Enhanced Recovery After Surgery

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery and the President of Main Campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm extremely pleased to have Dr. Kristen Ban here, who is one of the members of our staff, colorectal surgeon here at the Cleveland Clinic, who practices primarily on our West Side Campus. And we're going to talk a little bit about enhanced recovery after surgery, which we call ERAS. Dr. Ban, Kristen, welcome to Butts and Guts.

Dr. Kristen Ban: Thank you so much for having me. I'm thrilled to be here. And this is a topic very near and dear to my heart. So, excited to be here.

Dr. Scott Steele: Well, for the listeners, this is your first time here on Butts and Guts.

Dr. Kristen Ban: It is.

Dr. Scott Steele: So, give us a little bit about your background. Tell us where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Kristen Ban: As you alluded to, I'm a colorectal surgeon here at Cleveland Clinic on the West Side. I did my fellowship training at Washington University in St. Louis and was in Chicago before that. For my general surgery training, which is where my interest in enhanced recovery really started, I did two years of dedicated time doing research and quality work at the American College of Surgeons, and I had a focus on enhanced recovery during that time. I participated in one of the college's quality programs and they had a pilot program looking at enhanced recovery and how they could help hospitals do enhanced recovery better. And I also was involved in a 16-million-dollar contract between the Agency for Healthcare Research and Quality and the American College of Surgeons and Johns Hopkins with a goal of helping hospitals that wanted to implement enhanced recovery, but didn't really know where to start. And so, that was part of my job, was to collect all the data we had on how to build those teams, what should these care pathways look like, and then providing support to hospitals as they embarked on launching their own enhanced recovery programs.

Dr. Scott Steele: Well, we are super excited to have you here. So, let's start there. Just, a broad overview. What is ERAS or enhanced recovery after surgery, and who qualifies for it?

Dr. Kristen Ban: Enhanced recovery after surgery is a multimodal, evidence-based care pathway to achieve early recovery and minimize complications after surgery. So, what the heck does that mean? It basically means we're trying to figure out all of the things we should be doing before, during, and after surgery that have good evidence to support them so that patients can leave the hospital faster with fewer complications.

Dr. Scott Steele: So, how can ERAS help patients in other ways?

Dr. Kristen Ban: I think the major thing and one of the most exciting, early outcomes as people were exploring enhanced recovery - the enhanced refers to length of stay in the hospital. So, the huge impact is reducing length of stay in the hospital. And that's not to say you're not still recovering at home after surgery. But, you're doing that in a more comfortable environment, and you're doing that safely without an increased risk of having to come back into the hospital and be readmitted.

But the other benefits that we have demonstrated as enhanced recovery has been studied, decreased complications like wound infections, like urinary tract infections, like blood clots after surgery. And we've seen individual elements of these care pathways can have an effect, but it's really the additive effect of doing a lot of things in combination in a very standardized way that has the biggest impact on a patient's postoperative course.

Dr. Scott Steele: So, let's dig in a little bit deeper there. You had mentioned there's a lot of different components to it. And so, what makes up the ERAS plan, and how does that differ from more traditional practices?

Dr. Kristen Ban: So, that's a great question. Enhanced recovery spans all elements of the surgical journey. So, that starts even before an operation where there's a big education component helping patients prepare for surgery and understand what will be asked of them as they recover. It includes optimizing nutrition, trying to get their strength up going into surgery, and there are some specific components. Immediately before surgery we used to tell patients to fast for very prolonged periods of time, and we've gotten away from some of those elements, trying to ensure that they have good blood sugar control going into surgery.

And then, in the immediate preoperative area, I keep using this word multimodal, but what it refers to is using different families of medications or different strategies together to help manage things like pain and nausea, which is very common after a big operation. So, that's in the preoperative period. There are elements to reduce infection risk.

And then during surgery there are components managed by the surgeon. "Can I safely use a minimally invasive approach because smaller incisions mean less pain and faster recovery?" "Can I avoid the things like surgical drains and tubes?"

And then, on the anesthesia side, they're trying to minimize fluid use and that's one component there.

And then, in the postoperative period, I think this is really where patients get not surprised, but maybe it's unexpected that we want you to be up moving around quickly. We have moved towards letting you eat and drink pretty quickly even after a major colon or GI surgery. Trying to get urinary catheters out quickly, and all of those things together speed recovery and minimize complications.

Dr. Scott Steele: So, now we're going to go into the segment of our show we call "Truth or Myth?" So, truth or myth, Kristen: ERAS is equivalent to fast track.

Dr. Kristen Ban: Myth is how I'm going to answer that. Shorter length of stay is a benefit, but that's not the most important component of this in my mind. It's really minimizing complications and ensuring that overall, the patient is getting the best evidence-based care that they can throughout their operative period. And also, that they have good education so that they feel prepared and like they are a participant in the plan of care for their surgery and recovery.

Dr. Scott Steele: So, is there a situation where ERAS would not be used? Is there a specific patient population where you couldn't use all of it?

Dr. Kristen Ban: Absolutely. Because at the end of the day, we still have to individualize a care plan for a given patient that we are taking care of. But I would say that it provides a really helpful beginning framework to ensure that we are always revisiting, "how can I ensure good pain control?" "How can I minimize nausea?" "How can I minimize complications using evidence-based practices?" But for example, some medications aren't safe to give a certain patient if they have kidney disease, or if they're older, or if they have a specific surgical history. So always, that care plan is individualized to the individual patient.

Dr. Scott Steele: So, how is ERAS being utilized here at the Cleveland Clinic with colorectal surgery patients?

Dr. Kristen Ban: Colorectal surgery patients across the board here are benefiting from the use of enhanced recovery pathways individualized to that given patient. But I would say, more broadly, what is amazing is that enhanced recovery has actually, in my opinion, achieved almost a culture change. It's not brand new, it's been around for a little while. We have so much great data supporting utilizing these care pathways that it's now accepted within the surgical culture at Cleveland Clinic in colorectal surgery to apply that framework to any surgical patient that we are caring for.

Dr. Scott Steele: Okay, so I'm a patient listening to this, and I'm going to go and see one of our surgeons here. And so, how does a patient broach this entire topic with the doctor?

Dr. Kristen Ban: If a patient brings this up, I am so excited to be having this conversation with them. I think a good way to ask, and if you don't remember enhanced recovery after surgery terminology, asking, "How can I prepare for my surgery? And how can I participate in my recovery afterwards?" is a good place to start.

Dr. Scott Steele: You mentioned this very briefly, going back to the pre-op, the surgery, and the post-op, but at what point does the ERAS plan conclude?

Dr. Kristen Ban: The short answer is when the patient feels that they have recovered from surgery. But in practice, we are, for example, tracking compliance with how we're doing as providers implementing these protocols. That's really done primarily by the time of discharge. Although, we continue to track after discharge from the hospital for things like complications or readmissions to the hospital because we want to ensure that we have followed the patient really through the completion of their recovery course.

Dr. Scott Steele: So, what's on the horizon for enhanced recovery after surgery related to colorectal surgery?

Dr. Kristen Ban: So, we're still fine-tuning some of the individual components of these protocols, including use of things like regional anesthesia or specific medications. Specifically, there are some ongoing studies looking at medications that can prevent something called ileus which is where the bowel is slow to wake up after a surgery.

But in a way, the future of enhanced recovery is now and we're already living it. Because, as I said, this has been around for a while. We have such great data to support doing it, and there really has been a culture shift in surgery, in my opinion, to embrace some of these concepts around get the patient moving earlier. Don't starve them for a prolonged period of time after a surgery if there's no need to. Keep them active and make them a partner in their preparation and then recovery after surgery.

Dr. Scott Steele: So, now it's time to get our know our guest a little bit better. It's time for our quick hitters. So, first of all, what was your first car?

Dr. Kristen Ban: Ooh, first car was a Mazda3. It was silver. I loved it.

Dr. Scott Steele: I like it. I like it. Okay. So now what's your favorite meal?

Dr. Kristen Ban: Favorite meal? A beautiful risotto is really hard to beat. That's lovely.

Dr. Scott Steele: Fantastic. And so, tell me about maybe a trip that either you want to go on or that you've been on that you would recommend it to our listeners.

Dr. Kristen Ban: Oh, well. Paris and France is a place near and dear to my heart. I lived and worked there for a few years, and it's a magical city. And you can go back at any time in your life and have a totally new experience there. It's a timeless, amazing place. That's a dream vacation always.

Dr. Scott Steele: Parlez-vous français?

Dr. Kristen Ban: "Oui, je parle français."

Dr. Scott Steele: That's the extent of my knowledge. And then finally, tell us something that you like about Northeast Ohio.

Dr. Kristen Ban: Oh, this is such an easy, beautiful place to live. The lakefront is stunning. You really cannot beat summer in Cleveland. My husband and I are both cyclists. We enjoy road cycling and there are some beautiful, beautiful trails in the Metroparks system here, which is just such a luxury to have that right outside our back door.

Dr. Scott Steele: Absolutely concur. So, what's a final take home message for our listeners regarding this entire concept of enhanced recovery after surgery?

Dr. Kristen Ban: There is a lot of data and good data to support enhanced recovery practices. And these principles can be applied across procedures, not only in the elective surgery setting, but also if emergency surgery is required. Although always, we're individualizing these plans of care for the patient in front of us. And I would say it's a huge benefit on the patient side. Be a participant in that process, and knowledge is power. So, our job as providers is to provide education going into surgery so that you know what to expect and how to be a partner in a seamless recovery after surgery.

Dr. Scott Steele: Fantastic advice. And so, for more information about the colorectal surgery department, as well as enhanced recovery after surgery here at the Cleveland Clinic, please visit clevelandclinic.org/colorectalsurgery. That's clevelandclinic.org/colorectalsurgery. You can also call us at 216.444.7000. That's 216.444.7000. Dr. Ban, thanks so much for joining us on Butts and Guts.

Dr. Kristen Ban: Thank you so much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.