Enhanced Recovery Minimizes Opioid Use and Hospital Stay for Patients Undergoing  Mastectomy with Reconstruction.

McGugin et al. Enhanced Recovery Minimizes Opioid Use and Hospital Stay for Patients Undergoing
Mastectomy with Reconstruction. Ann Surg Oncol. 2019 Oct;26(11):3464-3471.

What is already known:

With the current opioid crisis and possible association with cancer recurrence plus all the other known side effects of their use, reducing the amount of opioids used perioperatively can only be beneficial.

What this paper adds:

In this study the authors conduct a retrospective observational cohort study. They compared a contemporary group with a historical pre-ERAS cohort group. All patients received a paravertebral block as part of their analgesic plan. Compared with the historical cohort, the patients undergoing mastectomy in the contemporary cohort were 26% less likely to require IV opioids and had a significantly decreased LOS. Even after adjustment for increasing rates of Nipple-Sparing Mastectomy and direct implant reconstruction over time, opioid use and LOS still were associated with the ERAS group and multimodal analgesia use.

Chris Jones, Guildford.


Nutrition in peri-operative esophageal cancer management

Steenhagen E, van Vulpen JK, van Hillegersberg R, May AM, Siersema. Nutrition in peri-operative esophageal cancer management. Expert Rev Gastroenterol Hepatol. 2017 Jul;11(7):663-672.

What is already known:
Nutrition is an essential part of a successful ERAS pathway. For oesophageal cancer patients malnutrition is especially common, so this is an even more important aspect for these patients.

What this paper adds:
This review explores the current literature on nutrition in the pre-, peri- and post-operative phases of the management of oesophageal cancer as part of an ERAS pathway.

Chris Jones, Guildford.


Implementation of a pediatric enhanced recovery pathway decreases opioid utilization and shortens time to full feeding

Phillips et al. Implementation of a pediatric enhanced recovery pathway decreases opioid utilization and shortens time to full feeding. J Pediatr Surg. 2019 Nov 15. pii: S0022-3468(19)30718-3. doi: 10.1016/j.jpedsurg.2019.09.065. 

What is already known:

There has been a drive to develop ERAS pathways for paediatric care with several institutions and groups offering publications which are largely variations on existing adult guidelines. Many previous studies on the efficacy of ERAS in paediatric surgery have focussed on laparoscopic surgery and shown benefits in reduced hospital length of stay, length of time to restoration of bowel function and opioid consumption.

What this paper adds:

This single-institution, retrospective study describes its development and implementation of an ERAS guideline for paediatric open and laparoscopic inflammatory bowel surgery. From an initial adult pathway of 21 elements they selected 15 for inclusion in their paediatric study. The ERAS cohort were significantly more likely to receive regional blockade and required less opioid postoperatively along with a significantly shorter time to oral fluid intake. Postoperative complications were no different to the standard care group. The results of this study are encouraging in showing that elements of adult ERAS pathways are translatable to paediatrics with effective results. Reduced opioid consumption is also particularly reassuring in light of the potential for harm in using opioids in the paediatric population.

Ben Morrison, Guildford @blouism


Enhancing recovery after minimally invasive repair of pectus excavatum

Litz CN et al. (2017) Enhancing recovery after minimally invasive repair of pectus excavatum. Pediatr Surg Int. Oct;33(10):1123-1129. 

What is already known:

Paediatrics is one of the newest specialities to embrace ERAS, and so currently the evidence bas is relatively sparse. That said a number of guidelines have been published and the 1st World Congress on ERAS for Paediatrics took place last year.

What this paper adds:

A comprehensive ERAS programme was introduced for patients undergoing minimally invasive repair of pectus excavatum and was compared to a retrospective control group. Length of stay was reduced together with a reduction in ICU stay, a reduction in morphine usage and a reduced urinary catherization rates.

Chris Jones, Guildford.


Enhanced recovery after surgery program in Gynaecologic Oncological surgery in a minimally invasive techniques expert center. 

Lambaudie E et al (2017)Enhanced recovery after surgery program in Gynaecologic Oncological surgery in a minimally invasive techniques expert center. BMC Surg. 2017 Dec 28;17(1):136.

What is already known:

Minimally invasive surgery is an important part of any comprehensive ERAS programme, but it is obviously not the only element. This single centre retrospective analysis of how the introduction of an ERAS pathway affected length of stay, morbidity and readmissions in their institution.

What this paper adds:

This paper shows that even in a high-volume centre, already used to performing minimally invasive surgery, a comprehensive ERAS pathway can still improve length of stay. Although in this study there was no effect on rates of morbidity or readmission.

Chris Jones, Guildford


International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery

Wijk L et al. (2019) International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery. Am J Obstet Gynecol. 2019 Apr 30.

What is already known:

The ERAS society have published guidelines on best perioperative care for a number of different specialities for a number of years now. Whilst these have always been produced using the best available evidence they have as yet never been externally validated. Evidence is also emerging that with increasing compliance of all the ERAS elements, outcomes will also improve (both short and long-term).

What this paper adds:

This is a hugely important paper. It is the first time a set of ERAS guidelines have been validated. The study group consisted of ten hospitals throughout North America and Europe. Data from over 2000 patients was uploaded via the web-based ERAS Interactive Audit System. They demonstrated an association between increasing compliance with the elements and a shorter length of stay. In addition the risk of having a complication was also lower with increasing compliance, again reinforcing the importance of good compliance.

Chris Jones, Guildford


Optimising recovery after surgery: Predictors of early discharge and hospital readmission

Carter J, Philip S, Wan KM. Optimising recovery after surgery: Predictors of early discharge and hospital readmission. Aust NZ J Obstet Gynaecol. 2016 Oct;56(5):489-495.

What is already known:

ERAS programmes have been consistently shown to reduce length of stay and post-operative complications. Minimally invasive surgery has largely become the gold standard, but laparotomies are still the mainstay in certain gynaecological cases. This large audit of 550 patients conducted over 7 years comprised all laparotomies for suspected or confirmed gynaecological malignancy in a single centre in Australia.

What this paper adds:

Since the introduction of their fast track surgery (FTS) programme they have shown an overall reduction in adverse events. Ultra-early discharges (on or before day 2) tended to be younger, have benign pathology, performance status 0 and a transverse incision. They report that factors associated with delayed discharge beyond day 3 were age, pathology, performance status, incision type, operating time, blood transfusion and COX-2 inhibitors. Unsurprisingly hospital readmissions were associated with longer operating times, lymph node sampling, longer length of stay, wound infections, febrile morbidity, returns to theatre, unplanned ICU admissions and presence of other complications. Their full ERAS protocol was not published.

This paper highlights that despite adherence to an ERAS protocol, the unmodifiable factors of baseline demographics and disease severity have a significant impact on length of stay and adverse events. ERAS protocols should therefore be encouraged in benign gynaecological laparotomies.

Katie Wimble, Guildford. @wimble_katie


Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs.

Schmidt HM, El Lakis MA, Markar SR, Hubka M, Low DE. Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs. The Annals of Thoracic Surgery. 2016;102(3):931-9

What is already known:

Oesophagectomy is high risk and complex surgery, and has been associated with significant impact in terms of morbidity and mortality in the past. The introduction of enhanced recovery programmes has dramatically improved outcomes in this high risk group, including post-op complications, first-day mobilisation, and length of stay in both critical care and hospital.

What this paper adds:

This prospective cohort study from Virgina Mason MC, Seattle, is based on previously published outcome data of patients in their institution that identified a subgroup of patients that exceeded their day-7 discharge goal. The study attempts to identify these patients capable of achieving ‘accelerated recovery’ (AR), as well as assessing outcomes in this group compared to those in ‘targeted recovery’ (TR) and ‘delayed recovery’ (DR) groups (defined as those with discharge days of 5 or 6 (AR), 7 or 8 (TR) and 9 or more (DR).

They found that AR patients made up 46% of their cohort, and were younger, more likely to have neoadjuvant chemotherapy, shorter operations, and less blood loss. All groups were comparable regarding comorbidities, cancer stage, and treatment approach, while DR patients were more likely to have complications. AR patients were more likely to be discharged home, with comparable 30-day readmission rates between groups. Overall costs (mean and readmission) were lower in the AR group.

It is exciting to see evidence that (already impressive) lengths of stay may be further improved in a significant subset of patients undergoing oesophagectomy, with associated decreased treatment costs. The authors conclude that ERAS programs should be designed to accommodate patients appropriate for AR. The question may be, given that a number of the variables associated with ‘accelerated recovery’ are intraoperative (though length of surgery and blood loss may be predicted to some extent), how these findings might best be translating to service provision and planned stays in hospital in this group.

Tom Barnes, East Surrey Hospital @TomBarn75870085


ERAS in Emergency Surgery

Effects of an Enhanced Recovery After Surgery programme on emergency surgical patients.

Effects of an Enhanced Recovery After Surgery programme on emergency surgical patients (2016) Wisely JC, Barclay KL. ANZ J Surg. 2016 Nov;86(11):883-888.

 

What is already known:
The majority of ERAS research has been focussed, quite rightly, on improving outcomes in elective surgery. However emergency surgery has high rates of morbidity and mortality and a lot more interest more recently has been directed at how ERAS elements could affect outcomes in this high-risk group.

What this paper adds:
In this retrospective review the authors compared 2 groups of patients undergoing emergency major abdominal surgery before and after an ERAS program had been introduced for their elective colorectal surgery patients. A total of 370 patients were included. The two groups were similar in age, co-morbidities and ASA scores. The post-ERAS group underwent significantly more left sided procedures. Hospital length of stay was similar in both groups [median 8 days], but the post-ERAS group received significantly less intravenous fluid, both intra-operatively and post-operatively. Significantly fewer patients in the post-ERAS group had a urinary catheter or PCA for more than 2 days. There were also fewer abdominal drains used in the post-ERAS group. This resulted in significantly reduced major post-operative complications in particular chest infections. Suggesting that ERAS elements could have a place in both elective and emergency surgery.

Chris Jones, Guildford.


ERAS in Emergency Surgery

Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes?

Quiney N, Aggarwal G, Scott M, Dickinson M (2016)Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes? World J Surg. 2016 Jun;40(6):1283-7 

 

What is already known:

Emergency general surgical operations carry a very high mortality rate, and it is estimated that they are at least ten times higher than many similar elective procedures. Roughly 55,000 emergency operations are carried out each year and it is estimated that will result in 8,000 deaths.

What this paper adds:

In this interesting paper the authors examine the evidence behind the ERAS elements and how they can be applied to emergency surgery. In particular they examine the delays can affect outcomes, in particular delays in diagnosis, resuscitation, antibiotics and definitive care. They also examine how inadequate postoperative care can affect outcomes.

Chris Jones, Guildford.


ERAS for Head and Neck Surgery

Enhanced recovery in patients having free tissue transfer for head and neck cancer: does it make a difference?

Bater M, King W, Teare J, D’Souza J.Enhanced recovery in patients having free tissue transfer for head and neck cancer: does it make a difference? Br J Oral Maxillofac Surg. 2017 Dec;55(10):1024-1029

What is already known:
Head and neck surgery is one of the newest specialities to embrace ERAS, but at present there are very few studies published in this area. Despite this the ERAS society have published consensus guidelines available here, based mostly on extrapolation from other surgical specialities.

What this paper adds:
This is one of the first papers to specifically describe an ERAS programme for head and neck surgery and compare it to a traditional care model. They compared 100 consecutive patients undergoing their ERAS programme and compared with 40 from a historical control group. Overall they demonstrated a 4 day reduction in length of stay (10 vs 14 days, p=0.003), with no change in morbidity or readmission rates. Suggesting that ERAS is safe and effective for this group of patients.

Chris Jones, Guildford.


ERAS for Neurosurgery

Hagan KB, Bhavsar S, Raza SM, Arnold B, Arunkumar R, Dang A, Gottumukkala V, Popat K, Pratt G, Rahlfs T, Cata JP. Enhanced recovery after surgery for oncological craniotomies. J Clin Neurosci. 2016 Feb;24:10-6.

What is already known:

The principles of ERAS have been applied to many new specialities over the recent years. One of the newest specialities is Neurosurgery. This group from the US explored how ERAS principles of ERAS could be applied to oncological craniotomies.

What this paper adds:

The authors should be congratulated for this interesting systematic review of the literature on ERAS for neurosurgery. They reviewed how each element could be applied to neurosurgery, including specific concepts such as scalp blocks and minimally invasive craniotomies. And whilst there is insufficient evidence at present for recommending a specific protocol it does support pursuing future research in this area.

Chris Jones, Guildford.