Allan Spigelman: Taking the fast track to recovery

THERE is a burgeoning literature, particularly in the field of colorectal surgery, on using Enhanced Recovery After Surgery (ERAS) processes to fast track patients after their operation.

What is ERAS? It is a set of simple and evidence-based perioperative measures that are structured as pathways to accelerate postoperative recovery.

These pathways may include patient education, optimisation of organ function prior to surgery, improved anaesthetic and postoperative analgesic techniques, and better understanding of perioperative care principles such as early oral feeding and ambulation.

ERAS may be seen by sceptics as a cost-reduction exercise, achieved by reducing the length of hospital stay. It would be that — if beds were closed after earlier discharge occurred.

However, to solve the ever-present issue of access to hospital care, there needs to be agreement that vacated beds be made available to other patients awaiting care.

ERAS is also an attempt to improve patient outcomes by reducing the risk for intra-hospital morbidity and improving patient satisfaction by earlier return to normal function.

Intuitively these would appear to be very probable outcomes. Although many studies have shown that a reduction in length of stay is achievable without an increase in patient re-admission rates, it is relevant to note that the most recent such analysis (from the United Kingdom) concluded that these studies were “methodologically constrained”.

Successful enhanced recovery pathways promise benefits to patients, doctors and health care systems. Patients benefit from better preparation for postoperative convalescence, doctors benefit as patients’ satisfaction improves and the health system benefits by both.

Although most active in colorectal surgery, ERAS would apply across the clinical spectrum.

The Australian Safety and Efficacy Register of New Interventional Procedures ― Surgical (ASERNIP-S) review of fast-track surgery and ERAS programs reported that fast-track surgery had been used for colonic surgery, colorectal surgery and hepatopancreaticobiliary surgery (pancreaticoduodenectomy, pancreatic resections and liver resections). One surgeon suggested that fast-track surgery protocols were relatively generic, and could be applied to any indication with clinically relevant adaptations.

The literature in this area is qualified by the relatively small size of the individual studies to date. This has meant that meta-analyses provide the basis for determining the benefit of the enhanced recovery approach.

In the 1980s, as a surgical registrar I observed that many of the principles of the current ERAS were employed by one of my consultants. It was a successful endeavour, at least in that era of anecdote.

To be widely accepted today, large, prospective, collaborative studies are needed, requiring, as usual, enough patients to provide the statistical power necessary to properly address the important issues of quality of life, patient satisfaction, morbidity, hospital stay and properly measured re-admission rates.

Only then could there be a conclusive statement made about the benefits of ERAS in the modern era.

Professor Allan Spigelman is professor of surgery at the University of New South Wales, clinical associate dean at St Vincent’s Clinical School and director of cancer services at St Vincent’s and Mater Health Services, Sydney. He also serves on the NSW Medical Board and was elected chair of the International Society of Gastrointestinal Hereditary Tumours at its recent meeting in Texas.

Posted 4 April 2011