Impact of ERAS on Recovery of Patients Undergoing Abdominal Surgery

Abstract

This paper aims to synthesize evidence on the role of enhanced recovery after surgery (ERAS) in the recovery of patients who had abdomen surgery. Although there are many studies that examine one or several aspects of this health concern, systematic reviews involving several specialties were not conducted recently. The qualitative review of 15 articles, which were retrieved from two key medical databases using the Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal tool, is performed with regard to their quality, results, and potential implementation advantages.

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The results of the review revealed that ERAS is a more effective method to assist patients in faster recovery compared to the conventional practices. The shorter length of stay (LOS), lower readmission states, and fewer post-surgery complications were reported by the majority of the studies. Costs savings were dependent on the LOS. Further exploration is required in order to determine patient satisfaction with ERAS and interdisciplinary coalition as a way to improve patient outcomes.

Background

Postoperative complications of abdominal surgeries present a critical risk to patients’ health. The most invasive operations, such as cystectomy, colorectal and gynecological procedures, and gastrointestinal surgeries, are associated with high mortality and morbidity rates. Tevis and Kennedy (2016) found that after colorectal surgeries, mortality could reach 16.4 percent, and morbidity – 35 percent. Patel et al. (2015) reported that among urologic procedures, cystectomies carry the highest morbidity (56 percent of complications and 10.2 days length of hospital stay) and mortality (3.2 percent).

On the other hand hysterectomy, the most frequently performed gynecological procedure, is associated with increased long-term risk of cardiovascular and metabolic disorders (Laughlin-Tommaso et al, 2018). Among the population undergoing elective major abdominal surgery, the elderly (65 years of age or older) is at highest risk of morbidity and mortality at a rate of 29 and 28.2 percent, respectively (Patel, & Semerjian, 2017; Schmidt et al., 2018).

Overall, Debas et al. (2015) found that of the seven million operations performed worldwide annually, in the last decade, at least 50 percent carried associated problems regarded as preventable. The issues associated with abdominal surgery deemed preventable include infections, venous thromboembolism events (VTEs), gastrointestinal paralysis, pulmonary issues, as well as nausea and vomiting (Ljungqvist, Scott, & Fearon, 2017).

In general postoperative complications include increased length of hospital stay (LOS), readmissions, and greater health care costs (Hurley et al., 2016; Tan, Lamb, & Kelly, 2015). In their review, Tevis and Kennedy (2016) and more recently Ljungqvist, Scott, and Fearon (2017) examined the impact of postoperative inteventions on patient recovery. The effect of perioperative care on surgical outcomes is the focus of the implementation of the enhanced recovery after surgery (ERAS) protocol put forth originally by Professor Kehlet in the 1990s (Tan, Lamb, & Kelly, 2015).

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ERAS is based on a multimodal approach and includes limiting the volume of infusion therapy, carrying out adequate anesthesia with minimizing the administration of opioid analgesics, and restoring patient mobility (Ljungqvist, Scott, & Fearon, 2017). The preoperative preparation of patients, careful monitoring during surgery, and postoperative management are proposed as the key points of ERAS. Such principles allow facilitating the rehabilitation of patients after surgery and reduce the level of adverse effects (Ljungqvist, & Hubner, 2018; Melnyk, Casey, Black, & Koupparis, 2011).

There is strong evidence (Pędziwiatr, 2015; Portinari et al, 2018) that ERAS is effective following colorectal surgery, but limited research is reported in other areas, such as urology, gynecology, and gastroenterology. The factors that impact patient recovery include faster bowel function restoration, shorter length of stay at the hospital after surgery, and decreased morbidity (Mosquera, Koutlas, and Fitzgerald, 2016). Compared to the conventional method of patient recovery, ERAS provides a more comprehensive and interprofessional team based approach (Koo, Brace, Shahzad, & Lynn, 2013). Additionally, Mosquera et al. (2016) pointed out the feseability and cost-effectiviness potential linked to ERAS adoption with regard to patients undergoing different abdominal procedures.

Rationale for Conducting the Systematic Review and Importance to Nursing

Today, ERAS is successfully implemented in a number of leading hospitals (Mosquera et al., 2016). However, there are significant obstacles to implementing ERAS protocols including excessive caution of doctors and unwillingness to supersede conservative methods (Vukovic & Dinic, 2018). Teamwork and engaged surgical physicians, anesthetists, rehabilitologists, clinical pharmacologists, medical personnel, and other necessary specialists are required to ensure that ERAS will be fully implemented and effective. Health care providers and patients may need to be educated about the potential benefits of ERAS protocols sufficiently informed about new treatment options (Pędziwiatr et al., 2015).

A secondary goal of this project was to learn how ERAS is adopted in the U.S. and potential barriers (Vukovic, & Dinic, 2018) to conclude that it is necessary to familiarize clinicians and patients more closely with the achievements of ERAS and conduct training. Given the importance of the problem, the development of clinical guidelines seems to be relevant. Additionally, in reviewing the literature the role of advanced practice registered nurses (APRNs) was examined in implementing ERAS protocols in conducting education, staff management, and problem-solving (Ljungqvist, & Fearon, 2017).

Objectives of the Systematic Review

The objectives of this project were first to conduct a systematic review of the literature focused on the components and impact of ERAS in decreasing the complications of abdominal surgery in patients, and second to utilize these findings in developing a quality improvement plan explicitly focused on planning for the implementation of an ERAS pathway post-cystectomy at a large academic tertiary care center. The review of the literature was guided by the PICO (population, intervention, comparison, and outcomes) clinical question: In patients undergoing abdominal surgery, what is the impact of implementing ERAS on patient recovery? The report is organized by surgical specialty: urology (GU); gynecology (GYN); colorectal procedures, and gastroenterology (GI). The following specific questions were addressed:

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  • How does implementing ERAS impact patient recovery after surgery?
  • Does ERAS result in reducing healthcare costs?
  • What is the potential contribution of APRNs in implementing ERAS at a large academic tertiary care center?

Methodology

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses [(PRISMA), 2015] was used in developing the study protocol and reporting the results in a flow chart as depicted in diagram 1.

Information Sources and Search Strategy

A university library scientist was consulted in developing the search strategy and a university library portal was used to search multiple databases including CINAHL, MEDLINE, Joanna Briggs Institute Evidence-Based Practice Resources (JBI EBP), and Cochrane. Only CINAHL and MEDLINE databases included relevant articles. The search terminology included : “Enhanced recovery after surgery“, “ERAS”, “implement”, “patient recovery”, “abdominal surgery”, and “patient outcome” keywords, word variations, and boolean phrases of “AND” and “OR” were utilized. Medical subject headings (MeSh/MH) served to refine the search.

Study Selection, Screening Method, and Eligibility Criteria

All of the 1040 studies identified in the databases, were initially screened (title and abstract) and examined according to the eligibility criteria. Full-text articles were deemed eligible if the study addressed the PICO question and the following eligibility criteria: 1. ERAS protocol intervention studies focused on colorectal, gynecology, digestive system, and urology surgical procedures; 2. English language article; 3. Publication date beginning January 1, 2010 and ending March 31, 2019 in consideration to the ERAS society establishment in 2010, 4. Non-adult subjects, and 5. The setting of the study was the United States with the exception of ERAS intervention studies focused on urologic surgery as this was the specfic area of interest.

Studies were excluded if the report did not inform on an ERAS protocol intervention. Simultaneously, those focused on emergency surgeries were not included assuming their higher complications rate that directly affects postoperative outcomes and therefore study results (Murtaza, Saeed, & Sharif, 2010). Similar consideration was given to those based on patients with neoadjuvant chemotherapy and added radiation or not for the expected existance of health-significant comorbidities concomitantly that could delay the time of the surgery and therefore modify surgical outcomes (Boeri et al., 2018).

Reports covering vascular procedures such as abdominal aneurysms or non-transabdominal surgery (solely vaginal or mainly thoracic approaches) were deemed not eligible to enable exclusive comparison of the factor “abdominal” among the various specialties and outcomes. Lastly, articles that were not a primary research study report were rejected, although incorporated into the background information. Consequently, a total of 15 articles were included in this this systematic review.

Study Selection, Screening Method, and Eligibility Criteria

Data Collection and Outcome Items

A data abstraction form developed for the study included author, year of publication, journal name, geographic locale, care unit or setting, research design, interventions, and study results including patient’s outcomes, LOS, and healthcare costs pointed out as relevant to the research question. Additionally, information about the actions of APRNs related to ERAS implementation was covered in the narrative accordingly.

Study Appraisal

To assess the quality of the studies, the Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal tool was used, and one of the evidence levels was assigned to each article (Holly, Salmond, & Saimbert, 2016). Characteristics from each research article including information about sample size, properties of outcome measures, and intervention fidelity were extracted. The quality of evidence from elegible studies ranged from I, the strongest level of evidence, to V, the weakest. Simultaneously, the Grade Practice Recommendations tool developed by the American Society of Plastic Surgeons (ASPS) was added for clinical decision making (Burns, Rohrich, & Chung, 2011).

The letters “A” and “B” described articles with strong recommendation and recommendation, respectively. While letter grades “C” and “D” labeled them as optional. With the exception of a ramdomized control trial (RTC) that graded I-A, the majority of the studies included in this report are level II evidence with recommendations for practice ranging from “A”-to-“C”.

Conceptual Framework

Five Stages in the Decision Innovation Process
Five Stages in the Decision Innovation Process.

The Diffusion of Innovation theory by Rogers (2003) was used to guide this study. Specifically, the theory was used to discuss and explain the results in regards to limited or slow adoption of ERAS in the United States, particularly in the area of urology, based on the limitted data obtained. The theory aims to provide the introduction of an innovative idea into practice through a set of stages: knowledge, persuasion, decision, implementation, and confirmation (Birken et al., 2015). Exposure to information occurs at the “knowledge” stage, here innovators embrace the change. Early adopters are then persuaded to try the innovation in the “persuasion” stage.

According to Rogers (2003), the “decision” stage is the most troublesome, giving birth to two categories of adopters. Those afforded less skepticism become the early majority by accepting the innovation. Meanwhile, the late majority are more incredulous or hesitant to change, and may reject the idea. The full or partial use of the innovation occurs during the stage of “implementation”. Evaluation, continuation, and dissemination of change happens during the last stage –“confirmation”-. Here laggards that break from tradition will adopt the innovation while new or improved ideas emerge.

In order to make innovation happen, it is essential to understand the current state of affairs, existing barriers, and the effectiveness of the proposed intervention, which are the key points of the theory. In this context, addressing obstacles and unnecessary variations in clinical practice will require an understanding of 1) the components of ERAS protocol, 2) the relevance of the data supporting its implementation, and 3) the cultural environment at a large academic tertiary center, where is intended to be practiced. The utilization of this theory seems to be appropriate as it informs the results on patients outcomes under ERAS care specific to patients undergoing abdominal surgery. It may also support how the conservative approach to postoperative care may be replaced by a more relevant one.

Results

Study Selection

The search for articles identified 804 studies in the MEDLINE database and 285 articles in CINAHL database. The elimination of duplicates left 1040 articles, and 917 did not meet the eligibility criteria. Articles, whose full text could not be found in FIU library, Google Scholar, or anywhere else in the web, were disqualified. The full-text articles were obtained and reviewed by the author for inclusion. The final review produced 15 eligible studies published. Diagram 1 provides the PRISMA Flow Sheet and Tables 1 – 4 outlines the final 15 studies and associated characteristics.

Study Characteristics

Of the 15 studies the patient sample varied as did the intervention focus. Six of the articles focused on colorectal surgery, five in urology, and two in gynecology, while the other two included the digestive system. Most of the studies were prospective or retrospective, when the historical patients with abdominal surgery recovered using a conventional method were enrolled in one group, and those who received ERAS composed the other one. The comparative nature of the studies was appraised as beneficial to comprehending the impact of ERAS on patients undergoing various types of abdominal surgery. The combination of qualitative and quantitative research methods allowed revealing more trends and gaps in the current literature. All the articles included in the review are of a high quality as they present evidence-based data and clearly explain the results.

Risk of Bias

Risk of bias assessment based on Quadas tool.
Table 1. Risk of bias assessment based on Quadas tool.

Results of studies

Sample

Most of the studies reviewed had sufficient sample sizes, with most samples ranging from 100 to 400 people. For example, the study by Bergstrom et al. (2018) had a sample size of 267 patients, and the study by Boitano et al. (2018) collected information from 376 participants. The smallest study was the one conducted by Persson et al. (2015), which included 70 patients, and the largest study was carried out by Martin et al. (2016) with 1036 patients. Admittedly, larger samples may account for greater research validity and render the findings inferential.

Besides sample size, the ratio between different groups of participants was important while reviewing the quality of studies. Some studies, such as the one by Persson et al. (2015), underrepresented women among the participants. Other sampling issues were also present, with some studies having a non-comparable number of patients in groups. For example, in the study by Bergstrom et al. (2018), non-ERAS participants were somewhat overrepresented (60%), and in the study by Zoog et al. (2018), the sample was dominated by so-called historical patients. Similarly, in a study by Morgan et al. (2016), the traditional care patients (control group) accounted for 78% of the sample, while ERAS patients only constituted 22%. The fact that some studies overrepresented the historical group is likely due to the fact that accessing historical data was relatively easy.

Setting

The overwhelming majority of the studies examined patients in clinical settings. The only exception is the study by Martin et al. (2016), the front and center of which was SJMH administrative and clinical database research, which did not imply any actual patient contact and examination. This type of setting did not allow the researchers to have much control over interventions. However, other studies were mostly done in clinical settings, including postoperative, urological, gynecological, and other departments of various hospitals. Most studies recruited patients from a single institution, which affected both the sample size and the volume of data collected. One study by Lin et al. (2018) collected information from 25 Chinese Bladder Cancer Consortium centers, thus contributing to the quality of the research.

Additionally, the majority of researchers relied on objective data gathered through patient examination and progress tracking rather than on patient reports. In studies that implied investigating post-discharge deliverables, clear discharge criteria were included to guide the process. The data items gathered during the research were similar in all of the studies, but there were some variations in the scope of data collected. For example, while all studies collected data on patient recovery, such as the length of stay or 30-day readmission rate, Chipollini et al. (2017), Geltzeiler et al. (2014), Miller et al. (2014), Morgan et al. (2016), Mosquera et al. (2016), and Semerjian et al. (2017) also collected information on hospital expenses.

Research Design

The research design used varied slightly depending on the specialization of the setting. In urological setting, most studies employed prospective research design and were based on the observation of phenomena or the lack thereof in progress. The only study that used retrospective design was the one by Palumbo et al. (2018). The authors noted that their choice was justified by the fact that they compared and contrasted two virtually contemporary cohorts of patients, therefore, rendering their methods relevant.

In gynecology, both studies employed retrospective control trial design without randomization, which is a major flaw as it does not allow to render the findings precisely inferential. In colorectal ERAS studies, most studies employed a retrospective comparative design that relied heavily on database research and post-factum observations. The only prospective study among those described is that by Geltzeiler et al. (2014), that included intervention, observation, and data analysis over the course of three years (2009, 2011, and 2012).

Finally, in gastroenterology, both studies compared and contrasted two groups of patients – traditional care and ERAS – against each other in a controlled trial. However, the study by Aviles et al. (2017) employed prospective design as its authors observed the phenomena in progress and could intervene at any point. The retrospective design of the study by Morgan et al. (2016) may be one of its downsides since researching databases gives one much less control over the process and, consequently, the outcomes.

Interventions

The primary intervention used in the studies was ERAS implementation. Nevertheless, there were some differences in its implementation in various settings. The study by Bergstrom et al. (2018) included all phases of ERAS intervention: preoperative, intraoperative, and postoperative measures. The research piece by Boitano et al. (2018), on the other hand, only focused on ERAS implementation post-operation. Bergstrom et al. (2018) mentioned that they had to additionally comply with the US guidelines for treating gynecological cancer patients. Therefore, they were obliged to monitor their participants for perioperative thromboembolism. Morgan et al. (2016) and Aviles et al. (2017) made sure to follow ERAS guidelines in their research. However, in the first case, every phase was a priority – preoperative, intraoperative, and postoperative, while in the second case, perioperative care was the focus of researchers.

In addition to ERAS implementation, some researchers also used other secondary interventions. In urology, the authors ensured fewer or no bowel preparation procedures prior to the medical invasion. Such studies, like the ones by Persson et al. (2015) and Lin et al. (2018), focused on early food and water intake to stimulate bowel activity. The majority of the reports advocated for early mobility, which might have also contributed to the reduced LOS in ERAS patients.

Some of the studies, such as the one by Zoog et al. (2018), set health promotion as one of its key objectives: the authors made sure to provide patient education as part of the intervention so that their patients understood the nature of procedures and the importance of self-management. Morgan et al. (2016) singled out two essential elements of care, which they used in their study: the restriction of IV fluid administration and preoperative carbohydrate loading to prevent insulin resistance during surgery. These secondary interventions could have contributed to the positive results achieved by ERAS in some studies.

Key Findings

The findings of the studies regarding patient recovery were mostly inconclusive. Most studies that focused on readmission rates and length of stay did not find significant differences between the ERAS and the control group. The study by Aviles et al. (2017) proved that enhanced recovery for pancreatic cancer patients was possible through comprehensive ERAS implementation. However, as compared to standard care, ERAS did not show any advantages regarding LOS, readmission rates, and morbidity rates. Some authors found a positive influence of ERAS implementation on patient recovery. The study by Morgan et al. (2016) demonstrated that ERAS was more efficient than standard care based on each and every criterion. In contrast, some studies found evidence against ERAS. A study by Martin et al. (2016) revealed that ERAS implementation contributed to higher readmission rates as opposed to those following traditional care application (14.6% vs. 8.7%).

There was less variation in the findings of researchers who focused on other indicators besides recovery. For instance, Geltzeiler et al. (2014) and Miller et al. (2014) found that ERAS implementation resulted in lower medical costs per patient. Chipollini et al. (2017) detected an insignificant growth in costs associated with ERAS, but the variance in billed charges was reduced. With regard to complications, some studies indicated a positive influence of ERAS implementation. Participants in the study by Boitano et al. (2018) reported milder ileus – nausea, and vomiting after surgery. Bergstrom et al. (2018) also noted that ERAS patients needed less narcotic analgesia due to the chosen treatment method.

Clinical Outcomes

As the analysis has shown, ERAS implementation tended to lead to improved clinical outcomes in most settings, although in some cases, the improvements were insignificant. In urology, LOS remained the same or was slightly shorter as compared to traditional postoperative treatment. Two studies demonstrated faster bowel function recovery after surgery (Lin et al., 2018; Chipollini et al., 2017). Two out of five studies implied lower complication rates for ERAS patients (Persson et al., 2015; Palumbo et al., 2018). In gynecology, no difference was noted between the control and intervention groups regarding LOS, 30-day readmissions, and complications associated with the postoperative period, which is reflected by de Groot et al. (2018). Morbidity and mortality rates remained similar to control groups compared to intervention cohorts.

Similarly, in colorectal settings, the results reported by Fabrizio et al. (2017) demonstrate that the enhanced recovery pathways (ERPs) did not significantly reduce hospitalization rates. However, ERAS implementation had a positive impact on hospitalization periods. The improved recovery was marked as noticeable with regard to site infections, while the cases of small bowel obstruction increased in number. Accordingly, it is possible to assume that the reproducibility of ERAS is sufficient to implement it in other local hospitals.

Finally, evidence regarding the effectiveness of ERAS in patients undergoing gastric surgery is not consistent even though some similar outcomes can be noted, which is also supported by Yamada et al. (2014). In particular, the key goal of reducing hospital days was achieved in the course of safe implementation of ERAS guidelines in clinical settings. Since this data was not proved by one of the reviewed articles, further research should explore this issue in detail via experimental studies and mixed methods design.

Despite inconclusive findings on major recovery indicators, studies showed that ERAS implementation had certain positive effects on other important variables. For example, ERAS implementation reduced the use of narcotics to relieve patients’ pain, and increased venous thromboembolism (VTE) prophylaxis (Bergstrom et al., 2018). It should be stressed that not all patients received quality and safe VTE education, which identified the necessity to introduce audit measures for continuous control and monitoring. Another important area that was covered by many studies is patient, and family satisfaction changes.

The comparison of two cohort groups by Fabrizio et al. (2017) revealed no difference in the attitudes of those who received ERAS protocol and did not, yet patients exposed to readmission rated their experience lower than those who avoided repeated hospitalizations. More positive results are shown in the study by Miller et al. (2014), who found that patients from the traditional group experienced higher pain rates compared to the intervention group, which is characteristic of their comfort levels.

Length of Stay (LOS)

Along with hospitalization rates, LOS is a significant factor that points to the success of the recovery-related intervention. With regard to LOS, the results of the studies varied greatly. In urology, two of five studies report that LOS did not change essentially (Lin et al., 2018; Persson et al., 2015). Additionally, studies by Bergstrom et al. (2018) and Morgan et al. (2016) demonstrated no significant differences in LOS after ERAS was implemented.

In other studies, the results were somewhat more promising. The research conducted by Boitano et al. (2018) revealed a significant decrease in LOS from 4.0 to 2.9 days. The research by Mosquera et al. (2016) demonstrated an almost 30% difference after ERAS implementation (6.4 days vs. 9.2 days), whereas Geltzeiler et al. (2014) came to even more promising conclusions. In their case, following ERAS guidelines helped to reduce LOS almost in half – from 6.7 to 3.7 days. Aviles et al. (2017) came to somewhat different conclusions: their study showed that following ERAS guidelines accounted for a decrease in LOS from 9.2 to 7.4 days. Given the differences in findings, one may say that the current evidence is not exactly conclusive, and the relationship between LOS and ERAS implementation requires further investigation.

Healthcare Costs

Some studies also researched the role of ERAS implementation in decreasing healthcare costs, but the results varied. In some cases, ERAS proved to be economically efficient, while traditional care costs were found to be more of a burden ($21,674 vs. $30,380) (Mosquera et al., 2016). Geltzeiler et al. (2014) and Miller et al. (2014) also found that ERAS implementation resulted in lower medical costs.

According to Geltzeiler et al. (2014), the reduction in medical costs was mostly due to the decreased length of stay, with estimated cost savings ranging from $3202 to $4803 per patient in 2011 and 2012, respectively. In the study by Miller et al. (2014), individual cost savings were not statistically significant, but the researchers stated that “the net reduction in medical costs achieved with the ERAS protocol was approximately 10% of traditional care medical costs before and after adjustment” (p. 1056). None of the studies showed increased medical costs associated with ERAS implementation, which allows concluding that the overall effect of ERAS on healthcare costs is positive.

Barriers to Implementation

As part of the research, some scholars noted possible barriers to implementation. The primary barrier to implementation identified in research was the lack of clarity regarding the constituents of ERAS. For instance, Bergstrom et al. (2018) noted that there was a lack of consensus on appropriate ERAS practices and interventions. In particular, ERAS guidelines had yet to be comprehensively translated into surgical practices, especially in regards to gynecology (Bergstrom et al., 2018). Other studies identified poor compliance with ERAS implementation as a significant barrier.

For example, Aviles et al. (2017) found that the lack of patient care coordination, variations in equipment availability, the providers’ lack of knowledge in hemodynamic monitoring, and contraindications to certain intervention items affected compliance with ERAS. Providers’ preferences were also outlined as barriers to ERAS implementation (Aviles et al., 2017; Palumbo et al., 2018). According to the conclusions made by Palumbo et al. (2018), “obstinate defense of traditional surgical dogmas by urologists as one of the main obstacles to widespread adoption” (p. 132). Addressing these barriers could help to ensure the widespread adoption of ERAS protocols.

Strategies for Overcoming Barriers to Implementation

Only two of the studies mentioned potential strategies for overcoming barriers to ERAS implementation. Aviles et al. (2017) recommended using the Plan-Do-Study-Act to enhance the implementation process, as well as to improve controls to reduce variations in postoperative care. Additionally, the researchers recommend a culture change that would increase patient centricity and promote interdisciplinary collaboration among providers (Aviles et al., 2017). Similarly, Zoog et al. (2018) insist that cultural change would have a positive effect on ERAS implementation. The specific strategies recommended by these authors include providing staff education, creating ERAS multidisciplinary teams, conducting regular evaluations and meetings, and monitoring ERAS implementation results (Zoog et al., 2018).

Generalizability of Conclusions

The existing evidence concerning applicability and reliability of ERAS protocols seems quite promising. However, there is some conflicting data that does not allow for putting together a full picture. For instance, described studies show different outcomes regarding LOS with some revealing a reduction as significant 50% and the others concluding no statistical differences as compared to traditional care. Further, according to some studies, readmission rates did not improve after ERAS implementation. So far, it is possible to presume that ERAS seems to be an appropriate strategy to relieve postoperative symptoms such as ileus.

Gaps in Research and Limitations

The studies analyzed have demonstrated some significant limitations such as insufficient sample size and underrepresentation of certain demographic cohorts. Almost in all the studies, the participants belonged to the same age group (>50) and were racially and ethnically homogenous. Moreover, convenience sampling employed in every research piece under investigation did not account for statistical conclusions that could be truly inferential. Further, traditional care to which control groups were subject was not exactly specified. There is a likelihood that preoperative, intraoperative, and postoperative care varied across the medical facilities involved.

Another limitation evident that affects the results and conclusions of the reviewed studies is that many of them use a retrospective design. The primary weakness of such design is that it could pose a high risk of bias associated with the availability of historical information about patients or the differences in indicators used. However, avoiding this limitation proved to be impossible because there are few recent studies that examine the effect of ERAS implementation on clinical outcomes in real time.

Conclusions and Recommendations for Future Research

In summation, ERAS protocols seem to be a feasible alternative to standard perioperative care. There is evidence that ERAS practices help mitigate postoperative symptoms, require less narcotic analgesia, and allow for faster recovery and ambulance. Future research should focus on expanding and diversifying study samples to include different demographic cohorts. It is also essential to clarify what ERAS guidelines should and should not include and how exactly they need to be adjusted depending on the field of application. This is especially relevant for fields such as gynecology and gastroenterology since there is very little evidence concerning ERAS implementation. Lastly, there is a need to make patient education part of ERAS implementation on site and study readmission rates given ongoing support and counseling.

Discussion

Summary of the Evidence

The included studies were scholarly articles retrieved from relevant medical databases and providing important knowledge regarding ERAS and patient recovery after abdomen surgery. The quality of the considered studies was regarded as sufficient to meet the inclusion criteria and offer valuable data to enrich the understanding of the topic. Some studies were excluded due to the unavailability of their full texts, background information, a focus on non-transabdominal surgeries, and non-U.S. context. Since the number of such operations tends to grow, this area presents an especial interest to surgeons and APRNs as those who are expected to lead change (Yamada et al., 2014).

The improved care quality was identified as the key indicator of success in gastrointestinal, urologic, gynecologic, and colorectal therapy practices. The findings of this systematic review are consistent with Patel and Semerjian (2017), who emphasize the potential of ERAS protocols in reducing complications and LOS in the field of urology. Similar outcomes were noted for other mentioned areas, which provide the opportunity for care professionals to work more on improving patient outcomes.

The reduction of complications in the post-surgery and follow-up periods is specified by the literature as one of the most important benefits. The number of ileuses and the use of narcotic analgesia decreased significantly, which especially evident in the articles that focused on colorectal and urologic surgeries. The studies exploring ERAS in the context of gynecology revealed little difference between control and intervention groups with regard to complications and readmissions, which can probably be explained by the insufficient experience of implementing ERAS pathways in this area of interest (Bergstrom et al., 2018).

The reduction in patient care variation is another significant aspect that was expected to be explored in the course of the systemic review. Based on the results obtained by the included studies, one may claim that ERAS is advantageous in care variation decrease as it proposes clear and standardized practices, which can change depending on the area, yet overall guidelines are analogous. In particular, early nutrition, staying out of bed, vacuum methods of post-surgery recovery, patient education, and follow-up within 30 or 90 days compose the key prospects of ERAS.

The optimized perioperative patient management integrates the possibility of a combination of elements of ERAS philosophy and the options available in each specific clinic. It is considered that informing patients about all stages of treatment and discussing the perioperative period and features of the postoperative period are the central elements of ERAS effectiveness. Consistent with other available articles, this systematic review results suggest that full and timely pain relief, which is achieved by setting an epidural catheter for prolonged intra- and postoperative analgesia, is of paramount importance (Koo et al., 2013).

In the view of the analyzed studies, the expansion of the role of APRNs can be regarded as a feasible and reliable way to improve staff awareness of ERAS. One should also state that Bergstrom et al. (2018) discusses the main barrier to the successful adoption of ERAS, such as the compliance of staff to new care principles. Similar ideas are expressed by other articles that attempt to determine the challenges related to this method utilization (Birken et al., 2015; Hurley et al., 2016). In this connection, it seems significant to identify the potential contribution of APRNs as the primary promoters of change. Koo et al. (2013) emphasize that their focus on practice regulation, education, and workforce distribution are essential for organizing, implementing, and monitoring ERAS protocols.

By leveraging the role of APRNs, it is possible to achieve greater compliance with new pathways and ensure that the current indicators of LOS, readmissions, and complications would be lowered. At the same time, collaboration among the members of the interdisciplinary team is specified as the paramount premise of effective ERAS provision before, during, and after surgery. The analysis of ERAS costs was another secondary goal of this systematic review, and it was found that it is not associated with significantly higher charges for patients or hospital spending. Even though some studies reported an increase in costs, the overall variation of patient charges remained or reduced. The alternative explanation of the results, namely, their heterogeneity in some cases, which was presumably caused by their varying directions, clinical settings, and methods used to collect and interpret data.

This systematic review reveals some literature gaps that should be examined in future research. First of all, it is critical to conduct studies that would adopt a comprehensive approach to studying ERAS as a recovery intervention for patients having abdomen surgery. In particular, the current articles tend to focus on one or two aspects such as LOS, while there is a need to pay attention to more issues within one study, including patient perceptions, comfort, site infection, et cetera. Secondly, the follow-up is one more area that is underrepresented in the current body of the academic literature. Because most patients care for themselves after discharge from the hopsital, there could be other factors affecting readmission rates and the risk of complications. For example, patient education provided before discharge and during follow-ups could increase adherence to medical recommendations, thus reducing the risk of readmission.

Limitations

The limited sample size of 15 articles restricts the generalizability of results. This is particularly due to the fact that most studies were carried out in a single institution or hospital. Moreover, no information from national databases or large reports was included, and thus it is not possible to generalize data to larger patient populations. Nevertheless, the findings of the studies reviewed here provide valuable insights into the experience of adopting ERAS in clinical settings. One of the key limitations that can be listed with regard to the studies reviewed in this paper is the emphasis of many studies on a single care success factor.

Indeed, many of the studies focused on a limited number of indicators, whereas the influence of ERAS implementation on other variable was not addressed. Also, the relatively small sample may be regarded as an issue that limits the generalization of results. Reviewing more articles with larger sample sizes and more indicators included could provide a realistic picture of ERAS benefits that could be extended to other patient populations, thus supporting ERAS implementation on a national level.

Conclusions

To conclude, this systematic literature review attempted to integrate the literature on the impact of ERAS on patients undergoing one of the following abdomen surgeries: colorectal, gastrointestinal, urological, and gynecological. The majority of the studies are focused on either colorectal or urological health issues since these areas were initially offered as the ones that are appropriate to utilize ERAS.

The two other spheres also tend to be focused on ERAS pathways as the opportunity to enhance care quality and reduce patient care variation. It was revealed that the given multimodal perioperative care treatment program allows reducing LOS, readmissions, and complications without adverse changes in morbidity, mortality, and patient charges. The systematic review also identified that the efforts of APRNs and cooperation between interprofessional care providers are critical to effectively implement ERAS protocols.

Further research is necessary to examine broader opportunities for using ERAS in clinical settings from different perspectives. It is needed to comprehend how to improve its positive impact and accomplish better patient outcomes. The potential benefits of ERAS should be explored in a comprehensive manner to reveal any links between them and also adjust some practices if required. In addition, the barriers to the adoption of ERAS should be analyzed in order to design the strategies to address them, thus making the perioperative practices more relevant to the needs of patients. The perceptions of patients as well as the compliance of their education to ERAS protocols should be evaluated as well since little attention is paid to their views and factors that enhance faster recovery, such as family support.

An important aspect of the paper was to judge whether or not ERAS implementation is feasible. Based on the information collected from research, there are two key reasons for introducing ERAS throughout the healthcare system. Firstly, most of the studies that cosidered the cost-effectiveness of ERAS implementation concluded that it has a beneficial effect on cost savings, up to several thousand dollars per patient. Secondly, the implementation of ERAS on a national level would help to improve care standardization. Because ERAS protocols involve specific procedures and activities, they could reduce variations in postoperative care, thus ensuring that the risk of complications and negative events remains comparable in different hospitals and departments. This would have a beneficial effect on the quality of care in the United States as a whole by ensuring that patients do not suffer from variations in postoperative care.

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Table: Summary of results on individual studies.

Author Year / Journal/ Country Purpose Sampling / Setting Methodology / Research Design ERAS key features Key Findings QRS
Aviles et al. (2017) Clinical Journal of Oncology Nursing
U.S.
To assess the feasibility of ERAS in patients undergoing pancreaticoduodenectomy (PD) n= 180, Carolinas Medical Center, level-1 trauma, academic center.
Patient allocation: 40 ERAS (22.2%, mean age 68.5, 60% male and 40% female) and 140 CRAS (77.8%: mean age 66, 53% male and 47% female)
Prospective and comparative effectiveness study, monocenter
Primary outcome: ERAS feasibility in a tertiary care academical center
Secondary outcomes: LOS, 30-day readmission and mortality rates, and surgical complications
3-phase implementation of ERAS guidelines:
Preop: Patient education and counselling on nutrition, ETOH and/or smoking cessation; bowel prep; fasting time reduced to 2 hours preop (regular diet up to 6 hours and CLD/ carbohydrate loading up to 2 hrs, preop), chemical VTE prophylaxis, Abx, and antiemetic as needed.
Intraop: GDFT, mechanical VTE prophyalxis, and normothermia
Postop: mechanical VTE and stress ulcer prophylaxis, control of PONV, blood glucose goal under 150 mg/dL; chemical VTE prophylaxis added, NGT removal and CLD started on POD #1; bowel regime, urinary catheter removal and IVF titration to off by POD #2; FLD, multimodal analgesia with transition from TEA to oral and IV narcotics as needed and scheduled NSAIDs by POD #3; regular diet and appropriate drain removal on POD #4; hospital discharge criteria: pain controlled with oral medication only, passage of stool, independent mobilization, and patients’ willingness; 1 week follow up as outpatient with a NP
The ERAS guidelines were found feasible for PD patients
Improved LOS for the ERAs group
No changes in 30-day readmission and mortality rates
ERAS group showed higher rate of some surgical complications (bile leak, bleeding, delayed gastric emptying, fistula, sepsis, and SSI); similar rate of respiratory compromise and UTI as the CRAS group, while cardiac dysrhythmias, reoperations, and POI rates decreased
II, A
Bergstrom et al. (2018) Gynecologic Oncology
U.S.
To analyze the impact of the first year of ERAS on patients outcomes, particularly perioperative narcotic, compared to one year pre-ERAS, in addition to existing quality and safety procedures in a Gyn-Onc service n=267, Johns Hopkins Hospital (JHH), major academic medical center
Patient allocation: 158 historical cohort patients (60%; mean age 51.7), and 109 ERAS cohort patients (40%; mean age 55.2).
Retrospective cohort, single-institution study
Primary outcomes: use of narcotics, hospital LOS, complication rates.
Secondary outcomes: pain levels after discharge, hospital readmission rates.
All phases of ERAS, particularly TEA
Bowel preparation (mechanical and Abx) used if colonic resection required.
No differences in LOS, complications, or readmission rates.
ERAS patients endorsed better pain tolerance, requiring less narcotics and PCA use.
II, A
Boitano et al. (2018) Gynecologic Oncology
U.S.
To determine gynecologic oncology patients’ gastrointestinal function response on ERAS compared to pre-ERAS methods n=376, University of Alabama at Birmingham (UAB), single academical medical center
Patient allocation: 197 (52%) standard postoperative care patients; 179 (48%) ERAS patients
Retrospective cohort, single-center study, before and after design
Primary outcome: POI
Secondary outcomes: LOS, and 30-day readmission rates.
Multimodal analgesia, early TTO, GDFT, and EPM POI and LOS rates were lower in the intervention (ERAS) group.
30-day readmissions rates remained similar for both groups.
II, B
Chipollini et al. (2017) Urology
U.S.
To assess the impact of ERAS on perioperative charges n=257, ERAS-RC database at Moffitt Cancer Center, a tertiary referral center
Patient allocation: 145 CRAS patients (57%, 82.9% male; median age 71) ; 112 ERAS patients (43%, 75% male; median age 69)
Retrospective, control trial without randomization, monocenter study
Primary outcome: Perioperative charges
Secondary outcome: LOS
Multidisciplinary ERAS protocol: the use of opioid receptor antagonists, avoidance of NGT, and early TTO ERAS group with no significant increase in costs, but less variance in charges (ERAS patients had higher medication charges, while control group had higher supplies, treatment, and miscellaneous expenses.
No difference in median hospital stay between control and intervention groups.
II, A
Fabrizio et al. (2017) Jorunal of Surgical Research
U.S.
To assess readmission rates with the implementation of ERP in patients having colorectal surgery and compare it to pre-ERP n= 676, Johns Hopkins Hospital (JHH), major academic medical center
Patient allocation: 330 (48.8%) ERP patients (mean age 53.5; 49.1% male and 50.9% female) and 346 (51.2%) pre-ERP (mean age 53.2; 48.3% male and 51.7% female)
Observational, retrospective study, single tertiary care center
Primary outcome: 30-day readmission rate
Secondary outcomes: LOS, POI, ileus, and patient perception
Preop carbohydrate loading, OSA, lmited narcotic use to 72 hrs post op, EPM
Same discharge criteria for both cohorts: ambulatory status, pain controlled on PO meds, tolerance of regular diet, and ROBF with stool production
No signficant impact of ERP on 30-day readmission rate (17.6% vs. 19.4%)
ERP group showed less readmision due to SSI (7.3% vs. 16.6%) while POI incidence increased (31% vs. 19.1%)
Overall, ERP showed shorter LOS for both postop and readmission.
No impact of ERP on patient perception pf discharge or transition of care
II, C
Geltzeiler et al. (2014) JAMA Surgery
U.S.
To examine whether the beneficial results provided by ERAS could be replicated at a community hospital n= 244, Legacy Good Samaritan (LGS), single community hospital
Patient allocation: 68 pre-ERAS in 2009 (27.8%, mean age 65; 38.2% male and 61.8% female), 96 partially-implemented ERAS in 2011 (39.3%, mean age 60; 49% male and 51% female) , and 80 fully- implemented in 2012 (32.7%, mean age 61; 42.5 male and 57.5 female)
Prospective. monocenter study
Primary outcomes: LOS, patients’ outcomes
Secondary outcomes: improved patients outcomes regardless laparoscopic approach
Laparoscopic approach, selective use of bowel preparation (only for left-sided and rectal procedures), 2 hours fasting preop, locoregional anesthetic use (principally intrathecal spinal anesthetic), GDFT, OSA, early TTO, and EPM Reduced LOS (6.7 vs. 3.7 days), use of narcotics (63.2% of all patients vs. 15%), and rate of POI (from 13.2% to 2.5%)
No significant difference in TE, infection rate (SSI and DSI), or readmission for the 2 years when compared to baseline
Laparoscopic cohort showed improved results in regards to decreased narcotic use -likely secondary to OSA- and LOS. NO differences found in other parameters cited above.
II, B
Lin et al. (2018) World Journal of Urology
China
To study the effect of ERAS in comparison with conventional recovery method in patients with radical cystectomy with ileal urinary diversion (RC-IUD) 25 centers of Chinese Bladder Cancer Consortium Centers
Patient allocation: 144 ERAS (85.5% male, mean age 62.9 +10.1) and 145 (87 male; mean age 63.3 +10.3) CRAS
Prospective, multi-institution, RCT
Primary Outcome: 30-day postop complication rate.
Secondary Outcomes: BMs, FLD and regular diet tolerance, ambulation.
No mechanical bowel prep for 3 days before surgery, early H2O intake within 24 hrs, and mobilization within a few hours after surgery No difference in 30-day complication rate.
ERAS group patients showed faster recovery of BMs, diet tolerance, and ambulation
I, A
Martin et al. (2016) Surgical Endoscopy
U.S.
To evaluate and compare the implication of ERAS in LOS and other patient outcomes n= 1036, administrative and clinical databases at Saint Joseph Mercy Health System (SJMH)
Patient allocation: 513 ERP (49.5%) and 523 pre-ERP (50.5%). Mean age was 63 for both groups with equal gender distribution (47% male and 53% female)
Comparative effectiveness study, multivariable regression analysis; single-academic non-university hospital.
Primary outcome: LOS
Secondary outcomes: Total postop complciations, SSI, DSI, sepsis, POI, 30-day readmission rate, 30-day reoperation rates, 30-day mortality rate,
16-item ERP pathway on the basis of the European Consensus template (Nygren et al., 2012). LOS decreased (3 vs. 5 days) for ERP group.
No difference in total postop complications or incicendence of SSI, DSI, sepsis, or POI as well as of 30-day reoperation or 30-day mortality rates between the two groups.
Higher 30-day readmission rate in the ERAS group
II, B
Miller et al. (2014) Anesthesia and Analgesia
U.S.
To explore clinical effectiveness, feasibility, and costs of ERAS n= 241, Duke University Medical Center (DUMC), major academic center.
Patient allocation: 99 CRAS (41%, mean age 56 +15 with a gender distribution of 43 males and 56 females) and 142 ERAS (59%, mean age 58 +15; 69 males and 73 females)
Quatitative observational comparative effectiveness study in 3 phases 1) retrospective analysis, 2) implementation, and 3) postimplementation; tertiary medical center
Primary outcome: LOS
Secondary outcomes: Postop pain, IV opioids, SSI (included SSI, DSI, and wound disruption), sepsis, TTB, 30-day readmission rate, and medical costs
Selective bowel prep, CLD until 3 hours preop, TEA and minimal use of IV opiods with transition to oral pain medication by POD #3, VTE prophylaxis, GDFT, no NGT postop, TTO on POD #0, indwelling urinary catheter removal on POD #1 ERAS group had a significant reduction in LOS (5 vs. 7 days), 30-day readmission rate, and UTIs (sepsis occurences).
Other improvements seen in the ERAS group were decline in IV opioids and IVF administration w/o affecting u/o, POI and SSI rates
Reduced medical costs in the ERAS group were not of statistical significance.
II, B
Morgan et al. (2016) Journal of the American College of Surgeons
U.S.
To implement ERAS in patients undergoing pancreatic surgery and evaluate its safety and effectiveness n= 378, Medical University of South Carolina (MUSC), level-1 trauma, academic tertiary institution
Patient allocation: 297 pre-ERAS (78.6%; mean age 54, 46% male and 54% female) and 81 ERAS (21.4 %; mean age 54, 54% male and 46% female).
Retrospective review of prospective collected data, monocenter
Primary outcomes: morbidty, mortality, LOS, and hospital costs
Preop patient optimization and education, fasting avoidance, TEA (open procedures), and TAP block (laparoscopic approach)
Intraop: perioperative GDFT, normothermia, and OSA in addition to standard Abx, VTE, and stress ulcer prophylaxis as well as antiemetics
Postop: Continue GDFT, early removal of NGT and urinary catheters, EPM, TTO on POD #1 with FLD and regular diet on POD #2
Similar morbidity rate for SSI, pneumonia, and fistula found in both groups
ERAS group showed a significant decline in rate of delayed gastric emptying, reduced LOS (7.4 days vs. 9.2 days), and lower hospital costs
No changes in readmission and 90-day mortality rate post ERAS implementation.
II, B
Mosquera et al. (2016) American Surgeon
U.S.
To reveal overall benefits of ERAS based on the experience of one surgeon n= 179, Vidant Medical Center; level-1 trauma, academic center.
Patient allocation: 87 ERAS (48.6%; mean age 61.4, 54% female and 46% male; 62.1% white, 34.5% black, and 3.4% other) and 92 CRAS (51.4%; mean age 63.1, 53.3% female and 46.7% male; 60.9% white, 34.8% black, and 4.3% other)
2-year retrospective chart review; multiple major abdominal surgeries, monocenter, single-surgeon
Primary outcomes: LOS, postop complications, 30-day readmission rate, mortality, and costs
Preop: 5-day protein-based nutrition, CLD and carbohydrate loading up to 3 hrs preop, TEA (for laparotomies only), and gabapentin administration
Intraop: GDFT and normothermia
Postop: Multimodal pain approach (TEA, OSA, and NSAIDs), bowel regime (stool softener, laxative), NGT removal by POD #1, early TTO, 5-day protein-based nutrition, EPM, and removal of drains by POD #3 if appropriate
ERAS patients had shorter LOS (6.2 vs. 9.6 days), lower 30-day readmission rate and costs (particularly post hepatectomy).
No difference in rate of postop complications between both groups; however, complication severity was lower in the ERAS compared to the CRAS group
Zero mortality reported in ERAS group versus 3.3% in the CRAS group
II, B
Palumbo et al. (2018) Urology
Italy
To compare ERAS and conventional practice on bowel function recovery and morbidity n=114, Urology unit at Santa Maria della Misericordia, single academic medical center
Patient allocation: 74 male (66%, mean age 72) ERAS patients; 40 male (34%, mean age 74) CRAS
Prospective single-center, single-surgeon study, cohort study
Primary outcome: Bowel function recovery
Secondary outcomes: 90-day postop complication and readmission rate
No pre-op diet restriction or bowel prep, OSA with RFA, no NGT, no postop stay in ICU, standardized pain control, no TPN, early TTO, and EPM. Recovery of bowel function significantly faster in ERAS group
No increase in 90-day complications or readmissions in ERAS patients
II, B
Persson et al. (2015) Scandinavian Journal of Urology
Sweden
To discuss the initial experience with ERAS in patients undergoing open radical cystectomy (ORC) n=70, Örebro University Hospital, single academic medical medical center
Patient allocation: patients’ age 42-80 y/o (mean age 66), 31 (44%) ERAS patients, 39 (56%) pre-ERAS patients.
Retrospective, feasibility, single-center study.
Primary outcome: Adherence to 20 ERAS items post RC.
Secondary outcomes: Perioperative complication rate, TTB, post-op LOS, and readmission rate.
Full ERAS cystectomy protocol No difference in complication rate and LOS
Lower readmission rate and faster TTB were characteristic of ERAS patients
II, B
Semerjian et al. (2018) Urology
U.S.
To report the experience regarding RC patients’ LOS, charges, and 30- and 90-day readmissions n= 110, recruited through the Johns Hopkins Hospital (JHH), major academic medical center
Patient allocation: 56 ERAS patients (86% male and 14% female) with a mean age of 68.6 and 54 pre-ERAS patients (87% male and 13% female) with a mean age of 69.5.
Prospective and retrospective cohort, single-institution study
Outcomes: complication rate, LOS, hospital charges, and 30- and 90-day readmission rate
No preop bowel prep, use of alvimopan and epidural anesthesia, early TTO, limit of opiods for pain control, and no routine use of NGT ERAS group showed significantly reduced LOS and POI , and consequently overall charges
30- and 90-day readmission and overall complications did not change
II, B
Zoog et al. (2018) American Surgeon
U.S.
To explore the efficacy and safety of ERP in patients undergoing colon resection compared to pre-ERP approach
Identify barriers to ERP implementation and PC
n=245, The University of Tennessee at Chattanooga (UTC), single academic tertiary care institution
Patient allocation: 68 ERP patients (27.7% male, mean age 61) and 177 pre-ERP patients (72.2% male, mean age 64)
Quantitative observational comparative effectiveness method and the retrospective analysis of patient data; monocenter study
Primary outcomes: LOS
Secondary outcomes: Readmission rate, 30-day complications, mortality, IVF, analgesia, ROBF, POI, and PC
Pre- and postop management interventions included patient education, GDFT, early TTO, reduce narcotic use, and follow-up with a surgeon, which are consistent with ERAS principles LOS was shorter in ERP patients
ERAS group showed less requirement for IVF intraop and narcotics for analgesia, faster ROBF, and reduced POI incidence
No difference in 30-day readmission rate
Larger PC lead to decreased LOS
II, A

Notes: Not all measures and outcomes are reported due to space limitations.

Abbreviations: antibiotics (Abx); bowel movement (BM); Conventional Recovery after Surgery (CRAS); deep surgical infection (DSI); early patient mobilization (EPM); enhanced recovery protocol (ERP); estimated blood loss (EBL); ethyl alchol (ETOH); full liquid diet (FLD); goal directed fluid therapy (GDFT); intensive care unit (ICU); length of stay (LOS); nasogastric tube (NGT); non-steroidal anti-inflammatory drugs (NSAIDs); Nurse Practitioner (NP); opiod-sparing anesthesia (OSA); oral [(PO) = per oral)]; postoperative day (POD); postoperative nausea and vomiting (PONV); postoperative ileus (POI); protocol compliance (PC); Quality Rating Score (QRS); randomized control trial (RCT); restrictive fluid administration (RFA); surgical site infection (SSI); thoracic epidural anesthesia (TEA); time-to-bowel (TTB); time-to-oral (TTO); total parenteral nutrition (TPN); thromboembolic event (TE); transversus abdominus plane (TAP); urinary output (u/o); with out (w/o).

Impact of ERAS on Recovery of Patients Undergoing Abdominal Surgery
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YourDissertation. (2022, May 16). Impact of ERAS on Recovery of Patients Undergoing Abdominal Surgery. Retrieved from https://yourdissertation.com/dissertation-examples/impact-of-eras-on-recovery-of-patients-undergoing-abdominal-surgery/

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"Impact of ERAS on Recovery of Patients Undergoing Abdominal Surgery." YourDissertation, 16 May 2022, yourdissertation.com/dissertation-examples/impact-of-eras-on-recovery-of-patients-undergoing-abdominal-surgery/.

1. YourDissertation. "Impact of ERAS on Recovery of Patients Undergoing Abdominal Surgery." May 16, 2022. https://yourdissertation.com/dissertation-examples/impact-of-eras-on-recovery-of-patients-undergoing-abdominal-surgery/.


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YourDissertation. "Impact of ERAS on Recovery of Patients Undergoing Abdominal Surgery." May 16, 2022. https://yourdissertation.com/dissertation-examples/impact-of-eras-on-recovery-of-patients-undergoing-abdominal-surgery/.

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YourDissertation. 2022. "Impact of ERAS on Recovery of Patients Undergoing Abdominal Surgery." May 16, 2022. https://yourdissertation.com/dissertation-examples/impact-of-eras-on-recovery-of-patients-undergoing-abdominal-surgery/.

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YourDissertation. (2022) 'Impact of ERAS on Recovery of Patients Undergoing Abdominal Surgery'. 16 May.

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