Enhanced recovery after surgery (ERAS) protocols for colorectal cancer in Japan

Dai Shida, Kyoko Tagawa, Kentaro Inada, Keiichi Nasu, Yasuji Seyama, Tsuyoshi Maeshiro, Sachio Miyamoto, Satoru Inoue, Nobutaka Umekita

Japan has one of the highest five-year relative survival rates for colorectal cancer in the world, with its own traditions of perioperative care and a unique insurance system. The benefits of enhanced recovery after surgery (ERAS) protocols in the Japanese population have yet to be clarified. We evaluated 352 consecutive cases of colorectal cancer resection at Tokyo Metropolitan Bokutoh Hospital between July 2009 and November 2012. Of these, 95 cases were performed according to traditional protocols (traditional group), and 257 according to ERAS protocols (ERAS group), which were introduced to the hospital in July 2010. Primary endpoints included length of postoperative hospital stay, postoperative short-term morbidity, and rate of readmission within 30 days. Intensive pre-admission counselling, no pre- and postoperative fasting (provision of oral nutrition), avoidance of sodium/fluid overload, intraoperative warm-air body heating, enforced postoperative mobilization, and multimodal team care were among the main changes brought about by the introduction of ERAS protocols. The median (interquartile range) length of postoperative hospital stay was 10 (10-12.75) days in the traditional group and seven (6-8) days in the ERAS group, i.e., a three-day reduction (p < 0.05) in the ERAS group. Moreover, the proportion of patients discharged within one week dramatically increased from 1 % to 77 % in the ERAS group. The overall incidence of grade 2 and 3 postoperative complications according to the Clavien-Dindo classification was 9.5 % in the traditional group and 9.3 % in the ERAS group, and 30-day readmission rates were 8.3 % and 6.6 % in the traditional and ERAS groups, respectively. There were no significant differences between the two groups. Although operative time and blood loss did not differ significantly between the two groups, the volume of intraoperative infusion was significantly decreased in the ERAS group (p < 0.05), possibly due to ERAS recommendations to avoid dehydration (i.e., avoidance of sodium/fluid overload, no preoperative fasting). ERAS protocols for colorectal surgery helped reduce the length of postoperative hospital stay without adversely affecting morbidity, indicating that ERAS protocols are feasible and effective in Japanese settings as well.