Enhanced recovery protocols benefit many types of surgery

Linda Williams Martin, MD, MPH, FACS

The four presenters at Tuesday morning’s session, Enhanced Recovery after Surgery (ERAS): Colorectal Surgery and Beyond, discussed how they have adapted ERAS concepts and techniques pioneered in colorectal surgery to their specialties.

Thomas A. Aloia, MD, FACS, who specializes in hepatobiliary surgery at MD Anderson Cancer Center, Houston, TX, said an ERAS program must be patient-centric instead of hospital-centric to get the best results. MD Anderson’s ERAS goal is to minimize overall disability introduced by surgical intervention and return the patient to normal life as soon as possible. But working at a cancer center, where surgery is just one part of the overall treatment, there’s a third goal: Return cancer patients to their Intended Oncologic Treatment, or RIOT.

When enhanced recovery was initiated at MD Anderson in 2013, almost a quarter of the patients didn’t get to their next therapy, and those who did took almost seven weeks to get there. By 2015, with enhanced recovery in full effect, 96 percent of patients were getting back to oncologic therapy, needing on average three weeks to get there.

Analgesic use played a critical role in the success of enhanced recovery at MD Anderson. Patients receive Celebrex, tramadol, and Lyrica when they arrive at the hospital; Lyrica is withheld in patients older than 65. After surgery, patients return to a triple-drug regimen, using narcotics only for breakthrough pain.

“Really, these are the medicines that provide the analgesia for the night of surgery,” Dr. Aloia said. “The reason you are giving them is not for the time that they’re asleep. You give them these medicines so you don’t have to give them morphine or dilaudid that night.”

Linda Williams Martin, MD, MPH, FACS, discussed how reliable pain relief is delivered at the University of Virginia Health System, Charlottesville, with surgeon-controlled analgesics. Liposomal bupivacaine is used for surgical-site injection at the start of a procedure and lasts for 72 to 96 hours, said Dr. Martin, who specializes in thoracic surgery at the hospital.

Dr. Martin said her team began using ERAS protocols about 18 months ago. She said morphine equivalents are down 60 percent to 75 percent, length of stay has substantially decreased, and there’s been a substantial cost savings—more than $1 million for 139 patients.

The Virginia team developed two pathways, one for minimally invasive surgery and one for thoracotomy, which has the greatest risk for prolonged opioid use of any major surgery, she said. Today, efforts are focused on pleural, pulmonary, and mediastinal diseases, but the team hopes to add esophageal surgery in the future.

Andrew S. Wright, MD, FACS, director, UW Medicine Hernia Center at Northwest Hospital and Medical Center, Seattle, said that hernia operations follow a similar path as the other types of surgery using ERAS, except hernia operations are almost always elective.

Hernia surgery patients are required to stop smoking eight weeks before the procedure, and Dr. Wright uses a urine cotinine test to check for compliance. Patients with a body mass index (BMI) higher than 40—and on occasion those with a BMI higher than 35—are referred to the UW Weight Loss Center, with a recheck by the surgeon at three months. The goal is a BMI less than 40, but Dr. Wright advised against giving patients a specific weight number in order to avoid patient discouragement.

Dr. Wright said that the ERAS protocols have to be a grassroots, local effort. It doesn’t work to copy an ERAS pathway with no changes. “You have to build a team, and you have to get administration buy-in,” he said. “In our case, building that business case really made a great benefit to getting the support.”

Liane S. Feldman, MD, FACS, FRCS, discussed the importance of prehabilitation when creating an enhanced recovery program. She focused on therapeutic exercise during her presentation, but said it was just one part of a multimodal culture of prehabilitation involving factors such as smoking cessation, nutrition, glycemic control, and patient engagement.

Poor exercise capacity places patients at a higher risk for complications following surgery, she said, but more studies are finding that a multimodal program before surgery leads to better outcomes, especially for low-fitness patients. In one study, 72 percent of patients improved with prehabilitation. And in seven of eight studies, prehabilitation improved at least one measure of functional capacity or cardiopulmonary fitness.

Older, more sedentary patients get the most benefit, Dr. Feldman said. “You can focus on these patients who are at risk,” she said. “You can improve them. You can train them up.”