Enhanced recovery after surgery: Current research insights and future direction

Aliza Abeles, Richard Mark Kwasnicki, Ara Darzi, Aliza Abeles, Richard Mark Kwasnicki, Ara Darzi

Abstract

Since the concept of enhanced recovery after surgery (ERAS) was introduced in the late 1990s the idea of implementing specific interventions throughout the peri-operative period to improve patient recovery has been proven to be beneficial. Minimally invasive surgery is an integral component to ERAS and has dramatically improved post-operative outcomes. ERAS can be applicable to all surgical specialties with the core generic principles used together with added specialty specific interventions to allow for a comprehensive protocol, leading to improved clinical outcomes. Diffusion of ERAS into mainstream practice has been hindered due to minimal evidence to support individual facets and lack of method for monitoring and encouraging compliance. No single outcome measure fully captures recovery after surgery, rather multiple measures are necessary at each stage. More recently the pre-operative period has been the target of a number of strategies to improve clinical outcomes, described as prehabilitation. Innovation of technology in the surgical setting is also providing opportunities to overcome the challenges within ERAS, e.g., the use of wearable activity monitors to record information and provide feedback and motivation to patients peri-operatively. Both modernising ERAS and providing evidence for key strategies across specialties will ultimately lead to better, more reliable patient outcomes.

Keywords: Enhanced recovery after surgery; Laparoscopic surgery; Outcome measures; Prehabilitation; Technology.

Conflict of interest statement

Conflict-of-interest statement: The authors have no conflict of interest for this article.

Figures

Figure 1
Figure 1
Uses of physical activity monitoring in the peri-operative period. Multiple opportunities exist for implementation of activity monitors in the peri-operative period. Pre-operatively, this includes the assessment of surgical fitness, and guiding a prehabilitation programme. Post-operatively there are multiple options for intervention and measurement in the hospital setting, as well as longer term assessments of functional outcome and encouraging an active lifestyle for overall physical and mental wellbeing.

References

    1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–617.
    1. Basse L, Raskov HH, Hjort Jakobsen D, Sonne E, Billesbølle P, Hendel HW, Rosenberg J, Kehlet H. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg. 2002;89:446–453.
    1. Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology. 2009;136:842–847.
    1. Basse L, Hjort Jakobsen D, Billesbølle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg. 2000;232:51–57.
    1. Lohsiriwat V. Enhanced recovery after surgery vs conventional care in emergency colorectal surgery. World J Gastroenterol. 2014;20:13950–13955.
    1. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31:783–800.
    1. Kennedy GD, Heise C, Rajamanickam V, Harms B, Foley EF. Laparoscopy decreases postoperative complication rates after abdominal colectomy: results from the national surgical quality improvement program. Ann Surg. 2009;249:596–601.
    1. Veldkamp R, Kuhry E, Hop WC, Jeekel J, Kazemier G, Bonjer HJ, Haglind E, Påhlman L, Cuesta MA, Msika S, et al. Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial. Lancet Oncol. 2005;6:477–484.
    1. van der Pas MH, Haglind E, Cuesta MA, Fürst A, Lacy AM, Hop WC, Bonjer HJ. Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol. 2013;14:210–218.
    1. Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld BA, van der Zaag ES, van Geloven AA, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study) Ann Surg. 2011;254:868–875.
    1. Kennedy RH, Francis EA, Wharton R, Blazeby JM, Quirke P, West NP, Dutton SJ. Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: EnROL. J Clin Oncol. 2014;32:1804–1811.
    1. Hirano Y, Hattori M, Douden K, Ishiyama Y, Hashizume Y. Single-incision laparoscopic surgery for colorectal cancer. World J Gastrointest Surg. 2016;8:95–100.
    1. Aly EH. Robotic colorectal surgery: summary of the current evidence. Int J Colorectal Dis. 2014;29:1–8.
    1. Kim CW, Kim CH, Baik SH. Outcomes of robotic-assisted colorectal surgery compared with laparoscopic and open surgery: a systematic review. J Gastrointest Surg. 2014;18:816–830.
    1. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part I. Gynecol Oncol. 2016;140:313–322.
    1. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part II. Gynecol Oncol. 2016;140:323–332.
    1. Cerantola Y, Valerio M, Persson B, Jichlinski P, Ljungqvist O, Hubner M, Kassouf W, Muller S, Baldini G, Carli F, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS(®)) society recommendations. Clin Nutr. 2013;32:879–887.
    1. Kagedan DJ, Ahmed M, Devitt KS, Wei AC. Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB (Oxford) 2015;17:11–16.
    1. Wang YC, Szatmary P, Zhu JQ, Xiong JJ, Huang W, Gomatos I, Nunes QM, Sutton R, Liu XB. Prophylactic intra-peritoneal drain placement following pancreaticoduodenectomy: a systematic review and meta-analysis. World J Gastroenterol. 2015;21:2510–2521.
    1. Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg. 2013;37:240–258.
    1. Lemanu DP, Srinivasa S, Singh PP, Johannsen S, MacCormick AD, Hill AG. Optimizing perioperative care in bariatric surgery patients. Obes Surg. 2012;22:979–990.
    1. Livhits M, Mercado C, Yermilov I, Parikh JA, Dutson E, Mehran A, Ko CY, Gibbons MM. Preoperative predictors of weight loss following bariatric surgery: systematic review. Obes Surg. 2012;22:70–89.
    1. Jones NL, Edmonds L, Ghosh S, Klein AA. A review of enhanced recovery for thoracic anaesthesia and surgery. Anaesthesia. 2013;68:179–189.
    1. Ibrahim MS, Twaij H, Giebaly DE, Nizam I, Haddad FS. Enhanced recovery in total hip replacement: a clinical review. Bone Joint J. 2013;95-B:1587–1594.
    1. Ibrahim MS, Alazzawi S, Nizam I, Haddad FS. An evidence-based review of enhanced recovery interventions in knee replacement surgery. Ann R Coll Surg Engl. 2013;95:386–389.
    1. McLeod RS, Aarts MA, Chung F, Eskicioglu C, Forbes SS, Conn LG, McCluskey S, McKenzie M, Morningstar B, Nadler A, et al. Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle. Ann Surg. 2015;262:1016–1025.
    1. Pędziwiatr M, Kisialeuski M, Wierdak M, Stanek M, Natkaniec M, Matłok M, Major P, Małczak P, Budzyński A. Early implementation of Enhanced Recovery After Surgery (ERAS®) protocol - Compliance improves outcomes: A prospective cohort study. Int J Surg. 2015;21:75–81.
    1. ERAS Compliance Group. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Ann Surg. 2015;261:1153–1159.
    1. Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Andersen J, Kessels AG, Revhaug A, Kehlet H, Ljungqvist O, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg. 2007;94:224–231.
    1. Ahmed J, Khan S, Lim M, Chandrasekaran TV, MacFie J. Enhanced recovery after surgery protocols - compliance and variations in practice during routine colorectal surgery. Colorectal Dis. 2012;14:1045–1051.
    1. Nicholson A, Lowe MC, Parker J, Lewis SR, Alderson P, Smith AF. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg. 2014;101:172–188.
    1. Lyon A, Payne CJ, Mackay GJ. Enhanced recovery programme in colorectal surgery: does one size fit all? World J Gastroenterol. 2012;18:5661–5663.
    1. King PM, Blazeby JM, Ewings P, Longman RJ, Kipling RM, Franks PJ, Sheffield JP, Evans LB, Soulsby M, Bulley SH, et al. The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis. 2006;8:506–513.
    1. Hendry PO, Hausel J, Nygren J, Lassen K, Dejong CH, Ljungqvist O, Fearon KC. Determinants of outcome after colorectal resection within an enhanced recovery programme. Br J Surg. 2009;96:197–205.
    1. Faiz O, Brown T, Colucci G, Kennedy RH. A cohort study of results following elective colonic and rectal resection within an enhanced recovery programme. Colorectal Dis. 2009;11:366–372.
    1. Zargar-Shoshtari K, Paddison JS, Booth RJ, Hill AG. A prospective study on the influence of a fast-track program on postoperative fatigue and functional recovery after major colonic surgery. J Surg Res. 2009;154:330–335.
    1. Knott A, Pathak S, McGrath JS, Kennedy R, Horgan A, Mythen M, Carter F, Francis NK. Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study. BMJ Open. 2012;2:pii: e001878.
    1. Bernard H, Foss M. Patient experiences of enhanced recovery after surgery (ERAS) Br J Nurs. 2014;23:100–102, 104-106.
    1. Roulin D, Donadini A, Gander S, Griesser AC, Blanc C, Hübner M, Schäfer M, Demartines N. Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg. 2013;100:1108–1114.
    1. Lemanu DP, Singh PP, Stowers MD, Hill AG. A systematic review to assess cost effectiveness of enhanced recovery after surgery programmes in colorectal surgery. Colorectal Dis. 2014;16:338–346.
    1. Lee L, Li C, Landry T, Latimer E, Carli F, Fried GM, Feldman LS. A systematic review of economic evaluations of enhanced recovery pathways for colorectal surgery. Ann Surg. 2014;259:670–676.
    1. Neville A, Lee L, Antonescu I, Mayo NE, Vassiliou MC, Fried GM, Feldman LS. Systematic review of outcomes used to evaluate enhanced recovery after surgery. Br J Surg. 2014;101:159–170.
    1. Feldman LS, Lee L, Fiore J. What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS) pathways? Can J Anaesth. 2015;62:120–130.
    1. Gillis C, Li C, Lee L, Awasthi R, Augustin B, Gamsa A, Liberman AS, Stein B, Charlebois P, Feldman LS, et al. Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology. 2014;121:937–947.
    1. Carli F, Scheede-Bergdahl C. Prehabilitation to enhance perioperative care. Anesthesiol Clin. 2015;33:17–33.
    1. Carli F, Zavorsky GS. Optimizing functional exercise capacity in the elderly surgical population. Curr Opin Clin Nutr Metab Care. 2005;8:23–32.
    1. Valkenet K, van de Port IG, Dronkers JJ, de Vries WR, Lindeman E, Backx FJ. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil. 2011;25:99–111.
    1. Lemanu DP, Singh PP, MacCormick AD, Arroll B, Hill AG. Effect of preoperative exercise on cardiorespiratory function and recovery after surgery: a systematic review. World J Surg. 2013;37:711–720.
    1. Santa Mina D, Clarke H, Ritvo P, Leung YW, Matthew AG, Katz J, Trachtenberg J, Alibhai SM. Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy. 2014;100:196–207.
    1. Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS, Kaneva P, Augustin B, Wongyingsinn M, Gamsa A, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc. 2013;27:1072–1082.
    1. Tew GA, Weston M, Kothmann E, Batterham AM, Gray J, Kerr K, Martin D, Nawaz S, Yates D, Danjoux G. High-intensity interval exercise training before abdominal aortic aneurysm repair (HIT-AAA): protocol for a randomised controlled feasibility trial. BMJ Open. 2014;4:e004094.
    1. Colquhoun DA, Roche AM. Oesophageal Doppler cardiac output monitoring: a longstanding tool with evolving indications and applications. Best Pract Res Clin Anaesthesiol. 2014;28:353–362.
    1. Pavon JM, Williams JW, Jr . Adam SS, Razouki ZA, McDuffie JR, Lachiewicz PF, Kosinski AS, Beadles CA, Ortel TL, Nagi A. VA Evidence-based Synthesis Program Reports. Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-risk Surgical and Medical Patients. Washington (DC): Department of Veterans Affairs (US); 2015.
    1. John M, Crook D, Dasari K, Eljelani F, El-Haboby A, Harper CM. Comparison of resistive heating and forced-air warming to prevent inadvertent perioperative hypothermia. Br J Anaesth. 2016;116:249–254.
    1. Appelboom G, Camacho E, Abraham ME, Bruce SS, Dumont EL, Zacharia BE, D’Amico R, Slomian J, Reginster JY, Bruyère O, et al. Smart wearable body sensors for patient self-assessment and monitoring. Arch Public Health. 2014;72:28.
    1. Dobkin BH, Dorsch A. The promise of mHealth: daily activity monitoring and outcome assessments by wearable sensors. Neurorehabil Neural Repair. 2011;25:788–798.
    1. Aziz O, Atallah L, Lo B, Gray E, Athanasiou T, Darzi A, Yang GZ. Ear-worn body sensor network device: an objective tool for functional postoperative home recovery monitoring. J Am Med Inform Assoc. 2011;18:156–159.
    1. Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57:1660–1665.
    1. Kwasnicki RM, Hettiaratchy S, Jarchi D, Nightingale C, Wordsworth M, Simmons J, Yang GZ, Darzi A. Assessing functional mobility after lower limb reconstruction: a psychometric evaluation of a sensor-based mobility score. Ann Surg. 2015;261:800–806.
    1. Cook DJ, Thompson JE, Prinsen SK, Dearani JA, Deschamps C. Functional recovery in the elderly after major surgery: assessment of mobility recovery using wireless technology. Ann Thorac Surg. 2013;96:1057–1061.
    1. Wasowicz-Kemps DK, Slootmaker SM, Kemps HM, Borel-Rinkes IH, Biesma DH, van Ramshorst B. Resumption of daily physical activity after day-case laparoscopic cholecystectomy. Surg Endosc. 2009;23:2034–2040.
    1. Takiguchi S, Fujiwara Y, Yamasaki M, Miyata H, Nakajima K, Sekimoto M, Mori M, Doki Y. Laparoscopy-assisted distal gastrectomy versus open distal gastrectomy. A prospective randomized single-blind study. World J Surg. 2013;37:2379–2386.
    1. Skender S, Schrotz-King P, Böhm J, Abbenhardt C, Gigic B, Chang-Claude J, Siegel EM, Steindorf K, Ulrich CM. Repeat physical activity measurement by accelerometry among colorectal cancer patients--feasibility and minimal number of days of monitoring. BMC Res Notes. 2015;8:222.
    1. Reid RE, Carver TE, Andersen KM, Court O, Andersen RE. Physical activity and sedentary behavior in bariatric patients long-term post-surgery. Obes Surg. 2015;25:1073–1077.
    1. Jauho AM, Pyky R, Ahola R, Kangas M, Virtanen P, Korpelainen R, Jämsä T. Effect of wrist-worn activity monitor feedback on physical activity behavior: A randomized controlled trial in Finnish young men. Prev Med Rep. 2015;2:628–634.
    1. Normahani P, Bicknell C, Allen L, Kwasnicki R, Jenkins M, Gibbs R, Cheshire N, Darzi A, Riga C. Wearable Sensor Technology Efficacy in Peripheral Vascular Disease (wSTEP): A Randomised Clinical Trial. European Vascular Endova Surg. 2015;50:e15–e16.
    1. Kwasnicki RM, Ali R, Jordan SJ, Atallah L, Leong JJ, Jones GG, Cobb J, Yang GZ, Darzi A. A wearable mobility assessment device for total knee replacement: A longitudinal feasibility study. Int J Surg. 2015;18:14–20.

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