“I wasn’t allowed to eat for two days prior to surgery, I had to do a bowel preparation, and I was incredibly weak when I was wheeled into the operating room.
After surgery, I was in bed for quite some time,” Jenkins recalls. “When I finally could walk around, it was really painful. After going home, I distinctly remember my husband cooking — the smell of spices made me cough, and the coughing caused such incredible pain that I had to tell him to stop.”
A decade later, when Jenkins’ cancer returned and her MD Anderson doctors determined that surgery was again necessary, she jumped at the chance to participate in a protocol designed to relieve patients’ symptom burden and improve functional recovery.
To her absolute surprise, Jenkins’ experience with her second operation was dramatically different than her first.
“The night before, I enjoyed a family dinner, drank clear liquids until two hours prior to surgery, and didn’t have to endure a bowel preparation that had caused so much discomfort,” she says. “After surgery, I had almost no pain — I was up and walking and was soon eating a full meal. I even felt well enough to talk to my friends and put on my makeup in recovery.”
The principles of MD Anderson’s Enhanced Surgical Recovery Program (ESRP) involve making interventions before, during and after surgery that get patients through their surgery and recovery process much quicker and with better outcomes.
The movement is not new. Rather, it was pioneered almost two decades ago by a group of surgeons in Europe. It’s only more recently that physicians and institutions in the United States, including MD Anderson, have started to look more closely at its components.
Actually, many surgical practices are based more on traditions and previous teachings than sound scientific evidence, explains Pedro Ramirez, M.D., professor of Gynecologic Oncology and Reproductive Medicine.
“The pioneers of the movement questioned many traditional standards of practice that had been ingrained in the care of patients before, during and after surgery, and by doing so, came up with strategies that could benefit the patient,” says Ramirez, an ESRP co-lead. “With implementation, they found that patients were recovering much faster and getting back to their regular activities much sooner, resulting in an obvious improvement in quality of life.”
A gynecology ESRP has already registered 597 patients since its initiation in November 2014. Since then, there’s been a one-day drop in average length of hospital stay, an 80% reduction in opioid consumption and an improvement in patient-reported outcomes, without noting any differences in postoperative complication rates or readmissions. The program also has significantly lowered the cost of caring for patients.
All Gynecologic Oncology patients who undergo traditional, open surgery performed through an incision are enrolled in an enhanced recovery protocol, “from pre-operative patient education to post-operative return visit.”
Principles of ESRP include patient education, opioid-sparing strategies for pain management, minimizing drains and tubes whenever possible, and managing intravenous fluid therapy. Also fundamental to the movement’s success are changes in anesthesiology practices, with an increasing focus on using short-acting intravenous anesthetics. This helps lessen patients’ post-operative confusion and allows them to emerge from anesthesia with less nausea, less vomiting and better pain control, says Vijaya Gottumukkala, M.D., professor of Anesthesiology and Perioperative Medicine.
“Patient education and engagement is paramount to the success of the program. We educate them on what to expect from their surgical experience. Just before surgery, we give the patients opioid-sparing oral medications that reduce pain immediately after surgery,” says Gottumukkala.
The plan also encourages patients to ambulate earlier and return to normal nutrition and physical activity as soon as possible.
All Gynecologic Oncology patients who undergo traditional, open surgery performed through an abdominal incision are enrolled in an enhanced recovery protocol, “from pre-operative patient education to post-operative return visit.” Ramirez and colleagues also have published inaugural enhanced recovery treatment guidelines for their field, with hopes of sharing best practices beyond MD Anderson.
In Thomas Aloia’s opinion, enhanced recovery is the most important surgery advancement in the past 30 years.
“It’s a care philosophy that’s exclusively focused on the patient, with the primary goal to return the patient to normal function,” notes Aloia, M.D., a liver surgeon who, with Gottukmukkala, is credited with introducing the concept at MD Anderson.
Starting a RIOT
A major goal of the liver team’s ESRP is patients’ return to intended oncologic treatment, or RIOT. It’s imperative, says Aloia, that patients are able to receive necessary chemotherapy or other cancertreatments after surgery.
Prior to initiating the program, Aloia, Gottumukala and colleagues found that, historically, 75% of liver surgery patients returned to systemic therapy, on average, in 45 days. In dramatic contrast, since ESRP was initiated, 95% of MD Anderson patients returned to therapy in an average of only 22 days.
“In liver surgery, we perform some surgeries that can be fairly intense, so we run the risk that surgery could derail the larger plan of care. ESRP helps us ensure that patients receive all their treatments,” explains Aloia.
A team effort
Almost all MD Anderson surgical departments have implemented variations of ESRP, with the specific needs of patients in mind. In collaboration with MD Anderson’s Institute for Cancer Care Innovation, the teams are mining patient information on a variety of clinical data points, including cost effectiveness.
Since its origin 20 years ago, every enhanced recovery study has shown patient benefit, says Ramirez, including the work published by MD Anderson. In their respective disciplines, Ramirez’s and Aloia’s research has shown reductions in functional impairment and symptom burden, including pain, length of hospital stay, opioid needs, and readmission and complication rates.
Paramount to ESRP’s success is the partnership across myriad specialties: surgery, anesthesiology, nursing, pharmacy, nutrition support and data coordination, to name a few.
“ESRP exemplifies one of our best successes of bringing together multiple disciplines,” says Stephen Swisher, M.D., head of Surgery. “MD Anderson is also unique in that we are incredibly disease focused at all levels, and the teams can enact changes that are most specific to their patients’ needs.”
Swisher believes MD Anderson is paving the way for enhanced recovery in oncology, with more active research and patients enrolled on protocols.
For Jenkins, the experience was such a positive one that when a friend called to tell her she was also diagnosed with ovarian cancer and would be treated at MD Anderson, Jenkins strongly encouraged her to participate in the same protocol.
“I just wanted her to have the same positive experience that I had.”