ERAS – yesterday, today and also for tomorrow? The ERAS Society perspective.

https://doi.org/10.58974/bjss/azbc004

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ERAS so far

It is more than 25 years ago that a multimodal approach to recovery after major surgery, called fast track surgery, was first proposed^1,2.  Combined with laparoscopic surgery it showed that old and frail patients were fit to leave the hospital in two days after major surgery³. Larger follow up studies reported that this could be achieved with fast track surgery alone. This inspired a group of surgeons from Northern Europe to form the Enhanced Recovery After Surgery (ERAS) Study Group in 2001⁴. The members hypothesized that bringing together all potential stress reducing and recovery improving care elements into one program, would enhance recovery after surgery.

The first ERAS protocol was published in 2005⁵. But alongside the guideline there was a need to also organize care in a new way to make ERAS fully functioning⁶ (Table 1). When the guideline was tested a clear relationship was shown with more care elements in the protocol in use and improved outcomes regarding both complications, length of stay and readmissions suggesting that detailed audit would be key^7-9.

In the Netherlands the ERAS recommendations were implemented in a structured program within a year and reported reduced length of stay from 9-10 to 5-6 days when guideline adherence improved from around 45 to 75%¹⁰. This showed that major improvements could be gained within a limited time with structured ERAS training. A follow up study a few years after the program and audit had finished revealed that most units had lowered compliance to ERAS and increased hospital stay¹¹.

Another milestone for ERAS was a meta-analysis on the randomized trials. This showed that with more ERAS recommended elements in use, complications were reduced by approximately 50% and length of stay shortened by several days¹². The main effect on complications were reductions in nonsurgical complications, suggesting that stress reduction of vulnerable organs played a role¹³.

Finding that evidence-based ERAS care pathways improved outcomes and understanding how to train units in ERAS stimulated the foundation of the ERAS Society in 2010. Starting in colorectal surgery, ERAS very quickly spread to just about all major surgical domains (Table 2). Many of the ERAS Society specialty guidelines have been developed in collaboration with other surgical and anesthesia societies. In addition, other societies have published similar ERAS like Guidelines.

Several programs have been developed to implement ERAS principles including national efforts in the UK¹⁴, Sweden¹⁵, and Spain⁸ to mention a few. The ERAS Society further developed the implementation program based on the experiences from the Dutch and has been working at a global level. The focus has been to implement ERAS primarily in leading units and to have them trained as trainers. The ERAS Implementation program is now active in almost 30 countries and in all continents (www.erassociety.org), Figure 1, and under variable circumstances, Figure 2.

Challenges for ERAS and surgery today

One would think that more than 20 years of existence of ERAS, and the results reported, it would have been implemented world wide and little need for spreading ERAS today¹⁶. Most surgeons around the world know about ERAS and most are likely to claim they “do ERAS or Fast Track”. However, national data on length of stay suggest that ERAS is not widely used. Instead of length of stay of 3-6 days for colorectal surgery, many countries report the double or more¹⁷.

One of the reasons for this poor insight is probably the lack of data collection. The lack of information on outcomes in surgery worldwide is monumental (https://www.lancetglobalsurgery.org/indicators). In some countries however, there are quality registries for many surgical disciplines. This allows an annual benchmarking and feed back to the units involved. This is a good start to drive improvements, but there is room for further developments. The ERAS Society opted to develop audit for the entire patient journey and focus on all details that make up the guidelines to cover all aspects and not just related to a specialty¹⁸.

Another obstacle is the slowness by which the medical profession and surgery adopts new treatments with often 15-20 years delay from proven efficacy to more general use. Implementing ERAS is facilitated by forming a multi professional and multidisciplinary team to lead ERAS locally. This change is also seen as an obstacle, but is a key for success. The team continuously audit outcomes and the compliance to ERAS care processes. By controlling all care elements, the unit can reveal poor compliance and identify which changes are needed. Driving change and managing care with data should be the new norm to secure improvements made are sustained, and quality maintained.

It has been argued that ERAS is too complex and that only a few care elements need to be used and/or that many of the elements do not need to be audited or focused upon. However, the variation in care delivery is huge.  Which elements that may be needed for improvements in one place will differ from another depending on the local “standard of care”. It is by reducing this unwanted variation in care delivery that will help improve surgery and anesthesia outcomes. Finally repeated studies have reported that it is a multitude of elements that impacts the outcomes^7-9.  Common ERAS elements in many guidelines are listed in Table 2.

The opportunities with ERAS

The pandemic of COVID-19 forced the health care professions to drastically change their work to cope with the inflow of patients. This proved that health care can change very fast when needed¹⁷. This insight should be used to start re organizing care to run ERAS. The timing could not be better; a large backlog of patients is waiting for surgery because of the pandemic, and the economic pressure on societies world-wide is at a high because of the global political situation and COVID-¹⁹. ERAS is one of the most cost-effective (if not the most) way to improve outcomes¹⁹, reduce suffering for patients and potentially also save lives20. The tools and the knowledge are here. It is up to hospital managers and decision makers to decide and allow the professions to take the lead to implement ERAS for the benefit of all.

COI and acknowledgements:

OL is a co founder of and the chairman of the ERAS Society, he is the founder and shareholder of Encare AB. He has given advise to Nutricia (NL), received speakers honoraria from Encar4e, Nutricia, BBraun (DE), Fresenius-Kabi (DE), Pharmacosmos (DK) and Medtronic (IT), the latter also with travel support. UG is a member of the Executive committee of the ERAS Society., no financial conflicts. HdB is member of the Executive committee and Treasurer of the ERAS Society. HdB is member of the global Advisory board of Merck, member of the Scientific Advisory Board of Senzime, member of the global Advisory Board of NMD Pharma.