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Improving postoperative outcome in rectal cancer surgery: Enhanced Recovery After Surgery in an era of increasing laparoscopic resection

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Abstract

Purpose

The Enhanced Recovery After Surgery (ERAS) protocol reduces complications and length of stay (LOS) in colon cancer, but implementation in rectal cancer is different because of neo-adjuvant therapy and surgical differences. Laparoscopic resection may further improve outcome. The aim of this study was to evaluate the effects of introducing ERAS on postoperative outcome after rectal cancer resection in an era of increasing laparoscopic resections.

Materials and methods

Patients who underwent elective rectal cancer surgery from 2009 till 2015 were included in this observational cohort study. In 2010, ERAS was introduced and adherence to the protocol was registered. Open and laparoscopic resections were compared. With regression analysis, predictive factors for postoperative outcome and LOS were identified.

Results

A total of 499 patients were included. The LOS decreased from 12.3 days in 2009 to 5.7 days in 2015 (p = 0.000). Surgical site infections were reduced from 24% in 2009 to 5% in 2015 (p = 0.013) and postoperative ileus from 39% in 2009 to 6% in 2015 (p = 0.000). Only postoperative ERAS items and laparoscopic surgery were associated with an improved postoperative outcome and shorter LOS.

Conclusions

ERAS proved to be feasible, safe, and contributed to improving short-term outcome in rectal cancer resections. The benefits of laparoscopic surgery may in part be explained by reaching better ERAS adherence rates. However, the laparoscopic approach was also associated with anastomotic leakage. Despite the potential of bias, this study provides an insight in effects of ERAS and laparoscopic surgery in a non-randomized real-time setting.

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Data availability

Yes.

Code availability

Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS, IBM)

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Acknowledgements

We would like to thank all the members of the ERAS team in NWZ Alkmaar for their efforts to sustain the ERAS protocol in rectal cancer surgery. We would like to thank A. Dekker for her role in improving ERAS adherence and collection of the data.

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Authors and Affiliations

  1. Northwest Clinics, Department of Surgery, NWZ Alkmaar, Wilhelminalaan 12, 1815 JD, Alkmaar, the Netherlands

    Nathalie Bakker, Hiëronymus J. Doodeman, Michalda S. Dunker, Wilhelmina. H. Schreurs & Alexander P. J. Houdijk

  2. Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands

    Nathalie Bakker & Alexander P. J. Houdijk

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  1. Nathalie Bakker
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  2. Hiëronymus J. Doodeman
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  3. Michalda S. Dunker
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  4. Wilhelmina. H. Schreurs
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  5. Alexander P. J. Houdijk
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Contributions

NB, JD, and AH: study conception and design. NB: acquisition of data. NB, JD, and AH: analysis and interpretations of data. NB and AH: drafting of manuscript. MD and WS: critical revision of manuscript.

Corresponding author

Correspondence to Alexander P. J. Houdijk.

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Ethical approval and informed consent were waived by the IRB of the Northwest Clinics in view of the retrospective nature of the study and all the procedures being performed were part of the routine care.

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The authors declare no competing interests.

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Bakker, N., Doodeman, H.J., Dunker, M.S. et al. Improving postoperative outcome in rectal cancer surgery: Enhanced Recovery After Surgery in an era of increasing laparoscopic resection. Langenbecks Arch Surg 406, 2769–2779 (2021). https://doi.org/10.1007/s00423-021-02266-x

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