Recently, several articles have commented on enhanced recovery programs (ERPs),1–7 and one even suggested that the concept is “obsolete.”2 As one of the developers of fast-track or enhanced recovery surgery in the early 1990s, such statements are quite disappointing, and while selected medical centers with long experience in ERP principles have been able to embed them in their culture, in most of the surgical world, ERP principles remain either foreign or unimplemented. In fact, we in no way have fulfilled the aims of these programs—that is, to achieve “the pain and risk-free operation.”8 Furthermore, such statements may negate all the progress that has been achieved to date in improving patient care and perioperative outcome. In this article, we hope to illustrate why ERP is not “obsolete,” and address the current controversies and concerns with ERPs, as well as identify areas for future research.
For a start, it is necessary to address the “knowing-doing gap” between scientific evidence and implementation of an ERP, which remains a problem.9 Frequently, even essential components such as preoperative patient information and optimization of organ dysfunction, procedure-specific optimal multimodal opioid-sparing pain management, fluid management, and anti-ileus management, as well as early postoperative mobilization and oral feeding have not been fully implemented.4,5 This is particularly true with implementation of the postoperative components.9 Such lack of compliance hinders sufficient interpretation of the effects of perioperative care on outcome, such as the use of regional anesthetic techniques10 and newer approaches to fluid management.11
One of the reasons for variable compliance with ERPs is related to the conflicting and confusing published recommendations.1 Many recommended components (elements) are not up to date, because they have not been modified based on recent evidence.1 Most ERPs consist of 15 to 20 recommended components1; however, the relative contribution of each component remains unknown. Many components lack definitive evidence with regard to improved outcomes.12 Also, some components may be procedure specific, and applying them broadly to many surgical procedures is inappropriate. For example, the recommendation for preoperative carbohydrate loading requires further clinical procedure-specific evidence,13 although the pathophysiological data are of major interest. Also, mechanical bowel preparation remains controversial. Although avoidance of bowel preparation may have advantages regarding fewer patient complaints and fluid management problems, this component may not be crucial for a successful outcome based on observations at a time when it was considered standard of practice.8,9,12,14 A recent study in patients undergoing bowel resection reported that among the 23 components, laparoscopic approach, early termination of intravenous fluid infusion, and early mobilization out of bed significantly predicted successful recovery (defined as absence of complications, discharge by postoperative day 4, and no readmission).4 However, to facilitate the interpretation of such data, future studies of ERPs need to be procedure specific and include updated scientific evidence,12 as well as a fully implemented program.
Currently, the most common outcome measure used to assess the success of an ERP is the hospital length of stay (LOS). Although it was an outcome of interest in the beginning, it is only a surrogate marker of recovery. Importantly, LOS does not necessarily reflect the true recovery of a patient who has to convalesce at home. It is necessary to focus our efforts beyond the LOS and readmission rate by understanding the factors that influence return to normal daily living after discharge from the hospital. The ultimate goal is to minimize postoperative organ dysfunction and enhance rehabilitation.8 Interestingly, a recent editorial argued that a properly informed patient with no pain, nausea, or vomiting and without drains and tubes, as well as free from postoperative complications should be willing to eat and ambulate.7 However, a patient with any of these issues will or may not necessarily be able to eat and/or ambulate. Therefore, early mobilization and early oral intake should be considered and monitored as outcome measures similar to LOS and being key components of ERP.7
The areas that need to be addressed are several: Diagnosing and treating preoperative anemia15 and other aspects of perioperative blood management, as well as to define the optimal hemoglobin level at the time of discharge that would allow early rehabilitation. Also, we need to assess the risks of thromboembolic complications and need for prophylaxis9 and postoperative delirium and cognitive dysfunction,16 both of which may be reduced by early mobilization and opioid-sparing analgesia. Another previously neglected, but clinically important problem, is the risk of orthostatic intolerance, which may occur in the early recovery phase in about 50% of patients undergoing major surgical procedures.17 So far, available studies have demonstrated postoperative orthostatic intolerance not to be related to fluid management, but to an inappropriate shift during mobilization from activation of the sympathetic nervous system to parasympathetic activation.17 Preliminary studies suggest that a specific α-1 agonist (midodrine) may be helpful.17 Also, major challenges persist to optimize postoperative pain management especially for major surgical procedures and where previous conventional use of opioids must be replaced by multimodal opioid-sparing analgesia on a procedure-specific basis.18 Although epidural analgesia continues to be recommended by several authorities, current evidence does not support its routine use in many operations, particularly in patients undergoing minimally invasive surgery.18 Recent data from high-dose preoperative steroid administration (ie, higher than 8 mg dexamethasone commonly used for or nausea, vomiting, and pain prophylaxis) are promising, because this allows improved pain relief, and reduces the inflammatory response and early fatigue, as well.19 Finally, it is necessary to define the role of prehabilitation20 and define the indications and the specific types of postoperative physical therapy.
The ultimate challenge in enhanced recovery is to improve our understanding of better preoperative risk assessment and reasons for being a “high-risk” patient.21 Interestingly, recent data on preoperative assessment of functional capacity in the immune system for such prediction seem promising.22 Consequently, there needs to be increased focus on the modification of undesirable inflammatory and immunological responses to the surgical insult,22,23 including the combined role of optimized minimally invasive surgical approach and pharmacological interventions.9,24 Also, there is a need for more comprehensive monitoring and assessment of postoperative morbidity to differentiate the time course of “medical” and “surgical” complications,24 because the “medical” morbidity may be related to implementation of ERPs, whereas “surgical” morbidity may be related to surgical expertise and technique.
In summary, we believe that the concept of fast-track surgery or enhanced recovery after surgery is in no way “obsolete.” In contrast, several challenges lie ahead to improve recovery elements and understand and modify mechanisms of organ dysfunction. What we need is to have an open mind while repeatedly asking the question of “why is the patient in the hospital today?” and “what are the reasons for developing a complication?” Furthermore, to shift the focus from LOS to “postdischarge” recovery of organ function.9,24 Several intellectual, pathophysiological, organizational, and outcome measures must be addressed to achieve the “pain and risk-free operation.” However, such progress on newer interventions requires a study design that includes the present knowledge of evidence of care.
Name: Henrik Kehlet, MD, PhD, FACS(Hon).
Contribution: This author helped prepare the manuscript.
Name: Girish P. Joshi, MD, MBBS, FFARCSI.
Contribution: This author helped prepare the manuscript.
This manuscript was handled by: Tong J. Gan, MD.
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