Learning curve of enhanced recovery after surgery program in open colorectal surgery

Enhanced recovery after surgery (ERAS) reduces hospitalization and complication following colorectal surgery. Whether the experience of multidisciplinary ERAS team affects patients' outcomes is unknown.

To evaluate and establish a learning curve of ERAS program for open colorectal surgery.

This was a review of prospectively collected database of 380 "unselected" patients undergoing elective "open" colectomy and/or proctectomy under ERAS protocol from 2011 (commencing ERAS application) to 2017 in a university hospital. Patients were divided into 5 chronological groups (76 cases per quintile). Surgical outcomes and ERAS compliance among quintiles were compared. Learning curves were calculated based on criteria of optimal recovery: defined as absence of major postoperative complications, discharge by postoperative day 5, and no 30-d readmission.

Hospitalization more than 5 d occurred in 22.6% (n = 86), major complication was present in 2.9% (n = 11) and 30-d readmission rate was 2.4% (n = 9) accounting for unsuccessful recovery of 25% (n = 95). Conversely, the overall rate of optimal recovery was 75%. The optimal recovery significantly increased from 57.9% in 1^st quintile to 72.4%-85.5% in the following quintiles (P < 0.001). Average compliance with ERAS protocol gradually increased over the time - from 68.6% in 1^st quintile to 75.5% in 5^th quintile (P < 0.001). The application of preoperative counseling, nutrition support, goal-directed fluid therapy, O-ring wound protector and scheduled mobilization significantly increased over the study period.

A number of 76 colorectal operations are required for a multidisciplinary team to achieve a significantly higher rate of optimal recovery and high compliance with ERAS program for open colorectal surgery.