Paving the road to recovery: the colorectal surgery ERAS pathway during the COVID-19 pandemic

Dear Editor,

NHS England reports that 4.7 million people are awaiting an operation in England, the highest in a decade. Healthcare systems are seeking methods to limit an accumulating impact on services. Clinical pathways can be used to improve patient outcomes when recovery is relatively predictable¹. The Enhanced Recovery After Surgery (ERAS) pathway has been shown to reduce rates of postoperative complications, reduce length of stay, and readmission and mortality rates². Implementation of this pathway during and after the COVID-19 pandemic could help reduce time spent in hospital, exposure to nosocomial infections, improve patient flow and help clear waiting lists. Preliminary data from Italy, however, suggested that a colorectal surgery ERAS pathway could not be implemented effectively during a national crisis³. Conversely, although supporting data are limited, it has been speculated that ERAS could play a vital role in the UK’s response to the pandemic⁴.

In conjunction with national guidance⁵ the authors’ tertiary colorectal centre implemented a brief moratorium on elective procedures during March and April 2020. Urgent and emergency cases received rapid SARS-CoV-2 PCR swab testing. Beyond April, elective cases were reintroduced with a pre-admission 14-day isolation period and 3-day preoperative SARS-CoV-2 PCR swab.

The effect of the COVID-19 pandemic on colorectal ERAS pathway adherence and patient outcomes was explored. Complete methodology and demographics can be found in Table S1. Patients were split into two cohorts; those admitted before (January 2019—February 2020, 110 patients) and during (March 2020—December 2020, 56 patients) the pandemic (Table 1). Compliance with 14 ERAS pathway factors, spanning 3 days after the operation and shown to be influential on postoperative outcomes², was assessed retrospectively (Table S2).

Table 1.

Surgical pathway adherence represented by compliance to the ERAS pathway and surgical approach and postoperative outcomes for colorectal ERAS patients before and during the pandemic

	Before pandemic (n = 110)	During pandemic (n = 56)	Overall (n = 166)	P †
Pathway adherence
Mean ERAS compliance (%)	58.6	68.2	61.8	<0.001
Surgical approach
Laparoscopic	41 (37.3)	27 (48.2)	68 (41.0)	0.175
Planned open	52 (47.3)	22 (39.2)	74 (44.6)	0.328
Converted to open	17 (29.3)	4 (19.9)	21 (23.6)	0.082
Robotic	0 (0)	3 (5.4)	3 (1.8)	–
Postoperative outcomes
Length of stay (days)*	7 (5–12)	7 (4–10)	7 (4.75–11)	0.172
Complications	55 (50.0)	23 (41.1)	78 (47.0)	0.276‡
30-day post-discharge readmissions	10 (9.1)	3 (5.4)	13 (7.8)	0.397‡
30-day post discharge mortality rate	0 (0)	0 (0)	0 (0)	N/A

Values in parentheses are percentages unless indicated otherwise;

*values are median (i.q.r.).

^†Mann–Whitney U test, except.

^‡χ² test.

Mann–Whitney U test analysis revealed an increase in colorectal surgery ERAS pathway compliance during the pandemic (P < 0.001) compared with before (Table 1 and Fig. S1). No significant difference in length of stay (Table 1 and Fig. S2) was observed. This was on the background of a reduction in admissions to 80 during year 2020 from 104 (median over past 10 years). Analysis using χ² test did not reveal a significant difference in postoperative complications (TableS3) or 30-day post-discharge readmission rates (Table 1). The 30-day post-discharge mortality rate remained at zero in both groups and no patients tested positive for SARS-CoV-2 PCR swabs during admission.

The colorectal surgery ERAS pathway has passed the ultimate stress test; it is safe, straightforward and improves outcomes. It should form part of the post-pandemic recovery with the aim to clear waiting lists.

Disclosure. The authors declare no conflicts of interest.

Supplementary material

Supplementary material is available at BJS online.