Enhanced Recovery After Surgery with Dr Conor Delaney

Podcast Transcript

Scott Steele: Butts Nʼ Guts. A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Today we are very pleased to have a friend and mentor who happens to be my boss, Dr. Connor Delaney, who is the Institute Chair of the Digestive Disease & Surgery Institute here at Cleveland Clinic. Conner, welcome to Butts Nʼ Guts.

Conor Delaney: Scott, thank you for having me. Such a fun project. 

Scott Steele: I always like to give the audience a little bit more about who our guests are. If you just very quickly tell us a little bit about yourself.

Conor Delaney: Ok, I'm an Irish colorectal surgeon who came to the U.S. for a year about 20 years ago and I’m still here, now as Chair of the Digestive Disease & Surgery Institute. We've got a phenomenal team of colorectal surgeons, general surgeons and gastroenterologists. And, and I help work with all of them and provide care around the community we serve.

Scott Steele: One of the things we're going to talk about today is right in your wheelhouse. It's this concept of how can we do better following surgery and, more importantly, the whole aspect of kind of that area around surgery, from before surgery during the time of surgery, then afterwards the so-called enhanced recovery. You've written a lot about this. You're one of the world's premier leaders in this and so, for starters, tell the audience a little bit more about what is this enhanced recovery.

Conor Delaney: Maybe let’s talk first about what is perioperative care, because that's really what it comes from. Because my goal for the last 20 years has been to look at ways we can optimize both the technical side of surgery, but also the perioperative experience. And so patients coming into an operation have three segments of their care: They've got the preoperative care and how we optimize them for surgery; they've got the intraoperative care, which is not just the operation, but it's the anesthesia, the IV fluids, the pain control; and then they've got the post-operative care, which is how we manage diet, analgesic and how they get ready to go home. And so the concept of enhanced recovery is trying to do all those in the best way for the patient.

Scott Steele: Let’s break each of those down. Let's start off with the time before surgery. Tell a little bit about this concept, what does that all involve? And is there something patients can do to get ready for surgery?

Conor Delaney: Absolutely. We've been doing this for quite a long time, but we're lucky at Cleveland Clinic that we have a really good collaborative, multidisciplinary team. And that brings together anesthesiologists and medical doctors, as well as the surgeons. One of the primary things getting patients ready for surgery is to work on their medical stabilization. Some people come into an operation fairly healthy, but a lot of people need a workup – whether it's cardiac optimization, or respiratory, or their diabetes, or what have you, to get them ready. But even for people who are healthy coming into surgery, increasingly there's evidence that we can pre-habilitate them. So you hear the term rehabilitate for how you recover after an operation. But you can pre-habilitate, meaning getting people ready. So you know that's getting up and moving around and walking, and being strong, and optimizing your nutrition, and maybe losing weight, if you have time to, or gaining weight if you're malnourished. But all of these things brought together are the preoperative side of enhanced recovery.

Scott Steele: Let's talk a little bit more about that. I may run into a situation where a patient might say, you know, that's all well and good, but boy I’m stressed about surgery and that's not the best time for me to try to quit smoking. Or I would love to get up and walk, but my knees are so bad because my weight is so kind of up and elevated, like it didn't used to be, and so I'm kind of in this Catch-22 where I don't have the ability to do the things that I want to do. What do you say to those patients? What are the things that they can do to put themselves in the best possible position prior to going into an operation?

Conor Delaney: It’s all about communication, right? And sometimes you can't do something. So somebody comes in with appendicitis or a perforated colon, and they’re an emergency case, and we just have to bring them in and do the best care that we can do. But there are people who have a little bit longer of a run before surgery, and we can work with them around smoking programs, we can work with them around weight loss and optimize nutrition. And perhaps, most important, we can communicate with them expectations of what surgery is going to be like and what recovery is going to be like. And, as an example, we've been able to get people home earlier after surgery because they want to go home. They feel healthy. But if you came in expecting to stay 10 days after an operation and we said on day two, hey you're good to go home, that's not going to work. The home preparations won't be done. You won't be psychologically ready. So a lot of this is working with the patients, and communicating and educating them about what optimal care is, and how we can look after them most effectively.

Scott Steele: You're a colorectal surgeon. I'm a colorectal surgeon. But is this something that's just specific to colorectal surgery?

Conor Delaney: No. This started with colorectal surgery and a surgeon in Denmark named Henrik Kahlet. We were the first program in the U.S. to do it and we started in early 2000. So we've been doing this for 18 years now. So the first five to 10 years were pretty much just colorectal surgery. But now we're seeing those same benefits throughout general surgery, gynecology, and urology. And so at Cleveland Clinic we’ve actually implemented it across all service lines and all of our hospitals, all of our regional hospitals and Florida, and even in Abu Dhabi we’re doing this. And the reason we're doing it is that over the two decades since we started doing it, the evidence base has matured and it's very clear that not only are we helping people recover more quickly, but we reduce their complications after surgery. And that's the biggest thing, obviously, providing better quality care to our patients.

Scott Steele: Just sticking first with the preoperative setting. I'm a patient. I'm going to go in for an abdominal surgery of any sort, whether it is colorectal or general surgery. What are some questions that they should ask their doctor about this whole concept of enhanced recovery?

Conor Delaney: Probably the first and most important question to ask your doctor is their experience working in the field that you have a condition with. You want somebody who is adequately trained and adequately experienced and works in the right kind of center with the right kind of support. Because there is pretty much no major abdominal surgery you can do without some kind of team or support network, certainly, if you're going to provide the best care to the patient. But then around enhanced recovery it's really asking when do you expect me to eat after surgery? That's one of the big changes with enhanced recovery – we let people eat more quickly. When do you let me drink? What do you expect my pain to be?
Are you and your team familiar with these pathways? Because, as I said, there's really good evidence these pathways work. And if your surgeon isn't choosing these pathways, you need to explore looking for a team who do. This is best standard care.

Scott Steele: So, Conor, you talked initially about the concepts of having perioperative care, and then the operation itself, and the post-operative care. Let's jump now from the preoperative that you're talking about into the operative pathway. What are some of the factors that go into this enhanced recovery that maybe has been a change from what the past was, in terms of that operative-type setting?

Conor Delaney: Absolutely. We covered pre-op – and the one thing I didn't mention is there are certain medications now that we know, and we've known for a long time, to give pre-operatively, or antibiotics with bowel prep. That reduces the chance of getting a wound infection. Certain analgesics the night before surgery modify how much pain you have the night before surgery. And then when you get to the operating room, it's having the team aware of the right medicines to give you. Because there's lots of options available to give patients around the time of surgery for anesthetic and for pain relief, and we have been able to evolve a pathway where we're able to spare patients opioids. That's something we might want to talk about later, reducing their opioid requirement. But that helps them recover more quickly. Standardize the fluids they get during surgery. Use specific minimally invasive or laparoscopic techniques to minimize pain and blood loss. And so those are all of the intraoperative components that you're really just setting your patient up well to recover after surgery.

Scott Steele: Is this surgeons alone that are doing this? Is it just the doctor? Is this a team? Who's all involved in this kind of operative setting that's involved with this enhanced recovery program?

Conor Delaney: It can be surgeon-driven, but the best results are when you have a team. So first, a team putting the care pathway together. And second, a team implementing that care pathway. And that includes the patient first, right? The patient has to be on board and you have to talk to them and explain to them the opportunity of improving their outcomes and improving their care. And, ideally, nursing needs to be on board, and that's many steps – nursing that you meet pre-operatively in the clinic; nursing that you meet in the operating room; and particularly nursing on the hospital floor after surgery. You've got to have anesthesia on board because they often, and particularly at some hospitals, will manage pain control – and if they're using the wrong pain control medicines, or if they're giving too much or too little fluids. Dietitians also have to be on board. So there are multiple groups involved.

Scott Steele: The things that you mentioned apply to laparoscopic or minimally invasive surgery. Let's say I’m a patient out there and my doctor doesn't do minimally invasive surgery – they don't do the robot. They are going to perform a standard open operation. Do these same concepts apply to an open operation the way that they also do with the minimally invasive procedures?

Conor Delaney: Absolutely, 100 percent. The first paper we published in 2000 or 2001 was on open patients. Because we were just starting to do laparoscopy then it was a new field for colorectal and we were the, the pioneers in that. And then over the next decade we were able to link in the enhanced recovery pathway with laparoscopy. So you do find benefits to recovery and safety both with open and laparoscopic surgery. But the best results for patients are with both. You want the team who are experienced in the enhanced recovery and the team who are experienced doing minimally invasive surgery. Because then you can have the smallest incision, the least pain, you get up moving more quickly, and you're more likely to have a safe recovery.

Scott Steele: What do you expect if you're a patient, if you’re now going to transition into the third phase of the kind of the perioperative setting, the post-operative course? What can a patient expect? Let's just say that they're going to undergo a major abdominal operation and something that removes the bowel for a little bit. What can a patient expect to do as a part of this enhanced recovery, and then also how is that different from what we used to do?

Conor Delaney:  Yeah I was actually going to start off with what we used to do, because that's where you see the big difference. So if you look back 20 years, honestly if you don't look back as far at many places, for many surgeons somebody would come in for a colon operation, colon resection for a cancer. They'd be brought into a hospital, they'd have surgery, they'd be put in the hospital bed with a tube in their nose, they'd be kept in bed for several days, they'd be kept fasting and drinking nothing until their bowels recovered, and then they get up walking on day three or four and start breathing exercises, and be given a diet, and maybe go home in seven days. And so the average stay was probably between seven and 10 days for a simple colon operation. And now that has all been revolutionized. First, there’s really robust evidence that putting a tube down your nose into your stomach doesn't help you recover after surgery. Actually, it slows your recovery and it increases the chance of a chest infection. Second, leaving patients lying in bed for a few days after surgery, it just weakens them. So if you lie in bed, you rapidly lose muscle strength. And so this is particularly bad for older, frailer patients because they don't have much muscle mass in the beginning. So you leave them in bed for three days and they end up so much weaker. They can sometimes have trouble getting up. Now what we do is we don't use these tubes. We’ll get somebody up and walking the day of surgery, particularly if they have morning surgery. And that's not to be cruel, that's to help them. It protects their muscle strength, it helps their breathing. It reduces the chance of them getting a clot in their legs, and it helps their G.I. tract recover. Those simple things are the foundations on which it's built. And then the other things that we clearly know help are feeding people early – and that's not gorging yourself on all of the soup and main course and dessert, but it's having a little bit of food. And that starts on the first day after surgery, and we give people stuff to drink on the evening of surgery. We give pain meds immediately post-op. But it used to be intravenously.

Now we give them orally and we give combinations of medicines. We'll give Tylenol, we'll give a nonsteroidal, like a Motrin or something similar, and we’ll give opioids, but we try and reserve opioids, Scott, for the patients who aren't doing well with nonsteroidal and acetaminophen. And the reason we do that is opioids tend to have a lot of side effects. First, there's increasing evidence that they don't actually get rid of pain, they more change perception of pain. And second, there's tons of evidence that they do bad things. They stop your breathing, so you are more likely to get a chest infection. They delay your bowel functioning, so you're less likely to recover quickly after surgery. And obviously, with all we see in the media nowadays, some percentage of people end up getting essentially hooked on these opioids. So the less we can use them the better. So we do all of these things together, and bringing all of those components together are the key components of the enhanced recovery pathway.

Scott Steele:  I want to focus on that last thing that we talked about – the opioids and pain medication. A lot of people are scared of surgery. They're scared especially with an abdominal operation, or even with a chest operation, that you’re going to have a large amount of pain that's going to limit the things they do – limit them getting out of bed and really delay their recovery. You mentioned a couple of things about trying to limit opioids. But let's say I'm a patient with chronic back pain, and I'm on chronic narcotics – is there something or some pathway that we can have involved that can still make sure that we cover patients’ pain adequately enough, but kind of reduce the side effects of these narcotics?

Conor Delaney: 100 percent. There are a couple of really exciting things going on – some that we've been doing for a long, long time. First, we have a specific pain control team, and so for patients with chronic pain we can get them involved, and certain patients will get an epidural or something else. Over the last four or five years we've researched and developed a way of giving it laparoscopically. And now we use it for open surgery nerve block during the operation, using a local anesthetic given into the abdominal wall. That helps. And now we have psychologists and a support team who help patients. And a lot of it, as well, is around education. And you teach and manage and mentor and coach the patients. You can do music therapy and other things and distract them, and they realize that they need fewer opioids. And then we try and structure it going home. We give them the appropriate amount and we don't give them more than they need. We do give them more if they need it. So the message isn't that, hey, there are no opioids and you're going to have terrible pain. It's quite the opposite. It's that we have evolved in the way we manage pain, so we can manage it much better, and opioids are less frequently required, or at least required in a smaller amount.

Scott Steele:   I’m in the last few minutes I want to touch base on a couple of things that I know there's a lot of misconception about out there. You talked briefly about the NG tube, the tube that goes down the nose and pumps out the stomach. Are you saying by this enhanced recovery that that's not needed at all?

Conor Delaney: It's not needed at all for elective surgery. We still use it sometimes for emergency surgery. So if somebody comes in with a blockage in their bowel for the variety of reasons that you can get an intestinal obstruction, then we often put a tube in before surgery because it makes the surgery safer. But it's for a very specific indication. And those patients will often end up with it after surgery. And then there's a very select group of patients having surgery on the stomach itself. So upper gastrointestinal surgery may get a nasogastric tube for a while. But if you look across surgical practice, it's really transformed over the last few decades, and they're very rarely required for elective surgery.

Scott Steele: What percentage of patients, would you say, might, at some stage in their operation, especially if they have a bowel resection, might need to have that just because their belly doesn't wake up right away and they start throwing up?

Conor Delaney: One of the other things that can happen to patients is they get an ileus. Patients may hear the term ileus or POI (post-operative ileus). And an ileus is when your G.I. track doesn't get back in gear after surgery. So when we do this optimal technique, often it happens the day after surgery. But there are 5 to 7 percent of patients who need it. And what happens is they get a bit bloated, and they get to standing and maybe they throw up. And so some of those patients need a nasogastric tube for a couple of days until the G.I. tract gets back in gear. But it's still well under 10 percent. 

Scott Steele: And then talk about the bowel prep. I don't want to drink a bowel prep drink, whether it’s colonoscopy or surgery. Do you have to have a bowel prep? And I heard there was some literature out there that there are some places or family members that didn't have to undergo bowel prep. What's this all about?

Conor Delaney: Yeah. There was a vogue about 10 years ago for trying to avoid bowel prep for patients. And so a number of studies were done, particularly in Europe, and they showed that avoiding a bowel prep looked fairly equivalent to having a bowel prep for things like wound infection after surgery. And so, in Europe, they went away from using bowel preps. But what had been missed in the literature, and what other studies have shown subsequently, is that bowel prep with oral antibiotics is better than bowel prep alone. So saying bowel prep/no bowel prep is like comparing two second-class teams you want to be on the first-class team. And if you're having colorectal surgery, the evidence is around a bowel prep with oral antibiotics. And then we also give a shot of antibiotics during surgery. That changes a little bit for upper GI surgery and liver surgery, where you don't necessarily need bowel prep. And then the bowel prep you have, there are a couple of different types. Pills are going out as a bowel prep pills alone because they can damage your kidneys. So there are low-volume and high-volume preps. Believe it or not, the higher volume preps are generally a little bit safer. So it's worth putting up with the inconvenience because at the end of the day, if you're a little nauseated or full drinking a drink before a life defining surgery, it's better to put up with that once off and be right for the rest of your life.

Scott Steele: And then can you talk about what patients can expect once they go home? Is there something that they can do to continue this enhance care recovery when they're out of the hospital and they’re at home?

Conor Delaney: Yeah, absolutely. Just like the preoperative information is the post-operative information. So first, patients can recover so quickly that we have a lot of patients asking to go home the day after surgery. So they have a bowel resection. They're eating and drinking the next day. They're taking Tylenol only for pain and they're walking round and they say, “Hey can I go home?” And we go, “Sure, absolutely you're doing fine.” And we have lots of evidence showing that that is completely safe. And when they go home, it's the same things – you walk around, you eat and drink a little bit without overeating or overdrinking. You're given pain meds, including opioids if you need them for breakthrough pain. You're given information about what to do if you get a fever, or if you were to throw up, or if something else changes. And so it's important to have a contact number for your physician that you can contact them. But generally, that's the information that we give patients after surgery.

Scott Steele:  I had one patient tell me once they said, listen this whole fast track stuff you're trying to do; you're pushing me out the door. Is enhanced recovery, is that something that leads to higher rates of them going home early, but do they come back much more often and get readmitted to the hospital much more often?

Conor Delaney: That's a great question. And I have a brief story I'll tell you about that. I have a friend in Ireland who is telling a patient about how well they can do with laparoscopic surgery with an enhanced recovery and fast track care. They go home the next day and they could be back at work in a week. Or if they had open surgery, they might be in hospital for a week, and they wouldn't go back to work for four weeks and they went, “Can I have the open surgery without enhanced recovery please?” We have tons of evidence it's really safe. So you're healthy faster, your complication rates are lower. In fact, the complications for the patients who go home early are less than the patients who stay. And for us now that's because we're defining the right patients to keep in for longer, because some patients need to stay in for longer. But when we look at the patients who go home in the first couple of days after surgery, if you look overall at a colorectal population, about 10 percent of patients, maybe 12 percent, will come in after surgery. If we look at the people who go home in the first day or two, it's less than 2 percent. So going home early is a marker of success. We've picked the right patients, we define by protocol the right time for them to get home early. And we have tons of evidence now showing that it's safe. They have better recovery, fewer complications, that's just the right way to provide care. We hear the term high reliability medicine. This is high reliability medicine.

Scott Steele: We're going to finish up with our quick hitters, and this is a chance to let the audience know you a little bit better. Favorite sport?

Conor Delaney: Soccer. 

Scott Steele: What's your favorite meal? 

Conor Delaney: Fish. 

Scott Steele: Like it. What's the last book you read? 

Conor Delaney: Last book I read is probably, sadly, a surgical textbook. 

Scott Steele: And then what's one of your favorite things you like about Cleveland?

Conor Delaney: Oh, Cleveland's been a fantastic city. We came here for a year and we're still here. Great quality of life. Fantastic people, great for our family, and probably top most is the fantastic health care that we have here at Cleveland Clinic.

Scott Steele: And if you would, I'm going to ask you to sum up enhanced recovery in 10 words or less.

Conor Delaney: Optimal, evidence-based, reliable medicine for patients. 

Scott Steele: Awesome. Thank you so much, Conor, for joining us here on Butts Nʼ Guts. 

Conor Delaney: It's a great pleasure, Scott. 

Scott Steele: For more information about Cleveland Clinic's Digestive Disease & Surgery Institute, visit clevelandclinic.org/digestive. That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts Nʼ Guts.