Enhanced Recovery After Surgery Experience in South Auckland Tarik Sammour Research Fellow South Auckland Clinical School

Major Abdominal Surgery

Surgical Stress Prolonged Recovery Physiological Psychological Haemodynamic instability Metabolic derangement Catabolic state Psychological Pain Fatigue Depression Prolonged Recovery

What is ERAS? A method of standardising peri-operative care Protocol of current best practice Multidisciplinary Medicine / Surgery Nursing Physio Dietetics Social Services Ongoing audit and improvement Major aim is to reduce surgical stress

What are the benefits? Wind et al, Br J Surg 2006 Meta-analysis of ERAS vs Traditional 6 Trials including 512 patients Significant benefits demonstrated Reduced Complications Reduced Hospital Stay

Complications 23.7% vs 43.6%

Hospital Stay

ERAS: Local experience In 2005, ERAS was implemented at the Manukau Surgery Centre. 200 patients have gone through so far.

ERAS: Pre-implementation Idea discussed and enthusiasts rallied. 2 nurses and 1 colorectal surgeon Visit to Prof Kehlet’s Institute in Copenhagen. Protocol adapted to local setting. Further input from Nursing and Anaesthesia Buy-in from management Employment of full time ERAS research fellow.

Pre-admit Information sheet given Milestones set Ward visit / orientation Social issues identified Pre-op Carbohydrate loading Admit day of surgery No bowel prep No sedation Intra-op Mid-thoracic epidural IV Dexamethasone IV fluid restriction No NG tubes / drains Day of surgery Day 1 Urinary catheter removed Active walking (physio) Full oral diet Protein supplement drinks Day 2 Epidural removed Regular tenoxicam Opiates avoided Cont. mobilisation / feeding Day 3 Discharge Discharge if: eating, passing flatus, off IV therapy, mobilising independently, adequate home support. Follow-up Mobilise to chair Oral fluids started Regular anti-emetics Heparin (LMWH subcut) Nurse contact by phone Emergency action plan Follow-up clinic in 1 week

ERAS: Prospective Audit Safety The first 30 ERAS patients. Zargar et al NZMJ 2008 Efficacy 50 ERAS vs 50 controls. Zargar et al DCR 2008 Influence on fatigue. Zargar et al JSR 2009 Cost Cost-effectiveness analysis. Sammour et al In Press Median day stay 3 days, 13% readmission rate

Efficacy: Clinical Outcome Zargar et al, Dis Col Rect 2008

Efficacy: Patient-Centred Zargar et al, J Surg Res 2009

Cost Sammour et al, In Press ERAS $550,380 Control $786,181 Cost Sammour et al, In Press Overall ERAS savings = $235,801 = $4,716 per patient

Current status of ERAS at MSC Program now well established Ingrained in hospital culture Safety and Cost-effectiveness demonstrated Where to from here? Ongoing prospective audit Research into new interventions Expansion to other areas

ERAS Online Database

Research ERAS standardises post-operative care Provides fertile ground for high quality research Incorporated into trial protocol Confident that patient care is optimised Reduces variability Controls factors other than one being tested

Future Research Directions: Anti-inflammatories

Steroids – Trial Completed Zargar et al, Br J Surg 2009 Randomised double-blinded RCT Open colonic resections (n = 60) IV Dex vs IV N Saline Significant reduction in... Peritoneal IL-6 and IL-13; Plasma IL-6 Fatigue at days 3 and 7 Nausea day 1 Passed flatus 1 day earlier Wound infection (0 vs 6, p 0.04)

Statins – Trial Planned Recently described anti-inflammatory effect Meta-analysis by Hindler et al 2006 44% reduction in mortality (2.2% vs. 3.2%; P 0.0001) Mainly observational and cardiac studies (co-intervention bias likely) Randomised controlled trial planned at MSC

Future Research Directions: Neural manipulation

Epidurals Central component of ERAS Used to block spinal somatic afferents Meta-analysis by Marrett et al, BJS 2007 Decreased pain / ileus Intravenous anaesthetic also effective Meta-analysis by Marrett et al, BJS 2008 Decreased pain scores, ileus, day stay ? Direct effect on mesenteric nerves  Intra-peritoneal administration needs investigation

Local Anaesthetic: Recruiting Randomised double-blinded RCT in ERAS Open / Hand assisted resections (n = 60) Intervention Intra-peritoneal Ropivacaine Administered intra-op Via wound catheter for 3 days postoperatively. Control Same protocol using Saline Post-operative recovery as primary outcome

Future Research Directions: Nutrition

Preop Feeding Preop carbohydrate administration Immuno-nutrition Reduces insulin resistance Trials needed to assess clinical endpoints in ERAS Immuno-nutrition Giger ASO 2007 => Impact preop vs Placebo Major abdo surgery Reduced day stay, inflammatory markers Multiple trials in UGI surgery => decreased morbidity ?Need in ERAS setting

Fluids Restrictive fluid regimen 1 – 2L intraop crystalloids, avoid postop IV fluid Meta-analysis by Nahbari et al, BJS 2009 Reduced morbidity vs conventional (OR 0·41, P = 0·005) Goal-directed fluid (Oesophageal Doppler) Meta-analysis by Nahbari et al BJS 2009 (OR 0·43, P = 0·001) Need to “Compare the Winners”

Oesoph Doppler: Trial recruiting Double blinded, randomised controlled trial Multi-Centre (MSC and NSH) Open and Lap colon resections (n = 74) Intervention Oesophageal Doppler inserted intra-op Use corrected flow time, stroke volume Control Current restrictive fluid protocol Post-operative recovery as primary outcome

Future Research Directions: Psychology

Cognitive therapy Improves recovery Wound healing? Meta-analysis by Devine et al, Pat Ed & Couns1992 Reduced day stay by 1.5 days (p < 0.001) Wound healing? Psychological stress is known to slow wound healing Directly reduces collagen deposition Never been studied in surgery

Cognitive therapy: Trial Recruiting Randomised double-blinded controlled trial Laparoscopic cholecystectomy (n = 80) Intervention Cognitive behavioral therapy 1 week before surgery Control No cognitive therapy Wound healing as primary outcome

IV Dexamethasone Cognitive therapy Doppler Statins IP Local Anaesthetic IV Dexamethasone

ERAS Expansion

Enhanced Recovery at North Shore Hospital ERAS Expansion Enhanced Recovery at North Shore Hospital Synchronising protocols across both sites Online data entry into unified ERAS database Future research programs will be multi-site

Future Expansion Other specialties in Manukau Surgery Centre General Surgery Bariatric Surgery Other upper GI surgery Vascular surgery Orthopaedics Obstetrics and Gynaecology Other hospitals Starship Children’s Hospital

Summary ERAS is protocol based, multi-disciplinary program that optimises peri-operative care Major aim is to reduce surgical stress Safe & cost-effective Ongoing refinement through research Future expansion to other specialties and sites