SAGES

Reimagining surgical care for a healthier world

Trends in Enhanced Recovery

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By Thomas A. Aloia, MD, Co-Chair SAGES SMART Committee, MD Anderson Cancer Center, Dept. of Surgical Oncology and Nisha Narula, MD Anderson Cancer Center, Dept. of Surgical Oncology

Although enhanced recovery seems to just be getting its footing on the US Surgical landscape, the concept and practice has been well described by Prof. Henrik Kehlet and others since the 1990s. It goes by many names – enhanced recovery after surgery (ERAS), enhanced recovery program (ERP), fast track surgery, and SAGES surgical multimodal accelerated recovery trajectory (SMART(TM)) – but its basic goal, then as now, is to more rapidly return a patient to his/her normal life and functional status.

Strategies:

With this goal in mind there are five strategies employed by most successful programs.  The foundation of any program is patient education and engagement.  The four programmatic pillars then include early mobility, early enteral feeding, multi-modality non-narcotic analgesia and goal-directed fluid therapy.  The tactics that flow from each of these pillars are placed into the preoperative, intraoperative, and postoperative periods. Some key components are preoperative discussion with the patient, selective bowel prep, minimal preoperative fasting, nutritional optimization and carbohydrate loading, regional blocks and narcotic-sparing anesthetic, maintenance of normothermia, minimizing tubes/lines/drains, preventing and treating nausea and ileus, VTE prophylaxis, and prescriptive ambulation orders.

Multiple studies in different surgical specialties, including colorectal, bariatric, gastric, HPB, urology, gynecology, pediatric, and thoracic, across a variety of practice types, have demonstrated the benefits. These studies have found decreased hospital length of stay, lower costs, and equivalent or reduced complications.  Patient-reported outcomes tools are proving that the experience with recovery can be vastly improved.  In oncology patients, time and frequency of return to intended oncologic therapy has also been achieved.

SMART Resources:

For hospitals and surgeons who want to bring these benefits to their patients there are a number of resources available, particularly within the SAGES educational platform. SAGES’ SMART task force, co-chaired by Dr. Liane Feldman at McGill and Dr. Thomas Aloia at MD Anderson (https://www.sages.org/smart-enhanced-recovery-program/), provides protocols that several institutions – MD Anderson, McGill, Case, University of Toronto, UW Medicine, and Methodist – use, as well as guidelines for how to implement them.

Dr. Feldman’s SAGES/ERAS Society Manual of Enhanced Recovery Programs for Gastrointestinal Surgery is comprehensive and presents a plan for how to implement ER in a hospital. The ERAS society website (https://erassociety.org/) and the ASER website (https://aserhq.org) also offer evidence-based pathways in bariatric, colorectal, gynecology, pancreas, liver, urology, and head and neck surgery, as well as anesthesia.

Lastly, SAGES has just launched the Enhanced Recovery Implementation Program, a great opportunity to get your ERAS program off the ground.  Geared towards those in the early stages of ERAS adoption, the program includes online mentoring and discussion as well as a course “SMART Enhanced Recovery – Beyond Colorectal,” and workshop “SMART Course for the Team,” on March 23, 2017, at the SAGES meeting in Houston. The online engagement will begin in early February via a closed Facebook Group and continue after the SAGES meeting.  For more information and to enroll, visit https://www.sages.org/enhanced-recovery/implementation-program/ or contact the SAGES SMART Staff Liaison, Linda Schultz, at linda@sages.org.

Enhanced recovery has significantly improved the surgical journey for many patients, but continued work is needed to realize its full potential.  Research on care pathways, patient-centered outcomes, and longer-term recovery should continue in order to prove efficacy and guide inclusion of evidence-based guidelines into future ERPs. In the next few years, we anticipate an expansion of ERPs to most hospitals that perform surgical and other procedures.  By keeping in contact with SAGES (web, print and meetings), surgeons and surgical teams can keep up-to-date on the most current research regarding protocols, audits, and progress.  Enhanced recovery is here to stay and the future is bright.

Click https://www.sages.org/wp-content/uploads/2013/09/SCOPE-2017-winter.pdf to return to SCOPE Winter 2017.

SMART Enhanced Recovery Program

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The SAGES SMART (Surgical Multimodal Accelerated Recovery Trajectory) Task Force provides the education and materials needed for surgeons to adopt a strong, evidence-based Enhanced Recovery Program (ERP) into their practices.

As such, SAGES has developed the following SMART Enhanced Recovery Program resources:

Enhanced Recovery: The Tool You Need to Go Beyond Minimally Invasive Surgery

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  • SAGES Surgical Multimodal Accelerated Recovery Trajectory (SMART) Initiative,combining minimally invasive surgical techniques with enhanced recovery pathways for perioperative care, improves outcomes and patient satisfaction.
  • “We’ve made great advances in improving patient recovery using minimally invasive surgical techniques, but outcomes can be further improved by combining laparoscopic surgery with an enhanced recovery care plan to deliver evidence based care throughout the perioperative period: preop, intraop and postop,” said Dr. Liane Feldman, Chair, SAGES SMART Task Force. “That’s the goal of SAGES SMART enhanced recovery program, to combine multiple perioperative interventions to maximize the value of minimally invasive surgery, but surgeons can’t do this alone.”
  • SMART enhanced recovery task force invites you to join us on Saturday, November 22, 2014 at the Hotel Delta Montreal, Quebec for the SAGES/ERAS Society Canada course on enhanced recovery for gastrointestinal surgery. This one-day practical introduction to creating and implementing  enhanced recovery programs. The course will bring together surgeons, anesthesiologists, nurses and other perioperative experts to review the building blocks of enhanced recovery and experiences in implementation to allow SAGES surgeons to implement enhanced recovery for a variety of procedures in their own practices.
  • The course directors include Dr. Franco Carli, Dr. Liane Feldman and Dr. Sender Liberman.  The essential building blocks of an ERAS program will be reviewed, and speakers will share experiences in implementing programs in foregut, bariatric, hepatobiliary and colorectal surgery.
  • For more information visit https://www.sages.org/wp-content/uploads/2013/09/ERAS-2014.pdf and to register, please contact the McGill Continuing Education Office at 514-934-8253 or cme@muhc.mcgill.ca

 

The Mission of the SAGES SMART Enhanced Recovery Task Force is to promote the integration of Enhanced Recovery care principles as a cornerstone of minimally invasive surgery to improve safety, efficiency and outcomes of GI surgery.

SAGES Research Grant Applications Now Open

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SAGES is now accepting Research Grant Applications for the 2015 year. To submit your grant, please visit:

https://www.sages.org/projects/research-grants/

The deadline is Friday, November 3rd, 2014 at 5:00PM EST.

The SAGES Research Awards are open to any principal investigator who is a SAGES member, including Candidate members. SAGES would like to especially encourage grant funding to young investigators/candidate members in the hopes that funding through SAGES will lead to additional extramural funding. Awards are conferred on a competitive basis by submission of a grant application, which is reviewed and evaluated by the SAGES Research Committee and approved by the Governing Board.

Grants are limited to no more than $30,000 each, for a period of one year, and are made to the principal investigator. The purpose of these grants is to stimulate original research in gastrointestinal and endoscopic surgery. The study may be either “bench” research or clinical.

This year the committee will be awarding ONE NEW GRANT dealing with enhanced recovery after surgery. For more information, detailed instructions and guidelines please contact research@sages.org

SAGES Launches GetWellSooner.org / SMART Care Program

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Minimally Invasive Surgery for Colorectal Cancer Yields Optimal Outcomes

Colon and rectal cancer together comprise the nation’s second-leading cause of cancer deaths. Each year, about 140,000 Americans are diagnosed with and more than 50,000 people die from colorectal cancers. Fortunately, the death rate from this disease has decreased over the last 20 years due to screening and more sophisticated surgical approaches, one of which is minimally invasive surgery (MIS).

SAGES has long been a champion of the use of MIS for colorectal surgery. To take full advantage of the benefits of MIS, SAGES has introduced its SMART Program, bringing together best practices in anesthesia, nursing, nutritional management, and physical therapy to speed up recovery after surgery – See more at Digestive Wellness News…

Visit GetWellSooner, the new SAGES Patient Information portal