Traci L. Hedrick, MD, MS
Assistant Professor, Surgery
Co-Director, Enhanced Recovery Program
University of Virginia Health System
The adoption of enhanced recovery after surgery (ERAS) protocols can improve not only the outcomes of patients after a procedure but can also reduce hospital costs, as has been seen in an ERAS program in colorectal cancer at the University of Virginia (UVA) Health System.
Surgical resection offers a cure for thousands of patients with colorectal cancer each year. Yet for many, this experience can be accompanied by surgical complications and prolonged recovery times. Colorectal surgery has traditionally been associated with higher morbidity rates than many other types of surgery for a multitude of reasons. The surgeries are often complex, involving multiple quadrants, and are further complicated by the anatomical constraints of the pelvis. Even with the advent of minimally invasive surgery, it was not uncommon for patients to be incapacitated for several weeks.
The ERAS movement, first proposed by Danish surgeon Henrik Kehlet, is based on many common-sense principles that had been overlooked with the advent of modern medicine.1
The basic premise of enhanced recovery is to keep the patient in a normal physiologic state during the perioperative period. This is accomplished through the avoidance of many well-meaning, yet misguided, traditional surgical practices, including preoperative fasting, liberal intravenous administration of high-salt fluids, and opioid-centric pain management strategies.
To date, more than 10 case-control studies including over 3000 participants have demonstrated shortened recovery time and decreased complications in ERAS patients within a variety of surgical patient populations.2-14
Instead of starving patients prior to surgery, patients are encouraged to consume clear liquids with carbohydrate loading up to 2 hours prior to surgery. This avoids the deleterious catabolic state at the onset of surgery, which has been shown to mediate insulin resistance, leading to loss of lean muscle.15
Given that patients are not dehydrated prior to surgery, they do not require resuscitation with salt-laden intravenous fluids that flow into the extracellular space. This helps to prevent peripheral edema, which can restrict movement postoperatively, and edema in the bowel wall, which contributes to ileus. To further reduce the reliance on intravenous fluids, patients are allowed oral intake immediately after surgery. Additionally, patients are mobilized early and frequently following surgery to further prevent muscle loss in the postoperative period.
Another one of the main tenets of ERAS protocols is the avoidance of opioids for pain control. For decades, opioid analgesia has provided the primary means of controlling pain in patients undergoing major surgery in the United States. However, opioid analgesia has deleterious effects on surgical recovery including respiratory depression, gut dysmotility, and delirium, in addition to the potential for abuse.
Prescription opioids are now among the leading causes of overdose deaths in the United States, and surgeons are one of the leading providers of opioid prescriptions nationwide.16,17
ERAS aims to reduce opioid intake through the use of multimodal analgesia, such as anti-inflammatory agents, local anesthetics, and other nonopioid pain management strategies.
Impact of Enhanced Recovery at the University of Virginia
We implemented a multidisciplinary ERAS protocol in patients undergoing major colorectal surgery in 2013 at the UVA Health Center.18 We observed dramatic improvements in colorectal surgery quality outcomes including a 2-day reduction in length of stay, an 80% reduction in opioids, and a 50% reduction in overall complications (Figure 1)
. There was a $6567 per patient reduction in total hospital costs and significant improvements in patient satisfaction.