Enhanced Recovery After Surgery:

What is it and is it worth the trouble?

Auckland Enhanced Recovery After Surgery Group

Andrew HillColorectal Surgeon

Middlemore Hospital, University of Auckland

What is ERAS?

• AKA Fast-track or ERP

• Developed by Kehlet in Denmark in colonic surgery

• Gradually has gained world-wide acceptance

• Originally described in Open Surgery but same advantages seem to apply for Laparoscopy

ERAS Results

Type of Operation Duration of stay

Carotid endarterectomy 1-2 days

Lung lobectomy 1-2 days

Prostatectomy 1-2 days

Colectomy 1-3 days

Aortic Aneurysm 3-4 days

What is ERAS?

Patient Information

• At the clinic

• Ward visit

Carbohydrate drinks

• 4 night before surgery if having bowel prep

• 2 morning of the surgery

No mechanical bowel preparation

• Enema morning of surgery for L) sided cases

Patients admitted on the morning of surgery

Pre-op

Thoracic Epidural Analgesia

Incision choice

• Transverse for R) sided

• Mid-line or Laparoscopic for L) sided

Avoidance of Drains and NGT post-operatively

Limited Intra-Operative fluid therapy

• Aiming to max of 1.5-2 L

• Goal Directed

Surgery

Cessation of IVF

• unless clinically indicated

• Pressors for epidural hypotension

Regular pre-emptive antiemetics

• ondansetron as first line

On arrival to the ward

• Patient sits up

• Starts drinking protein drinks (Resource/Fortisip etc)

After surgery

Day 1

• IDC removed in the morning

• 8 hrs of enforced mobilisation

• Resumes normal diet

• Pre-emptive oral analgesia is started

• Paracetamol and NSAIDs

• Avoid Opioids

Day 2

• Epidural infusion is stopped in the morning

• Epidural Catheter is removed at 1400 if pain controlled, and timed with Clexane dose

Day 3/4 - discharge criteria:

•Return of GI function

•Able to eat and drink without discomfort

•Passing flatus, or moved a B/M

•Pain controlled with oral analgesia

•Adequate home support

Discharge date is an important target for patients and staff but flexibility is vital

ERAS Group(n = 50)

Control Group(n = 50)

P Value

Intravenous fluids Intra-operative First 3 days

2 (1 – 8)2 (1 – 10)

3 (1 – 7.5)6.5 (1 – 12)

<0.0001†

<0.0001†

Epidural analgesia No. of patients Duration of use (days)

44 (89%)2 (0 – 3)

38 (76%)3 (0 – 4)

0.223‡

<0.0001†

Recovery Days to 1st full meal Days to passage of flatus Days to independent mobilisation

1 (1 – 3)2 (0 – 8)1 (1 – 3)

2 (1 – 15)3 (0 – 18)3 (1 – 7)

<0.0001†

<0.0001†

<0.0001†

Day stay No. admitted > 1 day before surgery Postoperative stay (days) Total hospital stay (days)

12 (24%)4 (3 – 34)4 (3 – 34)

29 (58%)6.5 (3 – 18)8 (4 – 29)

<0.0001‡

<0.0001†

<0.0001†

Readmissions No. patients readmitted 6 7 0.766‡

ERAS Group(n = 50)

Control Group(n = 50)

P Value

ComplicationsPatients with > 1 complication

DeathReoperationAnastomotic leakIntra-abdominal collectionIleusWound complicationUrinary tract infectionUrinary retentionCardiopulmonary

27

04415625

11

33

2431

1810123

21

0.221

0.4951.0001.0001.0000.0050.2750.0080.7150.032

Postoperative Fatigue

Differential cost analysis of 1st 50 patients

(Savings on day stay and complications)

minus

(Full implementation + maintenance cost)

Final tally= $446,000 – $102,000= $344,000= $6880 per patient

Length of hospital stay (days)

Experimental group= Enhanced Recovery After Surgery (ERAS) Control = Traditional Care (TC)

Complications

Experimental group= Enhanced Recovery After Surgery (ERAS)

Control = Traditional Care (TC)

Readmissions (days)

Experimental group= Enhanced Recovery After Surgery (ERAS)

Control = Traditional Care (TC)

Mortality

Experimental group= Enhanced Recovery After Surgery (ERAS)

Control = Traditional Care (TC)

A Personal Series-100 Colectomies

Age (median) and range 70 (16-92)

Male 48%

Malignancy 83%

Laparoscopic 17%

ASA 2+ 84%

Median Day Stay (range) 3 (2-60)

Readmission Rate 21%

Major Complications 8%

ERAS in Bariatrics

•Randomised Controlled Trial

•2 Arms

•ERAS vs. Standard Perioperative Care

Population

• Patients undergoing laparoscopic sleeve gastrectomy (LSG) for weight loss

• Eligibility Criteria

• Procedure at Manukau Surgery Centre (MSC)

• Consenting surgeon

• Exclusion Criteria

• Not at MSC

• Redo procedure

Intervention and Control

•Perioperative care as per Bariatric Specific ERAS protocol

VS.

•Standard perioperative care

Outcomes

•Primary outcome was initial median length of hospital stay (LOS)

•Powered to detect a reduction in median LOS from 3 (current figure) to 1 (target from the literature)

•α:0.05; β:0.8; Sample Size = 56 (28 in each arm)

Follow up time

•30 day follow up

•Further analysis planned for longer term follow up on weight loss data

Results•71 randomised

•11 post randomization exclusions

•60 patients included in analysis

•31 ERAS group

•29 Non ERAS group

Baseline Characteristics

ERAS (31) Non ERAS (29) p value

Mean Age 44.3 43.6 0.66

Female Gender (%)

23 (74) 24 (83) 0.54

Planned Admit to PCU (%)

8 (26) 1 (3) 0.027

Baseline Characteristics

ERAS (31) Non ERAS (29) p value

Mean Weight (kg)

132 133.6 0.78

Mean BMI (kg/m2)

46.2 46.7 0.80

Mean Excess Weight (kg)

66.9 67.8 0.85

Baseline Characteristics

ASA ERAS (31) Non ERAS (29) p value

ASA 1 1 0 1.00

ASA 2 18 18 0.80

ASA 3 12 11 1.00

Complications (Cx)ERAS (31) Non-ERAS (29) p value

Total Cx (%) 9 (30) 7 (24) 0.77

Major Cx (%) 5 (16.1) 4 (13.7) 1.00

Leak (%) 2 (6.4) 2 (6.8) 1.00

Bleed (%) 3 (9.7) 2 (6.8) 1.00

Length of Stay (LOS)

ERAS (31) Non ERAS (29) p value

Initial LOS (median)

1 2 <0.001

Readmissions (%)

5 (18) 5 (18) 1.00

Conclusion

ERAS is possible in a New Zealand public hospital.

ERAS is safe in a New Zealand Hospital

ERAS enhances recovery in a New Zealand Hospital

ERAS is cost-effective in a New Zealand Hospital

ERAS is more than just Colorectal Surgery