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ERAS
• Also referred as “enhanced recovery
programs” or “fast-track protocols”
• They are evidence-based, collaborative
perioperative care pathways designed
to improve recovery after major surgical
procedures.
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• AIM - To maintain preoperative organ function and reduce the body’s stress response
after surgery.
• ERAS protocols contain preoperative, intraoperative, and postoperative components
that include patient counseling, nutritional optimization, standardized analgesic and
anesthetic regimens, and early mobilization (Melnyk et al., 2011)
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• ERAS – first described by Henrik Kehlet in 1990.
• Meta-analyses of studies of colorectal surgery
patients have provided evidence for reduction of complications (50%) and hospital stay (2.5
days) by application of ERAS pathways (Varadhan et al., 2010).
• This has led to adoption of ERAS protocols in many surgical Specialties including
gynecologic,thoracic,vascular, pediatric, and orthopedic surgery, and most recently urology
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• Evidence based multimodal approach focused on peri-
operative period
• Improve patient recovery after surgery
- Modifyphysiologicandpsychologicalresponse
- Enabledischargehome earlier
- Without compromisingsafetyandwellbeing
• Several meta-analyses have shown accelerated
recovery and decreased hospital stay with ERASin
colorectal surgery.
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• In urology, the best studied ERAS
protocols are in patients
undergoing radical cystectomy and
urinary diversion.
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• In 2010, the ERAS Society was founded and headquartered in Kista,
Sweden.
• The mission of the ERAS Society is to “develop perioperative care and
to improve recovery through research, audit education and
implementation of evidence-based practice.”
• The Society website (http://www.erassociety.org/) offers procedure-
specific guidelines, useful information, and resources related to
enhanced recovery
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• The ERAS Society, the main society dedicated to the study of multimodal perioperative care pathways, has published guidelines that include 22
ERAS recommendations for patients undergoing
radical cystectomy (Cerantola et al., 2013).
• Majority of these recommendations are extrapolated from colorectal surgery literature without any direct
evidence from the cystectomy population supporting their use.
• Only 7 of the 22 ERAS recommendations, as outlined by the ERAS Society guidelines are backed by direct evidence from urology patients
(Cerantola et al., 2013)
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Bladder Cancer
Invasivebladder canceradisease of the elderly
- Most patientsare 65yrs or older
- Increasing %are 80+yrs
Multiple medicalconditions
Cumulative cigarette smokeexposure
- Cardiacdisease
- Decreased pulmonary function
Up to 1/3receiveneoadjuvantchemotherapy
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RadicalCystectomy
Among the most complex urologic
operations
- Associated with considerable morbidity and
prolonged inpatientstay
LOSremainsin the 8-9 day rangeandis
- the most reported quality indicator for RC
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Traditional Care
Surgeryisplanned ‘assoonaspossible’
- No training or conditioning
Bowel prep (mechanicalandantibiotic)
NPO(clear liquids only for preop1-2 days)
Compensatory overhydration at onset of case
- aggressivehydration during case–fluid overload
NGTand NPO untilflatus
Opioid analgesia
- Limiting mentalacuity and mobility
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Preoperative EnhancedRecovery
Framework
Written and oral pre-admission
information describing:
What will happensduring
hospitalization
What they shouldexpect
- Length of stay
- Home plan
Whowill be at homewith you after
discharge?
Their role in the preparation
and recoveryprocess
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Intra-operative Enhanced
Recovery Framework
Efficient and expeditioussurgery
Smaller incision
Lessbowel manipulation
Minimization ofblood loss and transfusion
Non-narcotic analgesiaintraoperatively
Instillation of local anesthetic at incision sites
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GIRecovery is an Important Driver for
Length of Stay and Readmission
Delayed GIrecovery (POI, “ileus”) is the most
common causefor prolonged hospital stay after
radical cystectomy
- Rate of POI:12and25%
POI-related increased LOScontributes to morbidity
- Increaserisk of secondaryclinicalconsequences(eg
nosocomialinfections,readmissions)
POI adds substantive cost burden to the healthcare
system
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Take home messages
ERASFramework
- BeginsPRIORto the actual admission
- Communicate expectations
Identify and treatcomorbidities
Physical Conditioning
Carbohydrate loading
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Take home messages
GIoptimization
- Avoid bowel prep
- Minimize bowel handlingintra-op
- No NGtubes
Reduceeffects ofopioids
- Alvimopan –start prior to surgery
- Non narcotic useintra-operative
- Long acting localanesthetic
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Take home messages
SurgeonFactors
- Expeditious surgery
- Minimize blood loss
EarlyMobilization
- Feedearly
- Walkearly
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ERAS(Enhanced Recovery After
Surgery)
A multidisciplinary approach involving
surgeons, anesthesiologists, nurses,
dieticians, and allied health professionals is
one of the key paradigm shifts that is now
neededto optimise recoveryof our patients
.
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Framework of Enhanced Recovery
Pre
operative
• Counseling
• Teaching(written
and verbal)
• Expectations
• Discharge plan
• Stomateaching
• Stomamarking
• Optimization
• Lungs
• Cardiac
• Prehabilitation
• Nutrition
• Carbloading
• No prolongedfast
• No bowelprep
• VTE prophylaxis
Post
operative
• Paincontrol
• Avoidance of opioids
and toxicity
• Early mobilization
• Early oralnutrition
• Nutrition drinks
• Avoid salt andwater
overload
• IleusControl
• Prevention ofN/V
• No NGtubes
• No aggressivebowel
regimen
• VTE prophylaxis
• Early follow-up
Enhanced
Recovery
Intra
operative
• Avoidance of saltand
water overload
• Maintenance of
normothermia
• Localanesthesia
• Antibiotics accordingto
AUA BestPractices
• Alvimopan(FDAapproved)