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SOUTH AFRICAN HEALTH REVIEW
SOUTH AFRICAN HEALTH REVIEW
1.
Oodit R, Warden C, Boutall A, et al. Improving perioperative cancer care: experience with the Enhanced Recovery After Surgery (ERAS) programme. SOUTH AFRICAN HEALTH REVIEW. 2024;26.
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  • Figure 1a. ERAS compliance - public sector
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  • Figure 1b. ERAS compliance - private sector
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Abstract

Aim

Surgery plays a pivotal role in the management of the majority of patients with cancer. Surgical cancer care in low-and middle-income countries is negatively impacted by high complication rates and failure to rescue the deteriorating patient. Implementation of the Enhanced Recovery After Surgery (ERAS) programme offers an opportunity to improve care.

Methods

Over eight years, one public and three private sector South African hospitals implemented the ERAS evidence-based colorectal guidelines tailored for context and led by multidisciplinary teams. Demographic variables, treatment and clinical outcomes were collected using an electronic audit system and analysed using statistical software for data science. Primary outcomes included length of stay and complication rates. The relationship between outcomes and compliance with ERAS guidelines year-by-year was evaluated.

Results

The study comprised 368 and 325 colorectal cancer patients from public and private sector hospitals, respectively, with an overall length of stay of 6 (interquartile ratio 4,9) and 4 (interquartile ratio 3,7) days, respectively. Complication rates were 39.9% (public sector) and 43.7% (private sector). Overall, ERAS compliance was greater than 70% in both sectors and ERAS compliance was greatest in the pre- and intra-operative phase. An association was seen between increasing compliance and decreased length of stay as well as decreased complication rates.

Conclusions

A robust colorectal cancer ERAS programme can achieve high compliance, decreased length of stay, and fewer complications in South Africa. This study provides a foundation for a large-scale national strategy for ERAS implementation for perioperative cancer care across all disciplines.

Introduction

Surgery plays a pivotal and irreplaceable role in the comprehensive management of 80% of patients with cancer.1 Surgical intervention may have a curative or palliative intent. The risks of complications are inherent in surgical procedures and can lead to delayed recovery, prolonged hospital stay, and increased healthcare costs.2 Actively reducing complications can have significant and far-reaching benefits. By prioritising and embedding efforts to minimise complications, healthcare providers not only mitigate the physical and emotional burdens on patients but also contribute to enhanced patient safety, reduced length of stay (LOS), earlier return to intended oncology treatment (RIOT), and a more streamlined and efficient healthcare system.3,4 Investing in strategies to improve perioperative care is thus crucial.

In this paper, insights from implementing an Enhanced Recovery After Surgery (ERAS) programme for colorectal cancer patients in the public and private sector in Cape Town are presented.

Context

In South Africa (SA), perioperative cancer care is fragmented, seldom patient-centred or evidence-based with limited availability of well-functioning multidisciplinary teams and monitoring and evaluation tools. In addition, there is a lack of robust data on LOS, complications, mortality, quality of life (QoL), and RIOT after cancer surgery.5,6 The Global Surgery Collaborative study, a multicentre, prospective cohort study conducted in 82 countries and among 15 958 patients, provides a global perspective on perioperative outcomes in high and low- and middle-income countries (LMICs).7 In that study, the proportion of patients who died after a major complication was highest in LMICs, with postoperative death after complications partly explained by patient (60%) and by hospital or country (40%) factors. Failure to identify and intervene in patients who were deteriorating after a complication (failure to rescue), was an important contributory factor to the higher mortality. The absence of consistent postoperative care facilities was associated with 7-10 times more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

Improving perioperative care is complex. Every surgical procedure requires careful planning prior to commencement and a well-functioning perioperative multidisciplinary team (patient, nurses, anaesthetists, surgeons, pharmacists, hospital managers, policy makers). The teams need to implement 20-25 key perioperative care elements to achieve improved patient outcomes. Key micro (e.g., essential drugs, oxygen, sterilised equipment) and macro resources (e.g., reliable water, electricity supply) need to be available. Improving care also requires adequate change-management and ongoing quality assurance.

The ERAS programme is an innovative service delivery platform for improved perioperative care that leverages the key principles of the WHO quality improvement framework.3,8 Institutions that have implemented the ERAS programme in different countries across the globe have reported a reduction in complication rates (20-25%), hospital stay (20-25%), in-hospital costs (10-25%), and nursing workload.9–11 A recent study from Sweden reported that the 5-year cancer-specific mortality rate decreased by 42% when compliance with ERAS guidelines was above 70%.12 Fewer studies have been conducted in LMICs but studies that have been conducted in these settings have achieved comparable results.13,14

The ERAS programme

The ERAS programme is based on three pillars:

  1. standardised evidence-based guidelines,

  2. an implementation programme, and

  3. a monitoring and evaluation tool.

Pillar 1: standardised evidence-based guidelines

The ERAS management guidelines address 20-25 elements of care in the pre-admission and pre-, intra- and postoperative period that are applicable to most cancer operations (Table1). Addressing these elements of care reduces the perioperative pathophysiological catabolic stress response and immunosuppression and allows the patient to eat, drink and mobilise sooner, i.e., faster recovery.

Table 1.Perioperative care guidelines
Pre-admission Preoperative Intraoperative Postoperative
  • Risk assessment
  • Refer & reassess
  • Risk assessment
  • Nil per mouth guidelines
  • Avoid premedication
  • Total intravenous anaesthesia
  • Multimodal analgesia
  • Maintain normothermia
  • Multimodal analgesia & avoid long-acting opioids
  • Optimal fluid balance
  • Prophylaxis for:
    • nausea & vomiting
    • thromboembolic disease
    • surgical site infection
  • Timely feeding
  • Timely mobilisation
  • Multimodal analgesia
  • Timely removal of drains, catheters & intravenous lines
  • Regular monitoring
  • Escalation when required
  • Prophylaxis for:
    • nausea & vomiting
    • thromboembolic disease
  • Review discharge plan & medication
  • 24-hour telephone access
  • Daily telephone calls for a minimum of 3 days
  • 30-day follow-up
Patient & family engagement
Multidisciplinary team
Data entry
Plan-Do-Study-Act (PDSA) cycle

Source: Oodit RL, Ljungqvist O, Moodley J. S Afr J Surg. 2018;56(1):8-11.

Pillar 2: implementation programme

The ERAS implementation programme focuses on establishing a well-functioning multidisciplinary team (MDT) able to implement the evidence-based guidelines. The 10-12-month implementation programme employs change management principles and features a series of MDT workshops and periods of active implementation. The MDT members include: the patient and their families, surgeon, anaesthetist, nurse care coordinator (NCC), nursing and theatre teams, physiotherapist, dietician, physician, data capturer, hospital management, and administrators. All members have a defined, unique and critical role in implementing the elements of perioperative care. A key member of the team is the ERAS NCC who supports the patient from the time of diagnosis to 30-days follow-up post discharge, manages the preoperative counselling, risk assessment and discharge planning, oversees intra- and postoperative care, data capture, and provides essential training to the MDT members.

Pillar 3: monitoring and evaluation tool

The ERAS monitoring and evaluation system, the ERAS interactive audit system (EIAS), allows the teams to continuously monitor adherence to the guidelines, measure outcomes and effect change. This is based on the Deming Plan-Do-Study-Act (PDSA) cycle.15 The ERAS database is web-based and available in real time. It is designed to allow centres to conduct relevant research and to benchmark results against other centres.

Methods

The ERAS programme was implemented in a public and three private sector hospitals in Cape Town, South Africa, for patients undergoing elective colorectal cancer surgery (September 2016 to June 2023, and April 2015 to April 2020, respectively). The public sector arm commenced later due to delays in recruitment of the ERAS nurse coordinator.

A dedicated perioperative ERAS MDT was established in each sector, and each worked independently.

The private sector MDT included:

  • 2 NCCs

  • 9 surgeons

  • 5 anaesthetists

  • 3 physiotherapy teams

  • 2 dieticians

  • 1 stomatherapy team

The public sector MDT included:

  • 1 NCC

  • 2 senior colorectal surgeons

  • many surgical registrars in rotation annually

  • 1 lead anaesthetist

  • 1 physiotherapy team

  • 1 dietician

  • 1 stomatherapy team

  • 2 hospital management personnel (CEO, surgical services manager)

The MDTs reviewed and implemented the ERAS evidence-based colorectal guidelines without any changes to the pre-admission and pre- and intraoperative period. For the postoperative period, the following items were added to the ERAS guidelines for the NCC: bi-daily ward visits, and telephone patient contact for a minimum of three days post discharge with a checklist questionnaire. Additionally, in the public sector hospital, every patient received a 24-hour emergency contact number, with a ‘call-me’ option. The lead surgeon and ERAS nurse coordinators met weekly and the entire MDT quarterly as part of the PDSA process.

Participant recruitment and measurements

Verbal consent to collect clinical data was obtained from all patients 18 years and older undergoing elective colorectal and/or small bowel surgery. Patients were enrolled consecutively. Although patients with both benign and malignant conditions were enrolled in the ERAS programme, for this analysis only patients undergoing surgery for colorectal cancer were included. All data were anonymised and entered in the database by the NCC. The following variables were measured: age, sex, pre-admission clinical details, pre-, intra- and postoperative clinical details, and compliance with the ERAS guidelines. See Appendix 1 for details on perioperative variables. Cancer stage was recorded using the stage and American Joint Committee on Cancer (AJCC) staging system, also called the Tumour, Node, Metastasis (TNM) staging system. The primary outcome measures were LOS, complications, and compliance with the guidelines. The LOS was defined as the duration (nights) spent in hospital from the date of admission to discharge. Any patient requiring readmission and/or repeat surgery within 30 days after the index operation was recorded. All complications occurring within 30 days of the procedure were recorded. The complication rate was calculated as the total number of complications divided by the total number of patients undergoing surgery. The Clavien–Dindo grade classification was used to classify complication events, as defined in the ERAS guidelines.4 The calculation of compliance (yes/no) with the ERAS guidelines was generated by the EIAS software. Any missing compliance data were recorded as non-compliant. Overall compliance reflects the average of the pre-admission, pre-, intra- and postoperative compliance. The impact of the degree of compliance on LOS and complications was assessed. The learnings from the weekly and quarterly meetings and the implementation workshops were recorded.

Data analysis was conducted using STATA v.16.16 Public and private sector data were analysed separately and not compared due to potential confounders such as the timeframe and other unmeasured differences between the two sectors. For continuous normally distributed variables, means and standard deviations are reported, while medians and interquartile range are used for distributions that were significantly skewed (Shapiro-Wilks test, p<0.05). For categorical variables, frequencies and percentages are reported. Within each data set, associations between LOS, any complication at 30 days, and overall compliance were assessed using linear regression of log transformed LOS, and logistic regression, respectively.

The study complies with the Declaration of Helsinki.17 Ethics approval was obtained from the University of Cape Town, South Africa (HREC 980/2023).

Results

A total of 556 and 514 patients were enrolled from the public and private sectors, respectively. In total, 368 public and 325 private sector patients had elective colorectal cancer surgery. Tables 2 and 3 summarise key demographic and clinical data for both sectors. Of note, in the public sector there was a trend of high American Society of Anaesthesiologists (ASA) scores, a greater number of patients requiring neoadjuvant therapy, and a prolonged use of opioids postoperatively.

Table 2.Demographic and preoperative clinical details for public and private sector groups
Public sector Private sector
n=368 n=325
Age (years) Mean (SD)* Med (IQR)** Mean (SD) Med (IQR)
61 (11.1) 62 (54-69) 66 (12.1) 67 (59-75)
Age group n % n %
<50 53 14.4% 30 9.3%
50–65 173 47.0% 117 36.1%
66+ 142 38.6% 177 54.6%
Gender n=368 n=325
Male 193 52.4% 160 49.2%
Female 175 47.6% 165 50.8%
Body Mass Index n=314 n=322
<30 252 80.3% 241 74.8%
30+ 62 19.7% 81 25.2%
Smoker n=368 n=324
Non or stopped 4 weeks before surgery 296 80.4% 289 89.2%
Yes 72 19.6% 35 10.8%
Alcohol Use n=368 n=324
Non or stopped 4 weeks before surgery 306 83.2% 153 47.2%
Yes 62 16.8% 171 52.8%
ASA Class n=364 n=325
ASA 1–2 206 56.6% 270 83.1%
ASA 3–4 158 43.4% 55 19.9%
Diabetes n=368 n=325
No 297 80.7% 275 84.6%
Yes 71 19.3% 50 15.4%
Radiotherapy to site n=368 n=325
No 164 44.6% 278 85.5%
Yes 204 55.4% 47 14.5%
Pre-op chemotherapy n=368 n=324
No 182 49.5% 262 80.9%
Yes 186 50.5% 62 19.1%

*SD = standard deviation
**IQR = interquartile ratio

Table 3.Intraoperative and postoperative clinical details for public and private sector groups
Clinical detail Public sector Private sector
n=368 n=325
n % n %
Final diagnosis – detail
1 – Primary adenocarcinoma 350 95.1% 299 92.0%
2 – Other primary malignancy 9 2.4% 19 5.8%
3 – Metastasis or recurrence of any malignant disease 9 2.4% 7 2.2%
Cancer stage n=354 n=323
0 2 0.6% 7 2.2%
1 83 23.5% 72 22.3%
2 127 35.9% 119 36.8%
3 114 32.2% 103 31.9%
4 28 7.9% 22 6.8%
Procedure group
Rectal 249 67.7% 142 43.7%
Colonic and small bowel 119 32.3% 183 56.3%
Surgical approach
Open 205 55.7% 77 23.7%
Laparoscopic 106 28.8% 235 72.3%
Laparoscopic converted to open 31 8.4% 13 4.0%
Robotic 26 7.1% 0 0.0%
Robotic converted to open 0 0.0% 0 0.0%
Duration of operation (hours: mins) Mean Median Mean Median
4hr00m 3hr50m 3hr9m 3hr4m
SD* IQR** SD* IQR**
1h30m 2hr55m–4hr55m 1hr13m 2h15m–3hr49m
General anaesthetic
Total intravenous anaesthesia 34 9.2% 201 62.2%
Inhalational volatiles 334 90.8% 122 37.8%
Antibiotic prophylaxis
No 1 0.3% 320 1.5%
Yes 367 99.7% 5 98.5%
Intraoperative opioids
No 29 7.9% 40 12.4%
Yes – short acting 289 78.5% 192 59.4%
Yes – long acting 50 13.6% 91 28.2%
Postoperative opioids
No 218 59.2% 291 89.5%
Yes – short acting 147 39.9% 14 4.3%
Yes – long acting 2 0.5% 20 6.2%

*SD = standard deviation
**IQR = interquartile ratio

The overall median LOS was 6 (IQR 4-9) and 4 (IQR 3-7) days in the public and private sectors, respectively, with a readmission rate of 12% in both sectors. The complication rate per Clavien-Dindo grade for complications and the common complications are shown in Table 4.

Table 4.Complications
Public sector Private
n=368 n=325
N % n %
Complication to 30 days 147 39.9% 142 43.7%
Minor (Clavien-Dindo 1–3) 96 26.1% 114 35.1%
Major (Clavien-Dindo 4–7) 51 13.9% 28 8.6%
Common complications during primary stay
Ileus 23 6.3% 24 7.4%
Anastomotic leaks 20 5.4% 15 4.6%
Urinary tract infection 1 0.3% 7 2.2%
Deep wound dehiscence 5 1.4% 3 0.9%
Wound infection 12 3.3% 7 2.2%
Lobar atelectasis 3 0.8% 3 0.9%
Pneumonia 6 1.6% 2 0.6%
Common complications during readmission
Anastomotic leaks 10 2.7% 6 1.8%
Urinary tract infection 2 0.5% 1 0.3%
Deep wound dehiscence 11 3.0% 6 1.8%
Wound infection 21 5.7% 27 8.3%
Lobar atelectasis 0 0.0% 1 0.3%
Pneumonia 1 0.3% 0 0.0%

Compliance is reflected in Table 5. Over the study duration, pre-admission and postoperative compliance was lower than preoperative and intraoperative measures in both sectors.

Table 5.ERAS guideline compliance
Compliance Public sector Private sector
n=368 n=325
Pre-admission n % n %
<50% 84 22.8 252 77.5%
50%–69% 152 41.3% 46 14.2%
≥70% 132 35.9% 27 8.3%
Preoperative
<50% 0 0.0% 1 0.3%
50%–69% 5 1.4% 8 2.5%
≥70% 363 98.6% 316 97.2%
Intraoperative
<50% 7 1.9% 7 2.2%
50%–69% 104 28.3% 43 13.2%
≥70% 257 69.8% 275 84.6%
Postoperative
<50% 207 56.3% 78 24.0%
50%–69% 156 42.4% 110 33.8%
≥70% 5 1.4% 137 42.2%
Overall
<50% 6 1.6% 12 3.7%
50%–69% 251 68.2% 129 39.7%
≥70% 111 30.2% 184 56.6%

The median pre-admission, pre-, intra-, and postoperative, and overall compliance with the ERAS guidelines in the public and private sectors per year are reflected in Figures 1a and 1b.

Figure 1a
Figure 1a.ERAS compliance - public sector
Figure 1b
Figure 1b.ERAS compliance - private sector

In both sectors, as overall compliance increased, LOS significantly decreased (Exp coefficient 0.98, 95% CI= 0.97-0.98; p<0.001[public]) and (Exp coefficient 0.98, 95% CI=0.98-0.99; p<0.001[private]). In both sectors, as compliance increased the odds of complications significantly decreased (OR (unadjusted)=0.96, 95% CI= 0.93-0.98; p=0.001[public]) and (OR (unadjusted)=0.97, 95% CI= 0.95-0.99; p=0.001[private]).

The key learnings of the weekly and quarterly meetings and the implementation workshops are summarised below. The NCCs’ notes identified lack of transport as a barrier to early discharge in the public sector. Implementing post discharge 24-hour availability for emergencies, and the daily telephone calls, helped to identify possible complications and reassured patients. Both sectors experienced a shortage of resources such as chairs and private spaces. Patients, surgeons, and nursing staff often challenged the early mobilisation and feeding guidelines as this was contrary to their previous knowledge and practice, and they feared medico-legal implications.

Discussion

Both LOS and complication rates are fundamental, albeit indirect, measures of the quality of care provided. The limited available data reflects a median LOS of 9 (IQR 9-16),18 and 11 days (IQR 7-15)19 for colorectal cancer surgery in SA. Both these studies imply that 25% of patients have a LOS of 15 or more days. Encouragingly, in this study, the overall median LOS in the public sector (6 days, IQR 4-9) and private sector (4 days, IQR 3-7) are more favourable than others reported in SA and comparable to international benchmarks. The readmission rate of 12% in both sectors is in keeping with results of established ERAS centres. There are several benefits associated with a reduced LOS for the patient and healthcare system. For the patient, streamlined service delivery and shortened recovery offer the possibility of fewer complications, improved QoL, and earlier RIOT. The healthcare system benefits include increased bed availability, improved efficiency, and cost reduction.3

Whilst there are numerous benefits to reducing LOS, this must be achieved without compromising the quality and safety of care. Establishing and maintaining appropriate support systems, such as effective preoperative discharge planning, adequate outpatient care, and follow-up need to be in place to ensure that patients receive the necessary care after hospital discharge. An important public sector barrier to early discharge was lack of transportation. Addressing this requires intersectoral collaboration.

The overall median complication rate compared favourably with international benchmarks from established ERAS centres worldwide.3 Scaling up ERAS has the potential to significantly improve patient outcomes, facilitate resource allocation, and improve the health service delivery platform in SA. The common complications of postoperative ileus, surgical site infection, pulmonary atelectasis, pneumonia, and urinary tract infections were less frequent than those reported in the literature for patients undergoing traditional care. This is probably a reflection on the benefits of optimal perioperative care.

Compliance measures adherence to the guidelines and is an indirect measure of the effectiveness of the MDT. Established ERAS centres with compliance levels greater than 70% consistently report lower LOS and fewer complications, with a reduction in LOS and complications as compliance improves.20 In this study’s ERAS programme, the overall median compliance was 72% in the public and 79% in the private sector, with a significant impact on LOS and complication rates. Post-operative compliance, a key measure of patient recovery, improved in both sectors, but the public sector was not able to reach the target of 70%. Possible contributing factors include: the high use of opioids postoperatively, need for ongoing staff training, and shortage of resources (e.g., space and chairs). Achieving postoperative compliance (e.g., feeding and mobilisation) challenges many long-held belief systems by patients and healthcare professionals. Future ERAS programmes need to adequately address these.

Each healthcare professional involved holds a distinct and vital role in addressing the various elements of care, necessitating mutual understanding and collaborative efforts. Nursing staff play a pivotal role in supporting and facilitating the implementation of early feeding and mobilisation. Dieticians must ensure that nutritional requirements are established and consistently met. Surgeons, anaesthetists, physicians, and pharmacists collectively contribute to optimal pain and fluid management, while physiotherapists are essential in initiating patient mobilisation. Operationally, creating dedicated spaces for seating and mobilisation is essential. Successful and sustained implementation of these changes relies on the synergy, coordination and shared commitment of the entire healthcare team.

The NCC serves as the vital link connecting patients and the MDT across the entire spectrum of care and provides essential support and training. In SA, although the SA Nursing Council (SANC) has ring-fenced perioperative care as a nursing speciality, to date there is no dedicated teaching for nurses at under- or postgraduate level.

A limitation of the study was the lack of baseline data which would have enabled a pre- and post-ERAS comparative analysis. International data show cost savings of between 20–25% and a return on investment between 5–7: 1 within the first year.21,22 If similar savings can be achieved in SA, there is a possibility of optimising the use of current resources and improving patient outcomes. Costing studies that include the entire patient journey are required to achieve uptake at the scale of ERAS programmes in the SA setting. User experience, particularly that of the patient, has been generally positive from anecdotal reports, but needs to be fully assessed. This could be achieved through collection of patients’ reported outcome measures or using a qualitative approach incorporating patient interviews and the disability-adjusted life year (DALY) tool.

The results achieved in these pilot projects hinged on the following key factors: strong leadership, well-functioning MDTs, a dedicated implementation programme, and a robust quality improvement framework. Although these results were achieved in elective colorectal cancer surgery, the programme lends itself to, and is available for, the management of major cancers across all disciplines.

Recommendations

Based on the findings of this study, the following are recommend:

  • Tertiary and quaternary academic units in SA establish perioperative hubs to implement the ERAS programme or similar and establish centres of excellence in perioperative care.

  • Intersectoral collaboration to address the identified barriers.

  • Liaison between the MDT, oncologists and palliative care specialists in ongoing patient care.

  • Development of national policy and guidelines on perioperative best practice.

  • Training at under- and postgraduate level for all MDT disciplines on perioperative care.

  • Once established, the academic hubs should collaborate with secondary hospital clinical leads, hospital managers and policy-makers to develop tailored implementation programmes with monitoring and evaluation tools.

Conclusion

The ERAS programme, with its focus on improving perioperative care, has the potential to significantly and meaningfully improve outcomes for cancer patients requiring surgical interventions in South Africa.

Abbreviations
Abbreviation Description
ASA American Society of Anaesthesiologists
AJCC American Joint Committee on Cancer
BMI body mass index
DALY disability-adjusted life year
EIAS ERAS interactive audit system
ERAS enhanced recovery after surgery
LMICs low- and middle-income countries
LOS length of stay
MDT multidisciplinary team
MUST malnutrition universal screening tool
NCC nurse care coordinator
PDSA Plan-Do-Study-Act
POSSUM physiological operative score for enumeration of mortality and morbidity
QoL quality of life
RIOT return to intended oncology treatment
SA South Africa
SANC South African Nursing Council
TIVA total intravenous anaesthesia

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Appendix 1

Preoperative variables

Weight (kilograms) and height (centimetres) used to calculated body mass index (BMI). Patients with a BMI ≥ 30 were classified as obese. The American Society of Anaesthesiologists (ASA grade 1–4) and the physiological operative score for enumeration of mortality and morbidity (POSSUM) risk scores for complications were recorded. The ASA grade was categorised into low risk (grade 1 & 2) or high risk (grade 3 & 4). The malnutrition universal screening tool (MUST) was used to identify patients who were either malnourished or at risk of malnourishment. Patients who had stopped smoking for more than 30 days were deemed non-smokers. Additional measures recorded were: HbA1c for diabetics; diagnosis on presentation; radiotherapy treatment received preoperatively; the use of a 12.5% complex carbohydrate drink up to 2 hours prior to surgery; and whether the patient received preoperative counselling and discharge planning with the ERAS nurse. Patients who were assessed as high risk were referred for preoperative optimisation and reassessed prior to proceeding with surgery.

Intraoperative variables

Surgical procedures were grouped into either colectomy or rectal resections. For each, the procedure was: laparoscopic; laparoscopic converted to open; or planned open. The duration of the surgical procedure reflects the total of surgical and anaesthetic time (minutes). Type of anaesthesia was categorised as: total intravenous anaesthesia (TIVA); or inhalational. The use of an epidural was defined as compliant for open procedures and non-compliant for laparoscopic procedures.

The following were also documented: the administration and timing on antibiotic prophylaxis; the use of a warming blanket; patient temperature on completion of the procedure; the quantity of intravenous fluid administered, and the use of long- and short-acting intravenous opioids.

Postoperative variables

The following were recorded daily: quantity (litres) and duration (days) of intravenous fluids; time to passage of flatus and stools; tolerance of oral fluids and a normal diet, and the use of long- and short-acting opioids in the first 48 hours.