Patients as partners in Enhanced Recovery After Surgery: A qualitative patient-led study

Gillis C, Gill M, Marlett N, MacKean G, GermAnn K, Gilmour L, Nelson G, Wasylak T, Nguyen S, Araujo E, Zelinsky S, Gramlich L. BMJ Open. 2017 Jun 24;7(6):e017002

What is already known:

Patient centered care is perceived as the most important part of healthcare but often patients are not really involved in shaping health services. This is a really interesting and important study as it is the first patient led ERAS study. Where patients were trained to conduct experimental patient research, and to characterise the needs and expectations of patients following ERAS care.

What this paper adds:

The main finding from this study is that patients wish ERAS pathways included their whole journey from diagnosis to recovery, and not just be limited to the perioperative phase. The ERAS protocol should be fully explained and the purpose of it should also be reinforced. The protocol should be extended to preoperatively to help patients prepare emotionally, psychologically and physically before surgery. Peer support should be available (I happen to think this is invaluable!). And finally for clinicians to realise that one-size-does not fit all and that personalised adaptations within the standardised pathway are required. It is not the largest of studies (only 20 patients) so cannot claim to speak for all patients but it still gives valuable insight to the wants and needs of patients undergoing ERAS programmes.

Chris Jones, Guildford. @chrisnjones


Impact of laparoscopy on adherence to an enhanced recovery pathway and readiness for discharge in elective colorectal surgery: Results from the PeriOperative Italian Society registry

Braga M, Borghi F, Scatizzi M, Missana G, Guicciardi MA, Bona S, Ficari F, Maspero M, Pecorelli N; PeriOperative Italian Society. Surg Endosc. 2017 Nov;31(11):4393-4399.

What is already known:

A lot of studies are single centre with small patient numbers, so studies using national databases with much larger patient numbers are to be welcomed.

What this paper adds:

Prospectively collected data from 13 different Italian hospitals were entered in an electronic national registry. Over 700 patients were included and were divided into 3 groups. Laparoscopic surgery, conversion to open surgery and primary open surgery. They found that patients undergoing laparoscopic surgery were more likely to successfully adhere to all the elements of the ERP; and multivariate analysis showed that having laparoscopic surgery was an independent factor for successful adherence. This was despite those undergoing open surgery being generally older and had higher rates of stoma formation.

Chris Jones, Guildford. @chrisnjones


Perioperative nutrition and enhanced recovery after surgery in gastrointestinal cancer patients. A position paper by the ESSO task force in collaboration with the ERAS society (ERAS coalition).

Sandrucci et al. Eur J Surg Oncol. 2018 Apr;44(4):509-514. Epub 2018 Jan 12.

What is already known:
Malnutrition is an important risk factor for all patients but in particular those undergoing oncological surgery. It is known to be associated with increased length of stay, increased post-op complications and mortality.

What this paper adds:
This is a combined statement from the ERAS Society and the European Society of Surgical Oncology (ESSO). It discusses the importance and role of a good ERAS programme, nutritional screening, prehabilitation, immunonutrients, the management of the frail and elderly, it even touches on how surgical technique could have an impact.

Chris Jones, Guildford.


Compliance with the ERAS Protocol and 3-Year Survival After Laparoscopic Surgery for Non-metastatic Colorectal Cancer.

Pisarska et al. World J Surg. 2019 Jul 8. doi: 10.1007/s00268-019-05073-0.

What is already known:
The short-term benefits of ERAS are well known but what is really exciting is how the evidence of long-term benefits are slowing building.

What this paper adds:
This study of patients undergoing laparoscopic colorectal surgery has an impressive overall compliance of all the elements (85.2%), but when they divided the patients into 2 groups (<80% and >80% compliance) there were differences in outcomes. 3-year survival was 88% in the high compliance group compared to 76% in the lower compliance group (p=0.0007). There were also fewer complications (44 vs 23%) and shorter length of stay in the high compliance group (6 vs 4 days). This paper nicely adds to the growing evidence of improved longer-term outcomes with ERAS.

Chris Jones, Guildford. @chrisnjones


Enhanced Recovery After Surgery (ERAS) Pathway in Esophagectomy: Is a Reasonable Prediction of Hospital Stay Possible?

Parise et al. Ann Surg. 2019 Jul;270(1):77-83. doi: 10.1097/SLA.0000000000002775.

What is already known:
An oeshophagectomy is probably the surgery with the biggest surgical stress response. It has high rates of morbidity and so patients undergoing this type of operation would have the most to gain from a comprehensive ERAS pathway. The ERAS society have recently published guidelines on the perioperative care of these patients, which can be found here.
A general difficulty in ERAS, is to predict which patients will fail to follow a pathway. If we could predict, then we could allocate time and resources to those who were at risk of not following the pathway.

What this paper adds:
The authors of this study attempted to come up with an Enhanced Recovery Predicting Score based on multivariate regression analysis of almost 300 patients who had previously followed an ERAS pathway for oesophagectomy. It included variables such as if a patients ASA score was greater than or equal to 3, if surgery lasted longer than 255 minutes, if non-hybrid surgical approaches were used and whether patients were able to meet their initial mobilisation goals. The authors then used this scoring system to a prospective cohort of patients undergoing surgery at their institution. The score had a sensitivity of 96.6% but the specificity was only 17.6%, so it may not be the definitive answer but is certainly a good start.

Chris Jones, Guildford. @chrisnjones


Active and passive compliance in an enhanced recovery programme.

Thorn CC, White I, Burch J, Malietzis G, Kennedy R, Jenkins JT. Int J Colorectal Dis. 2016 Jul;31(7):1329-39. doi: 10.1007/s00384-016-2588-4. Epub 2016 Apr 26.

What is already known:
We know that outcomes improve with increasing compliance of (all) elements. And a large number of trials have attempted to discover which individual element is the most important, so far without success.

What this paper adds:
This is a really interesting paper, where the authors have attempted to split the ERAS elements into active and passive ones. Active elements require patient participation (e.g. mobilising for a set distance per day); and so are more difficult to achieve than passive elements that do not require patient participation (e.g. undergoing goal directed fluid therapy). The authors defined 6 elements as active ones and 10 as passive elements. Compliance of active elements demonstrated superior discrimination of major morbidity and prolonged length of stay (LoS) compared to the passive elements. Failure to comply with these active elements could therefore be used as an early indicator of either potential morbidity or prolonged LoS, allowing for timely intervention.

Chris Jones, Guildford. @chrisnjones


REctus Sheath block for postoperative analgesia in gynecological ONcology Surgery (RESONS): a randomized-controlled trial.

Bakshi SG, Mapari A, Shylasree TS.REctus Sheath block for postoperative analgesia in gynecological ONcology Surgery (RESONS): a randomized-controlled trial. Anaesth. 2016 Dec;63(12):1335-1344.

What is already known:
Epidurals are often considered the gold standard when it comes to post-operative analgesia in open surgery. However, a lot of the evidence for this comes from the pre-ERAS era. There are also associated complications for example hypotension and muscle weakness, which can affect early mobilisation. Together with a consistent associated failure rate, this has given rise to a great deal of interest in different analgesic techniques in particular for open surgery.

What this paper adds:

This is a small RCT of patients undergoing an ERAS programme for open midline gynae-oncology surgery using Rectus Sheath catheters, randomised to receive either local anaesthetic or normal saline alongside a morphine PCA. Unsurprisingly the local anaesthetic group had better pain scores and had a significant morphine sparing effect. This group were also able to mobilise sooner and had an earlier return to bowel function, suggesting that rectus sheath analgesia could be an alternative analgesic modality. Although doesn’t answer the question of what is the optimal analgesia for open midline surgery within a comprehensive ERAS programme.

Chris Jones, Guildford. @chrisnjones


Renal outcome after radical cystectomy and urinary diversion performed with restrictive hydration and vasopressor administration in the frame of an enhanced recovery program: A follow-up study of a randomized clinical trial.

Wen Wu FM, Burkhard F, Turri F, Furrer M, Loeffel L, Thalmann G, Wuethrich P (2017) Renal outcome after radical cystectomy and urinary diversion performed with restrictive hydration and vasopressor administration in the frame of an enhanced recovery program: A follow-up study of a randomized clinical trial. Urol Oncol. 2017 Oct;35(10):602.e11-602.e17.

What is already known:

Radical cystectomy surgery is well known to have a prolonged length of stay and high morbidity, in particular postoperative ileus. In this groups original study looking at ERAS for open surgery with a restricted fluid regimen they demonstrated a reduction in both hospital stay and gastrointestinal complications. However, concerns were raised about postoperative renal dysfunction after using this restrictive regimen of 1ml/kg/hr in addition to a small dose of norepinephrine.

What this paper adds:

There has been a lot of discussion over the years about restrictive vs liberal use of fluids and whilst this is not the paper to answer those questions it does suggest that there is little difference in outcomes with the two regimens. What was interesting is that the authors used an oesophageal doppler as part of their protocol but did not seem to use it to guide fluid therapy? Which goes against most ERAS guidelines whereby the recommendation is very much towards individualised or goal directed fluid therapy.

Chris Jones, Guildford. @chrisnjones


What are the risk factors for delayed discharge within an ERAS programme?

Pędziwiatr M, Pisarska M, Kisielewski M, Matłok M,Major P, Wierdak M, Budzyński A, Ljungqvist O. Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery? Med Oncol. 2016 Mar;33(3):25.

What is already known:

ERAS programmes are well known to reduce length of stay, however the reasons for a prolonged stay are not as well studied. In this Swedish pilot study which included the ERAS society chairman in its authorship, aimed to assess what influences delayed discharge within an ERAS program for laparoscopic colorectal surgery.

What this paper adds:

Length of stay did not seem to be affected by traditional patient risk factors eg ASA grade, co-morbidities or cancer stage but simply by compliance of the ERAS protocol. The exact reason why a patient did not follow the protocol fully remains to be answered, and may well be tricky to address but a key question to answer in the future. Chris Jones, Guildford.


Risk of anastomotic leak after NSAID use within an ERAS programme

Bakker N, Deelder JD, Richir MC, Cakir H, Doodeman HJ, Schreurs WH, Houdijk AP. Risk of anastomotic leakage with nonsteroidal anti-inflammatory drugs within an enhanced recovery program. J Gastrointest Surg. 2016 Apr;20(4):776-82.

What is already known:

Anastomotic leakage is a much feared complication after colorectal resection. The incidence is higher in low rectal resections (up to 13%) than with colonic resections (3%). It can have a profoundly negative impact on length of stay, morbidity and mortality, and possibly on longer term oncological outcome. It is thought that NSAID’s can increase this risk.

What this paper adds:

In this single centre observational study the use of diclofenac was associated with a higher rate of anastomtic leakage in both colonic and rectal resections. Interestingly the other NSAIDS – Ibuprofen and Mebutan used in this study had no association.

Chris Jones, Guildford.


Regional anaesthesia and ERAS

Carli F, Clemente A. Regional anesthesia and enhanced recovery after surgery. Minerva Anestesiol. 2014 Nov;80(11):1228-33

Comments

This paper written by one of the board members of the ERAS society explores the role of regional anaesthesia within an ERAS program and how it can affect postoperative outcomes.

Chris Jones, Guildford.


Enhanced Recovery After Surgery: A Review 

Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surgery. Epub January 11th 2017.

Comments

This review, written by three members of the ERAS® executive committee, provides a great overview of how fast track or Enhanced Recovery has evolved. The rationale of ERAS® is discussed, its elements and the concept of multimodal care, with synergy between the individual elements of care, as well as the interplay between caregivers: surgeons, physicians, nurses, physiotherapists and dieticians.

The paper addresses how ERAS programmes are set up in individual institutions, underpinned by evidence based, procedure specific, guidelines and continuous audit. The ERAS® Society been at the forefront of worldwide implementation of ERAS®.

Whilst length of hospital stay may have been an early goal for patients treated within ERAS® programmes, we are now seeing other benefits in particular a reduction in complications and readmissions across a range of surgeries. This has resulted in considerable cost savings per patient. Excitingly, long term benefits of ERAS® are becoming evident in both orthopaedics and patients with colorectal cancer.

Since this prestigious review was written for JAMA Surgery, our friend, colleague and mentor, Professor Ken Fearon died, and this review provides a fitting testimony to his outstanding efforts, intellect and enthusiasm for the ERAS® programme.

Bill Fawcett, UK.


ERAS and the impact of sarcopenia on outcomes

Pędziwiatr M, Pisarska M, Major P, Grochowska A, Matłok M, Przęczek K, Stefura T, Budzyński A, Kłęk S. Laparoscopic colorectal cancer surgery combined with enhanced recovery aftersurgery protocol (ERAS) reduces the negative impact of sarcopenia on short-termoutcomes. Eur J Surg Oncol. 2016 Jun;42(6):779-87.

What is already known:

The presence of sarcopenia (loss of skeletal muscle mass) or myosteatosis (fat infiltration in skeletal muscle) can lead to increased rates of morbidity and mortality in colorectal surgery. However the majority of studies are in open surgery.

What this paper adds:

This study of 124 patients undergoing laparoscopic colorectal surgery demonstrated that a comprehensive ERAS program can minimise the negative impact of sarcopenia and myosteatosis on all post-operative outcomes in colorectal cancer surgery.

Chris Jones, Guildford.


The importance of high compliance with all ERAS elements.

Gustafsson U; Hausel J; Thorell A; Ljungqvist O; Soop M; Nygren J; Enhanced Recovery After Surgery Study Group. Adherence to the Enhanced Recovery After Surgery Protocol and Outcomes After Colorectal Cancer Surgery. Arch Surg. 2011;146(5):571-577.

What is already known:

This is now a relatively old paper but it was one of the first large studies to highlight the importance of adherence to all the ERAS elements.

What this paper adds:

This is a large prospective cohort study from a single centre. It compared an earlier phase (2002-5) during which ERAS was poorly implemented with a more recent period (2005-7) during which the ERAS programme was reinforced and as such achieved significantly higher compliance with the protocol. They demonstrated fewer major complications, fewer debilitating postoperative symptoms and shorter length of stay. Multivariate analysis showed that preoperative carbohydrate loading and perioperative fluid restriction were independent predictors of postoperative outcomes.

Chris Jones, Guildford


High compliance with ERAS elements can have huge long-term benefits.  

Gustafsson UO, Oppelstrup H, Thorell A, Nygren J, Ljungqvist O. Adherence to the ERAS protocol is Associated with 5-Year Survival After Colorectal Cancer Surgery: A Retrospective Cohort Study. World J Surg. 2016 Jul;40(7):1741-7.

What is already known:

ERAS protocols have mostly focused on the short-term outcomes such as length of hospital stay, morbidity or hospital costs. This is one of the few papers that have started to look at longer term outcomes. We know from Khuri et al in 2005, that perioperative complications can have a dramatic effect on long term survival (in both cancer and non-cancer surgery). We know that ERAS pathways can reduce morbidity but we don’t know what long-term effect this reduction of morbidity can have.

What this paper adds:

This is potentially a hugely important paper. In this Swedish single centre study with over 900 patients, they compared adherence of ERAS elements with 5-year overall and cancer specific survival. They found that patients with >70% adherence the risk of 5-year cancer-specific survival was lowered by 42%. And importantly avoiding fluid overload and early oral intake were shown as independent predictors of increased 5-year survival.

Chris Jones, Guildford