For patients undergoing cancer surgery, potential complications and long recovery times can delay the delivery of additional life-saving therapy. To improve patients’ perioperative outcomes and clear the way for timely ad ministration of additional therapies, several surgical teams at The University of Texas MD Anderson Cancer Center have begun using enhanced surgical recovery programs (ESRPs).
“After implementing ESRPs, we have seen reductions in symptom burden, improvements in functional recovery, reductions in length of stay, and fewer complications,” said Vijaya Gottumukkala, M.D., a professor in the Department of Anesthesiology and Perioperative Medicine and an ESRP leader at MD Anderson. “These transformative results for our surgical patients stem from the collective efforts of our multidisciplinary teams.”
Principles of ESRPs
The ESRP approach combines various principles aimed at reducing morbidity from surgery. These principles include skipping routine preoperative bowel preparation, using minimally invasive surgical techniques when possible, using goal-directed fluid therapy, minimizing the use of opioids in pain management, limiting the routine use of tubes and drains, and encouraging an early return to normal nutrition and physical activities, Dr. Gottumukkala said.
Where appropriate, ESRPs replace traditional practices with newer, evidence-based practices. For example, patients have traditionally been told not to eat or drink anything after midnight the night before surgery. But with the new approach, patients can drink clear liquids until 2 hours before arriving for surgery. This simple change means patients are better hydrated on the day of surgery. Likewise, ESRPs allow most patients to resume eating regular food on the same day of their operation.
At MD Anderson, ESRPs increasingly focus on the use of short-acting intravenous anesthetics instead of volatile anesthetic agents. These practices help minimize patients’ postoperative confusion and allow them to emerge from anesthesia with less nausea, less vomiting, and better pain control, according to Dr. Gottumukkala.
Because each patient has unique needs, every patient may not receive each element of the ESRP approach. However, Thomas Aloia, M.D., an associate professor in the Department of Surgical Oncology and a co-leader of the ESRP for liver surgery, said that following the general principles and guidelines has resulted in noticeably better outcomes compared with the traditional approach.
Incorporating the ESRP approach
Implementing an ESRP can be challenging simply because its practices are nontraditional. Changing the approach requires commitment and cooperation across multiple disciplines, according to Javier Lasala, M.D., an assistant professor in the Department of Anesthesiology and Perioperative Medicine and a co-leader of the gynecologic oncology ESRP. Almost all patients are candidates for ESRPs, according to Pedro T. Ramirez, M.D., a professor in the Department of Gynecologic Oncology and Reproductive Medicine and a co-leader of the gynecologic oncology ESRP at MD Anderson. “One of our successes in the gynecologic ESRP is that we have been able to implement the approach in all patients undergoing open gynecologic surgery,” he said. “And in December, we will initiate an ESRP for minimally invasive gynecologic surgery, so practically every patient who undergoes surgery in our department will receive an ESRP approach.”
Dr. Ramirez agreed. He said, “The entire surgical team has to agree that ESRP is in principle a good thing for patients. There are so many points along the path where ESRP needs to be incorporated that if there is no unification in the surgical team, the patients are going to fall off that pathway. The surgeons, the anesthesia team, the nursing team, and others involved in patient care have to focus on making sure the patient receives the ESRP approach.”
Dr. Gottumukkala also agreed, emphasizing the contributions to ESRPs by clinicians from the divisions of Nursing and Pharmacy and the departments of Clinical Nutrition; Palliative, Rehabilitation, and Integrative Medicine; and Symptom Research.
At MD Anderson, the initial results of the first three ESRPs—in liver, gynecologic, and bladder surgery—have shown improvements in functional recovery and reductions in symptom burden as measured by the MD Anderson Symptom Inventory instrument, a patient-reported symptom severity scale. Since the initiation of the ESRPs, the median length of stay of patients who undergo open liver surgery has decreased by 2 days, and that of patients who undergo cystectomy has decreased by 3 days. In addition, total opioid consumption has decreased by up to 60% and opioid-related adverse events and gastrointestinal complications by up to 30%. These improvements are largely the results of the change in anesthetic strategies and a patient-centered multidisciplinary effort, according to Jay Shah, M.D., an assistant professor in the Department of Urology, and Juan Cata, M.D., an assistant professor in the Department of Anesthesiology and Perioperative Medicine. Drs. Shah and Cata co-lead the bladder surgery ESRP, which is also called the Optimized Surgical Journey.
The ESRP approach has the potential to influence long-term outcomes in patients. “By continuing this program and this approach,” Dr. Gottumukkala said, “we aim to help patients return more quickly to their intended oncologic therapies, which ultimately may improve oncologic outcomes.”
Refining and expanding ESRP
Following the early success of the ESRPs in liver, gynecologic, and bladder surgeries, MD Anderson has initiated pilot programs for patients undergoing thoracic, colorectal, and spinal surgeries. And plans are under way to develop ESRPs for other treatments, including intracranial, head and neck, and reconstructive surgeries.
Furthermore, by capturing data that show which ESRP elements are used in which patients, MD Anderson clinicians seek to identify the elements most important to improving outcomes. “Our plan is to develop a system for prospectively collecting high-quality clinical data from patients. These data will include symptoms and functional interference at several time points, complications from surgery, length of hospital stay, readmissions, time to return to baseline functional status, and time to delivery of intended oncologic therapies,” said John Calhoun, a project consultant at MD Anderson’s Institute for Cancer Care Innovation.
Dr. Gottumukkala and the rest of the team expressed a hope that their data will lead other health care providers to see the value of the ESRP approach. “Increasing evidence is showing that there is absolutely a benefit to the patient,” Dr. Ramirez said. “It’s obvious which patients are in ESRPs—they have less pain, less nausea, and less vomiting; they’re eating sooner; and they’re getting back to daily activities sooner. We’re very encouraged to see the success of the program and the impact it’s having on patient care.”
For more information, contact John Calhoun at 713-745-3967, Dr. Vijaya Gottumukkala at 713-794-1398, or Dr. Pedro Ramirez at 713-745-5498.
OncoLog, September 2015, Volume 60, Issue 9
Many cancer patients undergo weeks or months of neoadjuvant chemotherapy before ablative surgery. Physicians have found that exercise regimens done during this preoperative period—prehabilitation—can help prepare patients for surgery and may even improve functional outcomes.
Like the ESRP approach, prehabilitation is aimed at improving functional outcomes and reducing surgical complications. But prehabilitation begins much earlier than do ESRP practices.
“The goals of prehabilitation before surgery are to improve patients’ functional status, reduce their postoperative complications, and ultimately enable them to receive additional cancer treatments,” said An Ngo-Huang, D.O., an assistant professor in the Department of Palliative, Rehabilitation, and Integrative Medicine. “Patients with poor performance status may not be able to receive certain treatments, but patients who are ambulatory, have better endurance, and have recovered well from surgery may be candidates for more aggressive therapies.”
Dr. Ngo-Huang provides prehabilitation guidance to patients who have a variety of cancers. Patients with spinal tumors may focus on strengthening their back muscles and other core muscles. Those with lung cancer may undergo intensive physical therapy and chest physiotherapy to improve their lung function and endurance. Patients with breast cancer may strengthen their arms and upper torso in anticipation of possible complications affecting the arms such as lymphedema or radiation fibrosis.
Each patient’s physical limitations also must be considered when planning the regimen. “In choosing exercises, we consider whether the patient has muscle loss, poor cardiopulmonary function, fatigue, a risk of fractures, or a risk of bleeding; and we consider the potential side effects of future treatments,” Dr. Ngo-Huang said.
From the limited evidence available so far, Dr. Ngo-Huang said, prehabilitation seems to lead to physiologic improvements that prepare patients for surgery and could contribute to better surgical outcomes.
For more information about prehabilitation for cancer patients, call Dr. An Ngo-Huang at 713-745-2327.