By rethinking practices around surgery, we can minimize complications and significantly improve well-being.
First developed in 1997 by the teams of Professor Henrik Kehlet, a Danish surgeon, the goal of the ERAS (Enhanced Recovery After Surgery) protocols is to review certain surgical and perioperative care practices to enable the patients operated on to regain their motor functions as soon as possible. This includes encouraging patients to eat earlier, helping them develop better pain management, and opting for pre-operative preparations. These techniques involve different disciplines, such as surgery, anesthesiology, physiotherapy, and nursing.
A world first
“Research conducted in 2008 at the CHUV on patients in the postoperative phase determined that lack of movement increases the risk of complications, including thrombosis and muscle breakdown. Hence the goal of promoting early mobilization,” sums up Valérie Addor, a clinical nurse in charge of ERAS at the CHUV. In the Lausanne University Hospital, the visceral surgery department was the first in Switzerland to deploy this type of protocol about fifteen years ago.
Dr. Emmanuel Melloul, a surgeon specializing in liver and pancreatic surgery and co-head of the ERAS program for visceral surgery, is pleased with the method’s effectiveness. “The incidence of peri-operative medical complications, such as liver failure, hemorrhage, or pulmonary embolism, has declined considerably by 24% for the pancreas and 40% for the liver.”
Today, eight surgical and anesthetic departments are implementing these protocols within the CHUV. The Department of Cardiac Surgery adopted them in May 2023. Five months later, the Department received accreditation from the ERAS Society, the competent body in this matter at the international level. This is a world first, as no other heart surgery department has ever been accredited. People who have undergone heart surgery and are admitted to the intensive care unit are often equipped with medical devices such as drains or catheters, which make early mobilization much more difficult.
In addition to interdisciplinary cooperation, the method also relies on the active involvement of the patient. “For the three weeks prior to the surgery, I had to maintain regular physical activity and practice getting up and out of bed safely. This preparation would allow me to get up more easily after the operation,” says Marie-Christine Jung, a sixty-year-old Lausanne-based woman who underwent heart surgery last March. “The first step is to strengthen patients' fitness in advance to maximize their resilience to surgery,” says Valentine Melly, ERAS Nurse Coordinator for cardiac surgery. This includes walking for at least 30 minutes every day.
Fewer opioids, fewer side effects
As a central element for any surgery, anesthesia has also reviewed its practices to speed recovery. To minimize the risk of excessive sedation and side effects due to opioids, which can impair blood flow and brain function, anesthesiologists now use an approach that facilitates the patient’s post-operative recovery and recuperation time. It is possible to use less potent alternatives, such as ketamine, and local delivery techniques. “The deeper an anesthesia is, the more it will affect the body’s ability to regain all its functions after the operation,” explains Valentina Rancati, a cardiac anesthesiologist.
Before the procedure, anesthetists also screen and treat anemia, which is considered a major source of complications. “Without treatment prior to surgery, blood transfusion is often the cure for anemia, but this increases the risk of post-operative complications such as infections and kidney failure,” the expert indicated.
Another crucial issue is post-intervention pain management. After a heart operation, a thoracic drainage tube is placed to prevent infection. “Following protocols, the tube is removed earlier, usually after three days, says Zied Ltaief, ICU specialist. This removal does not imply any major complications and reduces the duration of pain treatments with opioids.” Adverse side effects such as nausea and transit disorders are reduced by almost 30%.
Savings for the hospital and less costly treatment for the patient
Reducing the length of hospital stay also lowers the costs associated with surgical procedures, which are often major procedures and, therefore, expensive. According to an initial study conducted in 2013 on patients undergoing colorectal surgery, the overall costs of an operation were reduced by more than 6% for participants in the ERAS protocol.
In 2020, a case study conducted on six surgical departments measured the effectiveness of early recovery protocols in different departments: in colorectal surgery, the recovery process is reduced by six, even seven days, and four days in pancreatic surgery. The estimated savings were between CHF 4,000 and CHF 7,500 per person operated.
A Canadian research team also analyzed the potential of ERAS protocols to reduce costs. According to their results, obtained in a colorectal surgery department, for every dollar invested in the protocols, the return on investment was 3.6 dollars.
In cardiac surgery, where protocols have been introduced recently, initial results show a shortened hospital stay of an average day. “The aim is to make patients as comfortable as possible during their recovery,” says Zied Ltaief.
Getting back up a few hours after surgery
Marie-Christine Jung was able to stand up within hours of waking up. "I found the strength to get up and eat at the table." Like her, almost 35% of people admitted to cardiac surgery start moving again on the day of the procedure, whereas this rate was only 8% before the introduction of ERAS protocols. Marie-Christine admits to being “pleasantly surprised” by her general condition after the operation. “I was worried about feeling too much pain, but I never felt it in any significant way. The following days, I was able to walk for several minutes with the help of physiotherapists.”
According to Valentine Melly, encouraging patients to regain a certain autonomy of movement also helps to alleviate the psychological burden. “Just by moving regularly, you realize that recovery is running smoothly and that it is not necessarily synonymous with suffering and vulnerability.”
