The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair

Abstract

Background

Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS.

Methods

With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013–July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors.

Results

Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4 days (SD = 3.3). Independent perioperative predictors (P’s < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100 cm2), and age (8% increase per 10 years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7 days (95% CI 6%–24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (− 36%).

Conclusions

Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.

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Funding

Dr. Roth discloses he has Grant funding from Bard and Miromatrix; he is a consultant for Bard, Johnson & Johnson, and Allergan; and he owns stock in Miromatrix.

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Correspondence to John S. Roth.

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Disclosures

Mr. Ueland, Mr. Walsh-Blackmore, Mr. Nisiewicz, Drs. Davenport and Plymale, and Ms. Plymale have no conflicts of interest or financial ties to disclose.

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Ueland, W., Walsh-Blackmore, S., Nisiewicz, M. et al. The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair. Surg Endosc 34, 4638–4644 (2020). https://doi.org/10.1007/s00464-019-07233-8

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Keywords

  • Ventral hernia repair
  • Enhanced recovery after surgery
  • Length of stay
  • ERAS compliance