Evolution and Future of ERAS in Perioperative Management

Franco Carli

McGill University

Montreal, Canada

SwERAS 2019

Surgery

Stress

Short-term

outcomesactivities

mobility

Long-term

outcomesfunction

re-integration,

quality of life,

disability

Short-term changes

1) Biologic / systemic

endocrine

inflammatory

pulmonary

circulatory

2) Impairment

pain

fatigue

weakness

Strong Weak Not yet

demonstrated

? ?

A Model for assessing outcome of

therapeutic interventions after surgeryF Carli & N Mayo, British Journal of Anaesthesia 2001; 87:531-533

Need for Surgery Identified

Surgery

Preoperative Phase Intraoperative Phase Postoperative Phase

Trajectory of Surgical Care

Home transfer

Revolution Started in 1996

60 patients (74 yo) Open colon resection + postop care

program Epidural, early feeding (POD0) and early

mobilization Median LOS 2 days (avg 3 days)

PATIENT

RegionalAnesthesia

Preventionof ileus/

prokinetics

CHO - loading/no fasting

Early mobilisation

Peri-op fluidmanagement

DVT prophylaxis

Pre-op counselling/o

ptimization

Fast acting anesthtetics

No - premed

No bowel prep

PerioperativeNutrition

Temperaturecontrol

Opioid sparing/MultimodalAnalgesia

Minimal Invasive Surgery

No NG tubes

Early removalof catheters/drains

Adapted from Fearon et a al 2005, Lassen et al Arch Surg 2009, ERAS Guidelines 2012

Surgical stress:pain, catabolism, fluid/salt

retention, immune dysfunction, nausea/vomiting,

ileus, impaired pulmonary function, increased cardiac

demands, hypercoaguability, sleep disturbances, fatigue

Kehlet and Wilmore, Ann Surg 2008 (revised)

Elements of the stress response

Surgery is a stressor

Insulin resistance muscle

• Reduced glucose uptake

• Reduced glycogen storage

• Increased protein catabolism

Courtesy of O. Ljungqvist

Insulin resistance muscle

Lean body mass

Muscle function

Mobilisation

Energy supply

Need for Surgery Identified

Surgery

Enhanced Recovery After Surgery Program

Preoperative Phase Intraoperative Phase Postoperative Phase

Trajectory of Surgical Care

Fast-Track

Home transfer

Successes

• Trials and publications – ERAS works !

• Collaborative work – tumour board like

Challenges• Shifting paradigm – function matters to pt

• Frail olderpatients - need more attention

• Engaging patients - is it an art?

ERAS successes

Int J Colorectal Dis 2016

“Health care historically has been a very siloed field that’s organized around medical specialties...”

“The patient is the ping-pong ball that moves from service to service..”

Michael Porter

Sir Dave Brailsford

Coach UK cycling team London Olympic 2012:

0 track cycling gold medals

Theory of Marginal Gains

Successes

• Trials and publications –ERAS works !

Collaborative work – tumour board like

Challenges

• Shifting paradigm – function matters to patients

• Frail older patients - need more attention

• Engaging patients - is it an art?

Patients(n=17)

Clinicians(n=15)

Energy Level 88% 47%

Carrying out daily routine 76% 40%

General physical endurance 53% 33%

Sensation of pain 47% 87%

Recreational activities 47% 33%

Walking 41% 47%

Sleep functions 41% -

Appetite 35% 40%

Moving around 65% 47%

Defecation functions 18% 47%

Quality of consciousness - 60%

Doing housework - 47%

Family relationships - 40%

Informal social relationships - 40%

Lee L, How well are we measuring postoperative “recovery”? Qual Life Res, 2015

Outcomes that matter to patients recovering from GI surgery

Patients emphasized energy level, functional status (daily routine, recreational activities, endurance) and sleep

Clinicians put more emphasis on symptoms (pain, cognition, bowel function)

• 38 comparative studies• LOS primary outcome• Focus on in-hospital period

Neville A, Br J Surg 2014

Ann Surg 2018;268: 918-919

…….quantifying patient-centered outcomes represents the next critical step to incorporating these measures into mainstream surgical care……

………function as an outcome measure appears to be the leading candidate to best quantify patient centered postoperative outcomes for older adults……

……..outcome of function provides a concrete, meaningful variable for patients because it represents the ability to maintain living at home and avoid institutionalization

Function is an outcome meaningful to patient

What about postoperative functional capacity and physical activity?

ERAS Society Guidelines

• “Prolonged immobilization increases the risk of pneumonia, insulin resistance and muscle weakness. Patients should therefore be mobilized.”

Gustafsson et al, Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018. . World J Surg 2019

Level of evidence: LowStrength of recommendation: Strong

Present Standard Care ProvidedPatient Education Booklet

24

Fast-Track is associated with more mobilization in first week

Total time out of bed POD 1-7

=87 (67-121) vs 61 (19-84) hours P<0.01

Both groups had thoracic epidural

Requires very good pain control, patient education, well-defined daily requirements for nurses and patients to follow

Basse et al, BJS, 2002

Variability in Mobilization Goals in ERAS

who POD0 POD1

Delaney 2001 (USA) ? Permitted to walk if desired

Encouraged to walk ward 60mx5Out of bed between walks

Basse 2002 (Denmark) Nurse Mobilized 2h Mobilized 8h

Henriksen 2002(Denmark) Nurse 4h out of bedWalk 80m x1

6h out of bedWalk 80m x2

Anderson 2003 (UK) Physio Sit x 20 min Walk length of ward

Kennedy 2006 (UK) ? Chair 2h Dressed, assisted daily mobilization 4x 60m

Zargar 2009 (NZ) ? Mobilized Mobilized for 8 hours

De Aguilar 2009 (Brazil) ? 2h out of bed 6h out of bed

Carli 2009 (Canada) ? Encouraged out of bed for mealsWalking or sitting up to 8 h

Chen 2010 (Taiwan) ? Immediate mobilization

Lee 2011 (Korea) ? 1 h in chair 3h in chairWalk ward >400m

McGill Colorectal ERP Daily Goals

POD 0: out of bed

POD 1: walk length of hallway at least 3x with helpBe out of bed, on and off, for at least 8 hoursSit in the chair for all meals

POD 2: walk length of hallway at least 3x Be out of bed, on and off, for at least 8 hoursSit in the chair for meals

Mobilized:

27%

44%

31%

Castelino et al, Surgery, 2016

n Intervention Outcomes

Liebermann , 2013 Gyne 129 Specified ambulation goal, signs and reminders

Pedometer steps: NDLOS: ND

Waldhausen, 1990 abdom. 35 walking >75 yds persession

GI myoelectric activity: ND

Ahn 2013 colon ca

31 Structured stretching, core and resistance exercises

Decreased LOS (7.8 vs 9.9 days)*Decreased time to flatus (52 v 71h)*

Complications: NDPerformance measures: ND

Walking distance: ND

Arbane, 2014 lung ca 131 Daily cycle and strength training

Complications: NDLOS: ND

Performance measures: ND

Granger, 2013 lung ca 15 Structured exercise program:

aerobic, resistance, and stretching

LOS: ND

Arbane, 2011 lung ca 51 Strength and mobility training

Complications: NDBetter quadriceps strength *

Conclusion: Patients shouldn’t be kept in bed, but little guidance on how to achieve

early mobilization and what type of activity is beneficial

Facilitating mobilization• 99 patients randomized to:

• ERAS including written daily activity goals

• ERAS plus additional staff dedicated to mobilization

VS.

Fiore et al Ann Surg 2017NCT02131844

In hospital physical activityusual ERAS facilitated

mobilization

Time out of bed (self-reported), min

POD 0 0 (0-30) 30 (0-120)

POD 1 180 (90-300) 420 (240-720)

POD 2 240 (120-540) 360 (300-600)

Non-supine time (actigraphy), min

POD 0 38 (4-108) 52 (14-172)

POD 1 402 (268-532) 596 (378-696)

POD 2 464 (322-682) 618 (404-758)

When add walking helper to ERAS:>2x more steps walked >2x more time out of bed

0

200

400

600

800

1000

1200

POD 0 POD 1 POD 2

Ste

p c

ou

nts

(ac

tigr

aph

y)

*

*

Out of bed POD 0:37% vs 72% * Fiore et al Ann Surg 2017

Total: 1763 [478-4955]

Total: 840 [287-2009]

*p<0.05

• No difference in GI function• No difference in length of stay or

readiness for discharge (median 3 days)• No difference in complications• No difference in recovery to baseline

walking capacity at 4 wks (51% vs 54%)

Exercise: Resistance Training

Lavin KM, Physiology. 2019 Mar 1;34(2):112-122

Aerobic Resistance (1 set of 12 repetitions)

Walking up and down the hospital hallway (2-5 minutes)

• Shoulder abduction

• Pushups

• Chest

• Seated row

• Biceps Flexion

• Quadriceps Extension

• Triceps extension

• Leg flexion

• Calf raises

• Abdominal curls

Supervised In-hospital Exercise POD 0-3

Shram A, EJSO 2019

Results n = 30 patients

Discharge ≤2 days(n=14)

3-4 days(n=10)

≥5 days(n=7)

Average length of stay: 3 days

• 2 refusal• 4 in-bed• 1 standing

POD 1 Exercise:• 13 standing• 1 in-bed

• 3 standing• 4 seated• 2 in-bed• 1 refusal

Shram A, EJSO 2019

Adherence

43

27

63

0

10

20

30

40

50

60

70

80

POD1 POD2 POD3

Pe

rce

nt

Ad

he

ren

ce (

%)

Compliance to resistance exercises during the first threepostoperative in-hospital days for the supervised group

Overall C

om

plian

ce

76

POD = postoperative day

Shram A, EJSO 2019n=30 n=20 n=18

Successes

• Trials and publications –ERAS works !

Collaborative work – tumour board like

Challenges

• Shifting paradigm – function matters to patients

• Frail older patients - need more attention

• Engaging patients - is it an art?

Age & Surgery, limited access

Front Aging Neuroscience 2014

Age-related Muscle Loss and Acute Injury

Frail Elderly Patients Undergoing Colorectal Cancer Resection (mean age 78 y)

POP data, 2019

December 2017

Successes

• Trials and publications – prehab works !

• Collaborative work – tumour board like

Challenges• Shifting paradigm – function matters to pt

• Frail older patients - need more attention

Engaging patients - is it an art?

ENGAGING PATIENTS: Is it an ART ?

• Engaged pts have higher levels of satisfaction, understanding of their care….improved health and outcomes

• Participate in sharing decision making

• Understand criteria participation in plain language

What can be done to Improve Patient Engagement and Understanding?

• Do patients understand what we are saying to them?

• Should we test health literacy level?

Osborne, H. (2006), health literacy consulting, http://www.npsf.org; Rhoades et al. (2001). Family

Medicine 33(7): 528-532; Zulick et al., (2009) Perioperative Nursing Clinics, 4,131–139; Navarro-Bravo

B., et al., (2010), Patient education and counseling, (81) 2, 272-274; Houts et al.,(2006) Patient

Education and Counseling, 61,173–190.

HEALTH LITERACY is the degree to which individuals can obtain, process and understand basic health information and services they need to make appropriate health decisions.

Prevalence of low Health LiteracyUSA and CANADA 40-60%

Europe , 46%

The European Health Literacy Project. /The European Health Literacy Project 2009-2012

Patients with low Health Literacy may...

• Fill in registration forms incompletely or inaccurately.

• Frequently miss appointments.

• Fail to follow through with laboratory tests, imaging tests or referrals to consultants.

• Be unable to name their medications, explain what they are for or tell when they are supposed to take them.

Barrow S. (jan.-2012) Access; O’Reilly, K. (2012). Amednews.com

Strategies

Use plain

language

Eliminate distractions

Speak up

Use teachback

method

Avoid acronym

s / medical jargon

Use "univers

al precautio

ns"

“I want to be sure I explained everything clearly.

Please tell me in your words what you heard me say”.

“When you go home tonight, your wife (or husband or family member) might ask you what we have discussed, just to make sure that I have explained clearly can you tell me what you will tell them”

PHYSICIANACCELERATEAPPROXIMATECONSUMEONSETMODIFYUTILIZEIMPLEMENTADMINISTERHOSPITALIZATION

VSVSVSVSVSVSVSVSVSVS

DOCTORSPEED UPABOUTEATSTARTCHANGEUSEDOGIVEHOSPITAL STAY

Improving Patient Engagement

Training your staff

Surgery

Stress

Short-term

outcomesactivities

mobility

Long-term

outcomesfunction

re-integration,

quality of life,

disability-free

survival

Short-term changes

1) Biologic / systemic

endocrine

inflammatory

pulmonary

circulatory

2) Impairment

pain

fatigue

weakness

Strong Weak Not yet

demonstrated

? ?

A Model for assessing outcome of therapeutic

interventions after surgeryF Carli & N Mayo, British Journal of Anaesthesia 2001; 87:531-533

ERAS

CAN ERAS IMPACT ON LONG TERM DISABILITY-FREE SURVIVAL?

Shulman MA, 2015

Need for Surgery Identified

Surgery

Enhanced Recovery After Surgery Program

Preoperative Phase Intraoperative Phase Postoperative Phase

Trajectory of Surgical Care

Fast-Track

Home transfer

Prehabilitation for high-risk

patientsLink with the community, preoperative

clinic

Continuum of care

ERAS for now, but what next?

• Knowledge of pathophysiology is at the basis of ERAS

• ERAS requires another paradigm shift in culture and outcomes

• Need to expand the perioperative course : before and after ERAS

• Engaging patients to empower them is next effort for us all

• Impact on clinical short-term outcomes YES, but what about Patient-centre Outcomes?

a sustainable population health strategy needs to be comprehensive and thus include perioperative medicine as an essential component of the complete cycle of patient-centered care.

Solomon Aronson, 2017

ERAS Programs

JAMA Surgery, 2017

“Health care historically has been a very siloed field that’s organized around medical specialties...”

“The patient is the ping-pong ball that moves from service to service..” Michael Porter

Prehabilitation cannot work in silos

McGill Pre Operative Program

SurgeryClinic

Preoperative Clinic

Prehabilitation Clinic

Perioperative Platform

• Allergy• Blood Management • Coagulation • Pulmonary Function• Exercise/Stress Test• ECG, Echocardiography• Physiotherapy• Nutrition Modification• Smoking, Alcohol Cessation• Opioid Tapering• Cognitive Strategies• Geriatric Assessment• Health literacy• Healthcare Data Monitoring

Carli F, Minnella EM, Awasthi R, Baldini G, Bessissow A

• Perioperative Physician

• Exercise Specialist

• Nutritionist

• Anxiety-Coping Specialist

• Nurse• Internist, Family doctor • Anesthesiologist

2nd Canadian WorkshopPrehabilitation and Preoperative Clinic

For Information please contact: Dr. Francesco Carli: franco.carli@mcgill.ca,

Rashami Awasthi: rashami.awasthi@gmail.com

November 16, 2019Montreal General Hospital

WHAT IS RECOVERY?

19

06

20

14

19

0

10

20

30

40

50

Baseline 1 week 1 month

kcal.kg

-1.w

k-1

higher intensity lower intensity

Feldman LS, Kaneva P, Demyttenaere S, Carli F, Fried GM, Mayo NE. Validation of a physical activity questionnaire (CHAMPS) as anindicator of postoperative recovery after laparoscopic cholecystectomy. Surgery, 146 (1): 31-9, 2009.

p<0.05

p=0.68

Preop Postop

Surgery

ERAS

Traditional

Wh

at’s

on

th

e Y

axis

?

Enhancing Recovery

Early ambulation: History

• A few case reports of early ambulation after surgery in early 20th century

• Rediscovered in late 1930’s-controversial

• 1940’s: no complications related to early ambulation, hastened recovery of strength and morale, reduced pressure on hospital beds and nursing services, reduced pulmonary and thrombotic complications (Leithauser DJ. Confinement to bed for only 24 hours after operation. Arch Surg 1943; 47:203-15)

• Early ambulation standard practice by 1950’s Brieger, Early Ambulation, Ann Surg 1983

Predictors of “successful hospital recovery”(LOS≤4d, no complications, no readmission)

ERP element OR 95% CI p-value

Laparoscopy 4.32 2.260 – 8.267 < 0.001

Early mobilization* 2.25 1.130 – 4.474 0.021

Early termination of IV fluids 1.99 1.158 – 3.445 0.013

Regular food on POD 1 2.37 0.952 – 4.393 0.067

Early termination of urinary drainage 2.05 0.956 – 5.854 0.063

Adjusted multivariate regression model (n=347)

*Early mobilization = out of bed at least once in first 24 hours Adherence = 79%

Pecorelli et al, SAGES, 2016

So…

• Lower exercise capacity at baseline is associated with complications and prolonged recovery• Can physical fitness be improved preoperatively?

• Will this reduce complications and improve recovery?

• Early mobilization is associated with better in-hospital recovery • Can physical activity be increased after surgery?

• Will this reduce complications and improve recovery?

Functional w

alk

ing c

apacity (

6M

WD

)

SurgerySurgery

+ERP

Traditional

Prehabilitation +ERP

Preop Recovery

Trajectory of functional ability throughout the perioperative period

Prehab +Rehab +ERP

Carli, Silver, Feldman et al, Prehab Expert Round Table, Montreal Nov 2015

Prehabilitation and Rehabilitation

What about postoperative physical activity?

ERAS Society Guidelines

• “Prolonged immobilization increases the risk of pneumonia, insulin resistance and muscle weakness. Patients should therefore be mobilized.”

Gustafsson et al, Guidelines for perioperative care in elective colonic surgery: ERAS society recommendations. World J Surg 37: 259-84, 2013

Level of evidence: LowStrength of recommendation: Strong

Present Standard Care ProvidedPatient Education Booklet

69

ERPs are associated with more mobilization in first week

Total time out of bed POD 1-7

=87 (67-121) vs 61 (19-84) hours P<0.01

Both groups had thoracic epidural

Requires very good pain control, patient education, well-defined daily requirements for nurses and patients to follow

Basse et al, BJS, 2002

Variability in Mobilization Goals in ERPs

who POD0 POD1

Delaney 2001 (USA) ? Permitted to walk if desired

Encouraged to walk ward 60mx5Out of bed between walks

Basse 2002 (Denmark) Nurse Mobilized 2h Mobilized 8h

Henriksen 2002(Denmark) Nurse 4h out of bedWalk 80m x1

6h out of bedWalk 80m x2

Anderson 2003 (UK) Physio Sit x 20 min Walk length of ward

Kennedy 2006 (UK) ? Chair 2h Dressed, assisted daily mobilization 4x 60m

Zargar 2009 (NZ) ? Mobilized Mobilized for 8 hours

De Aguilar 2009 (Brazil) ? 2h out of bed 6h out of bed

Carli 2009 (Canada) ? Encouraged out of bed for mealsWalking or sitting up to 8 h

Chen 2010 (Taiwan) ? Immediate mobilization

Lee 2011 (Korea) ? 1 h in chair 3h in chairWalk ward >400m

McGill Colorectal ERP Daily Goals

POD 0: out of bed

POD 1: walk length of hallway at least 3x with helpBe out of bed, on and off, for at least 8 hoursSit in the chair for all meals

POD 2: walk length of hallway at least 3x Be out of bed, on and off, for at least 8 hoursSit in the chair for meals

Mobilized:

27%

44%

31%

Castelino et al, Surgery, 2016

n Intervention Outcomes

Liebermann , 2013 Gyne 129 Specified ambulation goal, signs and reminders

Pedometer steps: NDLOS: ND

Waldhausen, 1990 abdom. 35 walking >75 yds persession

GI myoelectric activity: ND

Ahn 2013 colon ca

31 Structured stretching, core and resistance exercises

Decreased LOS (7.8 vs 9.9 days)*Decreased time to flatus (52 v 71h)*

Complications: NDPerformance measures: ND

Walking distance: ND

Arbane, 2014 lung ca 131 Daily cycle and strength training

Complications: NDLOS: ND

Performance measures: ND

Granger, 2013 lung ca 15 Structured exercise program:

aerobic, resistance, and stretching

LOS: ND

Arbane, 2011 lung ca 51 Strength and mobility training

Complications: NDBetter quadriceps strength *

Conclusion: Patients shouldn’t be kept in bed, but little guidance on how to achieve

early mobilization and what type of activity is beneficial

Facilitating mobilization• 99 patients randomized to:

• ERP including written daily activity goals

• ERP plus additional staff dedicated to mobilization

VS.

Fiore et al (unpublished) 2016NCT02131844

In hospital physical activityusual ERP facilitated

mobilization

Time out of bed (self-reported), min

POD 0 0 (0-30) 30 (0-120)

POD 1 180 (90-300) 420 (240-720)

POD 2 240 (120-540) 360 (300-600)

Non-supine time (actigraphy), min

POD 0 38 (4-108) 52 (14-172)

POD 1 402 (268-532) 596 (378-696)

POD 2 464 (322-682) 618 (404-758)

When add walking helper to ERP:>2x more steps walked >2x more time out of bed

0

200

400

600

800

1000

1200

POD 0 POD 1 POD 2

Ste

p c

ou

nts

(ac

tigr

aph

y)

*

*

Out of bed POD 0:37% vs 72% * Fiore et al (unpublished) 2016

Total: 1763 [478-4955]

Total: 840 [287-2009]

*p<0.05

• No difference in GI function• No difference in length of stay or

readiness for discharge (median 3 days)• No difference in complications• No difference in recovery to baseline

walking capacity at 4 wks (51% vs 54%)

Aerobic Resistance (1 set of 12 repetitions)

Walking up and down the hospital hallway (2-5 minutes)

• Shoulder abduction

• Pushups

• Chest

• Seated row

• Biceps Flexion

• Quadriceps Extension

• Triceps extension

• Leg flexion

• Calf raises

• Abdominal curls

Supervised In-hospital Exercise POD 1-3

Shram A, EJSO 2019

results

Discharge ≤2 days(n=14)

3-4 days(n=10)

≥5 days(n=7)

Average length of stay: 3 days

• 2 refusal• 4 in-bed• 1 standing

POD 1 Exercise:• 13 standing• 1 in-bed

• 3 standing• 4 seated• 2 in-bed• 1 refusal

Adherence

43

27

63

0

10

20

30

40

50

60

70

80

POD1 POD2 POD3

Pe

rce

nt

Ad

he

ren

ce (

%)

Compliance to resistance exercises during the first threepostoperative in-hospital days for the supervised group

Overall C

om

plian

ce

76

POD = postoperative day

Shram A, 2019n=30 n=20 n=18

Stages of Recovery

Phase of recovery Definition Time frame Outcomes Threshold

Early From OR to discharge from PACU

Hours Physiologic and biologic

Safety (sufficiently recovered form anesthesia and safe to go to floor

Intermediate From PACU to discharge from hospital

Days Symptoms and impairment in ADL

Self-care (able to care for self at home)

Late From hospital discharge to return to usual function and activities

Weeks to months

Function and health-related quality of life

Return to normal (baseline or population norms)

Lee L, 2017

Recovery of functional walking capacity 8 weeks postop

59 5340

62

84

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No Prehab,Open, -ERP

ExercisePrehab,

Open, -ERP

No prehab,+MIS +ERP

No Prehab,+MIS, +ERP,

+Rehab

TrimodalPrehab,

+MIS, +ERP,+Rehab

Not recovered

Recovered

Moriello C, Mayo NE, Feldman L, Carli F Arch Phys Med Rehab 2008

Recovery of functional walking capacity 8 weeks postop

59 5340

62

84

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No Prehab,Open, -ERP

ExercisePrehab,

Open, -ERP

No prehab,+MIS +ERP

No Prehab,+MIS, +ERP,

+Rehab

TrimodalPrehab,

+MIS, +ERP,+Rehab

Not recovered

Recovered

Moriello C, Mayo NE, Feldman L, Carli F Arch Phys Med Rehab 2008Carli F, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim DJ, Scott S, Mayo NE. BJS, 2010

Recovery of functional walking capacity 8 weeks postop

59 5340

62

84

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No Prehab,Open, -ERP

ExercisePrehab,

Open, -ERP

No prehab,+MIS +ERP

No Prehab,+MIS, +ERP,

+Rehab

TrimodalPrehab,

+MIS, +ERP,+Rehab

Not recovered

Recovered

Moriello C, Mayo NE, Feldman L, Carli F Arch Phys Med Rehab 2008Carli F, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim DJ, Scott S, Mayo NE. BJS, 2010Li C, Carli F, Lee L, Charlebois P, et al Surg Endosc 2013

Recovery of functional walking capacity 8 weeks postop

59 5340

62

84

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No Prehab,Open, -ERP

ExercisePrehab,

Open, -ERP

No prehab,+MIS +ERP

No Prehab,+MIS, +ERP,

+Rehab

TrimodalPrehab,

+MIS, +ERP,+Rehab

Not recovered

Recovered

Moriello C, Mayo NE, Feldman L, Carli F Arch Phys Med Rehab 2008Carli F, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim DJ, Scott S, Mayo NE. BJS, 2010Li C, Carli F, Lee L, Charlebois P, et al Surg Endosc 2013Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS, Carli F. Anesth 2014

Recovery of functional walking capacity 8 weeks postop

59 5340

62

84

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No Prehab,Open, -ERP

ExercisePrehab,

Open, -ERP

No prehab,+MIS +ERP

No Prehab,+MIS, +ERP,

+Rehab

TrimodalPrehab,

+MIS, +ERP,+Rehab

Not recovered

Recovered

Moriello C, Mayo NE, Feldman L, Carli F Arch Phys Med Rehab 2008Carli F, Charlebois P, Stein B, Feldman L, Zavorsky G, Kim DJ, Scott S, Mayo NE. BJS, 2010Li C, Carli F, Lee L, Charlebois P, et al Surg Endosc 2013Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS, Carli F. Anesth 2014

Take home messages

• Fast-track, ERAS, Prehab complement the perioperative trajectory. Need to extend to Recovery

• Poor exercise capacity places patients at higher risk for complications and poor recovery

• Functional recovery is important to patients and can be quantified and improved

• Perioperative care requires multidisciplinary, structured,personalized, resource-intensive approach

Clinical outcomes: not much

Study type of surgery

design LOS HRQOL Comp.

Arthur et al, 2000

CABG, n=246

RCT -

Asoh andTsuji, 1981

GI, n=29 obs.

Bobbio et al, 2008

lung cancer, n=12

obspilot

Carli et al, 2010

colorectal, n=112

RCT

Cesario et al, 2007

lung cancer, n=8

obspilot

Dronkers et al, 2010

GI cancer, n=42

RCT

Jones et al, 2007

lung cancer, n=20

obs

2 exercise related adverse events (transient hypotension)

“…appears feasible and safe”

O’Doherty, BJA, 2013

• 112 patients randomized

• 2 groups: – Intense exercise (biking + strength program 30 min/d)

– Control (walk 30min/d + deep breathing)

• 4-5 weeks prior to surgery. Home based

• Primary outcome: Functional walking capacity (6MWT)

• No differences in mean functional walking capacity after prehabilitation or at postoperative follow-up

• %improving with prehabilitation was higherin walk group than bike group: 47 vs 22% (p=0.051)

• %recovered to baseline postoperatively was higherin walk group than bike group: 41 vs 11% (p=0.019)

-34(10)m

-12(11) m

+9(7)m

-11(7)m

Mean 9.6 wks

One-third of patients deteriorated while waiting for surgery Mayo N, Feldman L, Carli F, Surgery, 2011

-60

-40

-20

0

20

40

60

Baseline Pre-surg 9 weeks

Improved No Change DeterioratedA

vera

ge c

hange in 6

MW

D (

m)

Prehabilitation

Phase

High rate of serious complications

18% vs 2%

What happened?

• Poor compliance (16%) – too intense?

• Anxiety and depression in 20%

• Nothing addressing nutrition

• Lack of continuity to postop period

• Lack of Enhanced Recovery Program