RT Book, Section
A1 Senagore, Anthony J.
A2 Zinner, Michael J.
A2 Ashley, Stanley W.
A2 Hines, O. Joe
SR Print(0)
ID 1160036969
T1 Enhanced Recovery Programs for Gastrointestinal Surgery
T2 Maingot's Abdominal Operations, 13e
YR 2019
FD 2019
PB McGraw-Hill Education
PP New York, NY
SN 9780071843072
LK accesssurgery.mhmedical.com/content.aspx?aid=1160036969
RD 2024/04/18
AB Enhanced  recovery  protocols  (ERPs)  were  developed  primarily  for  the  care  of  the  colorectal  surgical  patient  during  the  late  1990s  and  demonstrated  early  success  in  the  2000s.1-7  These  efforts  represented  consensus  from  dieticians,  nurses,  surgeons,  and  anesthesiologists  at  the  time  and  ultimately  grew  into  codified  components  of  care  with  excellent  outcomes.8-11  This  work  truly  represents  the  culmination  of  the  best  science  that  has  assessed  the  surgical  stress  response  and  mitigating  therapies,  principally  from  the  work  of  Henrik  Kehlet  who  deserves  the  title  of  “Father  of  Enhanced  Recovery  After  Surgery.”8  ERP  implementation  has  evolved  from  a  convoluted  and  often  complex  set  of  care  plans  to  a  true  discipline  for  evidence-based  care  of  the  surgical  patient.  Although  the  early  focus  was  on  length  of  stay,  the  science  has  evolved  into  an  approach  for  improved  patient-centric  care  that  deserves  the  more  proper  title  of  “enhanced  recovery  protocols”  (ERPs).  The  concepts  related  to  preoperative  cardiovascular  and  pulmonary  risk  assessment  and  risk  modification  are  well  defined  by  surgical  and  anesthesia  textbooks  and  preoperative  anesthesia  clinic  processes,  and  although  they  are  clearly  an  essential  part  of  a  strong  perioperative  care  plan,  they  are  not  typically  considered  ERP  components  of  care.  The  majority  of  a  gastrointestinal  (GI)  surgery–related  ERP  consists  of  a  variety  of  shared  components  that  will  be  addressed  in  a  later  section.  These  strategies  are  designed  to  recognize  and  optimize  preoperative  physiologic  adverse  factors,  the  perioperative  stress  response,  narcotic-sparing  analgesia,  evidence-based  reduction  of  “potentially  preventable  complications,”  early  and  aggressive  ambulation,  and  early  return  to  enteral  intake.3,8  The  optimal  use  of  these  strategies  has  consistently  demonstrated  a  significant  reduction  in  hospital  stay  and  costs,  while  significantly  improving  patient  safety.  The  potential  components  of  care  include  preoperative  assessment  and  education,  nutritional  repletion,  improvement  in  perioperative  glycemic  management,  anesthesia/analgesia,  goal-directed  fluid  therapy,  prevention  of  nausea  and  ileus,  thromboembolic  prophylaxis,  minimally  invasive  techniques,  temperature  monitoring,  early  postoperative  nutrition,  and  early  mobilization.2  The  net  result  of  a  well-developed  program  with  a  high  degree  of  institutional  compliance  has  been  a  universal  improvement  in  clinical  outcomes,  reduced  length  of  stay,  reduced  cost,  and  most  importantly,  significantly  improved  physical  recovery  of  the  patient.5,9  An  interesting  institutional  journey  is  reflected  in  the  work  by  Bakker  et  al,10  who  determined  that  the  strongest  predictors  for  a  shorter  duration  of  stay  (5.7  days  with  high  compliance  vs  7.3  days  with  low  compliance)  were  no  nasogastric  tube,  early  mobilization,  early  oral  nutrition,  early  removal  of  epidural,  early  removal  of  catheter,  and  nonopioid  oral  analgesia.  However,  despite  the  institutional  recognition  of  these  fairly  simple  components  of  care  and  the  benefits,  the  mean  adherence  rate  was  73%  in  2006  and  2007,  66%  in  2008  and  2009,  63%  in  2010  and  2011,  and  82%  in  2012  and  2013.10  This  implies  that  constant  monitoring  of  both  process  and  outcome  is  essential  for  durable  success  with  ERPs.