ERAS ushers in new age of surgical care

Enhanced Recovery After Surgery, or ERAS, is radically changing and standardizing preoperative, perioperative, and postoperative approaches to major surgeries, including radical cystectomy. And while the changes can seem troublesome at first, urologic surgeons who perform radical cystectomy say letting go of dogma is worth it for patients, physicians, and staff.

Dr. Preston“We do a lot of cystectomies here-probably about 120 or so a year-and I find ERAS has been one of the biggest advances in how we do the operation,” said Mark A. Preston, MD, MPH, assistant professor of urologic surgery at Brigham and Women’s Hospital in Boston. “What it looks to do is take a complex procedure, such as a radical cystectomy with urinary diversion, and standardize portions of it. Using best practices and the best evidence we have, we try to maintain the normal body homeostasis as well as possible to aid recovery.” 

Brigham and Women’s started using its ERAS protocol in May 2015 and today performs all cystectomies using the protocol.

What’s different?

Pre-ERAS, patients having radical cystectomy would do bowel preparations and have no food or drink for 12 to 24 hours prior to surgery. Anesthesiologists would give lots of fluids and narcotics intraoperatively and providers would place a nasogastric tube for days after surgery. Patients wouldn’t get any food by mouth until they were passing gas, which could be 4 or 5 days after the procedure. And length of stays were routinely 7, 8, 9, or 10 days or more, Dr. Preston said.

All that has changed.

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There are no more bowel preps, and in many ERAS protocols, patients drink a high-energy carbohydrate beverage 2 to 3 hours before surgery. Anesthesiologists give minimal fluids during the operation, minimizing narcotics, which are known to slow down the small bowel.

Urologists and other staff use multimodal pain strategies and wait until it’s absolutely necessary to give opioids.

Postoperatively, the focus is on early ambulation and feeding.

“We give them clear fluids on day one, a full diet on day two and really get them up moving around,” Dr. Preston said. “We also have instituted extended-duration deep-vein thrombosis prophylaxis as part of our ERAS protocol, and we’ve noticed a decreased rate of deep vein thrombosis and blood clots, which are typically quite high risk in this operation.”

Of course, if there are issues postoperatively, patients can fall off the ERAS pathway and have their recovery adjusted accordingly, says Jeffrey Montgomery, MD, associate professor of urology at University of Michigan, Ann Arbor.

And ERAS protocols, while they’re standardized, are not set in stone, according to Dr. Montgomery.

“We instituted a form of ERAS pathway for cystectomy in 2008 and, as ERAS has gained traction over time, we’ve added things and adjusted. And those of us who do cystectomies meet periodically and review our protocol and come to a consensus as far as any changes that are done,” Dr. Montgomery said.

Next: Outcomes, best practices

Outcomes, best practices

Dr. Preston says the ERAS protocol has dramatically shortened hospital stays after radical cystectomy, from an average 7 days to 5 days.

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Less time in the hospital equals less cost, according to a 2016 study that found cost center-specific 30-day expenditures of the ERAS protocol for radical cystectomy were $4,488 less than standard management (Eur Urol Focus 2016; 2:92-6).

Dr. PruthiGenerally, the early data on ERAS showed that it reduces complications, according to Raj S. Pruthi, MD, MHA, Rhodes distinguished professor and chair of urology at University of North Carolina at Chapel Hill.

“The data shows that it hasn’t increased readmissions. That’s a reasonable concern if patients are getting out of the hospital faster,” Dr. Pruthi said.

Early, unpublished data from University of North Carolina suggest that the average number of opioids cystectomy patients take under ERAS has decreased significantly, according to Dr. Pruthi.

“We are increasing non-narcotic analgesic medications, thereby reducing the narcotics people require. That has short-term benefits: less nausea, vomiting, bowel dysfunction, less of a cognitive effect,” he said. “As we pay more attention to long-term opioid prescription use and effects, reducing the short-term narcotics might have better long-term benefits.”

To minimize opioid use, Tudor Borza, MD, a urologic oncology and health services research fellow at University of Michigan, says the staff uses acetaminophen and tramadol for its initial pain regimen.

“Once we’ve documented that kidney function is OK, we add nonsteroidal medicines like ketorolac. Then, we really rely on opioid medication in the emergency setting,” Dr. Borza said.

ERAS seems to be better for patients, all around. Patients seem to like ERAS because they’re more comfortable and know what to expect, according to Dr. Preston.

“They become active participants in the procedure and in their recovery,” Dr. Preston said.

From the provider perspective, urologists also give ERAS a thumbs-up.

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“Whether it’s the nursing staff, physical therapy, the residents, or anesthesia, everybody knows what to expect because we’ve standarized our protocol,” Dr. Preston said. “I think the standardization of care also improves outcomes for patients because it makes it less likely that things will be missed.”

Next: Getting started and why

Getting started and why

Dr. DaneshmandSia Daneshmand, MD, associate professor of urology and director of urologic oncology at the University of Southern California, Los Angeles, says hospitals that don’t have ERAS protocols in place might start simply by changing basic tenets of nutrition and pain control, eliminating use of nasogastric tubes, and instituting early feeding.

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All are evidence-based modifications, according to Dr. Daneshmand.

Preoperatively, eliminating bowel preparation and allowing patients to consume food until the hours prior to surgery are easy to implement, he says.

“Some surgeons are concerned about the infection rate. If you read the literature on the topic, infection rates are not increased,” Dr. Daneshmand said.

Next, no nasogastric tubes. That greatly enhances the patient experience without causing harm, according to Dr. Daneshmand.

“Number three is the use of alvimopan [Entereg], a mu-receptor antagonist that blocks the effect of opioids on the bowel,” he said. “Opioids are known to slow down the bowel, which leads to ileus-a very common finding after any kind of bowel surgery. Our group and others have shown a significant decrease in gastrointestinal complications with the use of ERAS protocols. Our ileus rates have gone down from 23% to 7%,” he added, citing a 2017 study (Eur Urol Focus Apr 25, 2017 [Epub ahead of print]).

Last among the initial steps to setting up an ERAS protocol: early feeding. 

“One key factor in enhancing postoperative recovery is to administer calories early,” Dr. Daneshmand said. “In our ERAS protocol, patients are getting a regular diet literally the next day after major bowel surgery. And we’ve found that most patients-more than 90% of them-will tolerate that very well. They are able to get through their hospital stays quicker because they are eating, their bowels are moving, and they don’t have a nasogastric tube.”

ERAS beyond radical cystectomy

While it’s a protocol used largely at major academic centers, ERAS offers potential benefits for community and national health systems that perform major surgeries, according to Dr. Pruthi.

“[Nationally, there are] pressures and goals of transparency, cost reduction, and error reduction,” Dr. Pruthi said.

Academic centers are using ERAS protocols in a growing number of procedures.

Brigham and Women’s has ERAS protocols in colorectal surgery, where the adoption of ERAS got its start, as well as in plastic surgery and gynecologic oncology, according to Dr. Preston.

“All those specialties have adopted the standard principles and maybe some slight modifications for their individual specialties to speed recovery,” Dr. Preston said.

The University of Southern California has implemented ERAS in other major urologic operations, including radical nephrectomy and resection of large retroperitoneal tumors, where the bowel might not be resected but it is mobilized or manipulated, Dr. Daneshmand points out.

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And the University of Michigan is in the process of expanding ERAS to retroperitoneal lymph node dissection and complex reconstructive procedures, according to Dr. Montgomery.

Next: ERAS continues to evolve

ERAS continues to evolve

The University of Michigan is incorporating concepts of pre-habilitation, which is strength and cardiovascular training prior to surgery, as well as pre-surgical nutritional interventions, according to Dr. Montgomery.

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The university’s ERAS protocol is also establishing a postoperative care plan to manage patients once they leave the hospital.

Dr. Montgomery“How do you follow up with these patients, monitor them after discharge, and also rescue them if they have issues and try to minimize the impact of those perioperative complications? We have programs for patients to come in if they’re dehydrated or are exhibiting failure to thrive; we give them IV fluids in our clinic instead of sending them to the ER or admitting them to the hospital,” Dr. Montgomery said.

Managing patients in the first 90 days with ERAS protocols is important, according to Dr. Pruthi.

“Two-thirds to three-quarters of cystectomy patients will have a complication. In fact, Medicare data is showing over 40% will be readmitted to the hospital,” Dr. Pruthi said. “Taking ERAS forward, how do we adapt to that environment? There’s an opportunity there, whether it be telehealth or health care wearables or at-home monitoring and standardizing those during the first 90 days.”

Change is good

A hurdle to implementing ERAS is that the complexity of the team requires buy-in from different specialists-from urologists to anesthesiologists, nursing, dietitians, physical therapists, and potentially others, according to Tudor Borza, MD, a urologic oncology and health services research fellow at the University of Michigan.

Dr. Borza“It requires someone to be willing to change their practice, from an anesthesia standpoint,” Dr. Borza said. “Similarly, from a surgeon’s standpoint, there are lots of things to do beforehand, like getting the patient to see a nutritionist and getting their physical state optimized before surgery. Then, being committed to using non-narcotic pain medicines and educating your patients about that, and limiting your use of nasogastric tubes, particularly for cystectomy. Many urologists still use nasogastric tubes routinely.”

The biggest obstacle to urologists adopting this in major surgeries might be the notion of early feeding, Dr. Borza said.

“Having to change practice patterns with both urologic surgeons and anesthesiologists will take a little time and definitely buy-in from the community as a whole,” Dr. Borza said.

Surgeons doing something radically different than what they’ve been doing is difficult, according to Dr. Daneshmand.

“I think you have to let go of dogma. We have so much of it in postoperative care of patients. Once you let go of dogma and trust the literature and trust experience, then you can essentially dive right into it,” Dr. Daneshmand said.

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