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

BACKGROUND: Enhanced recovery after surgery (ERAS) reduces hospitalization and complication following colorectal surgery. Whether the experience of multidisciplinary ERAS team affects patients’ outcomes is unknown. AIM: To evaluate and establish a learning curve of ERAS program for open colorectal surgery. METHODS: 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. RESULTS: 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. CONCLUSION: 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.