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Enhanced recovery pathway

Rethinking pre- and postoperative surgical care for colorectal patients

A decade ago, minimal access procedures radically changed the practice of colorectal surgery. Smaller incisions shortened recovery times, reduced the risk of infection, and decreased trauma and scarring. Today, the field is undergoing another transformation with the growing acceptance of enhanced recovery pathway (ERP), an innovative, multidisciplinary approach to surgical care.

ERP is an evidence-based, multimodal program that seeks to reduce postoperative stress responses and organ dysfunction so that patients recover more quickly, easily and naturally. According to colorectal surgeon Robert R. Cima, M.D., it also overturns decades of established medical practice.

"Many standard interventions for colon surgery don't necessarily benefit patients, yet they remain in use. Enhanced recovery programs focus on novel practices shown to improve outcomes and quality of care."

Feeding vs. fasting

One of the tenets of ERP is that improving the health of patients before surgery results in a faster, less traumatic recovery. For this reason, ERP avoids traditional preoperative fasting and bowel cleansing.

"No studies suggest an increased risk of complications when patients forgo bowel prep and eat a normal diet the day before surgery. Certainly they feel much better; they're stronger and not dehydrated," Dr. Cima says.

Contrary to standard practice, patients also eat and drink shortly after surgery. Fluid intake begins in the recovery room. Most people eat a small meal that evening and consume a protein-enriched drink the next morning.

"Practice has shown that eating doesn't increase vomiting or paralytic ileus after bowel surgery. Rather, it seems to improve gut function. The gut was designed to survive on food, not clear liquids," Dr. Cima points out.

In addition, drains and nasogastric tubes are not routinely used and urinary catheters are promptly removed after 24 hours. These measures not only reduce urinary tract infections, but also encourage early ambulation, which begins the evening of surgery and is another cornerstone of ERP.

Fewer opiates and fluids

Perhaps the most significant issues differentiating enhanced recovery from standard practice involve pain and fluid management.

ERP emphasizes both optimal pain control and rapid healing. Before surgery, patients receive anti-nausea medication, ibuprofen and acetaminophen to reduce nausea and pre-emptively treat pain. Patients are also assessed for a 24-hour spinal anesthetic. Postoperative pain management includes short-term, low-dose oral opioids and regularly scheduled anti-inflammatories.

Dr. Cima points out that one of the defining characteristics of ERP is the limited use of IV narcotics — a critical factor in speeding the return of normal intestinal function and encouraging early ambulation.

"By the time patients leave the recovery room, they don't need IV medications. Because they're eating, we can use oral analgesics, which have fewer side effects and provide more sustained pain control."

Fluid restriction is another key component of ERP. The goal, both during and after surgery, is to avoid sodium and fluid overload. When euvolemic status is maintained, patients retain less than 1 pound (0.5 kilogram) of fluid.

Measurable benefits

The ability to reduce surgical stress and restore normal function as quickly as possible has profound implications for patients and for health care in general.

Enhanced recovery programs have been shown to cut the average hospital stay in half — from five or six days to just two or three days — without increasing complications or readmissions. This alone reduces hospital costs by an average of $1,343 per patient.

Research on ERP also shows improved cardiac and pulmonary outcomes, improved muscle function, decreased fatigue, and fewer long-term complications. As important, patients have a better overall experience, with minimal discomfort, a faster return to normal life, and greater independence and participation in their care.

First pioneered 15 years ago, in Denmark, ERP has been successfully used at Mayo Clinic in Rochester, Minn., since November 2009. The improvement in patient rehabilitation has been well documented.

"This is a data-driven program," Dr. Cima says. "We're evaluating patient care the way we once evaluated open surgery. In the latter case, we said, 'Do we really need a big incision?' Now we're asking, 'What restores the body to health as soon as possible?' "

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