ERUS 2018: Enhanced Recovery After Surgery – This Is How It Works In My Center - Institut Paoli-Calmettes, Marseille, France

Marseille, France ( Dr. Brun and Dr. Pignot gave an overview of the ERAS protocol used in their center of Paoli Clamettes Cancer Institute (PCCI), in Marseille, France.  Surgery results in a neuroendocrine and inflammatory post- aggressive response. Aside from the surgery, the patient is undergoing; he is also feeling anxiety, enduring pneumoperitoneum, he/she might potentially receive a blood transfusion and endure hypothermia. All these results in several unfavorable responses, including:

- insulin resistance
- catabolism
- cortisol and catecholamines secretion
- prostaglandin and cytokine release

ERAS entails the undertaking of several procedures and following some principles to decrease the effect of these responses and improve patient outcomes. Key factors consist of minimally invasive approach, removal of the nasogastric tube, no drain placement, multimodal analgesia, early mobilization and early resumption of normal diet. These should result in improved outcomes, including the decreased length of stay, and a lower rate of complications.

At PCCI, beginning from 2015, more than 2000 procedures have undergone through the ERAS protocol, including urological, gynecological, and general surgery procedures. This has resulted in a significant reduction of length of hospital stay from 4.24 to 2.88 days, p<0.05 in radical prostatectomy, and from 4.8 to 3.84 days, p<0.05 in partial nephrectomy. However, the postoperative complication and readmission rate has remained stable.

According to Dr. Pignot and Dr. Brun, there are three pillars to the ERAS strategy:

  1. Minimally invasive surgery
  2. Multi-disciplinary teamwork – This requires standardized perioperative care specific to each surgical procedure
  3. Patient factors – including education and sufficient information, securing a return to routine home life, and a hospital-city network, through external nurse networks.
The five key points of surgical management include:

  1. No bowel preparation
  2. Minimally invasive surgery
  3. No placement of a drain
  4. Early diet reintroduction
  5. Early mobilization
The summarized protocol of PCCI is shown in Figure. What makes ERAS a success story is the consistent, standardized protocol, maintaining consistency in all patients and all staff members, teamwork, and regular evaluations.

Figure 1 – ERAS protocol in PCCI:
UroToday ERUS2018 ERAS protocol in PCCI

Dr. Brun provided some principle factors in the field of anesthesia in the ERAS protocol. These included the usage of short-acting drugs and monitoring, optimal pain management, including multimodal anesthesia, use of local anesthetics, and morphine sparing. Additionally, optimal postoperative nausea and vomiting management is a key factor, and hemodynamic protocol unique for ERAS is used with the most important factor being goal-directed fluid therapy. It also entails protective ventilation with low volume and low pressure. Lastly, optimal postoperative pain management with nonsteroidal medications being the first line of therapy, in an attempt to avoid opiates.

Presented by: Brun, and Dr. G. Pignot, Marseille, France

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter:@GoldbergHanan at the EAU Robotic Urology Section (ERUS) Meeting - September 5 - 7, 2018 - Marseille, France