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Melanie Cole (Host): Enhanced Recovery After Surgery programs aim to hasten functional recover and improve postoperative outcomes. Here to tell us about the success in gynecologic oncology, is Dr. Charles Leath III. He’s a Professor in the Division of Gynecologic Oncology at UAB Medicine. Welcome to the show, Dr. Leath. Tell us a little bit about the rationale behind ERAS programs and Enhanced Recovery Programs, in general.

Dr. Charles Leath III (Guest): Yeah, thanks for having me today, Melanie. And on behalf of my colleagues, Drs. Straughn and Haller Smith, I would like to provide a brief update on ERAS and Gynecologic Oncology. I think we all recognize that in the current time in medicine, certainly, we’re under a microscope in trying to figure out ways to improve outcomes. Everything is being measured. There are metrics for really everything that’s being done.

One of the areas that we look at in Gynecologic Oncology is the postoperative length of stay. Although a large number of our patients are able to have a minimally invasive surgery -- either with traditional laparoscopic approaches or with robotic-assisted laparoscopy -- we still perform a large number of exploratory laparotomy surgeries. If we can find a way to perhaps decrease the length of stay for these individuals and improve their surgical outcomes, then that would be a very meaningful endpoint for us to tackle.

A couple of years ago, several colleagues at the Mayo Clinic among others, started to look at this whole idea of enhanced recovery after surgery. Unfortunately, in medicine, a lot of the things that are done, we don’t necessarily have the level one evidence for. You can’t do a randomized controlled trial of everything that’s out there. We started to look at this collectively and figure out many of the things that we thought we knew about surgery and about perioperative care in fact, probably were not true. And so as we started to dig a little bit deeper, we figured out that there were some things that could be done that if we applied this to a group of patients undergoing a major abdominal surgery, we could improve their outcomes, get them out of the hospital quicker, and still have similar oncologic outcomes, which is clearly the most important thing to us as cancer surgeons.

Melanie: So, speak a little bit about what they’re associated with, really as far as your rationale. And also, have ERPs in general, been widely adopted in gynecology – in gynecologic oncology or is this a newer progression?

Dr. Leath: Yeah. So, I think what we’ve seen with this whole ERAS movement we’ve tried to focus on the entire operative event. That really occurs the first time you meet the patient in the clinic once you determine that she’s going to need to go to the operating room and your surgical plan is in place, that’s where the education for ERAS starts. We discuss with the patient what the implications are, what we’re trying to do. That’s going to be reinforced by the nurses also going back over many of the highlights that we’ve hit.

At UAB, we have some programs where patients will be sent videos that they can review. These videos give them information both about ERAS, in general, and then a surgery-specific video that really talks about what they need to expect based on their operation. Again, when they see the anesthesia providers at their preoperative appointment, many of the aspects about perioperative pain control, allowing a clear liquid diet up until a couple of hours prior to surgery – which again, used to be prohibited and almost heretical to allow a patient to drink a few hours before surgery, but now, is really standard fare. And then again, the morning of surgery, going back through things, looking at the ways to increase or improve rather, pain control postoperatively, ensuring that the aspects of the protocol have been stuck with.

Melanie: So then if we’re looking at these ERPs and ERAS, what are we seeing as some of the key elements in establishing a successful program, and is there a high-degree of coordination that’s required? Who’s involved in all of this?

Dr. Leath: Yeah, so coordination, if anything, that’s probably the most important thing to get from this small – this brief interview is the fact that this is not something that you can turn on almost like a light switch. When we first heard about ERAS and started to go through the process, it took about five-months of reviewing the available information, of drilling down the potential variables that we would like to be able to track and to figure out could we really those variables? It is a highly coordinated effort that again, involves the providers as well as the nursing staff in the clinic, the anesthesia providers in the perioperative areas – both in the pre-op clinic as well as in the operating room – the nursing staff in the recovery room, and then ultimately, both nurses and physicians on the postoperative wards.

Taking those parts into account, we really can look at a lot of different things. One of the things that we wanted to look at was can we shorten the length of stay after an exploratory laparotomy? We can look at what is referred to as an O to E Ratio, which is the Observed to the Expected Ratio, and really our goal was to decrease that, meaning that we thought the patients would stay for X-period of time and if we can decrease that based on the complexity of the surgery, their preoperative diagnosis, their other medical issues, then that certainly would be very beneficial. We have benchmark information showing that as we’ve gone through this process, we’ve consistently been able to keep the patient length of stay below the baseline.

The other thing that’s important is when you think about doing surgery and having a goal of getting patients out of the hospital quicker, what you don’t want to do is discharge everyone and then have everybody be readmitted because that really defeats the purpose. It’s clearly better for a patient to stay in the hospital a little bit longer than be discharged and then be readmitted, which is just another one of the metrics that is tracked. Again, looking at our data, what we see is that we’ve been able to decrease our hospital readmission rate from the baseline – or what our preidentified goal was. Again, we’re not going to be able to prevent every readmission, but if we’re sending patients home sooner, I think one of the things we want to see on the back end is that we’re not having patients be readmitted. We’re not sending them home too soon.

I think another important aspect of that, of course, is that we really want to make sure that this is an opportunity for the majority of patients. Again, if you really cherry-pick and say, “Well, we’re just going to do these three, or four, or five patients that appear to be the healthiest so that we can get the best data, then again, that’s not really helping the majority of patients because those are the patients that likely would have done well anyway. Our goal was that when we had this pathway up and running that we really wanted to have this available to at least 90% of our patients undergoing a laparotomy. Again, that allows those patients that have other medical comorbidities -- patients that maybe traditionally, you would think would be a little bit higher risk to stay in the hospital longer, be readmitted, and other things along those lines – being able to benefit from these pathways.

Melanie: Such interesting information on evaluating that impact of these programs, Dr. Leath. So now, tell us some of the important components of the postoperative strategies – pain management, drains and catheters, early mobilization – speak about how some of those come into play in this ERAS strategy.

Dr. Leath: Yeah, that’s a perfect lead-in. When we think about the postoperative experience for patients, I think one of the first things that we all noted was the improvement in postoperative pain control. I can literally remember my first patient where I walked into her hospital room, postoperative day number one; she was sitting up, she was sitting in a chair, she had her own clothes on, she had her make-up on. She looked great. I remember the residents telling me she was postop day number one and I was almost looking at them quizzically, thinking there’s no way she’s postoperative day number one. Maybe day two, but clearly she’s not day one, but yet, in fact, she was.

I think a lot of that, though, also gets back to the point of although we’re thinking of postoperative pain control, what’s important is really the preoperative pain control. The vast majority of these patients will get what’s referred to as an intrathecal administration of medications – almost like a spinal shot – which has certainly – in our experience; it has been associated with significant decrease in postoperative pain. In addition, they’ll get some oral pain medicines in the preoperative area – things like acetaminophen, gabapentin, and some others.

And then postoperatively, we’re getting them up the day of surgery, they’re sitting in a chair the day after surgery -- postoperative day number one, they’re walking around. And rather than going through the typical clear liquid diets, maybe some full liquids before getting to a regular diet the second or third postoperative day, we really allow patients to eat normal food from the get-go. If they’re hungry and they’re ready to eat, they can eat right away. Really, I think those aspects of early ambulation, improved pain control, quick advancement to diet, and also getting all catheters and lines out in a very timely fashion – usually on postoperative day number one – allows the patient to feel better, allows them to become mobile a lot quicker, and then ultimately, should allow them to get out of the hospital quicker.

Melanie: In summary, Dr. Leath, tell other physicians what you’d like them to know about the importance of an enhanced recovery after surgery program.

Dr. Leath: Well, I think that again, the most important thing that we touched on earlier is this is not a light switch. It’s not something you can turn on or off. And so the first question, of course, is what need is there? And certainly, there is a need in multiple aspects of surgical care in the twenty-first century. At UAB, we have three current programs with a fourth about to start -- colorectal surgery, in the urology department, they have this for patients undergoing a cystectomy, generally for bladder cancers. We have this in gynecologic oncology, and then our colleagues in the benign gynecology arena are also involved in this, as well.

I think there are going to be other programs and other disciplines that are out there that likely can identify a group of patients that with the all-encompassing aspect or the approach of ERAS, that those patients can be benefitted going forward.

I think the other thing that’s important is that this is a constant reassessment. Just because you set it, again, it’s not on cruise control. You don’t say, “Hey, this is great. We’re ready to go.” We’ve identified several aspects during the last year that we’ve been doing ERAS here in our gyn-oncology division, where patients probably should not undergo ERAS. There are some patient-related factors -- for instance, if a patient comes in with a bowel obstruction, then maybe that’s not the best patient there just from a dietary standpoint and some of the other aspects that will allow us to tweak the algorithm, and again, figure out ways to improve outcomes for all patients.

Melanie: Thank you so much, Dr. Leath, for being with us today in this fascinating segment. A community physician can refer a patient to UAB Medicine by calling the MIST Line at 1-800-UAB-MYST. That’s 800-822-6478. For more information on resources available at UAB Medicine, you can go to UABMedicine.org/Physician, that’s UABMedicine.org/Physician. This is Melanie Cole. Thanks so much, for listening. This is Melanie Cole. Thanks so much for listening.