Examining the Evidence with Implementing ERAS Protocols

Raoul Concepcion, MD: Is anybody studying this in a systematic fashion? Obviously, you could compare open, open with ERAS (enhanced recovery after surgery), robotic, or laparoscopic with ERAS. You could do open without ERAS. Is anybody looking at that in a systematic fashion?

Declan Fleming, MD: Oh my goodness. I don’t know that there are any randomized trials comparing this. I think that there’s been a lot of basic science work in looking at bowel manipulation in the release of inflammatory mediators, nitric oxide, and the rest of that. It’s clear that the more the bowel is manipulated, the more that these inflammatory mediators are released, which increases the likelihood of developing both hypomotility and edema of the intestine. So, from a basic science standpoint, we understand that that’s the truth. Now, with respect to, is anyone doing a true randomized trial? I’m afraid we are still zealots around things. You find people that have decided ERAS is the way to go. And frankly, I’m not sure I’d be willing to step back to do non-ERAS care. I’ve stopped thinking of ERAS as “enhanced recovery after surgery.” I think it should be “expected recovery after surgery.” We need to be following these principles because they work.

Traci Hedrick, MD, MS, FACS, FACRS: I will say that we didn’t randomize it, but we looked, in our open and laparoscopic cases, before and after implementation of enhanced recovery. What we found is that after we implemented enhanced recovery, our open patients were going home sooner and had less complications than our laparoscopic patients did in the pre-enhanced recovery movement. So, there are a lot of people that think if you’re doing minimally invasive surgery you don’t need these principles. We know that is not true. If you take a laparoscopic patient and you give them a couple doses of intravenous opioids, it will have the same effect as if it is an open surgery. So, I think the 2 are not mutually exclusive.

John Dalton, MD: And I think if you focus on length-of-stay and complications, as Traci pointed out, and measure those, that may replace randomized controlled trials, as far as how we move forward. If your length-of-stay and your complication rate is still higher than you would like, and you have a protocol, you change one thing as an institution and see if it makes a difference. That’s the real power of standardization, at least in private practice. And I think it will be in academics, as well. It’s hard to get a randomized controlled trial together, but if you have a way you do things and you measure your outcomes, if something impacts your outcomes, then that’s the way you do it.

Declan Fleming, MD: Virtually, in every place where enhanced recovery has been implemented in a system, there have been positive effects. It’s universally reproducible because the principles hold wherever it is done—in every place it’s been done. Length-of-stay and complication rates have also been improved as it is brought into play in the system. It’s happened in a variety of specialties. In the hospital where I primarily practice, we started not in colorectal, but in complex upper gastrointestinal conditions—hepatobiliary and pancreatic surgery. We started there because I was the champion and that’s what I do, mostly. As we began to develop the system, then we were able to begin to allow the colorectal surgeons, and the urologists, and the orthopedic surgeons to also begin to implement it. It was the success in the first area that led to the adoption in the other areas.

Transcript edited for clarity.