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

2. Major Abdominal Surgery

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

4. 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

5. 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

6. Complications
23.7% vs 43.6%

7. Hospital Stay

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

9. 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.

10. 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

11. 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

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

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

14. 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

15. 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

16. ERAS Online Database

17. 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

19. Future Research Directions:
Anti-inflammatories

20. 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)

21. 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 )
Mainly observational and cardiac studies
(co-intervention bias likely)
Randomised controlled trial planned at MSC

22. Future Research Directions: Neural manipulation

23. 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

24. 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

25. Future Research Directions: Nutrition

26. 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

27. 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”

28. 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

30. Future Research Directions: Psychology

31. 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

32. 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

33. IV Dexamethasone
Cognitive therapy
Doppler
Statins
IP Local Anaesthetic
IV Dexamethasone

34. ERAS Expansion

35. 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

36. 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

37. 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