American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Getting a head start: Enhanced recovery after surgery protocols

OCTOBER 24, 2017
Clinical Congress Daily Highlights, Tuesday First Edition

Preparing patients for the rigors of surgery in advance of an operation is gaining in popularity as an increasing body of evidence demonstrates the ability to optimize clinical outcomes and reduce costs. These Enhanced Recovery After Surgery (ERAS) protocols seek to increase a patient’s resilience  through “prehabilitation,” which uses the preoperative time to optimize physical, emotional, medical, and pharmacological conditions, speakers at a Tuesday panel said. This may take the form of smoking cessation, improved nutrition, relaxation strategies, or optimal glycemic control.

“Just like you would train for a stressful metabolic event like a marathon, you may go out and train for that metabolic stressor, and that’s the concept of prehabilitation,” said Liane S. Feldman, MD, FACS, FRCS, director, Division of General Surgery, McGill University, Montreal, Canada. In addition, she emphasized a move away from simple risk assessment (whether a patient is fit for surgery) to optimization, which emphasizes metabolic preparation, prehabilitation, and patient activation. This change in philosophy has the potential to help prepare patients for a surgical procedure and achieve functional recovery more quickly.

Enhanced recovery protocols are being explored across various types of surgery. Thomas A. Aloia, MD, FACS, director of quality and outcomes, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, discussed the benefits of Enhanced Recovery in Liver Surgery (ERIS) programs he has seen in his practice. He shared data on the ability of preoperative preparation to help cancer patients continue on to an intended therapy after surgery, measured using the Return to Intended Oncologic Treatment (RIOT) metric. He found that with ERIS, 96 percent of patients were able to return to oncologic treatment within approximately three weeks after surgery.

Implementing these protocols in a hospital doesn’t happen in a vacuum, said Linda W. Martin, MD, MPH, FACS, University of Virginia Medical Center, Charlottesville, VA. She highlighted the importance of a multidisciplinary team in designing and employing enhanced recovery preparations: “It’s a systemic culture change. It’s not something that one physician champion can do, it involves nursing care, anesthesiologists, physiotherapists. All different specialists are involved.” Dr. Martin’s team has created a website that patients can use to learn about their surgical procedures and to download checklists in preparation for an operation.

Another goal of ERAS protocols is to reduce the use of opioids postoperatively. This goal is particularly important for thoracic surgery, which is one of the most painful procedures and associated with a 2.5-fold increased risk of prolonged opioid use. Within the first year of implementing enhanced recovery programs, Dr. Martin and her team have observed shorter lengths of stay as well as a 60 to 70 percent reduction in morphine equivalents.

The length of the preoperative period can vary across procedures. In instances of hernia surgery, which is often elective, patients may have an extended period of time to improve their physical condition. Modifiable risk factors such as tobacco use, obesity, and nutrition can be altered through various techniques and improve not only health outcomes, but also reduce costs. Andrew S. Wright, MD, FACS, University of Washington Medicine, Seattle, WA, showed that through such preoperative efforts, he has seen a reduction in length of stay, direct costs and 30-day readmission rates. Dr. Wright also introduced a mobile app that he uses called CeDAR, which helps assess a patient’s preoperative status, risk of developing complications and corresponding cost of treatment. Applications like these may help other surgeons design and guide preoperative care.

According to Dr. Aloia, “If you set up the program to be patient-centric instead of hospital-centric, it will be very successful.” By putting patients at the heart of such recovery protocols, surgeons are seeing improved postoperative outcomes, highlighting the importance of preparing for a surgical operation even before the first incision.

Additional Information:
The Panel Session, Enhanced Recovery after Surgery (ERAS): Colorectal Surgery and Beyond, was held October 24, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at

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