ERAS is 20 years old—now it’s time to standardized the intra-op part of our care

Dr. Rogers an associate have presented an interesting paper that looks at The impact of enhanced recovery after surgery protocols for lung cancer.

We agree with the authors that this concept of enhanced recover after surgery (ERAS) is nothing new and appreciate the authors citing our 2001 article on fast tracking pulmonary resection. However, that idea was probably not new then, almost 20 years ago when we first started that trial.

Dr. Rodger’s excellent study showed a benefit to ERAS but this has more to do with what the authors were doing before they started their ERAS program than ERAS itself.

The concept of standardizing any part of a process, even complicated ones has been shown in many business models since it reduces errors, and eliminates variables to improves quality and therefore increases value.

Many of the pre- and post-operative parts of care studied in this article are well-known and have already been adopted in many centers: carbohydrate loading close to surgery and not the dogma of nothing to eat or drink since midnight, the use of minimally invasive surgery—70% in this series, the use of a single chest tube for lobectomy, digital air leak meters, etc.

We can continue to tweak these initiatives both pre and post (or after) surgery and enjoy some small incremental changes to our patients but there is much lower hanging fruit that offers significantly greater value care during surgery.

Now it’s time we tackle the more difficult part of this equation, the intra-operative care. Too many anesthesiologists and surgeons continue to say as they do the same procedures day after day: “I do it this way different from Dr. X because I prefer…” or “I like to do…” with only their opinions to back up their belief. Each minute in the operative room is costly.

It is past the time we take the concept of standardization and apply it to the art of what we do every day and forget the fragile egos of the performers. No matter how complex a system or patient or an operation maybe, we can subdivide it into parts that can be performed in an optimal way and access the value of each step and adjunct.

And today with the use of 3D simulation and other virtual reality devices we can teach it better than ever at a lower cost.

Fast tracking?—Yes. Enhanced recovery after surgery? Yes, but its more than after surgery it is before, after and during.

Acknowledgements

None.

Footnote

Conflicts of Interest: The author is a consultant and/or teacher for the following organizations: Intuitive, Ethicon, Covidien, Bovie, Novartis, Pinnacle, TransEnteric, Medtronic, Google, Verb, C-SATS video review, ConMed/AirSeal, Aztraseneca. He also is the President of ROLO-7 Consulting Firm.