Determinants of late recovery following elective colorectal surgery

Abstract

Background: Despite the implementation of enhanced recovery protocols, a significant proportion of patients experience delayed recovery. Identifying potential determinants of delayed recovery is crucial for optimizing perioperative protocols and tailoring patient pathways.

Objective: This study aims to identify possible determinants of delayed recovery.

Design: Retrospective observational study based on a prospectively collected dedicated register spanning from 2015 to 2022.

Setting: Twenty-two Italian hospitals specializing in high-volume colorectal surgery and trained in enhanced recovery protocols.

Patients: Patients undergoing elective colorectal resection for cancer or benign disease.

Main outcome measures: Recovery status on postoperative day 2. Late recovery was defined as the failure to meet at least two indicators of postoperative recovery (oral feeding, removal of the urinary catheter, cessation of intravenous fluids, and mobilization) on postoperative day 2.

Results: A total of 1535 patients were analyzed. The median overall adherence to pre- and intraoperative enhanced recovery protocol items was 75.0% (range: 66.6%-83.3%). Delayed recovery was observed in 487 (31.7%) patients. Multiple regression analysis revealed six enhanced recovery protocol items that independently positively influenced postoperative recovery: pre-admission counseling (adjusted odds ratio [aOR] 2.596), a preoperative carbohydrate drink (aOR 1.948), intraoperative fluid infusions < 7 ml/kg/h (aOR 1.662), avoidance of thoracic epidural analgesia (aOR 2.137), removal of nasogastric tube at the end of surgery (aOR 4.939), and successful laparoscopy (aOR 2.341). The rate of delayed recovery progressively decreased with increasing adherence to these six positive items, reaching 13.0% when all items were applied (correlation coefficient [r] = - 0.99, p < 0.001).

Limitations: This study is limited by its retrospective analysis of a register containing data from multiple centers and a diverse patient population.

Conclusions: Adherence to specific pre- and intraoperative enhanced recovery protocol items, including counseling, preoperative carbohydrate intake, restrictive intraoperative fluid management, avoidance of thoracic epidural analgesia, early removal of nasogastric tube, and successful laparoscopy, appears crucial for promoting early recovery following elective colorectal resection.

Keywords: Colorectal surgery; ERAS; Enhanced recovery protocol; Late recovery.