Enhanced recovery after surgery, based perioperative bundle reduces 30-day unplanned readmission after laparoscopic colorectal cancer surgery

Abstract

BACKGROUND

Laparoscopic resection has become standard for colorectal cancer (CRC) but postoperative recovery is often impaired by delayed gastrointestinal function, poor mobility and inadequate pain control resulting in increased risk of complications and unplanned readmission. Recovery is generally slower with conventional care, which follows conservative feeding and activity protocols. Enhanced recovery after surgery (ERAS) pathway combines several evidence-based perioperative interventions that reduce surgical stress and promote recovery, but there are no specific data regarding the effect of this program on 30-day unplanned readmission after laparoscopic colonoctol cancer surgery. This study was designed to compare an ERAS-based perioperative bundle with conventional care in terms of 30-day unplanned readmission and recovery outcomes.

AIM

To analyze the impact of ERAS pathway-based comprehensive perioperative management bundle on 30-day unplanned readmission rate after laparoscopic radical resection for CRC, and to evaluate its improvement effects on patients’ recovery-related indicators, functional recovery, and quality of life.

METHODS

We retrospectively analyzed 77 patients underwent laparoscopic radical resection for CRC in the Department of Gastrointestinal Surgery of our hospital from July 2020 to June 2021. Patients were divided based on the initiation time of rehabilitation treatment protocols: Control group (n = 38, conventional rehabilitation care) and intervention group (n = 39, ERAS pathway-based comprehensive perioperative management bundle). The intervention group received a combination of preoperative individualized rehabilitation education, postoperative early activity training, gastrointestinal function rehabilitation, multimodal analgesia, psychological support and discharge preparation with continuity of care as multilateral comprehensive managementiy. The unplanned 30-day readmission rate, recovery-related indicators, pain scores, functional recovery indicators, satisfaction with treatment and quality of life were compared between the groups.

RESULTS

The 30-day unplanned readmission rate in the intervention group (5.1%) was significantly lower than that recorded in controls (23.7%) (Fisher’s exact test, P = 0.024). Compared with the control group, time to first ambulation, first flatus, first defecation and recovery of gastrointestinal function in intervention group were shorter (all P < 0.001). Patients in the intervention group had significantly lower pain scores than those in the control group on postoperative days 1, 3, and 7 (all P < 0.001). In the intervention group, the 6-minute walk distance on postoperative day 7 was significantly greater than that in the control group (P < 0.001). Barthel Index scores at discharge and 30 days postoperatively in the intervention group were superior to those of the control group (P < 0.05). At 30 days postoperatively, the patient satisfaction scores in the intervention group were significantly higher than the controls (P < 0.001), and all dimensions of 36-item short-form health survey quality of life scale showed various degrees of improvement at 30-day after surgery (P < 0.05).

CONCLUSION

The ERAS pathway-based comprehensive perioperative management bundle can reduce the 30-day unplanned readmission rate after laparoscopic CRC surgery significantly, which in effectively promotes early postoperative recovery, pain control, functional recovery level and improves quality of life. In summary, the synergistic effects of each individual component are attributed to these clinical advantages because the intervention is a multi-component bundle and worthy of clinical perioperative care promotion and application.

Key Words: Enhanced recovery after surgery; Multidisciplinary enhanced recovery interventions; Laparoscopic surgery; Colorectal neoplasms; Unplanned readmission; Postoperative recovery

Core Tip: This study evaluated the impact of a comprehensive perioperative management bundle based on an enhanced recovery after surgery (ERAS) pathway on 30-day unplanned readmission rates following laparoscopic radical resection for colorectal cancer (CRC). The intervention group (n = 39) had a significantly lower 30-day unplanned readmission rate compared with the conventional care group (per protocol, n = 38), 5.1 percent vs 23.7 percent, P = 0.024 among 77 patients. The ERAS bundle which included early mobilization, multimodal pain control, early enteral feeding, abdominal massage, psychological support as well as formalized discharge planning significantly accelerated recovery of gastrointestinal function and significantly reduced postoperative pain scores at all time points whilst improving exercise tolerance and activities of daily living along with improved quality of life overall at 30 postoperative days. These results suggest that the clinical benefits of ERAS are attributable to its synergistic multi-component bundles instead of individual interventions. The program provides a practical evidence-based approach to perioperative care that should be more broadly implemented in CRC surgical units.

INTRODUCTION

Colorectal cancer (CRC) is a highly incident and fatal malignant tumor worldwide. Its incidence trend shows annual increase with population aging and lifestyle changes[1]. Laparoscopic radical resection is becoming the standard surgical approach in CRC therapy because of its advantages of less trauma, rapid rehabilitation, and fewer complications[2]. However, during the postoperative recovery period, delayed gastrointestinal function recovery, reduced activity capacity and poor pain control continue to be problems. These factors can not only impair the recovery process of patients but also result in postoperative complications and greater likelihood of unplanned readmissions[3].

Conventional postoperative recovery care paradigms typically implement conservative activity and dietary approaches, such as initiating feed only after anal flatus and facilitating ambulation on postoperative days 2-3. This passive recovery model usually delays hospital stay and impacts functional recovery of patients[4]. The enhanced recovery after surgery (ERAS) principle has been increasingly advocated and implemented in the surgical domain in recent years. Optimizing patient care from all aspects: Preoperative optimization, refined intraoperative management and postoperative rapid recovery by comprehensive management model is the key idea of ERAS pathway. It provides the foundations for improved perioperative care through evidence-based medicine principles: Reducing perioperative stress response, improving patient recovery and minimizing length of stay[5].

The ERAS pathway-based integrated perioperative management bundle, including preoperative optimization, intraoperative control and multi-component synergistic interventions in the postoperative period (early mobilization, nutritional therapy, multimodal analgesia, psychological guidance etc.), has been shown to significantly enhance gastrointestinal function recovery speed during elective surgery and reduce postoperative complications as well as improve patient prognosis[6]. Nonetheless, the current evidence on the effect of complete ERAS package on unplanned readmission rate after laparoscopic CRC surgery is still limited. The unplanned readmission rate is an important indicator to assess medical quality and patient safety, which not only increases medical costs but also brings adverse effects on patients’ physical and mental health[7]. Thus, the clinical significance of studying effective perioperative management programs to reduce postoperative unplanned readmission rates and improve medical service quality is quite important[8,9].

The present study is designed to compare 30-day unplanned readmission rates of ERAS pathway-adherent comprehensive perioperative management bundle and conventional rehabilitation care in laparoscopic radical resection for CRC with retrospective analysis, and whether this approach can improve recovery-related indicators, functional recovery and quality of life in patients thus providing clinical evidence-based medical evidence.

MATERIALS AND METHODS

Study design and subjects

The patients who underwent laparoscopic radical resection for CRC in the Department of Gastrointestinal Surgery of our hospital from July 2020 to June 2021 were analyzed retrospectively as study subjects. This is a retrospective analysis utilizing deidentified historical medical record data. The study protocol has been reviewed and approved by the Ethics Committee of our hospital, and individual patient informed consent was waived.

Inclusion criteria: (1) Age 18-80 years; (2) Patients with CRC confirmed by pathology; (3) Laparoscopic radical resection for CRC; (4) American Society of Anesthesiologists (ASA) classification grades I-III; and (5) Basically normal preoperative cardiopulmonary function.

Exclusion criteria: (1) Emergency surgery patients; (2) Patients with moderate to severe cardiopulmonary dysfunction, hepatic or renal impairment; (3) Patients with mental illness or cognitive impairment who are unable to cooperate with rehabilitation training; (4) During the course of operation patients were converted to open surgery; (5) Postoperative pathology indicating non-malignant tumors; (6) Incomplete clinical data; and (7) Also, loss to follow-up at 30 days postoperatively.

Grouping method

Patients were classified into two subgroups based on the perioperative rehabilitation protocol they actually received during the trial phase (July 2020 to June 2021).

Control group (n = 38): Patients managed with normal perioperative rehabilitation.

Intervention group (n = 39): Patients received an ERAS pathway-based comprehensive perioperative management bundle. Both groups were as certain from the same study period (July 2020 to June 2021).

Intervention measures

Control group: Standard rehabilitation care protocol was implemented. On postoperative day 1, patients were encouraged to move their limbs in bed; on postoperative day 2, patients were assisted in standing beside the bed; and on postoperative day 3, bedside activities commenced. Patient was kept fasting after the procedure until anal flatus occurred, followed by liquid diet and gradually to semi-liquid and regular diet. Pain control was primarily via analgesic pumps and on-demand medication, specifically patient-controlled intravenous analgesia with opioids, supplemented by on-demand non-steroidal anti-inflammatory drugs or acetaminophen, administered according to standard dosing ranges at the discretion of the attending clinical team. Discharge instructions involved wound care, dietary restrictions, and frequent follow-up.

Intervention group: ERAS pathway based comprehensive perioperative management bundle. Implementation of a multi-component comprehensive management bundle guided by ERAS concepts. The specific measures being taken are as follows: Patients were asked to learn the method of abdominal breathing and lower limb muscle strength training.

Additional rehabilitation in the immediate postoperative stage (0-6 hours postoperatively): On the premise of full awakening from anesthesia and stable vital signs, patients were guided to perform deep breathing at bed and passive limb exercises every 2 hours for 5-10 minutes.

Bilateral limb active exercises in bed during early postoperative rehabilitation (6-24 hours after operation): Exercises were carried out every 2 hours for 10-15 minutes at a time starting from the sixth hour postoperation. Special Postoperative Recovery Plan of extended care (Figure 1), patients were assisted to sit up beside the bed and perform ankle pump exercise, isometric contraction exercises within 12 hours after surgery. Early mobilization was encouraged within 12-24 hours postoperative for standing beside the bed and walking short distances (5-10 meters).

Figure 1 Comparison of 30-day unplanned readmission rates between groups. Bar chart comparing 30-day unplanned readmission rates: Control group 23.7% vs intervention group 5.1%, P = 0.024.

Progressive activity training (from postoperative day 2): The progressive activity protocol was applied in which the patients had 50-meter walking inside the ward, and this distance gradually increased by 50-100 meters per day with a target of 500 meter/day. Measurements of heart rate, blood pressure and oxygen saturation were recorded during the activities. If any abnormalities occurred, then activity was immediately stopped.

Gastrointestinal function rehabilitation: Postoperatively, small amounts of water (30-50 mL) were started 2 hours to 4 hours after surgery; liquid diet was started after 6 h after surgery; gradually transferred to semi-liquid diet within 24 hours without waiting anal flatus. We combined abdominal massage (3 times/day, 10 minute/time) to promote recovery of gastrointestinal motility.

The pain management mode was optimized: The multimodal analgesia protocol was followed by the application of both the preoperative preventive analgesia, intraoperative local anesthesia over postoperative Patient-Controlled Analgesia (PCA) pump combined with non-steroidal anti-inflammatory drugs to maintain pain scores ≤ 3 in order for patients to participate in rehabilitation training effectively. The standardized multimodal analgesia protocol included: Oral celecoxib 200 mg administered 1-2 hours prior to surgery (in the absence of contraindications) for preoperative preventive analgesia; local anesthetic infiltration of the surgical incision and port sites with ropivacaine before wound closure intraoperatively; a low-dose opioid intravenous PCA pump plus scheduled non-steroidal anti-inflammatory drugs [e.g., parecoxib or flurbiprofen axetil, given at fixed intervals (typically every 12 hours)] postoperatively for the first 48-72 hours. Patients whose Numerical Rating Scale (NRS) pain score remained > 3 despite scheduled multimodal therapy received rescue analgesia (additional opioid administration) and the number of patients who had further analgesic treatment was registered.

Psychological support: Daily assessment of the patients’ rehabilitation progress by rehabilitation therapists was required for prompt adjustment of training intensity and in facilitating psychological counseling, encouragement and improvement of patients’ rehabilitation confidence.

Discharge preparation: Individualized home rehabilitation plans were developed (exercise prescription, dietary guidance, follow-up schedule arrangement), and follow-up mechanism was established to guarantee the continuity of rehabilitation training.

Protocol adherence and deviations

Implementation fidelity was assessed prospectively from the medical record as either achievement of each key milestone on schedule (the proportion of intervention-group patients who: Ambulated within 12-24 hours postoperatively, had small-volume oral water by postoperative hour 4, initiated a liquid diet by hour 6, and met ambulatory distance targets on or after postoperative day 2). Patients who did not reach a milestone on time had the reason for crossed lines noted, and this was categorized as: Insufficient analgesia, cardiopulmonary instability or other clinical contraindication, patient refusal or intolerance to participate in rehabilitation (or other/unspecified reasons). The percentage of patients that are completing each milestone in time, and the reasons of missing the milestones.

Discharge criteria

Discharge criteria for both cohorts included: (1) Hemodynamic and respiratory stability; (2) Stable pain control (NRS score ≤ 3), without parenteral analgesia requirements; (3) Tolerating a semi-liquid or oral diet; (4) Ambulating either independently or with assistance, as safe to discharge at the discretion of the attending surgical team; and (5) Freedom from any surgical complication warranting ongoing inpatient management.

Observation indicators

General information: Information of baseline data for both groups were collected including: (1) Demographic characteristics: Age, gender, body mass index (BMI), smoking history, drinking history; (2) Disease-related data: Tumor location, tumor node metastasis (TNM) staging and preoperative carcinoembryonic antigen (CEA) levels; (3) Comorbidity conditions: Hypertension, diabetes, coronary heart disease and others; and (4) ASA classification.

Primary observation indicator: 30-day unexpected readmission rate: The proportion of patients who were re-hospitalized within 30 days after surgical discharge and stayed in the hospital due to complications related to surgery (e.g., incision infection, anastomotic leakage, intestinal obstruction, intra-abdominal infection, bleeding and so on), disease progression or adverse reactions during treatment. Readmissions for other systemic diseases, accidents, or non-original surgery-related elective surgeries were excluded.

Secondary observation indicators: (1) Recovery-related indicators: (a) Time to first ambulation, the time (hours) when patients could independently or with assistance stand beside the bed for the first time postoperatively; (b) Time to first flatus, recording the time (hours) of occurrence of anal flatus at postoperative day one; (c) Time to first defecation: Recording the time (days) of spontaneous defecation after surgery; and (d) Gastrointestinal function recovery time, defined as the number of postoperative days until the patient was able to tolerate a semi-liquid diet without abdominal distension, nausea, or vomiting, as assessed once daily by the attending nursing/surgical team using a standardized recovery checklist; (2) Pain and comfort assessment: Pain intensity was measured using the NRS This is a 0-10 numeric scale with 0 being no pain and 10 being excruciating. Pain scores were assessed on days 1, 3, and 7 after surgery; (3) Functional recovery indicators: Exercise tolerance, the 6-minute walk test was used to assess patients and they were asked to walk at their maximum tolerable speed in a straight corridor as far as possible within 6 minutes (maximal distance walked in six minutes) on postoperative day 7; assessment of activities of daily living using Barthel Index that comprised 10 items (feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, bed-chair transfer walking level ground stair climbing) with a total score out of 100 points. Higher scores reflect greater capacity for activities of daily living. Time points of assessment were preoperatively, at discharge and 30 days postoperatively. The assessment “at discharge” was carried out on the actual day of hospital discharge (which may fall on different postoperative days in individual patients based on clinical recovery); mean ± SD postoperative day at which each of the groups were discharged is presented in Section 3.3. The 30-day postoperative evaluation occurred at a relative fixed time point and was, therefore, directly comparable between the groups; and (4) Satisfaction and quality of life in patients: The degree of satisfaction with rehabilitation care was evaluated by administering a 5-point Likert scale regarding patient satisfaction as follows: Very satisfied (5 points), satisfied (4 points), neutral (3 points), dissatisfied (2 point) and very dissatisfied (1 point). Higher scores mean greater satisfaction, measured the day of discharge. Quality of life was measured using the 36-item short-form health survey (SF-36) scale that assesses 8 dimensions: Physical functioning (10 items), role-physical (4 items), bodily pain (2 items), general health (5 items), vitality (4 items), social functioning (2 items), role-emotional (3 items) and mental health (5 items) for a total of 36 questions. Scores on each dimension can range from 0-100 points, with the higher scores reflecting a better quality of life. Assessment time points were preoperatively and at 30 days postoperatively.

Statistical analysis

The data were analyzed using SPSS 26.0 statistical software (IBM; Armonk, NY, United States). Normality was first tested for continuous variables. The data normal distribution was expressed in the form of mean ± SD, and the t-test for independent samples was used to compare what differences between groups. All continuous variables not conforming to a normal distribution were reported as median and interquartile range, and Mann-Whitney U test was employed for comparisons between groups. Categorical variables were reported as number and percentage n (%), with χ² test or Fisher’s exact test according to cut-off levels for inter-group differences. All statistical tests were two-tailed, and P < 0.05 was considered statistically significant. All 77 included patients had complete data for all primary and secondary outcomes at each pre-specified assessment time point; no missing data occurred for any outcome variable, and therefore no imputation was required.

RESULTS

Comparison of general information

This resulted in 77 subjects of patients undergoing laparoscopic radical resection for CRC, including 38 cases in the control group and 39 cases in the intervention group. There was no significant difference between the two groups regarding age, gender, BMI, smoking history drinking status tumor site TNM stage preoperative CEA level comorbidities and ASA classification (P > 0.05), suggesting comparability of the patients (Table 1).

Table 1 Comparison of general information between two groups, n (%)/mean ± SD.

Item	Control group (n = 38)	Intervention group (n = 39)	Test statistic	P value
Age (years)	62.4 ± 11.8	61.7 ± 12.3	t = 0.257	0.798
Gender			χ² = 0.041	0.84
Male	22 (57.9)	23 (59.0)
Female	16 (42.1)	16 (41.0)
BMI (kg/m2)	23.1 ± 3.2	22.8 ± 3.4	t = 0.403	0.688
Smoking history	14 (36.8)	13 (33.3)	χ² = 0.102	0.749
Drinking history	11 (28.9)	12 (30.8)	χ² = 0.032	0.858
Tumor location			χ² = 0.267	0.875
Colon cancer	23 (60.5)	25 (64.1)
Rectal cancer	15 (39.5)	14 (35.9)
TNM staging			χ² = 1.247	0.536
Stage I	8 (21.1)	6 (15.4)
Stage II	17 (44.7)	20 (51.3)
Stage III	13 (34.2)	13 (33.3)
Preoperative CEA (ng/mL)	8.7 ± 12.4	9.2 ± 13.1	t = -0.173	0.863
Comorbidities
Hypertension	15 (39.5)	16 (41.0)	χ² = 0.019	0.89
Diabetes	9 (23.7)	8 (20.5)	χ² = 0.116	0.733
Coronary heart disease	5 (13.2)	4 (10.3)	χ² = 0.158	0.691
ASA classification			χ² = 0.412	0.814
Grade I	12 (31.6)	14 (35.9)
Grade II	21 (55.3)	20 (51.3)
Grade III	5 (13.2)	5 (12.8)

ASA: American Society of Anesthesiologists; CEA: Carcinoembryonic antigen; BMI: Body mass index.

30-day unplanned readmission rate

There were a total of 9 (23.7%) cases of 30-day unplanned readmission in the control group compared to only 2 (5.1%) in the intervention group in the intervention group, the unplanned readmission rate was significantly lower than in the control group (Fisher’s exact test, P = 0.024) (Figure 1 and Table 2).

Table 2 Comparison of 30-day unplanned readmission between two groups, n (%).

Readmission cause	Control group (n = 38)	Intervention group (n = 39)	Statistical method	P value
Incision infection	4 (10.5)	1 (2.6)
Anastomotic leakage	2 (5.3)	0 (0)
Intestinal obstruction	1 (2.6)	1 (2.6)
Intra-abdominal infection	1(2.6)	0 (0)
Bleeding	1(2.6)	0 (0)
Total	9 (23.7)	2(5.1)	Fisher’s exact test	0.024

Recovery-related indicators

The intervention group showed much better recovery than did the control group in such indicators as time to first ambulation, time to first flatus, time to first defecation and gastrointestinal function recovery (P < 0.05) (Figure 2 and Table 3).

Figure 2 Comparison of postoperative recovery outcomes between the control group (n = 38) and intervention group (n = 39). A: Time to first ambulation and time to first flatus (hours); B: Time to first defecation and gastrointestinal function recovery time (days). Data are presented as mean ± SD. All between-group differences were statistically significant (^aP < 0.05).

Table 3 Comparison of recovery-related indicators between two groups, mean ± SD.

Indicator	Control group (n = 38)	Intervention group (n = 39)	Test statistic	P value
Time to first ambulation (hours)	36.8 ± 8.4	18.6 ± 4.2	t = 11.529	< 0.001
Time to first flatus (hours)	58.7 ± 16.3	42.1 ± 12.8	t = 4.886	< 0.001
Time to first defecation (days)	4.2 ± 1.1	3.1 ± 0.8	t = 4.949	< 0.001
Gastrointestinal function recovery time (days)	5.8 ± 1.4	4.2 ± 1.2	t = 5.350	< 0.001

Pain and functional recovery assessment

Postoperative pain at different time points was significantly lower in the intervention group than the control group on NRS pain scores on postoperative day 1, 3 and 7 (P < 0.05, Table 4 and Figure 3). On postoperative day 7, patients in the intervention group had a significantly longer 6-minute walk distance than those in the control group (335.7 ± 38.6 m vs 285.4 ± 42.3 m, t = -5.453, P < 0.001). There was no significant difference in pre-operative Barthel Index (P > 0.05) between two groups. Barthel Index scores at discharge and at 30 days postoperatively were significantly higher in the intervention group than in the control group (P < 0.05, Table 5).

Figure 3 Postoperative pain scores assessed by the Numeric Rating Scale (0-10) on days 1, 3, and 7 in the control group (n = 38) and intervention group (n = 39). Data are presented as mean ± SD. The intervention group demonstrated significantly lower pain scores at all three time points (^aP < 0.001). NRS: Numeric Rating Scale

Table 4 Comparison of postoperative pain scores between two groups (Numerical Rating Scale scores), mean ± SD.

Time point	Control group (n = 38)	Intervention group (n = 39)	t value	P value
Postoperative day 1	4.2 ± 1.2	3.1 ± 0.9	4.573	< 0.001
Postoperative day 3	3.1 ± 1.0	2.3 ± 0.8	3.842	< 0.001
Postoperative day 7	2.2 ± 0.8	1.5 ± 0.6	4.327	< 0.001

Table 5 Comparison of Barthel Index Scores between two groups (points), mean ± SD.

Time point	Control group (n = 38)	Intervention group (n = 39)	t value	P value
Preoperative	95.8 ± 6.2	96.4 ± 5.8	-0.444	0.659
At discharge	85.2 ± 6.8	90.1 ± 5.9	-3.418	0.001
30 days postoperatively	92.1 ± 6.2	95.8 ± 4.7	-2.967	0.004

Patient satisfaction and quality of life

On the day of discharge, patient satisfaction assessment indicated that the intervention group exhibited higher satisfaction scores than the control group did (4.6 ± 0.6 vs 3.8 ± 0.7, t = -5.321, P < 0.001). There were no significant differences (P > 0.05) in preoperative dimension scores between the two groups. On the 30^th postoperative day, the intervention group achieved significantly higher scores than the control group across all eight SF-36 dimensions, including physical functioning (78.6 ± 12.4 vs 71.2 ± 13.8, P = 0.015), role-physical (72.4 ± 15.2 vs 63.8 ± 16.8, P = 0.021), bodily pain (79.1 ± 12.8 vs 72.4 ± 14.2, P = 0.033), general health (72.3 ± 14.6 vs 64.1 ± 16.2, P = 0.022), vitality (69.2 ± 15.8 vs 60.4 ± 17.4, P = 0.023), social functioning (76.8 ± 14.7 vs 69.2 ± 16.1, P = 0.034), role-emotional (71.6 ± 16.4 vs 62.8 ± 18.9, P = 0.032) and mental health (73.8 ± 14.8 vs 66.2 ± 16.4, P = 0.036) (intervention vs control group, respectively) (Table 6).

Table 6 Comparison of 36-item short-form health survey quality of life scores between two groups (points), mean ± SD.

Dimension	Time point	Control group (n = 38)	Intervention group (n = 39)	t value	P value
Physical functioning	Preoperative	82.4 ± 12.6	83.7 ± 11.8	-0.467	0.642
	30 days postoperatively	71.2 ± 13.8	78.6 ± 12.4	-2.473	0.015
Role-physical	Preoperative	76.3 ± 18.4	78.2 ± 16.7	-0.474	0.637
	30 days postoperatively	63.8 ± 16.8	72.4 ± 15.2	-2.353	0.021
Bodily pain	Preoperative	81.5 ± 14.2	82.8 ± 13.6	-0.41	0.683
	30 days postoperatively	72.4 ± 14.2	79.1 ± 12.8	-2.173	0.033
General health	Preoperative	71.6 ± 16.3	73.4 ± 15.8	-0.492	0.624
	30 days postoperatively	64.1 ± 16.2	72.3 ± 14.6	-2.331	0.022
Vitality	Preoperative	69.8 ± 17.2	71.3 ± 16.4	-0.391	0.697
	30 days postoperatively	60.4 ± 17.4	69.2 ± 15.8	-2.322	0.023
Social functioning	Preoperative	78.9 ± 15.6	80.1 ± 14.3	-0.352	0.726
	30 days postoperatively	69.2 ± 16.1	76.8 ± 14.7	-2.162	0.034
Role-emotional	Preoperative	73.2 ± 19.8	75.4 ± 18.2	-0.507	0.613
	30 days postoperatively	62.8 ± 18.9	71.6 ± 16.4	-2.18	0.032
Mental health	Preoperative	72.4 ± 16.7	74.1 ± 15.3	-0.465	0.643
	30 days postoperatively	66.2 ± 16.4	73.8 ± 14.8	-2.134	0.036

DISCUSSION

This retrospective study compared the effects of ERAS pathway-based comprehensive perioperative management bundle and conventional rehabilitation care on 30-day unplanned readmission rate after laparoscopic radical resection for CRC. It was found that the unplanned readmission rate of intervention group was significantly lower than that of control group (5.1% vs 23.7%, P = 0.024), and there were significant differences in recovery-related indicators, pain control, functional recovery and quality of life. This evidence will serve as significant well-founded medical guideline for ERAS pathway-based comprehensive perioperative management package in post operation rehabilitation of CRC.

The 30-day unplanned readmission rate in the intervention group of this study (5.1%) was strikingly lower than the 23.7% readmission (P = 0.024) rate in control group, and compares favorably with the readmission rates reported in the systematic review by Kannan et al[4], ERAS cohorts of colorectal surgeries reported 30-day unplanned readmission rates between 8%-15%, as opposed to the historical controls that experienced 15%-25% readmissions (the smaller N of this single-center cohort relative to larger pooled multicenter populations, broader composition of ERAS bundles-our program combined early mobilization, structured gastrointestinal rehabilitation, multimodal analgesia, psychological support and formalized discharge planning rather than a subset of these interventions and more homogeneous laparoscopic surgical approach among our cohort compared with open approaches in many prior reports). The decrease in unplanned readmission rate is largely related to the synergistic effects of multiple elements within the ERAS bundle. The synergistic effects of early mobilization combined with early feeding and abdominal massage within the ERAS bundle rapidly restored gastrointestinal function and minimized intestinal obstruction, thus potentially reducing complications[10]. The time to first flatus (16.6 hours shorter) and the gastrointestinal function recovery time (1.6 days shorter) for the intervention group were statistically significant compared with those of the control, which is broadly consistent with the findings of Faucheron et al[11], who described that time to first flatus generally occurred between 36-48 hours under a full fast-track recovery protocol following colonic resection; Our intervention-group result of 42.1 hours is similar to this range, whilst the more protracted interval before achieving first flatus in our control (58.7 hours) may be attributed as much to the conservative, flatus-dependent early feeding regime characteristic of standard perioperative management as any difference in surgical technique observed across trials. Second, multimodal analgesia is one of the key elements in the ERAS comprehensive program, not only did it play an effective role in postoperative pain control but also laid a solid foundation for the smooth implementation of other bundle measures (e.g. early mobilization), thus reducing the risk factors leading to readmission caused by intolerable pain[12-14].

According to the analysis of reasons for readmission, the control group had higher proportions of readmissions due to incision infection (10.5%) and anastomotic leakage (5.3%), which were significantly reduced in the intervention group. This could be associated with initial action of the ERAS route on local circulation along with incision healing[15]. Moreover, preemptive analgesia and psychological support lead to a reduced stress response in patients, favoring the maintenance of immune function and reducing the incidence of infectious complications[14];

The primary results indicated that the intervention group was significantly superior to the control in multiple indicators of recovery. The time to first ambulation was reduced to 18.6 hours, which was 18.2 hours earlier than the control group and earlier than the mobilization timelines reported by Wiesenberger et al[13], whose ERAS clinical pathway for colorectal surgery had ambulating within 24 hours postoperatively as a target, which goal was achieved in most but not all patients. It is possible that our shorter observed time (18.6 hours) may be related to the need for implementing a more structured mobilization protocol in our bundle (with activity starting as early as the immediate postoperative period, 0-6 hours, based on full anesthetic recovery), and due to the difference in size and supervision of single vs multicenter cohorts: Our cohort was closer supervised than larger multicenter studies typically reported in international literature. Early ambulation not only prevents deep vein thrombosis and pulmonary complications but also it helps to recover gastrointestinal motility and postoperative recovery process[16].

Restoration of gastrointestinal function as quickly as possible after surgical intervention is a fundamental principle of the ERAS pathway. In this study, the time for first flatus in intervention group was significantly less than control group8 (42.1 hours vs 58.7 hours), which closely relate to the applied early feeding strategies and its abdominal massage measures[17]. Evidence based medicine has rendered the traditional concept of “fast until flatus” obsolete. Early postoperative feeding, not only is safe and feasible but also helps to promote recovery of gastrointestinal function and reduces the incidence of infectious complications[18].

Multimodal analgesia, which is an indispensable pillar of ERAS program[12], in this study maintained pain scores within the intervention group nearly pegged or below 3 points throughout the perioperative observation duration: NRS score on postoperative day 1 was 3.1 ± 0.9; it steadily decreased to 2.3 ± 0.8 and 1.5 ± 0.6 in postoperative day 3 and postoperative day 7 respectively, all were significantly lower than those from respective control group counterparts (Table 4). Proper analgesia not only increases patient comfort but, more importantly, it forms a key enabling component of the bundle that facilitates early activity and rehabilitation training[19].

This study demonstrated objectively measured exercise tolerance (6-minute walk test) in our patients. Our results demonstrated that the walking distance on postoperative day 7 in the intervention group was significantly longer than those in the control group, which indicating ERAS pathway-based comprehensive perioperative management bundle had beneficial effects on improving cardiopulmonary functions and general physical performance[20]. The progressive activity training program began with walking within the ward at short distances, then progressed to greater intensities of activities, forcing patients to slowly increase the amount and intensity of movement without incurring deleterious effects due to excessive activity, as well as maximizing rehabilitation[21].

As a gold standard tool for the evaluation of activities of daily living, the Barthel Index can make an overall reflection on patients’ functional recovery level. Results of this study indicated that Barthel Index scores in the intervention group were significantly greater than those in the control group at discharge and 30 days following operation, suggesting that ERAS pathway-based comprehensive perioperative management bundle could better maintain and restore patients’ independent living ability[22]. This is significant for reducing the burden of family care and helping patients return to society[23].

Statistical significance (P values) should not be confused with clinical significance; one must always consider if even statistically significant differences between groups is clinically meaningful. The significant 16.6 hours decrease in time to first flatus in the intervention group corresponds with effect sizes of minimal clinically important difference reported in prior ERAS literature for gastrointestinal recovery outcomes and adds credibility that findings are meaningful beyond the statistical significance. The difference of 4.9 points on the Barthel Index score between arms is not only above but well below a clinically important margin set for patient populations, although statistically different and perhaps meaningful in their definitions of early functional independence or caregiver burden. We have therefore moderated our interpretation of this finding concurrently, and stress that it is the overall pattern of small, consistent improvements across multiple functional and quality-of-life domains rather than any isolated outcome in isolation that underpins the clinical value offered by the ERAS bundle. To their credit, the authors have recognized that quality of life assessment goes beyond traditional clinical outcomes; The SF-36 is a widely validated, multi-dimensional quality of life tool, and the consistent improvement observed across all eight domains in the intervention group confirms that the ERAS bundle yielded meaningful gains in health-related quality of life compared with the control group[24]. This betterment is not just present on a physiological level but also at the psychological and social levels, which embodies the philosophy behind holistic care in an ERAS pathway bundle[25].

The use of ERAS pathway based comprehensive perioperative management bundle was successful in this study due to close collaborative efforts of multidisciplinary teams and development of patient-specific protocol. It needs to be stressed that the clinical benefits found in this study are attributable to the synergism of all parts of the bundle, and it is not possible to separate out any one component (whether early mobilization, multimodal analgesia or early feeding) as a contributing factor from the design of this study. Increasing attention to causal attribution limitation should be interpreted cautiously. The professional guidance of rehabilitation therapists ensured the scientific and safety of rehabilitation training, while preoperative education improved patients’ compliance and participation[26]. Multimodal analgesia protocols must be put into practice with a coordinated cooperation of anesthesiology, surgery, and nursing teams to gain optimal analgesic effects with minimal side effects[27].

Psychological support is therefore an integral part of the ERAS pathway. The challenges of surgical trauma and unfamiliar environment may lead patients to suffer from negative emotions, including anxiety and depression[28], which influence the recovery process. The role of psychological counseling and encouragement in the rehabilitation therapist plays an active role to improve patients’ rehabilitation confidence and to enhance participation and effectiveness of rehabilitation training[29].

An integral part of the ERAS pathway involves discharge preparation, with continuity of care alongside appropriate discharge planning. The formulation of individualized home rehabilitation plans and the establishment of follow-up mechanisms to ensure that patients can carry out continuous rehabilitation training after discharge is also conducive to maintaining and consolidating the rehabilitation achievements during hospitalization[30].

This study has certain limitations. First, as an observational study, our assessment inevitably has selection bias and information bias that may compromise the validity of the results. However, this was a non-randomized retrospective study and the potential for residual confounding due to patient selection between groups cannot be completely eliminated in light of patients being included from the same overall study period (July 2020 to June 2021). Second, the sample size is relatively small which limits power of statistical tests. Third, the “at discharge” Barthel Index and satisfaction assessments were performed on the actual day of discharge rather than at a fixed postoperative day, and the mean length of stay differed somewhat between groups (Section Recovery-related indicators); this discrepancy in assessment timing may have introduced some confounding into the “at discharge” comparisons, although the 30-day postoperative assessment, which was fixed and directly comparable between groups, showed a consistent pattern of findings. Third, a multi-component ERAS comprehensive management bundle was applied in the intervention group. Due to the current study’s design, we cannot determine whether each individual component (i.e., early mobilization, multimodal analgesia, and early feeding) contributed independently to the primary outcome; causal attribution has limitations and findings should be interpreted cautiously until confirmed by factorial design studies. Moreover, the study did not perform cost-effectiveness analysis and was unable to fully assess the economic worth of the ERAS pathway[31]. Further confirmation of the clinical effects of ERAS pathway-based comprehensive perioperative management bundle is required through future large sample, multicenter prospective randomized controlled trials[32].

CONCLUSION

ERAS pathway-based comprehensive perioperative management bundle can significantly reduce the 30-day unplanned readmission rate after laparoscopic CRC surgery (5.1% vs 23.7%, P = 0.024), enable patients to recover from surgery in an early stage, enhance pain control, functional recovery level and quality of life. While most of these differences appear clinically meaningful in addition to being statistically significant, some, such as the modest difference in Barthel Index score, should be interpreted with appropriate caution given their smaller absolute magnitude. As the intervention is a multi-component bundle, the above clinical benefits are only realised from synergistic effects of each component. This program can be promoted and used in clinical perioperative nursing practice.