What has been your experience with ERAS pathways?

“We’ve been following ERAS for 3 years. The big game changer, in my experience, is the use of Entereg (alvimopan), the change in bowel management, and not using an NG tube. I did a cystectomy 2 days ago and the patient started drinking liquids the day after.

Most of the delay in discharge is due to poor recovery of bowel function after a long surgery with bowel anastomosis, so anything you can do to expedite that is a positive.

We don’t have good numbers on ERAS’s results yet. At a recent meeting, they looked at a pre-cystectomy diet, an immune stimulatory diet. There wasn’t enough information to reach any conclusion about its effectiveness, but something like that that doesn’t cost anything, and since it’s good for you anyway, that’s fine.

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Patients are doing well and are happy. When you have a huge operation, to get out of the hospital in 4 days is pretty amazing. People accept things better if they don’t have to stay in the hospital for 2 weeks.

For Entereg to be given, patients have to be off all narcotics for a week. You give it the morning of surgery and it blocks the opioid receptors in the bowel-patients can have the morphine, or other pain control and not have the terrible ileus that otherwise occurs.

I’m old-fashioned. I still give liquids and have patients do mild bowel prep, but we don’t really have to do that. I understand that, I’m just not that brave yet. I hope we can continue to improve ERAS, but it’s already a significant advance.”

Donald Lamm, MD

Phoenix

Next: “ERAS is not one specific protocol or one way of doing things, it’s more of a process."
“ERAS is not one specific protocol or one way of doing things, it’s more of a process.

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We know that feeding patients earlier, not having them starve in the hospital, is a good thing. We know minimizing excess fluids, multimodal pain control, not just opioid analgesia, are good things.

We’ve been doing it in our own way for a couple years, and we’ve had overwhelmingly positive results. Patients are happier and we have a more standardized way of caring for patients after surgery. Hospital stays are shorter, returning to normal activities is faster, and complication rates possibly lower.

The surgery where we’ve adopted this the most is radical cystectomy and urinary diversion because that’s the one surgery where we actually work on bowels. We extrapolated the process for that surgery from the colorectal surgeons who work on the bowels as well.

Then we extrapolated the process to other surgeries where we don’t work on the bowels. The protocols are different, but the concept the same.

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Literature from major academic institutions is all a little different, but the concept is the same. If you start by making people catabolic and super-dehydrated, you’re already starting them a couple steps behind. How you implement the protocol is less important than just doing it.”

Rian Dickstein MD

Hanover, MD

Next: “We’ve been involved with ERAS about a year. It’s a positive experience."“We’ve been involved with ERAS about a year. It’s a positive experience. Based on historical data, some elements are very helpful.

We haven’t identified the exact elements that are beneficial; that remains an unanswered question. ERAS has a host of interventions associated with a better outcome, but it would be nice to know which ones are truly effective and which are not. That way we wouldn’t waste time and expense on protocols that don’t benefit patients.

We do things fairly similarly from patient to patient, but there are always tweaks. ERAS is in flux because we don’t have any set guidelines.

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We lack critical studies that identify which interventions will benefit and which won’t. Some people argue that you need to do the entire combination for them to be effective. We try to isolate things. You’ve got ‘lumpers’ and ‘splitters,’ people who look at things as a holistic intervention, and others who split things out to see which specific elements are beneficial. I’m a splitter. I would rather study and know what’s contributing, rather than lump it all together and do everything, whether needed or not.

The problem is that things change over time. We don’t know if improvements are a natural progression of treatment, or if improvements result from one of these interventions.

I still don’t have an opinion about ERAS in terms of its benefits. We need a randomized study. People are following slightly different protocols anyway, so why not use that to learn as much as we can for each of these procedures?”

Mark Garzotto, MD

Portland, OR