Enhanced Recovery After Surgery (ERAS) society was born in Europe in 2001 and its first congress was held in Sweden by the year of 2003. The objective was to promote guidelines aiming at reducing postoperative complications. Almost 20 years have passed since then. Many hospitals around the world adopted their guidelines and recommendations. There is now the ERAS USA and its third congress is approaching. But…Is the present-day ERAS program faithful to its original objective to reduce postoperative complications? Did the primary outcome change?
I am not going to present ERAS guidelines for colorectal surgery for this is not the objective of this post. Though it is clear to me that ERAS protocol for colorectal surgery presents many factors that a good quality surgery and anesthesia should already be doing since many years ago. That is the case of early oral intake which has been part of normal medical practice in the US for long time. Additionally, some factors pointed out by the ERAS guideline itself as not having a rigorous scientific support, are being applied in clinical practice, for instance: surgical wound infiltration with topical anesthetic and specific measures aimed at early patient mobilization. We must not blindly follow a guideline… In that setting, I found an interesting paper about the ERAS protocol, showing a viewpoint from Professor Dr. Stavros Memtsoudis from the Hospital for Special Surgery and the Weill Cornell Medical College of New York. I believe this is a must-read paper, but many of you are not going to like.
With ERAS Europe achieved the similar LOS of the US. But in US it was driven from financial pressures.
ERAS could reduce complications and fasten recovery, and as crucial factors the authors highlight the epidural analgesia, early mobilization, early feeding and fluid therapy aimed at euvolemic. These principals led Europe to achieve shorter length of stay (LOS) approximating to the LOS historically shorter in the US. However, Dr Stravos et al say that the shorter LOS in the US was driven from financial pressures and from minor procedures in ambulatory setting. In Europe doctors must realize that health care system in the US is completely different and opposite to ours… The authors say in Europe there is a movement shifting towards ERAS applied to other surgeries (not colorectal) based on pathways extrapolated from one surgery to another. This is a mistake! Systemic inflammatory and catabolic response is largely dependent on the specific surgery. Just because it is good for one surgery, does not mean it is good for others. Science is much more complicated than this… Continuing this idea, many factors of ERAS are driven from publications lacking scientific rigor, are driven from cohort studies rather than clinical trials, are driven from studies with a small number of highly selected patients with limited validity. We cannot support the idea of not using nasogastric tube only in one small paper. Science is much more than this…
ERAS protocol is being implemented to reduce LOS but is submitted to limited scientific scrutiny.
One major problem of some factors in ERAS protocol is that components are not individually evaluated to determine their individual role in contribute to better outcomes. They are empirically added assuming they will provide benefit. Multimodal analgesia is pointed out as an example of this mistake. How to distinguish potential interactions and individual effects? Is there unnecessary risk to patients? ERAS protocol is being implemented to reduce LOS but is submitted to limited scientific scrutiny, which is a matter of concern. According to Dr Stravos et al. a fast-track implementation must have a strong and high-quality scientific support. The lack of scientific scrutiny was used by some companies to promote their products claiming they would fasten recovery, avoid opioids use and prolong pain relief. This is a serious accusation. Medical practice must be based on science not on business. We must not forget that once in a protocol, inadequately tested interventions are rarely removed or replaced, reducing the likelihood of widespread. Meaning, if there is neither supportive nor contradicting data, a component will not be removed. The justification is always the same: it may not contribute to better outcomes, but we never know… Science is much more than this...
ERAS protocol has lost the original goal of reducing complications to use LOS as the most important outcome.
Evidence based interventions developed for a specific population and purpose are being extrapolated to other procedures. This is being made usually without research or scientific support, Dr. Stravos say. This way of working has led in the past to the conclusion of ineffectiveness of some interventions, but usually after causing economic and medical consequences. In COVID-19 era this way of working led to several deaths. The use of hydroxychloroquine to treat SARS-CoV-2 was assumed without scientific support. This assumption eventually caused the death of several patients.
An important idea the authors present is that ERAS protocol has lost the original goal of reducing complications to use LOS as the most important outcome rather complication’s rate. This shift “may not be consistent with patient-centered outcomes”. Medical community cannot replace evidence-based practice with empirical interventions based on assumptions without good scientific support. Doctors must read the guidelines, think about them, understand their origin, and take conclusions about their true value. Guidelines should not be blindly followed. Sometimes the same guideline is good for one patient but not good to another. Tailored medicine is the ultimate objective. Medicine and surgery cannot be practiced based solely on guidelines. I will never forget a sentence from Dr. Jordi Rello about guidelines: “Guidelines are very important mainly for those who do not know, because those who know can do marvelous things outside the guidelines.”
Medical community cannot replace evidence-based practice with empirical interventions based on assumptions without good scientific support.
“ERAS began as a patient-centered science, based on clear pathophysiological principals, and should not be replaced by uncertain approaches that seek to replace true measures of recovery such as complications, readmissions, or quality of life with LOS.” Knowledge is much more than guidelines, and many things seem to be lacking so that ERAS protocol can be called rigorous science, I think. I finish with a sentence from the authors: “Failure to apply rigorous science to ERAS may ultimately lead to its demise as yet another non-evidence-based practice.”
Link to article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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