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.
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