SIU 2018: Oncology Updates -ERAS Protocol

Seoul, South-Korea (UroToday.com) Jay Shah, MD presented ERAS (enhanced recovery after surgery) protocols and highlighted the work that still needs to be done in this arena. 
He provided a brief history of ERAS and highlighted some basics of the ERAS protocols. 

  • Henrik Kehlet, MD PhD – General surgeon who started to look at things outside of surgical technique that could “fast track surgery”. Should receive credit for really starting this process
  • Within urology, Raj Pruthi (UNC, USA) and Sia Daneshmand (USC, USA) helped pioneer this concept, both with cystectomy

Basic components of ERAS protocols that are generally well-accepted (though not always well adopted!):

Dr. Shah, during his first few years out of fellowship, as an attending staff at MD Anderson, was the first to institute these changes at MD Anderson. While he initiated these changes, his partners did not – and their internal analysis found that patients on ERAS has shorter LOS (3 days), less complications (37% less overall complications, 59% fewer GI complications), improved patient experience (patient QOL outcomes), and lower costs (~$15,000/patient). 

Yet, despite all this recent evidence to support ERAS, uptake is relatively slow. A survey that they sent out to high-volume (>20 cystectomies/year) urologic oncologists in the United States that specifically asked about 6 components of the ERAS protocol found that uptake, even among this select group, was ~20%.

Even once ERAS is initiated, there are additional improvements that can be made. He then touched upon some other related areas that he and others are working on:

1. Opioid use following urologic surgery – a project he is working on at Stanford. They initiated system based changes in their prescribing patterns, which resulted in a 50% reduced rate of opiate use following most major urologic surgeries!

2. Prehabilitation – focus on pre-operative patient preparation. Jeff Montgomery (Urology) and An Ngo Huang (PM&R) are 2 individuals working this area. No strong data yet, but hoping to find some regimen that works!

3. Patient engagement – Use of smartphone technology to engage patients pre- and post-op. Hope to identify minor complications before they become major, reduce unplanned care, and free up care team to deal with major issues.

4. Predicting recovery – while others are working on molecular biomarkers to assess disease, he is interested in using these genomic biomarkers to potentially predict recovery. He, along with a medical student at Stanford, will be doing a CyTOF analysis of blood collected at various time points to predict recovery after cystectomy.

His take-home points:

1. If you don’t have an ERAS protocol, start one! (He can help)

2. If you have an ERAS protocol, keep finding ways to improve it! (and share what you find so others can benefit)

3. Reach out to collaborate

Presented by: Jay Shah, MD, Stanford University

Written by: Thenappan Chandrasekar, MD, Clinical Instructor, Thomas Jefferson University at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea
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