ERAS Protocol Applied to Oncological Colorectal Mini-invasive Surgery Reduces the Surgical Stress Response and Improves Long-term Cancer-specific Survival

Abstract

Background: Enhanced recovery after surgery (ERAS) protocols are known to reduce postoperative complications and improve short-term outcomes by minimizing the surgical stress response (SSR). Retrospective reviews of large cohorts suggest that they may also have an impact on long-term oncological outcomes. In 2016, Mari et al published a randomized trial on ERAS protocol and the impact on the SSR; they found that IL-6 was less expressed in patients who undergo laparoscopic colorectal surgery within an ERAS protocol compared with controls. The aim of the present study is to report the long-term oncological outcomes of patients enrolled 5 years after the conclusion of the study. Methods: Patients enrolled had received the indication for major colorectal surgery, aged between 18 and 80 years, with American Society of Anesthesiologists (ASA) grades I to III, autonomous for mobilization and walking, eligible for laparoscopic technique. In total, 140 patients were enrolled and randomized into 2 groups of 70 patients each. Among these patients, 52 in the ERAS group (EG) and 53 in the Standard group (SG) had colorectal cancer. For them, a 5-year oncological follow-up according to the NCCN16 guidelines was planned. IL-6, C-reactive protein, prolactine, white blood cell count, albumin, and prealbumin were compared between oncological patients in the EG and in the SG. Results: EG showed lower IL-6 on postoperative day 1 (21.2±9.1 vs. 40.3 ±11.3; P<0.05) and on day 5 (14.9±6.2 vs. 38.7±8.9; P<0.05), lower C-reactive protein on day 1 (48.3±15.7 vs. 89.4±20.3; P<0.05) and on day 5 (38.3±11.4 vs. 74.3±19.7; P<0.05), and lower pre-albumine on day 5 (18.9±7.2 vs. 12.3±6.9; P<0.05) compared with SG. Median oncological follow-up was 57 months [46.5 to 60]. There was no statistically significant difference in overall survival (log rank=0.195) and disease-free survival (Log rank=0.089) between groups. Cancer-specific survival was significantly better (log rank=0.038) in the EG compared with patients in the SG. Conclusions: ERAS protocol applied to colorectal laparoscopic surgery for cancer is able to minimize the SSR. As a possible result, cancer-specific survival seems to be improved in patients within enhanced protocols. However, even though there may be an association between an excess of SSR and worse oncological outcomes, the favorable effect of ERAS protocols toward better overall and disease-free survival is yet to be demonstrated.

Anatomic Lung Resection Outcomes After Implementation of a Universal Thoracic ERAS Protocol Across a Diverse Healthcare System

“…In addition, patients benefitted from ERAS implementation regardless of their sociodemographic background. Our data continues to support the notion that ERAS protocols improve postoperative outcomes through the mitigation of the surgical stress response, a speculation backed by several studies examining the association of ERAS compliance with a downregulation in well-known stress markers 21,22 …”

Protocolo de recuperación mejorada después de cirugía (ERAS) atenúa el estrés y acelera la recuperación en pacientes después de resección radical por cáncer colorrectal: experiencia en la Clínica Universitaria Colombia

“…En cuanto a los resultados posoperatorios, diversos estudios han indicado que la falta de tolerancia a la alimentación temprana y la ausencia de movilización el día de la cirugía están asociadas con una estancia hospitalaria prolongada [21][22][23] . En nuestra cohorte, el tránsito intestinal se restableció en el segundo día, y el tiempo medio para la tolerancia a la vía oral fue de 2 días.…”

“…La tasa de reingreso y reintervención a los 30 días fue del 11,4 % y 11,6 %, respectivamente. Estos resultados concuerdan con series recientes de cirugía colorrectal de recuperación mejorada, en las cuales los reingresos hospitalarios oscilaron entre el 9 % y el 13 % 23,24 .…”

Impact of Postoperative Naples Prognostic Score to Predict Survival in Patients with Stage II–III Colorectal Cancer

“…In a meta-analysis comparing laparoscopic and open colorectal surgeries, laparoscopic surgery demonstrated lower levels of CRP and IL-6 compared to open surgery [39]. Additionally, the implementation of ERAS protocol to minimize surgical stress response through minimally invasive surgery has shown an association with improved long-term cancer-specific survival in CRC patients [40]. It is expected that a prospective, large-cohort study utilizing the ERAS protocol in combination with minimally invasive surgeries can enhance the assessment of the NPS system and perioperative assessment to predict oncologic outcomes in CRC patients.…”