Here’s a frightening statistic that most surgeons won’t tell you if you are undergoing major abdominal surgery: You stand up to a 1-in-4 chance of developing a major complication, according to peer-reviewed research.
But there’s good news: We have a new system to reduce complications, infections, and mortality — and to do this without actually changing the surgical operation itself. We instead change the process around the surgery.
How? We now use a system called ERAS — Enhanced Recovery After Surgery. Since we implemented it at VCU Health, we’ve seen a rapid decline in wound infections and readmission rates, and a big increase in patient satisfaction scores.
The concept was started in the early 2000s in Europe; I was a National Clinic Adviser during its implementation. It’s now a standard of care in the U.K. Recognizing its benefit to patients, ERAS is now championed by the American College of Surgeons and taking hold in the U.S. ever since its introduction here in 2010.
ERAS standardizes care before, during, and after surgery. It is a bundle of elements that by themselves don’t make a huge difference in outcomes, but together make a dramatic improvement — the sum of incremental gains as we change what happens to the patient around the time of surgery without changing the surgical procedure itself.
For example, before surgery, we ensure that patients know what to expect and how their pain will be controlled. We screen and correct their anemia, optimize diabetes control and nutritional status. For some procedures we also give them a special antiseptic wash to shower with to lower infection rates.
If you’ve ever had an operation, perhaps before the procedure you were counseled not to eat or drink anything before surgery. We now know that many patients become dehydrated, so we give them a carbohydrate drink two hours before surgery.
During surgery, anesthesiologists maintain body temperature, give nausea and vomiting prophylaxis, and use short-acting anesthetic agents. The use of non-opioid regular pain killers and nerve blocks are key to avoiding all the horrible opioid side effects as well as reducing the risk of long-term opioid addiction — a massive problem currently for the U.S. We measure the anesthetic depth to ensure that not too much is given, and control blood flow and blood pressure using the right amounts of fluid, with non-invasive flow monitors to ensure the brain and vital organs are not injured during surgery.
After surgery, what surprises patients is that we get them to drink, eat, and mobilize very quickly — even after bowel surgery. Patients are given high-protein drinks within hours of surgery, and the morning after surgery most patients will have their Foley catheters and IV lines disconnected. We help patients target their mobility goals and help them get there — something vital to reducing complications such as chest infections and venous thrombosis.
VCU has been a leader in the ERAS field, holding the first World Congress on ERAS in Pediatrics last year. Along with Professor Steve Kates, chair of Orthopedic Surgery, I am co-editing the guidelines to roll out ERAS across the U.S. under a federal grant.
The most amazing thing about ERAS is that by standardizing and driving quality it reduces length of stay and complications, and ultimately saves money — something we desperately need as U.S. health care continues to swallow a larger proportion of our GDP. If a surgery’s in your future, ask your doctor about it.