Has the Use of Enhanced Recovery Protocols in Colorectal Surgery Increased Postoperative Bleeding Complications?

Background: Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways shown to improve postoperative complications and decrease length of stay after surgery. A critical component of an enhanced recovery after surgery protocol is the use of multimodal non-opiate analgesia using non-steroidal anti-inflammatory drugs and COX-2 inhibitors.

Objective: To compare the incidence of postoperative gastrointestinal bleeding between patients treated with and without an enhanced recovery after surgery protocol.

Design: Retrospective review of a prospective maintained colorectal registry.

Settings: Large colorectal referral center.

Patients: Preoperative elective colorectal surgery requiring an anastomosis.

Intervention: Standardized enhanced recovery after surgery protocol included celecoxib and ketorolac.

Main outcome: Postoperative outcomes included bleeding (+/- sequelae), reduction in hematocrit after operation, intervention for bleeding (transfusion, endoscopy or surgery), length of stay and hospital readmission.

Results: The enhanced recovery after surgery group (n = 630) and non-enhanced recovery after surgery groups (n = 739) were comparable in baseline clinical features except for surgical indication, with more inflammatory bowel disease and less malignant disease in the enhanced recovery after surgery group. Minimally invasive surgery was more commonly performed in the enhanced recovery after surgery group. Both bleeding with sequelae (p < 0.0001) and bleeding without sequelae (p = 0.0004) were significantly more common in the enhanced recovery after surgery group compared to the non-enhanced recovery after surgery group. In addition, there was a significantly larger hematocrit decline after operation noted in the enhanced recovery after surgery group (p < 0.0001). Both the need for transfusion and intervention for bleeding however did not significantly differ between patient groups. Factors associated with bleeding were the use of an enhanced recovery after surgery protocol (OR = 2.96; 95% CI, 1.57-5.58; p < 0.001) and performing a small to large bowel anastomosis (OR= 2.68; 95% CI, 1.49-4.81; p < 0.001).

Limitation: Retrospective observational design and inability to determine which component of the enhanced recovery after surgery protocol caused the bleeding.

Conclusion: Use of an enhanced recovery after surgery protocol in patients undergoing colorectal surgery with an anastomosis is associated with an increased incidence of bleeding without significant difference in the need for transfusion or intervention. See Video Abstract.