Enhanced Recovery After [Cancer] Surgery

Have you heard of Enhanced Recovery After Surgery (ERAS)? It’s a term that describes a multimodal, multidisciplinary approach to perioperative patient treatment that has been slowly gaining traction since its conceptualization in 1997. Research around the effectiveness of ERAS has shown vast short-term (the jury is still out on the long-term) improvements in clinical outcomes and a marked reduction in hospitalization costs.

Understanding ERAS

The downsides of traditional perioperative patient care include that it lacks standardization, is surgeon rather than patient-centric, and less than 15% is evidence-based. ERAS completely turns the tables on this.

There are a number of key elements that are involved in the ERAS protocol, namely:

  • Pre-operative counselling: this can take place in-person, over the phone, or via multimedia. It should involve, among other things, education about ERAS, an explanation of fasting guidelines, and a PONS (pre-operative nutrition score) and PONV (post-operative nausea and vomiting) assessment.
  • Optimization of nutrition: poor pre and/or post-operative nutrition (particularly in relation to cancer surgery) increases a patient’s risk of complications and a longer hospital stay. Pre-operative carbohydrate loading, shortened pre-operative fasting times, and early feeding after surgery reduce insulin resistance, protein loss, and anxiety. Even the simple act of chewing gum after surgery can decrease the length of a hospital stay by 1 to 2 days by causing bowel function to return more quickly. 
  • Early mobilization: the benefits of early mobilization include improved function, reduced length of hospital stay, and a reduction in the risk of post-operative complications. 
  • Standardized anaesthetic and analgesic regimens: Non-opiates should always be the first choice of pain medication. The use of opioids as pain relievers after surgery can result in a lifelong addiction. Each year, over 2 million people become dependent on opioids following prescriptions given after elective surgery. By using an opioid-sparing approach (which involves the use of regional anaesthesia, peripheral nerve blocks, non-pharmacologic approaches, and non-opioid medications), in combination with pain management and education at every stage of the surgical journey, the ERAS technique reduces the risk of opioid misuse.

Economic Benefits of ERAS

There is some variation in the level of cost savings as a result of the implementation of ERAS protocols, but there appears to be no doubt that ERAS has economic as well as clinical benefits. A study conducted in New Zealand showed that even though it cost about R100 000 (at the August 2022 exchange rate) to set up an ERAS program, this was offset by the savings of around R7000 per patient because of reduced postoperative resource utilization. Another study showed that patients saved $1535, while an assessment of an ERAS plan showed that the return on investment for hospitals would be $3.8 for every $1 invested.

ERAS in Africa

A medical company called PangeaMed has completed a medical trial across private and state-owned hospitals across the African continent. The outcomes of this trial indicate that ERAS implementation leads to a 25-50% reduction in hospital stay, a 25-50% reduction in complications, a 25% cost saving, a 40% increase in 5-year survival rate, and a reduced workload for nurses.

In South Africa, most of their work has revolved around the treatment of cancer patients. 

Looking Ahead

Despite all the positive effects of ERAS on patients, hospital staff, and hospital budgets, changing the status quo (as with all things in life) is a challenge. Many healthcare providers are reluctant to change their clinical habits and management pathways, and the implementation costs can be off-putting. Increasing the amount of available data and improving education around the benefits of ERAS amongst investors, healthcare providers, and the general public are examples of effective ways to combat this.  

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