1. 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

2. 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

3. 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

4. What is ERAS?

5. 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

6. 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 L
Goal Directed

7. 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)

8. 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

9. 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

10. 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.

11. 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.

12. Postoperative Fatigue

13. 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

14. 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

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

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

17. 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)

18. 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%

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

22. 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

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

24. 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)

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

26. 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.

27. 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

28. 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

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

30. 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)

31. 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

32. 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