Surgery takes a significant toll on patients, physically, emotionally, and mentally. Currently, recovery is often measured in terms of clinical metrics: hospital length of stay, ICU admission rate, surgical complications (1). It is also important to consider personal, patient-centered aspects of recovery. As clinicians continue to improve perioperative protocols through research, new strategies for recovery after surgery have emerged.
One evidence-based protocol that has been shown to improve postoperative recovery is known as the Enhanced Recovery After Surgery (ERAS) protocol (1). It is used throughout surgical subspecialties, including but not limited to colorectal, vascular, thoracic, and gynecological surgery (2). The protocol includes appropriate preoperative counselling, preoperative nutrition, carbohydrate loading up to two hours prior to surgery, standardized anesthetic regimen and early mobilization (2). Much of the focus of ERAS is preoperative: assessment and treatment of malnutrition greatly improves 90-day mortality rates and mechanical bowel prep is no longer necessary (2). Furthermore, ERAS disavows the preoperative recommendation of fasting from midnight, and instead recommends carbohydrate loading up to two hours prior to surgery (2). This has been shown to improve postoperative insulin resistance, preserve musculoskeletal mass and reduce postoperative hunger, thirst, and anxiety (2).
Intraoperatively, ERAS recommendations are aimed at preventing postoperative ileus and include use of epidural anesthesia and minimally invasive surgery whenever possible and avoiding fluid overload (2). Postoperatively, ERAS describes the need for early enteral nutrition and avoidance of routine nasogastric tube2. These recommendations have been shown improve postoperative recovery in terms of shorter length of stay, lower complication rates, faster return to bowel function, protection of cardiopulmonary function, and quicker return to normal activities of daily life (2). However, due to long-time surgeon and anesthesiologist preoperative recommendations that go directly against these recommendations, implementation of ERAS has proven to be challenging (2). Turning new recovery strategies for after surgery into widespread protocols will require continuous effort.
While these metrics are important to define recovery from a clinical perspective, improving the patient experience of recovery requires more patient-centered definitions (3). A 2021 JAMA article conducted an international qualitative study aiming to understand which aspects of recovery mattered most to patients3. Thirty patients undergoing abdominal surgery were interviewed, and they described that recovery meant recovery of symptoms and ability to complete activities of daily living, regaining independence, overcoming mental stress, and overall enjoying their lives again (3). Clinical metrics previously used in research to define postoperative recovery, such as length of stay and complication rates, were not brought up by patients, indicating that these metrics may not be as relevant from a patient perspective (3). Furthermore, this study highlights the importance of measuring recovery using patient-reported outcomes instead of only the clinical metrics used widely in the literature prior (3). However, these metrics are not as clearly defined as clinical metrics, and thus require further development in future studies (3).
Overall, recovery from major surgery is a profoundly stressful experience for patients that innovative and developing strategies are attempting to improve. Implementation of ERAS and other patient-centered protocols is important to reducing the burden of post-operative recovery on both individual patients and the overall healthcare system.
References
1. Lassen K, Soop M, Nygren J, et al. Consensus Review of Optimal Perioperative Care in Colorectal Surgery: Enhanced Recovery After Surgery (ERAS) Group Recommendations. Arch Surg. 2009;144(10):961–969. doi:10.1001/archsurg.2009.170
2. Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct;5(5):342-8. doi: 10.5489/cuaj.11002.
3. Rajabiyazdi F, Alam R, Pal A, et al. Understanding the Meaning of Recovery to Patients Undergoing Abdominal Surgery. JAMA Surg. 2021;156(8):758–765. doi:10.1001/jamasurg.2021.1557
