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