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Benefits of the ERAS Protocol in Post-colorectal

Surgery Patients: A Literature Review.

Amrita Alkesh Tailor

MSC Adult Nursing

Word Count: 2746

Introduction

The term ‘Colorectal Surgery’ refers to surgical procedures undertaken to treat colorectal conditions such as colorectal cancer and inflammatory bowel diseases (Kings College Hospital NHS Foundation Trust, 2023). Commonly, colorectal cancer patients receive surgical interventions and the prevalence of stage one colorectal cancer within the United Kingdom between 2016 and 2020 was 90% (Cancer Research, 2021). A National Bowel Cancer Audit showed 76% of patients received laparoscopic surgery (Healthcare Quality Improvement Partnership, 2020), implying a high demand and large population size of patients who require surgical interventions. The speciality vast in procedures that involve removing or re-sectioning the colon, rectum and anus (Cancer Research UK, 2022). For example, one procedure is a colectomy which is the partial, total or half removal of the colon or the permanent opening called ‘stoma’ (Dohrn and Klein, 2023); the differences in surgery procedures indicate different post-operative (PO) needs. Background Kehlet (1997; as cited in Golder and Papalois, 2021) introduced the multimodal Enhanced Recovery After Surgery (ERAS) pathway for colorectal surgery. A growing body of literature recognises the importance of ERAS in PO care, such as Thiele et al (2015) who concluded that the ERAS protocol improved patient satisfaction and reduced length of hospital stay (LOS). Furthermore, Gustafsson, Hausel and Thorell’s (2011) observational study found that adherence to the ERAS protocol reduced delays in hospital discharges; together, these studies provide insights into the success of ERAS. There are three stages within the protocol; Firstly, pre-operative focuses on surgery preparation, secondly, intra-operative focuses on processes during surgery and thirdly, PO which involves post-surgical aspects such as mobilisation and analgesia (Altman et al, 2019). Post-operatively, patients are encouraged to mobilise daily to prevent thromboembolism complications and promote recovery which the importance of mobilising on PO day one is stated in a National Health Services’ (NHS) hospital information guide (Tazreean, Nelson and Twomey, 2022; Sawyer and Aryal, 2022). Further facilitating PO mobilisation, multimodal analgesia’s,

Review of Literature and Rationale There has been growing evidence supporting the success of the ERAS protocol as the implementation enhances recovery through ongoing monitoring where maximising recovery is vital to surgical nursing (Nestler, 2019). The components of early mobilisation and analgesia can be applied to PO care to reduce LOS after colorectal surgery (Wainwright, Jakobsen and Kehlet, 2022). In this review, the benefits of early mobilisation and the multimodal analgesia regimens within the ERAS protocol will be critically analysed to evaluate the influence in reducing LOS within four ethically approved research studies whilst identifying researchers’ methodologies and assessing credibility and reliability of findings to draw on the differences in research approaches. Patient-controlled Analgesia (PCA) and LOS Brown et al (2020) conducted a quantitative observational cohort study to assess effectiveness of PCA in managing PO pain after colorectal surgery and they rationalise that optimal pain management is central to the success of ERAS. Ethical approval was sought and reviewed by the National Research Ethics Service who promote the ethical principal ‘beneficence’ through maximising benefits of findings and protect participants through the process (Jacobsen, pp. 139. 2021). Their participants were from multi-centre facilities, suggesting that the sampling strategy requires extensive collaborative planning (Cheng et al, 2017); theorizing the process could have been expedited to achieve a faster outcome within a target duration. However, the large sample size facilitates the generalisability of findings to apply to a wider population within clinical practice. Moreover, incorporating

observational and prospective data collection highlights strengths between exposures and variables to provide flexibility in comparing multiple outcomes specific to the research question. However, there are risks of attrition bias as data can be lost between follow-up periods (Song and Chung, 2010). The study provides insights into pre- and post-surgical pain scores by identifying complications through statistically analysing data to differentiate scores between two cohort groups. This method allows more than one variable to be analysed without altering hypotheses and useful in estimating prevalences within a population; one limitation is that if the variables are not accurately obtained the results could be unreliable (Aggarwal and Ranganathan, 2019). For example, inaccurate pain scores between each cohort produce unrealistic findings which can not be practically applied to clinical practice, therefore, this method could conflict results. Overall, the researchers concluded that patients using PCA scored higher (74.8%) compared to those without PCA on PO day one and the PCA was frequently administered within the ERAS protocol. Patient outcomes were improved as the median hospital stay was six days which indicates shorter LOS comparing to the implementation of traditional PO protocols. In validation, Turaga’s (2023) systematic review deduced from eighteen studies that ERAS significantly reduced LOS by a mean difference of -1.64 days. Oral Verses intravenous (IV) acetaminophen within the ERAS protocol and LOS. Marcotte et al (2019) conducted a quantitative retrospective observational study evaluating IV acetaminophen analgesia within the ERAS protocol in colorectal surgical patients; they stated that the multimodal analgesic regimen within the ERAS protocol decreases opioid use, encourages mobilisation and decreases PO complications relating to LOS. However, they hypothesized that changes in PO pain management would not differ in patient outcomes and opioid use. Their research was ethically approved by an investigational review board (IRB) who ensures compliance and ethical conduct of research is discussed to minimise harm to participants and in specific circumstances where informed consent is unable to be directly gained, the IRB has authority to waive this requirement in the participants best interest (Byerly, 2009 and Grady, 2015). Suggesting that IRBs are guided by the

hypothesized the implementation of ERAS reduces PO complications relating to mobilisation and LOS. Prior to data collection, the study was ethically approved by a committee from both international and UK departments, and consent was obtained from participants. The researchers combine prospective longitudinal methodology and retrospective historical methodology (Capili, 2022), and their sampling strategy included cohort groups which were based on exposure and non-exposure status of the ERAS protocol. For example, Elsenosy et al (2023) exposed one group to the ERAS protocol and the other two groups were already exposed to the ERAS and traditional protocol. This is a useful way of conducting research, however the differences between each cohort groups and institution bases can be confusing to readers. There are three groups, group one included Twenty-two patients were retrospectively enrolled on the traditional protocol, the second group included twenty patients were prospectively enrolled on the ERAS protocol and group three included twenty-three patients were enrolled retrospectively on the ERAS protocol. The longitudinal process involved the researchers prospectively sampling participants to measure the success of the protocol throughout the post-operative recovery journey to prospectively compare findings to the ERAS pathway. Using retrospective cohort designs, they were able to review past data which are predictor variables that explain response variables (Vandever, 2020) to examine outcome which is cost-effective. However, this implies the possibility of incomplete data sets as the researchers can not directly observe findings. On the other hand, prospectively analysing data allows researchers to determine new outcomes and investigate associations between variables and outcomes (Hulley, 2013; as cited in Capili, 2023). Overall, using statistical analysis to measure the primary outcomes of LOS, readmission and complication with the secondary outcomes of pain, bowel function and mobility, the researchers were able to conclude more informed findings as data was analysed on a statistical package for the social science software (SPSS) to identify patterns and correlations. This method allows analysis to be conducted with minimal risks of error relating to the hypothesis and provides comparisons between differences and categorical variables (Vandever, 2020). However, there are

disadvantages to statistical analysis such as the analysis may not reflect the underlying reality (Aggarwal and Ranganathan, 2016). The researchers concluded that early mobilisation occurred significantly in the ERAS group and LOS was shorter as participants were likely to mobilise and be discharged from hospital within three to give days. Despite the lack of randomisation due to a small sample size and the researcher’s inability to directly observe the implementation of ERAS directly within group one and three, the findings showed that the researchers successfully assessed their hypothesis, and their findings reflect the benefits of the ERAS pathway in post-colorectal surgical patients. Early mobilisation within the ERAS protocol Mathiasen et al (2021) conducted a qualitative study using thematic content analysis to explore patient views and gain future recommendations on the effectiveness of early mobilisation after colorectal surgery. They include the phenomenological approach which enables practice development and provides in-depth meaning of the ERAS protocol. Supporting this, Pyo et al (2023) state that qualitative research promotes deeper understandings of specific phenomenon. Prior to conducting research, informed consent was sought, and the study was ethically approved by a regional ethics board and the participant sample included nineteen patients in which eleven patients consented to take part in the study. Within qualitative research, a smaller sample size can be advantageous as interviewing processes are less time-consuming compared to a larger sample size, however, according to Faber and Fonseca (2014) smaller participant sampling can undermine the validity of the study to the inability of accurately expanding trends into clinical practice, therefore, limits generalisability of findings. However, in support of the researchers’, the small sample size supports in-depth content analysis relevant to the phenomenon (Vasileiou et al, 2018). In addition, the analysis encourages researchers to gain natural perspectives on variables and thematically analysing data aides in identifying grouped variables and development of themes based on interpreting participant responses (Thomas, 2006). For example, Mathiasen et al (2021) derived themes based on participant responses to semi-structured interview questions by systematically content analysing patterns to draw on inferences. Although the method is useful, Braun and Clarke (2020; as

Future recommendations The literature search of this review identified limited research within the UK relating to the benefits of ERAS in post-surgical colorectal patients, therefore UK research should investigate whether a person-centred approach can elevate patient outcomes whilst exploring professional perspectives on the protocol. This suggestion contributes to improving ERAS protocols to meet patient specific needs and identifying the need to compare traditional pathways to the ERAS pathway relating to PO early mobilisation and analgesia strategies. Conclusion In conclusion, this literature view has highlighted the benefits of ERAS in post- colorectal surgical patients where findings of the multimodal analgesic regime prove to reduce LOS and LOS is dependant on effective pain management (Brown et al, 2020; Marcotte et al, 2019). Additionally, early mobilisation has shown to reduce LOS within the ERAS protocol due to reduction in pain during mobilisation (Mathiasen et al, 2021; Elsenosy et al (2023). Furthermore, ERAS protocols continue evolving, therefore addressing the future recommendations, research can contribute to improving evidence-base practice within the National Health Service (NHS) to enhance post-surgical quality of care in colorectal patients. Abbreviations PO = Post-operative. ERAS = Enhanced recovery after surgery. LOS = Length of hospital stay. PCA = Patient-controlled analgesia.

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Appendixes Appendix 1: Inclusion and Exclusion Criteria Appendix 2: Data Extraction Source Database Method and tools Colorectal Post-surgery Mobilisation Analgesia LOS ERAS UK based. 2019- Population Setting Ethical approval Brown et al (2019) Royal College of Surgeons of England PubMed Exploratory Quantitative Prospective Observational Cohort Multicentre Trainee collaborative Microsoft excel

Descriptive statistics. Statistical analysis. Yes, Laparoscopic elective colorectal re-sections. Analgesia LOS ERAS Yes NHS hospital in the Northeast of England. Participants over 18 years old. Colorectal surgery National research ethics service ethically reviewed and approval was sought from participating NHS centres. Mathiasen et al (2021) Gastrointestinal nursing MAG Online Library Google Scholar Qualitative Single centre Content analysis Exploratory Phenomenological Yes, post- colorectal surgery. Analgesia LOS Mobilisation No – international study. Yes - 2019 Department of gastroenterology at a tertiary referral hospital in Denmark. Approved by Danish Data Protection Agency. Regional ethical

approach. Semi-structured interview ERAS Adults Colorectal surgery board Informed consent. Helsinki declaration (WHO, 2013). Elsenosy et al (2023) PubMed NHS Open Athens Prospective Observational Statistical analysis Quantitative Multi-centre Yes- post- colorectal surgery. Mobilisation ERAS Half UK based, half international. Yes- 2023 General surgery and surgical oncology department in Maadi Armed Forces Medical Complex. Trauma and orthopaedics hospital (Poole, GBR) Consent obtained. Approval from institutions Marcotte et al (2019) PubMed Quantitative Statistical analysis. Variables. Cohort groups. Retrospective Observational. Single centre. Yes- post- colorectal. Analgesia LOS International. America Hospital Department of General Surgery Cooper University Hospital, Camden, Montclair. Approved by the cooper health system investigational review board.