Thorn Christopher C, White Ian, Burch Jennie, Malietzis George, Kennedy Robin, Jenkins John T
St. Mark's Hospital, Watford Road, Harrow, London, HA1 3UJ, UK.
Int J Colorectal Dis. 2016 Jul;31(7):1329-39. doi: 10.1007/s00384-016-2588-4. Epub 2016 Apr 26.
Enhanced recovery after surgery (ERAS) is a well-established and accepted practice following colorectal surgery and has been demonstrated to reduce hospital length of stay (LOS) and 30-day morbidity. Despite evidence to support the individual elements on which the programme is based, there remains uncertainty as to how many and which of these are required to realise its benefits. Furthermore, elements of an ERAS programme might either precipitate or reflect recovery, in which case compliance could have a role in the improvement or prediction of outcome.
A multidimensional prospective database of 799 consecutive patients undergoing colorectal surgery within an established ERAS programme at a single institution was interrogated. After application of exclusion criteria, 614 patients were studied. The novel concept of 'active compliance' is introduced. An ERAS element is classified as 'active' if the participation of the patient is required to achieve its compliance. This contrasts with 'passive' compliance, where an intervention is delivered to the patient without their direct contribution. The short-term surgical outcomes of this cohort are reported with reference to ERAS protocol compliance.
Compliance with the passive elements of the programme was higher than with the active elements. Univariate and multivariate analyses demonstrate that poor compliance with active but not passive elements of the programme was significantly associated with major morbidity. Receiver operator characteristic curve analysis demonstrated active compliance to be a stronger predictor of both major morbidity (AUC 0.71 vs. AUC 0.56) and length of stay (AUC 0.83 vs. 0.57) when compared with passive compliance.
The results suggest that poor active compliance may be a surrogate marker of morbidity which can be recognised in the early post-operative period. This implies the potential for timely diagnosis and intervention. This aspect of ERAS compliance is clinically relevant yet has achieved scant attention. Independent validation of our observations is required.
术后加速康复（ERAS）是结直肠手术后一种成熟且被广泛接受的做法，已被证明可缩短住院时间（LOS）并降低30天发病率。尽管有证据支持该方案所基于的各个要素，但对于实现其益处需要多少以及哪些要素仍存在不确定性。此外，ERAS方案的要素可能会促进或反映恢复，在这种情况下，依从性可能在改善或预测结果方面发挥作用。
对在单一机构的既定ERAS方案下连续接受结直肠手术的799例患者的多维前瞻性数据库进行了调查。应用排除标准后，对614例患者进行了研究。引入了“主动依从性”这一新颖概念。如果需要患者参与才能实现依从性，则将ERAS要素分类为“主动”。这与“被动”依从性形成对比，在被动依从性中，干预措施是在患者没有直接参与的情况下实施的。参考ERAS方案依从性报告了该队列的短期手术结果。
该方案被动要素的依从性高于主动要素。单因素和多因素分析表明，对该方案主动而非被动要素的依从性差与主要并发症显著相关。受试者工作特征曲线分析表明，与被动依从性相比，主动依从性对主要并发症（AUC 0.71对AUC 0.56）和住院时间（AUC 0.83对0.57）的预测更强。
结果表明，主动依从性差可能是术后早期可识别的并发症替代指标。这意味着有及时诊断和干预的可能性。ERAS依从性的这一方面具有临床相关性，但很少受到关注。需要对我们的观察结果进行独立验证。
