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IL PROGRAMMA

In recent years, a trend towards new peri-operative treatment strategies has been observed.
Although the impact of surgery is strictly related to the type and extent of a procedure, recovery is commonly adversely affected by pain, organ dysfunction, nausea and vomiting, ileus, hypoxaemia, malnutrition, fatigue and immobilization. To minimize these problems and accelerate recovery, structured multimodal approaches to perioperative management and postoperative care have been applied to different fields of surgery under a variety of names: enhanced recovery after surgery program, standardized care pathway, postoperative pathway.

Regardless of label, these programs seek to improve clinical practice by incorporating evidence-based medicine into patient management. (Kehlet 2008).

Adopted techniques include optimal pain control by epidural and local anaesthesia, minimally invasive techniques, and aggressive postoperative rehabilitation (Lassen 2009; Wilmore 2001).

Considering the overdose of information to which healthcare professionals are exposed (almost 10,000 well-organised trials are included in Medline every year nether), it is hardly surprising that a lot of valuable new insights are not adopted in daily practice of patient care.

Guidelines are an important intermediate step in the process of implementation of scientific knowledge. Thus, by reducing variability between practitioners and improving the effectiveness of care an enhanced recovery program attempts to accelerate recovery, reducing morbidity and shortening hospital stay.

Although in most studies, enhanced recovery programs are associated with reductions in postoperative length of stay, their impact on postoperative complications is less consistent (Gustafsson 2011). This could be related to the fact that ultimate length of hospital stay is influenced by both patient’s need for care (‘demand factors’, determined by patient characteristics such as age, severity of disease and complications, co-morbidity and social circumstances) and the provision of care (‘supply factors’, including clinical practice style, availability of beds and hospital discharge policies) (Maessen 2007).

The development of postoperative complications obviously has the strongest adverse influence on length of stay but all the other patients will benefit from a standardized enhanced recovery program.

Many centers especially in northern Europe and America have already introduced the use enhanced recovery programs in their practice. In few cases a nationwide implementation has taken place, promoted by the local government itself, as it happened in Netherlands (Maessen 2009).

In 2005 the Dutch Institute for Healthcare Improvements (CBO) identified the improvement of perioperative care practice as an interesting topic for a nationwide breakthrough project. All Dutch hospitals were invited to participate and within a short timeframe 26 Dutch hospitals (one quarter of all Dutch hospitals) signed up for the Breakthrough Series ‘‘Perioperative Care’’.

Changes were guided by the best available evidence.

From 2006 a multimodal care programme drafted by the enhanced recovery after surgery (ERAS) group was introduced. The ERAS programme contained all the necessary elements of routine care for patients undergoing colorectal surgery. With the focus on stress reduction and promotion of return to function the ERAS programme aims at a faster recovery from major surgery (Fearon 2005).

First, all hospitals gathered knowledge about their usual practice prior to the start of the project and retrospectively assembled data for a baseline measurement. In preparation for the project, the participating hospitals created a multidisciplinary team, including at least an anaesthetist, a surgeon and a nurse or nurse manager. These teams were to direct local improvement activities and to attend the project meetings.

A starting meeting was organised in January 2006 respectively May 2006, where information was given about all the elements of the ERAS programme and instructions were given about the various techniques of quality improvement.

At the starting meeting, teams got acquainted with each other and had the possibility to exchange ideas, knowledge and practice experience.

Every three months learning sessions were organised, at which teams reported on activities, methods and results. Each hospital started with treating patients according to the ERAS programme as soon as the local dissemination activities (educational sessions to involved professionals, development of care plans, re-design of care processes) were finished.

At the end of the project, one year after the kick-off meeting, 861 patients had been treated according to the ERAS programme. An online database was accessible for the prospective collection of patient characteristics, process indicators (protocol adherence, reasons for non-adherence) and outcome measures (length of stay and time to resumption of normal food, to independency in activities of daily living (ADL) and to pain control on oral analgesics).

Some result of these effort have already been presented and published.

Two papers analyzed nationwide multicentre data showing how the program had an overall improvement of postoperative management of the patient. One demonstrated that the median time to resumption of normal food decreased significantly (p <0.0001) from 5 days in the historical control (pre-ERAS) group to 2 days in the ERAS group (Maessen 2009). The patients having a nasogastric tube postoperatively dropped from 88.3% (historic control group) to 9.6% (p < 0.0001) after the implementation of the ERAS program (Jottard 2009).

As expected, these results had a major influence on the results concerning time to start drinking, time to normal food intake, duration of intravenous fluid intake and length of stay. One center involved in the study also published its personal experience with ERAS protocol reporting a median postoperative length of stay of 6 days (range = 2-28) in the pre-ERAS group and 4 days (range = 2-55) in the ERAS group (P = 0.007) with no significant differences in 30-day readmissions, 30-day reoperation rate, and 30-day mortality (Haverkamp 2011).

In Italy, literature reports only few single-centre sporadic tries to implement a perioperative program focusing on single surgical procedures rather than involving the entire surgical practice (Balzano 2008). These studies showed some benefit even with a small number of patients but a large centralized national program is still needed. There is also lack of information about the safety of these protocols and with yet no available data on well-defined risk assessment and management strategies after the implementation of an ERAS protocol.

Bibliography

Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fast track surgery. Ann Surg. 2008;248(2):189-198.

Lassen K, Soop M, Nygren J, et al; Enhanced Recovery After Surgery (ERAS) Group. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009; 144(10):961-969.

Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ. 2001;322 (7284): 473-6.
Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007; 94(2): 224-231.

Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466–77.

Maessen J, Hoff C, Jottard K, Kessels A, Bremers A, Havenga K, Oostenbroek R, von Meyenfeldt M, Dejong C. To eat or not to eat: Facilitating early oral intake after elective colonic surgery in the Netherlands. Clin Nutr 2009; 28: 29–33.

Jottard K, Hoff C, Maessen J, van Ramshorst B, van Berlo CL, Logeman F, Dejong CH. Life and death of the nasogastric tube in elective colonic surgery in the Netherlands. Clin Nutr 2009; 28: 26-28.

Haverkamp MP, de Roos MA, Ong KH. The ERAS protocol reduces the length of stay after laparoscopic colectomies. Surg Endosc 2011.

Balzano G, Zerbi A, Braga M, et al. Fast-track recovery programme after pancreatico duodenectomy reduces delayed gastric emptying. Br J Surg. 2008;95:1387–1393.

Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg. 2011;146:571-7.

Sammour T, Zargar-Shoshtari K, Bhat A, Kahokehr A, Hill AG. A programme of Enhanced Recovery After Surgery (ERAS) is a cost-effective intervention in elective colonic surgery. N Z Med J. 2010 30; 123: 61-70.

Birkmeyer JD, Skinner JS, Wennberg DE. Will volume-based referral strategies reduce costs or just save lives? Health Aff (Millwood). 2002; 21(5):234-41.

Balzano G, Zerbi A, Capretti G, et al. Effect of hospital volume on outcome of pancreaticoduodenectomy in Italy. Br J Surg. 2008;95:357–362.

Dimick JB, Cowan JA Jr, Colletti LM, Upchurch GR Jr. Hospital teaching status and outcomes of complex surgical procedures in the United States. Arch Surg. 2004; 139(2): 137-41.

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