Nicolas DemartinesProf Nicolas Demartines is Professor of Surgery, and Chairman of the Department for Visceral Surgery, at the University Hospital CHUV in Lausanne, Switzerland. He is a member of the ERAS (Enhanced Recovery After Surgery) Society Executive Board where he promotes ERAS throughout the world.

Prof Nicolas Demartines' clinical and surgical activity focuses on oncologic surgery, mainly hepato-pancreatico-biliary, colorectal surgery, and oesophagus surgery. His research interest includes the entire perioperative management with Enhanced Recovery programs and minimal invasive approaches, especially in oncologic patients.

As part of the upcoming Enhanced Recovery Programmes: Where are we after 20 years? session at ESCP’s Annual Conference, Prof Demartines explains that we’re in a time where surgical technique and technology are at a very high standard. In order to further improve patient care, and outcome, multidisciplinary strategies should be implemented, but global perioperative management must be developed including input from the patient themselves, nursing staff, anaesthetists and surgeons.

The main aim of ERAS is to promote enhanced recovery and better patient care, including preoperative and post-operative measures. A fair number of studies have demonstrated significant decrease in complications, length of stay and costs in departments that apply ERAS principles and audit their outcomes.

For example, a study by Roulin D, Donadini A, Gander S, Griesser AC, Blanc C, Hübner M, et al, entitled: Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. BJS 2013; 100: 1108-1114 indicates that by implementing ERAS principles a saving of €1,651 per patient was made. Additionally, the study found that the number of complications post-surgery was reduced by 40 per cent.

Despite emergence of compelling evidence in favour of ERAS principles, Prof Demartines explains that the practice faces some barriers:

“The main issue in implementing ERAS in hospitals, across a number of disciplines, is old dogmas. Our ERAS implementation team, which supports hospitals and departments to put ERAS in place, often observed that many surgeons think and claim that they are applying ERAS principles but in reality they have no outcome on real length of stay, readmission rate and number of ERAS principles really applied. In fact, in these cases there are usually only between 25 and 45 per cent of ERAS elements really implemented. “That is why auditing is very important. When our teams implement ERAS, we help establishing a very systematic process to ensure all parties learn each ERAS aspect, apply it and the audit the reality of clinical practice. It is very important to implement systematically at the very beginning because a multidisciplinary approach is a complex task.”

ERAS has now been adopted by over 120 hospitals in Europe, Asia North and South America.

The main sites for ERAS remain for the moment in Europe, where for example, Prof Demartines’ department, has already performed surgery on about 3,000 patients over five years using ERAS with estimated savings over €5 million.

Further to geographical growth of ERAS, other surgical specialties are adopting ERAS practice for example liver, pancreas, and upper GI surgery, or urology and gynaecology.

“In reality, each element of ERAS taken individually seems easy. The difficulty is bringing and coordinating all these elements together, to form a multidisciplinary strategy prior, during and after surgery, this is the hardest part,” continued Prof Demartines.

“Once ERAS is fully implemented, which takes about one year, short term outcomes are improved as demonstrated by the interactive ERAS audit system. Of interest, the first results about the impact of ERAS on long term oncological outcomes have recently been published in 2016 on more than 900 colorectal cancer patients, with a significant increased five year survival in favour of ERAS patients. These results need however to be confirmed by further studies.

“In Berlin, I’ve been asked to focus on certain aspect of ERAS: the treatment of pain and nausea. It is important to prevent more than to treat these symptoms in order to promote immediate post-operative mobilisation and recovery.

“In colorectal surgery, 30 to 40 per cent of patients may have nausea which is a major issue when recovering from surgery.

“The key is prevention and specifically at the early stage of anaesthesia. If performed successfully, nausea rates can be reduced to between seven to 10 per cent.

“There is increasing evidence in favour of ERAS pathways. While surgeons like to focus on technique and technology, ERAS philosophy aims to go beyond surgery to further improve outcomes, provided the basic surgical skills and oncological strategies are respected. I would therefore encourage all surgeons and medical practitioners to attend this session as it is a truly multi-disciplinary approach to improve patient care.”

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