And if everyone can mute their screen, just so. Okay, so a topic I picked for today was enhanced recovery after surgery, a topic that I'm sure you've heard much about as it has been becoming more and more state of the art for our subspecialty as well as other surgical subspecialties. And I wanted to touch on it because of a recent publication of the updated gyne-oncology guidelines, as well as my personal interest in the topic. So whenever you hear or Google tradition or dogma, this is one of the slides that comes up a lot. The pictures of the Sanford Festival in Pamplona, chasing bulls to the bull ring in the middle of the city after a night of revelry and drunkenness. And the sentence that comes to mind is just because you've always done something a certain way doesn't always mean it's a good idea. So really ERS is about reevaluating surgical traditions and dogmas. It is about evidence-based perioperative care. What evidence do we have and how do we improve our practice based on the evidence and then analyzing the impact of our interventions on these measurable outcomes potentially. And the history of ERS dates back to about 20 years ago when a small group initially in Denmark and then in Northern Europe in general introduced the concept of fast track surgery. And then this evolved into a society and ERS was founded in the first recommendations being published in 2005. The guiding oncology ERS guidelines were first published in 2016 and then a recent publication again in 2019 updated those. And really ERS is about the entire trajectory of the patient's journey from the preoperative period through the OR and to the postoperative period. But it can also be broken down differently into different elements of care. This presentation is much too short to address all of them, but some of the main ones that I will be talking about today is pain control, nutrition and GI management, fluid management, and then prevention of infection and thromboembolic complications. In terms of our pre-op, I will take this opportunity to mention that the patient's journey really begins before admission to the hospital and prehabilitation is another big concept that has received more attention lately. This is about medical optimization, a good assessment of comorbidities, smoking and alcohol cessation, geriatric assessment, and many of our patients who are in the right age group. Nutritional assessment, especially for our cancer patients, especially for ones who present in more advanced phases of their disease or who have received neoadjuvant chemotherapy. And then education and counseling, which is a big part of ERAS, as you'll hear about. Now in terms of pain control, this is a major issue in surgical patients in terms of their hospital experience and their recovery at home and has a tremendous impact on many of their elements of care, including their ability to ambulate and the respiratory function, as well as their thromboembolic risk, including their opioid utilization, which can affect the level of their postoperative nausea and vomiting, their postoperative ileus. It also affects the level of stress and insulin resistance, which is another big topic for research in a perioperative setting and can affect many of the recovery processes. And finally, ultimately, it will impact on the recovery and the length of stay in hospital, which has an impact on our healthcare resources. So one of the main concepts in managing postoperative pain is really starting pain management before the actual trauma to tissue happens and moving the curve of pain sensitization to the right. We know that pain and tissue trauma cause central nervous system hypersensitization and hyperalgesia, and the analgesia given preemptively will break that cycle and prevent that hypersensitization and will also reduce insulin resistance, which comes up a lot in these studies. So what we do and what many centers have begun to do is giving oral analgesia, which is multimodal before even taking the patient into the DOR. And that's usually composed of some combination of NSAIDs, acetaminophen, and gabapentin or pregabalin. An epidural is another good way to achieve preemptive analgesia, and it also has many advantages in terms of response during anesthesia, consumption of intra and postoperative opioids, and the need for muscle relaxants and anesthetic is all reduced. And it also improves and decreases complications postoperatively. This is just one meta-analysis, including over 9,000 patients reporting on morbidity and mortality. And you'll see that epidural analgesia significantly decreased risks of multiple medical complications of surgery, but it also has some disadvantages. It has significant failure rate, up to 30% in some studies, the risk of an epidural hematoma, especially when we begin VT prophylaxis preoperatively, hypotension and the need for further IV fluids, which is one of the things that we're actually struggling to decrease in ERAS. And then the question of motor block, which shouldn't happen, but does happen in some of our patients, decreasing their ambulation and possibly causing urinary tension. So are there really good alternatives for an epidural, which is ideal in many ways? Well, tap blocks and quadratus lumborum blocks have been trialed. There's no good head-to-head studies yet, looking and comparing them to epidurals, but they do show promise and that they can be given either pre or post-operatively by anesthesia or by the surgical team. And another method is wound infiltration, which can be continuous or using liposomal pipivacaine, for example, which has a very long half-life to have sort of long-term effect. So those are all promising modalities. One of the important things to remember in terms of pain control is that analgesia has to be multimodal. And there are several RCTs and meta-analysis that have shown multimodal analgesia to decrease post-operative pain and post-operative opiate consumption, which in turn will then decrease post-operative nausea and vomiting, ileus, and sedation, all important outcome. These are one of the best studies and are really an important component of this multimodal analgesia. And there is some hesitancy on the other side in some teams in terms of the risk for GI and surgical site bleeding, in terms of the risk for leak, especially in left colon anastomosis. So this is still controversial, but most ERAS groups feel it's very important to include NSAIDs in the multimodal analgesia. In terms of fluid management, there's a question of what, and there's a question of how or how much. And really, in terms of fluids, NACL, normal saline, is really one of the most commonly used post- and intraoperative intravenous solutions in the world, despite the recognition that it harbors inherent issues and complications, can cause hyperglycemic acidosis. In the OR, because ringer lactate interacts with blood, there's always a hesitancy to give it in case blood needs to be transfused. And on the ward, it's just one of the things that's easiest to prescribe, especially as the youngest learners are often the ones prescribing fluids. So it is really something that we try to stress to our surgical teams to try to avoid normal saline and give balanced crystalloids instead. This is a big retrospective study from a large US-based automated hospital claims database, looking at over 30,000 patients undergoing major abdominal surgery and comparing major morbidity and mortality between normal saline and balanced crystalloids. And the interesting thing is, both in terms of overall complications and mortality, there was a significant difference in favor of balanced crystalloids as opposed to normal saline. So just something to watch out for. A really important component of ERAS is goal-directed fluid therapy, which is something that is really up to anesthesia to do in the OR. So it really requires their collaboration and engagement in any ERAS program. Goal-directed fluid therapy really maintains central normal volumia by using hemodynamic parameters to assess responsiveness to fluid. And those can be either invasive or non-invasive. There's plenty of softwares now that are simple to use based on oximetry, wave, or BP measurements in order to calculate goal-directed fluid therapy. And it is shown to reduce cardiovascular overload as well as postoperative nausea, vomiting, ileus, as well as ultimately length of stay. So results are quite convincing. The risk of complications is lower, length of stay improves, and it is something that if you can engage your anesthesia team to do, would make a big, big difference. This is just one example of a meta-analysis of 14 trials, including the 1,000 patients or so. Another important component of ERAS is nutrition and GI management. And this is certainly a big issue. We feel that both the stress of surgery as well as patient starvation, if they come into surgery having taken nothing for us for many hours, will increase insulin resistance, which is something that is consistently found perioperatively. This will in turn cause hyperglycemia, inducing a catabolic state, also an inflammatory response, susceptibility to infection. And ultimately, I'm going to skip ahead because of time limits. This causes a process of basically accelerated diabetes in the perioperative patient and patients who are prone to diabetes, but also in the general population. And we see that reduced insulin sensitivity is an issue in multiple surgeries. And the more complex the surgery, the more likely we are to run into insulin resistance. And also that the complications and even mortality are directly correlated with the level of insulin resistance perioperatively. So this is a real thing, and there's lots of studies that I could show you. The idea is to try to break this vicious cycle that is formed. And how do we do that? I mean, there's multiple ways to address that. The stress of surgery needs to be addressed, and patient education is very important to do that. So providing appropriate materials before surgery, making sure patients know what they're coming in for, what they're going to experience in terms of their trajectory from admission and into the OR, as well as in surgery and after surgery, goes a long way to alleviate the stress of surgery. And the other issue is the starvation. So can we do better bringing our patients in better metabolic and catabolic state into surgery? Well, one question is the mechanical bowel preparation. We know the mechanical bowel preparation is associated with dehydration, electrolyte disturbances, and starvation and insulin resistance, particularly in the elderly patient population. And a Cochrane review on mechanical bowel preparation in colorectal surgery, which included 18 randomized controlled trials and almost 6,000 patients, really showed no advantage for mechanical bowel preparation in terms of either an asthmatic leak rate or total surgical site infections. Not for peritonitis, not for reoperation, and certainly not for mortality. And this meta-analysis stratified the trials by type. So even in rectal surgery with low anterior resection, none of these advantages were found to be true for mechanical bowel preparation. However, we do know that recently a meta-analysis published since and several population-based studies based on the NISQIP quality improvement in surgery system have brought our attention back to the question of bowel preparation and have shown that oral antibiotics in combination or not in combination with mechanical bowel preparation might have some advantages. And this is just one of the meta-analysis looking at that. As you can see, the rate of complications is lower if we combine mechanical bowel prep with oral antibiotics as compared to either mechanical bowel prep alone or no prep at all. So bottom line, if you're giving your patients bowel prep prior to surgery because you feel a bowel resection might be necessary and you're a proponent for bowel prep, be sure to give a combination rather than mechanical only. The other question is, do patients really need to be fasting for as long as they classically have been doing prior to surgery? Classically patients have been on fast starting at midnight for any surgery happening during the next day. We know that that longstanding dogma has undergone some change and multiple surgical as well as anesthetic societies have released guidelines saying that a six-hour solid, two-hour clear fluid fast is enough before any surgery unless a patient is at increased risk, delayed gastric emptying, et cetera. But what we also know is that we can add complex carbohydrate to our clear fluid mix in order to ensure our patients come in better metabolic state into surgery. And there's multiple commercial preparations like this one that I'm showing here that include 50 grams of complex carbohydrate in a clear fluid. And so patients, even after having fasted for six hours off solids. They don't need to drink sugary drinks. We know that that's just going to cause a sugar crash a couple of hours later. Complex carbohydrates go a long way to decreasing that insulin resistance that can happen during and after surgery. And it's also been shown not to increase the risk of aspiration, which is a fear. We know that pre-op carbs reduce post-op insulin resistance, but they also have been shown to be associated with better bowel function, decreased time to flatus and bowel movements, and decreased post-operative ileus. I'm going to skip ahead again because this is a bit of a longer presentation than we need for this. The second issue with GI function is early post-operative feeding. We've talked about pre-op, and now we're into the post-op phase. We know that early post-operative feeding is very important in terms of encouraging early flatus and early bowel movements, and reducing length of stay, and that early post-operative feeding is not associated with complications such as reinsertion of an NG tube or insertion of an NG tube, or increased vomiting. Safe and effective in decreasing our length of stay. Other things that have been looked at in the post-operative period to decrease ileus rates and hasten bowel recovery are different sorts of laxatives, which have been shown to decrease, again, the time to first bowel movement, and flatus, and chewing gum. Other things that I'm not showing here, which are simple, is black tea and coffee. Again, encouraging patients to go back to whatever they were drinking before rapidly after surgery. Finally, in terms of VTE and SSI prevention, again, multiple publications have come out about SSI prevention bundles. Bundle and interventions have become very popular in quality improvement programs. The idea is that we don't look at one specific intervention by itself, but a combination of interventions which have synergistic effect with one another. We can't break it down and say which one was the most important, but what we are seeing more and more in these SSI prevention bundles are skin preparation, so providing patients with these chlorhexidine sponges to shower with at home night before or morning of surgery. Prevention of hypothermia, so we use bear huggers in the preoperative area, not just in the OR to keep patients warm. Antibiotic prophylaxis, which should be appropriately dosed in terms of the patient's weight and repeated four hours after the beginning of surgery if surgery is still ongoing. Using separate gloves and closing trays from fascia and above to reduce the rate of incisional infections, especially if procedure included appendiceal or bowel resection. Then avoiding drains and tubes, which are unnecessary in most of our surgeries. Finally, control of perioperative hyperglycemia, so screening patients for insulin resistance pre-op by doing hemoglobin A1Cs on patients with risk factors, even if they're not diagnosed with diabetes, and avoiding that perioperative insulin resistance, which we've already discussed. Those are examples of factors within the bundled intervention. These are a couple of studies looking at bundled intervention for SSI prevention. Both of them are QI studies. The top one is one out of MD Anderson, including almost 800 patients and implementing a bunch of these different interventions and showing SSI rates falling from 12% to 7% before and after intervention implementation. Difference in laparotomy was even bigger, 20% to 13%. They also showed that this bundled intervention provided a cost saving for the hospital. The bottom graph there is from a Canadian institution implementing a similar bundled intervention, again, including a good number of patients, 600 patients, and showing a sustained drop from 12% to about 5%. That drop was sustained over six quarters that they looked at this, which is really important in QI studies, the ability to sustain the effects of an intervention. In terms of VTE prophylaxis, this is not news to us. We know that preoperative initiation of VTE prophylaxis is important, so not giving our anticoagulants just after the OR, but starting before the OR. This is one study including over 7,000 patients across different services in the Memorial Sloan-Kettering, and showing implementation of preoperative VTE prophylaxis decreased VTE rates without increasing the risk of bleeding, complications, or transfusion. And then a second study looking at the dual prophylaxis. Their early studies looked at pneumatic compression devices and preoperative heparin, and some studies have actually shown those to be equally efficacious, but combining the two in several studies has been shown to be more efficacious than either one on its own. Mechanical prophylaxis plus chemoprophylaxis for VTEs. And then finally, really important is the extended prophylaxis. This is true for cancer surgeries, abdominal pelvic cancer surgeries, but any abdominal pelvic surgery in fact. So this is one Cochrane meta-analysis and review looking at this specific question in abdominal pelvic surgeries that included a lot of studies focusing on cancer, but not only on cancer, and showing overall decreased risk of VTEs, but also decreased risk of DVTs, proximal DVTs, symptomatic DVTs across the board without, again, an increase in bleeding risks or transfusion. So very important is extended VTE prophylaxis, and these studies, you know, ran between three and five weeks of VTE prophylaxis after the OR. So patients should be discharged with extended prophylaxis after our cancer surgeries. There is a lot more controversy when it comes to laparoscopies, where we know ambulation is a lot quicker, and jury's still out on that question. We don't have a lot of good quality evidence on laparoscopies. So we've briefly talked about these different elements in care across the disease trajectory or perioperative trajectory from the pre-op period to the post-op period. And really what we've talked about is that what we are doing to patients, or we calcically had been doing to patients, is stressing them, starving them, and drowning them. And even though we have all the evidence, and we've known this for a while, really knowing that something works well and doing it are two entirely different things. And implementation or knowledge translation are one of the most challenging aspects of clinical professions in general. We know that studies in medical education and policy and quality improvement show that it takes a lot of time for information to filter into clinical practice, especially when, you know, when addressing ubiquitous practice change that is not just driven by technology or drug discovery. So we need to be really consistent about what we do and how we do it. This is just another really good example of a classical study looking at ventilator settings after a big publication showing a certain change in ventilator settings in the ICU and decreased patient mortality. So when attendings were surveyed about whether they were familiar with this information and what they actually did, 92% said that they used the new settings when treating their patients. But when the settings in the ICUs in which these attendings worked were actually looked at, only 4% were set to the new setting. So this is a good example of knowledge translation failure. So ERS is about putting all of these things together, which, you know, is important to measure. We can look at any of these interventions on their own, but really it's about putting them all together, their synergistic effect across the patient care trajectory. And by now in multiple subspecialties, including gynecology, there have been multiple studies that look at the effect of an ERS program on the length of stay, which really was the primary outcome that was most commonly looked at, but also other outcomes which we feel are important. ERS programs are difficult to assess because protocols vary across different programs and different programs choose to focus on different aspects of care. Implementation, as we said, is never perfect and is very difficult to assess, especially when it's a complex intervention like ERS. But as I said, in multiple subspecialties, certainly in terms of length of stay, which is an easily measurable outcome, ERS does work. And in fact, in this one interesting study that looked at the number of ERS elements implemented in the programs, we see that there is a direct correlation between how well ERS was implemented and the length of stay. It has also been shown that ERS decreases perioperative complication rates and leads to faster GI recovery, decreases in morbidity, improvement in patient reported outcomes like pain and fatigue, and no increase in readmissions despite the decreased length of stay. And we've seen this for different types of procedure, various complexity, various organ systems. And it's also been looked at specifically in subgroups like geriatric populations and obese populations in which we encounter a lot. One interesting study out of Switzerland implementing ERS, they use a software that actually quantifies nursing workload in terms of the procedures that they do. And what they showed is that after a bump in the initial implementation phase, that nursing workload and nursing minutes actually decreased after implementation of ERS because really ERS is about engaging the patients to become more proactive in their own recovery. And other studies, both out of the US and out of Canada, the right side that you see there is an implementation in Alberta, which is a province in Canada that has a very integrated healthcare system where they basically implemented this across the entire province at once. And what they showed was that even if you take into account the setup and monitoring costs, which are quite significant, that the gross cost savings were indeed significant. As in any other new program, quality improvement takes some time. And so we see that compliance does improve over time. And sustainability is key. And what we've also seen is that the better the compliance with the program, the better the outcome of the program, which is not surprising. In gynecology, again, multiple publications are already out there showing that ERS improves quality of care and outcomes in gynecology, oncology programs. So something that's relevant for our specific context. So what we should be doing is we should be looking at the evidence and we should be creating the evidence and using the evidence to implement change in the and using the evidence to implement change in a way that's measurable and that we can audit in order to be able to learn from the process. ERS Society has released guidelines across different specialties, including gynecology. This is the initial gynecology ERS guideline. And then again, it's been revised just recently. I think it's a very important document to read. It gives a great summary of the recommendations. But what's also important to remember is like any other quality improvement program, there are barriers to implementation. The engagement and collaboration of the team members is really important. This is something that is not just up to us surgeons. We need our nursing team, our allied healthcare teams, our anesthetists, our nutritionists, they all need to be part of this and the patients themselves. All these different disciplines have to have champions who are really interested in this in order to make it work. Hospital administration needs to be recruited. Ideally, there should be an auditing system in place with any new implementation of a program, which takes either manpower or money. And then consistent training of all of the different collaborators across the patient care trajectory needs to happen to make this work. Because otherwise patients will be getting mixed messages from different care providers, which can be very confusing. There's a framework that's easy, relatively easy to implement. So you create order sets that need to be consistent across surgical teams, education materials that the patients can get. But it's really about the day-to-day implementation of the teams and of the patients. One good way to engage patients is to give them materials and checklists that they need to meet. So you could do it on paper, you could make a passport to recovery, you could give out stickers, or you could use more sophisticated technology like apps that exist in multiple institutions in North America, at least, that remind patients of what the milestones that they need to meet on an everyday basis need to be. What we know is that quality improvement is an iterative process. It's about planning, doing, but also self-auditing and self-monitoring in order to improve implementation. Multiple cycles of this need to happen to make it work. So sustainability is key. And what I like about ERS is that it, you know, this is not a sophisticated targeted drug or a sophisticated medical device or technology. This is something that any of us with limited resources can implement anywhere. And it makes a very big difference in our patient care. I'm done.

Enhanced Recovery After Surgery

perioperative care

evidence-based care

patient outcomes

fast-track surgery

pain control

nutrition and GI management