, shorter length of hospital stay and lower 30-day mortality.