Middlemore Hospital, University of Auckland Enhanced Recovery After Surgery: What is it and is it worth the trouble? Andrew Hill Colorectal Surgeon Middlemore Hospital, University of Auckland Auckland Enhanced Recovery After Surgery Group

What is ERAS? AKA Fast-track or ERP Developed by Kehlet in Denmark in colonic surgery Gradually has gained world-wide acceptance Originally described in Open Surgery but same advantages seem to apply for Laparoscopy

ERAS Results Type of Operation Duration of stay Carotid endarterectomy 1-2 days Lung lobectomy Prostatectomy Colectomy 1-3 days Aortic Aneurysm 3-4 days

What is ERAS?

Pre-op Patient Information Carbohydrate drinks At the clinic Ward visit Carbohydrate drinks 4 night before surgery if having bowel prep 2 morning of the surgery No mechanical bowel preparation Enema morning of surgery for L) sided cases Patients admitted on the morning of surgery

Surgery Thoracic Epidural Analgesia Incision choice Transverse for R) sided Mid-line or Laparoscopic for L) sided Avoidance of Drains and NGT post-operatively Limited Intra-Operative fluid therapy Aiming to max of 1.5-2 L Goal Directed

After surgery Cessation of IVF Regular pre-emptive antiemetics unless clinically indicated Pressors for epidural hypotension Regular pre-emptive antiemetics ondansetron as first line On arrival to the ward Patient sits up Starts drinking protein drinks (Resource/Fortisip etc)

Day 1 Day 2 IDC removed in the morning 8 hrs of enforced mobilisation Resumes normal diet Pre-emptive oral analgesia is started Paracetamol and NSAIDs Avoid Opioids Day 2 Epidural infusion is stopped in the morning Epidural Catheter is removed at 1400 if pain controlled, and timed with Clexane dose

Day 3/4 - discharge criteria: Return of GI function Able to eat and drink without discomfort Passing flatus, or moved a B/M Pain controlled with oral analgesia Adequate home support Discharge date is an important target for patients and staff but flexibility is vital

Days to passage of flatus Days to independent mobilisation 1 (1 – 3) ERAS Group (n = 50) Control Group P Value Intravenous fluids Intra-operative First 3 days 2 (1 – 8) 2 (1 – 10) 3 (1 – 7.5) 6.5 (1 – 12) <0.0001† Epidural analgesia No. of patients Duration of use (days) 44 (89%) 2 (0 – 3) 38 (76%) 3 (0 – 4) 0.223‡ Recovery Days to 1st full meal Days to passage of flatus Days to independent mobilisation 1 (1 – 3) 2 (0 – 8) 2 (1 – 15) 3 (0 – 18) 3 (1 – 7) Day stay No. admitted > 1 day before surgery Postoperative stay (days) Total hospital stay (days) 12 (24%) 4 (3 – 34) 29 (58%) 6.5 (3 – 18) 8 (4 – 29) <0.0001‡ Readmissions No. patients readmitted 6 7 0.766‡ Less fluids used intra-op and post-op Epidurals removed earlier Quicker recovery of bowel function and mobilisation Reduced day stay…no difference in number of readmissions.

Patients with > 1 complication Death Reoperation Anastomotic leak ERAS Group (n = 50) Control Group P Value Complications Patients with > 1 complication Death Reoperation Anastomotic leak Intra-abdominal collection Ileus Wound complication Urinary tract infection Urinary retention Cardiopulmonary 27 4 1 5 6 2 11 33 3 18 10 12 21 0.221 0.495 1.000 0.005 0.275 0.008 0.715 0.032 Less fluids used intra-op and post-op Epidurals removed earlier Quicker recovery of bowel function and mobilisation Reduced day stay…no difference in number of readmissions.

Postoperative Fatigue

Differential cost analysis of 1st 50 patients (Savings on day stay and complications) minus (Full implementation + maintenance cost) Final tally = $446,000 – $102,000 = $344,000 = $6880 per patient

Length of hospital stay (days) The results from the present meta-analysis suggest that the implementation of four or more elements of the ERAS pathway leads to a reduction in length of hospital stay by more than 2 days. However, there was significant heterogeneity for the effect of ERAS on the length of hospital stay and hence, could potentially weaken the treatment effect. Experimental group= Enhanced Recovery After Surgery (ERAS) Control = Traditional Care (TC) 14

Complications 50% reduction in complication rates. Experimental group= Enhanced Recovery After Surgery (ERAS) Control = Traditional Care (TC)

Readmissions (days) no significant difference was noted in readmission rates Experimental group= Enhanced Recovery After Surgery (ERAS) Control = Traditional Care (TC)

Mortality Experimental group= Enhanced Recovery After Surgery (ERAS) Of the 452 patients, 4 died during the 30 day follow-up period, with one death (myocardial infarction) in the ERAS group and three ( 2 myocardial infarctions and 1 pulmonary embolism) in the traditional care group. Experimental group= Enhanced Recovery After Surgery (ERAS) Control = Traditional Care (TC)

A Personal Series-100 Colectomies Age (median) and range 70 (16-92) Male 48% Malignancy 83% Laparoscopic 17% ASA 2+ 84% Median Day Stay (range) 3 (2-60) Readmission Rate 21% Major Complications 8%

ERAS in Bariatrics Randomised Controlled Trial 2 Arms ERAS vs. Standard Perioperative Care

Population Patients undergoing laparoscopic sleeve gastrectomy (LSG) for weight loss Eligibility Criteria Procedure at Manukau Surgery Centre (MSC) Consenting surgeon Exclusion Criteria Not at MSC Redo procedure

Intervention and Control Perioperative care as per Bariatric Specific ERAS protocol VS. Standard perioperative care

Outcomes Primary outcome was initial median length of hospital stay (LOS) Powered to detect a reduction in median LOS from 3 (current figure) to 1 (target from the literature) α:0.05; β:0.8; Sample Size = 56 (28 in each arm)

Follow up time 30 day follow up Further analysis planned for longer term follow up on weight loss data

Results 71 randomised 11 post randomization exclusions 60 patients included in analysis 31 ERAS group 29 Non ERAS group The clinical result of this surgical stress response is increased morbidity, increased recovery time and subsequently impaired recovery.

Baseline Characteristics ERAS (31) Non ERAS (29) p value Mean Age 44.3 43.6 0.66 Female Gender (%) 23 (74) 24 (83) 0.54 Planned Admit to PCU (%) 8 (26) 1 (3) 0.027

Baseline Characteristics ERAS (31) Non ERAS (29) p value Mean Weight (kg) 132 133.6 0.78 Mean BMI (kg/m2) 46.2 46.7 0.80 Mean Excess Weight (kg) 66.9 67.8 0.85

Baseline Characteristics ASA ERAS (31) Non ERAS (29) p value ASA 1 1 1.00 ASA 2 18 0.80 ASA 3 12 11

Complications (Cx) ERAS (31) Non-ERAS (29) p value Total Cx (%) 9 (30) 7 (24) 0.77 Major Cx (%) 5 (16.1) 4 (13.7) 1.00 Leak (%) 2 (6.4) 2 (6.8) Bleed (%) 3 (9.7)

Length of Stay (LOS) ERAS (31) Non ERAS (29) p value 1 2 <0.001 Initial LOS (median) 1 2 <0.001 Readmissions (%) 5 (18) 1.00

Conclusion ERAS is possible in a New Zealand public hospital. ERAS is safe in a New Zealand Hospital ERAS enhances recovery in a New Zealand Hospital ERAS is cost-effective in a New Zealand Hospital ERAS is more than just Colorectal Surgery