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Enhanced Recovery After Surgery – the new frontier for positive post-surgical outcomes

22/03/2022

Healthcare digital Coverage

Some fifty years after the first human heart transplants took place, the procedure – if not common place – now saves the lives of at least 5,000 people per year. Such has been the speed of development in surgery that highly complicated procedures – like complex brain surgery or minute but lifesaving robotic surgery – are undertaken across the world regularly, while significant orthopaedic procedures such as hip, knee and ankle replacements are positively transforming the lives of people every day.

As medicine reaches the frontiers of what is possible with surgery – a place where clinical gains will become more marginal – medical practitioners are looking to recovery as a new opportunity to enhance medical outcomes.

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Introduction

The development of modern forms of surgery, including laser, computer assisted and robotic surgery, have had significant positive impacts on surgical outcomes. Robotic surgery enables doctors to perform complex procedures using enhanced techniques that deliver more precision, flexibility, and control than traditional techniques.

Robotic surgery can also mean less invasive surgery, allowing for complex procedures to be performed through tiny incisions. This has enabled surgeons to be far more precise and confident in surgical outcomes, making previously challenging surgery more routine. As well as being less invasive, this will ideally ensure that patients require shorter recovery time and are scarred far less than would have previously been the case.

These developments in surgery are driving new thinking around how patients recover from challenging traditional approaches to surgical procedures, leading to medical processes and technologies that can enhance recovery and allow for faster healing and improved quality of life post-surgery.

 

A traditional approach

While there is evidence that medical surgery has existed for thousands of years, the developments in the last 50 have been astonishing. Minute surgical interventions that would have been perceived as impossible even a decade ago, are now commonplace. This has prompted new thinking across the entire process of surgery – from how to interact with a patient in the run up to a surgical intervention to what happens afterwards.

Historically, following illness or surgery, rest was considered the primary positive medicine.  It was not uncommon for patients to be encouraged to remain still, often in bed, either with or without much food and drink, until bodily functions were perceived to be returning. There are, of course, many benefits to resting post-surgery – rest uses up less energy and your body does the majority of healing when asleep. However, this approach could lead to prolonged pain and immobility for patients.

Sustained immobility also has issues of its own. Long periods of immobility have been associated with increased risk of blood clots, known as venous thromboembolism (VTE).  Around 55 – 60 per cent of all VTE cases occur during or following hospitalisation[1], resulting in approximately 25,000 deaths in England each year. [2]

Sustained time in hospital can also increase the risk of infection.  According to the World Health Organisation, healthcare associated infections are the most frequent adverse event in healthcare delivery worldwide: 10 per cent of patients in developing countries and seven per cent in developed countries will acquire at least one healthcare associated infection during their time in hospital.[3]

 

Enhanced recovery after surgery

As surgery techniques and outcomes have improved, the accepted approach to recovery has also been brought into question.  Smaller, more precise, surgical interventions have led to new thinking around recovery.

Enhanced recovery after surgery (ERAS) is a new pathway for patient care.  ERAS emerged from study groups during the early 2000s that challenged the traditional approaches. The introduction of enhanced recovery pathways within elective surgery has gained momentum over recent years since the concept of ‘‘enhanced recovery’’ was first described and promoted by Henrik Kehlet.[4]

ERAS protocols are care pathways designed to achieve earlier recovery after surgical procedures.  The key elements include preoperative counselling, optimisation of nutrition, standardised analgesic and anaesthetic regimens, and early mobilisation post-surgery.  By preparing patients for surgery more effectively and then getting them moving more quickly after surgery, ERAS can help avoid some of the complications associated with post operative recovery.

ERAS protocols involve four distinct areas:

  • Pre-operative: clinicians aim to optimise the wellbeing and medical condition of patients and set realistic expectations through pre-operative education and counselling.
  • Intra-operative: by using atraumatic and minimally invasive surgical techniques, alongside shortened surgical times and optimised anaesthesia – usually involving lighter sedation.
  • Post-operative: this includes physiotherapy intervention and promotion of walking as soon as possible alongside regular and effective pain medicine that avoids opiates where possible. Patients are encouraged to re-introduce normal feeding and hydration quickly and drips and catheters are removed earlier.  Patients are encouraged to act independently with regards to washing, dressing and socialisation.
  • Discharge: patients are discharged home with clear instructions on how to progress rehabilitation independently.

While initially the ERAS protocols were developed for specific procedures, the principles of the pathways have been used in procedures including general, visceral, vascular and thoracic surgery, as well as orthopaedic, urological and gynaecological operations.

 

ERAS in orthopaedics – the experience of Bournemouth

During 2007, The Royal Bournemouth Hospital – an NHS district general hospital based in Dorset – set up new protocols for its orthopaedic patients visiting for knee and hip replacements to reduce the average length of stay in hospital and enhance the quality of care provided.

Subsequently the hospital published a paper detailing the measures taken in each of the areas above, which is viewable here. By standardising care procedures across the entire process, the hospital reduced the time patients spent in hospital. Before the changes, the average stay was almost eight days.  After the changes this had fallen – with most patients leaving hospital on either the third or fourth day after the operation.[5] This in turn enabled the hospital to carry out many more procedures than would have otherwise been possible.

 

Post operative swelling in hip and knee replacements

The positive outcomes of ERAS are only fully maximised if patients who are discharged are not then readmitted in the future. Matthew Kelly et al published a paper on the reasons for readmissions and emergency visits in patients that had received a Total Joint Arthroplasty (TJA) in the United States.

TJAs consist of either Total Hip Arthroplasty (THA) or Total Knee Arthroplasty (TKA) – the full replacement of a hip or knee through surgery. Using the Kaiser Permanente Total Joint Replacement Registry, the Kelly study looked for patients that had at least one 90-day postoperative emergency visit or readmission for any reason post discharge. 2344 total hips and 5520 total knees were analysed, and the results show that swelling, related to these procedures, was the most frequent reasons for 90-day emergency visits, with readmissions most commonly due to infection.  Indeed, one in 10 patients made an emergency visit during the first 90 days post-surgery. [6] Critical therefore to reducing the overall burden on healthcare systems of TJAs are measures that can reduce swelling in patients, particularly those that have been discharged following an ERAS protocol.

Dr Asit Shah, MD, is Chief of Orthopaedics at Englewood Hospital in New Jersey and outlines the issue succinctly: “We carry out over 800 joint replacement surgeries and 200 foot and ankle surgeries annually. Critical to improving patient outcomes and controlling costs is identifying and mitigating preventable causes of unplanned emergency department visits and readmissions. We have long since recognised that swelling, related to these procedures, is the most frequent reason. Oedema can also reduce functional performance while oedema-related surgical site infection can also slow the speed of recovery.”

There are many different protocols for addressing oedema in post operative TJA patients, including cryotherapy, graduated compression stockings, pressure bandaging, continuous passive motion, pneumatic compression devices, and manual lymph drainage. However, many of these procedures are not suitable to recuperation outside the hospital environment and if the objective of ERAS is to safely enable post operative recovery in the home, this can be problematic.

 

New applications to address oedema

Recently healthcare professionals have started to trial an alternative: the geko™ device.  The geko™ device is battery powered, disposable, neuromuscular electro-stimulation therapy that is applied non-invasively to the skin over the common peroneal nerve at the side of the knee. It gently stimulates the nerve, once every second, activating the calf and foot muscle pumps resulting in increased blood flow in the deep veins of the calf, at rate equal to 60 per cent of walking without the patient having to move.

It is clinically proven to treat and prevent post-operative and trauma-based oedema. It is the first bioelectronic muscle pump activator of its kind to be cleared by the FDA for VTE prevention across all patients including non-surgical patients – providing adjunctive blood clot prevention to at-risk TJA patients, alongside oedema reduction.

Dr Shah has been using the geko™ device for post operative and trauma-based oedema control following orthopaedic surgery and has been seeing significant benefits in doing so.   “The geko™ device turns the tables on oedema-based complications. Through its unique mechanism of neuromuscular electrostimulation, it activates the calf and foot muscle pumps increasing blood flow in the deep veins of the calf at a rate equal to 60 per cent of walking – reducing both pre-operative oedema and preventing the build-up of post-operative oedema.”

The Al Hikma Modern Hospital in Jordan has followed Englewood’s lead in using the geko™ device to address post-operative swelling in lower limb patients as well as deploying the device for trauma-based treatment of swelling.  Dr Sameih Ismail Abu Khaleifa, Consultant Orthopedic Surgeon, highlighted the benefits: “My team were keen to explore the geko™ device use as an alternative mechanical intervention to enhance recovery in post operative and trauma-based applications. The device is now in routine use providing safe and well-tolerated oedema control, ensuring that all our patients can now receive appropriate oedema management for better clinical outcomes – and importantly improved patient satisfaction.”

Because the device is relatively small (the size of a wristwatch), simple to apply (to the leg below the knee with an adhesive pad) and battery powered, the geko™ device can additionally be easily incorporated into the ERAS discharge process with simple instructions for application and use. It has the potential to reduce post operative swelling, cutting the number of readmissions and emergency visits required by TJA patients and speeding the recovery of patients as part of a wider ERAS procedure.

Care consortium Kaiser Permanente is one of the largest non-profit healthcare plans in the US.  The company has been pioneering a same day joint replacement programme for knee surgery, where the proportion of patients that avoided an overnight hospital stay increased from 7.2 per cent in 2016 to 62.0 per cent in 2019.[7] The geko™ device has the potential to further enhance this percentage by addressing oedema risk both in the hospital and, critically, when patients return home. Dr. Ronald Navarro, the Southern California Regional Chief of Orthopaedic Surgery, comments: “Our Kaiser Permanente Total Joint Arthroplasty home recovery or Same-Day Joint Replacement program has many benefits.  It removes some degree of controlled elevation of the lower extremities and VTE prophylaxis in the way of sequential compression. The geko™ device can enable similar benefits in the home setting at a low cost to the overall system.”

The geko™ device is still a relative newcomer to treatment of oedema but as ERAS procedures continue to develop, it is likely that the device – and others like it – will become significant contributors to aiding quicker recovery from surgery.

 

Conclusion

The pace of surgical development has been astonishing and the scope of what is possible today compared to even a generation ago has been huge. While incremental improvements in surgery will likely continue, many healthcare practitioners now believe that the major area of focus to drive improved patient outcomes lies in improvements to healing.  The relative success of ERAS programmes in multiple surgical fields demonstrates the potential for improvements across medicine by taking a holistic approach towards pre- and post-surgical interventions and building pathways that maximise the opportunity for success.  Products like the geko™ device have an important role to play in enabling patients to help themselves speed recovery outside of the hospital environment.

 

References

  1. Thrombosis Statistics. [Internet]. 2018 [accessed 2018 Oct]. Available from: https://www.thrombosisuk.org/thrombosis-statistics.php
  2. House of Commons Health Committee. The prevention of venous thromboembolism in hospitalised patients. London: The Stationary Office. [Internet]. 2005 [accessed 2018 Oct]. Available from: https://publications.parliament.uk/pa/cm200405/cmselect/cmhealth/99/99.pdf
  3. World Health Organisation. Health care-associated infections. Available from: https://www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf
  4. Ljungqvist, O., & Hubner, M. (2018). Enhanced recovery after surgery-ERAS-principles, practice and feasibility in the elderly. Aging clinical and experimental research, 30(3), 249–252. https://doi.org/10.1007/s40520-018-0905-1
  5. Wainwright, T., & Middleton, R., An orthopaedic enhanced recovery pathway. Current Anaesthesia & Critical Care. Volume 21, Issue 3, June 2010, Pages 114-120. https://doi.org/10.1016/j.cacc.2010.01.003
  6. Kelly, M. P., Prentice, H. A., Wang, W., Fasig, B. H., Sheth, D. S., & Paxton, E. W. (2018). Reasons for Ninety-Day Emergency Visits and Readmissions After Elective Total Joint Arthroplasty: Results From a US Integrated Healthcare System. The Journal of arthroplasty, 33(7), 2075–2081. https://doi.org/10.1016/j.arth.2018.02.010
  7. Kaiser Permanente. Permanente physicians lead charge to reduce overnight stays after joint replacement. 2021. Available from: https://permanente.org/permanente-physicians-lead-charge-to-reduce-overnight-stays-after-joint-replacement/