Michael Vlessides

Originally published by our sister publication, Anesthesiology News

A four-year initiative found that a standardized enhanced recovery after surgery (ERAS) protocol was associated with a host of improved outcomes after Whipple pancreaticoduodenectomy, including reductions in hospital length of stay (LOS), readmission rates, reoperations and surgical site infections/pancreatic leaks.

“We first became interested in enhanced recovery protocols in early 2015,” said Nazareth Asorian, DO, the medical director and surgeon advisor of quality and safety at Lee Health in Fort Myers, Fla. “After more than a year of planning and meetings, a team representing surgery, anesthesia, nursing, leadership/administration and information technology launched the ERAS pathway in April 2016 for colorectal surgery.”

As part of the pathway, the researchers employed a process compliance checklist of 25 measures based on that of the American College of Surgeons National Surgical Quality Improvement Program. Highlights of the protocol included:

• preoperative patient optimization;
• 24 ounces of a glycemic endothelial drink the day before surgery and 12 ounces on the morning of surgery (up to two hours before induction);
• goal-directed fluid therapy with a target of 1 to 4 mL/kg per hour;
• pain management;
• medications for postoperative nausea and vomiting (PONV);
• perioperative normothermia;
• avoiding routine use of nasogastric tubes;
• removal of Foley catheter within 24 hours;
• early ambulation; and
• rapid progression to a general diet.

“As with any ERAS protocol, you can’t assume that any one specific measure is really effective on its own,” Dr. Asorian said. “But collectively, they certainly seemed to help.”

Patients were followed for 30 days, at which point they were assessed for a variety of factors, including LOS, hospital readmission, reoperation, mortality, surgical site infection, pancreatic leak, intraoperative transfusion, glycemic surveillance, procedure time and risks.

Improvements Seen Across the Board

In a presentation to the 2021 virtual Annual Congress of Enhanced Recovery and Perioperative Medicine (abstract 1), Dr. Asorian reported that the final study cohort comprised 179 patients (mean age, 66 years) who underwent Whipple pancreaticoduodenectomy at Lee Health between November 2016 and 2020. For comparative purposes, the investigators used data from a group of patients who underwent the procedure during the pre-ERAS period, from August 2015 to October 2016.

“The most important thing for the team was making sure the process was standardized,” Dr. Asorian said. “So, once the pathway was created and surgery, anesthesia and nursing were in agreement, we knew we had to standardize the individual protocols.”

The majority of patients received at least two medications for PONV, including ondansetron (93%) and famotidine (80%). Multimodal pain medications were many and varied: ketamine (90% of patients), gabapentin (87%), acetaminophen (82%), hydromorphone (70%), naproxen (52%), fentanyl (35%) and ketorolac (27%). Only 6.7% of patients underwent intraoperative blood transfusion. Normothermia was maintained in 96% of patients intraoperatively and in 97% of patients in the PACU. Goal-directed fluid therapy was maintained at a mean target fluid level of 4.8 mL/kg per hour.

The researchers found that mean LOS fell after the protocol was implemented, from 11.0 to 6.7 days. Similarly, the patient readmission rate fell from 29.0% to 10.1%, while the reoperation rate decreased from 23.5% to 11.6%. The combined rate of all surgical site infections/pancreatic leaks was 29.4% in the pre-ERAS period, which fell to 15.2% once the pathway had been implemented. Finally, postoperative pancreatic fistula occurred in 8.7% of patients, a figure the researchers said compares favorably with high-volume centers.

“The improvement was remarkable,” Dr. Asorian noted.

Despite these differences, however, the rate of mortality was comparable between the two periods (2.7% pre-ERAS vs. 2.8% post-ERAS).

Changes in Protocol Aren’t Easy

Yet as encouraging as the findings were, the researchers were quick to point out that implementing such a protocol does not happen by chance. As Dr. Asorian discussed, it is the product of significant planning and collaborative effort.

“Culture change is vital,” he explained. “You need surgeons and anesthesiologists who will champion the cause and can get their peers to accept the idea of an ERAS pathway, because many anesthesiologists and surgeons are resistant to change.”

Process standardization is also critical, as is the collection of benchmark and follow-up data. “A quality measure is not really helpful without follow-up data to show how things are changing,” he said. “Finally, the key to any program is sustainability, especially because most people seem to start losing interest after around six months.”

For Tong Joo (T.J.) Gan, MD, MBA, MHS, the study’s results were impressive, despite what he felt was a relative lack of detailed data from the researchers. “The results are not surprising, since once you successfully implement an enhanced recovery protocol you typically see improved outcomes in terms of length of stay, readmissions and reoperations,” said Dr. Gan, a professor and the chairman of anesthesiology at Stony Brook Medicine, in Stony Brook, N.Y.

As Dr. Gan discussed, the general principles for enhanced recovery are comparable, regardless of the procedure involved. “These include preoperative patient education, preoperative optimization, multimodal analgesia, postoperative nausea and vomiting prophylaxis, rational fluid management, early feeding and early mobilization,” Dr. Gan said.