Enhanced recovery protocol feasible, improves outcomes after radical cystectomy

Jackey Suen
21 Aug 2017
Dr Lui-Shiong Lee

Implementing enhanced recovery after surgery (ERAS) is easy and intuitive and confers better patient outcomes in radical cystectomy, experience from a Singaporean hospital has shown.

“ERAS should be the standard of care and advocated in radical cystectomy,” suggested Dr Lui-Shiong Lee of the Singapore General Hospital, Singapore.

The ERAS protocol for radical cystectomy was described in 2013 by the ERAS Society. It comprises 22 items involving multimodal care in preoperative, perioperative and postoperative settings. [Clin Nutr 2013;32:879-887]

“For example, the ERAS protocol allows intake of solid food up to 6 hours and liquids up to 2 hours before surgery,” said Lee. “This is in contrast to the conventional practice of fasting after midnight, due to fear of pulmonary aspiration while under general anaesthesia.”

“The protocol also advocates intraoperative Doppler-guided fluid administration to prevent over-hydration that may result in ileus, increased morbidity and increased length of hospital stay,” he continued. “In a randomized controlled study, the combination of restrictive-deferred hydration [1 mg/kg/hour until end of cystectomy, then 3 mg/kg/hour until end of surgery] and pre-emptive norepinephrine infusion [2 µg/kg/hour] was shown to reduce complications and blood loss vs 6 mg/kg/hour of fluid infusion throughout surgery.” [Anesthesiology 2014;120:365-377]

“Postoperatively, early nasogastric tube removal and gum chewing can minimize the risk of ileus and allow for fast bowel recovery after cystectomy,” noted Lee. “Patients should also be encouraged to drink instead of relying on intravenous hydration. Normal food intake should be re-established as soon as possible.”

Since 2014, the Singapore General Hospital has implemented the ERAS protocol in all radical cystectomy procedures performed for bladder cancer except for cases requiring pelvic exenterations.

“So far, 15 patients have been managed with the ERAS approach in our hospital. Their median age was 67 years. Forty-seven percent of the patients had stage 3–4 disease, and 27 percent had lymph node involvement,” said Lee. “The compliance rate to each component of the protocol was 93 to 100 percent.”

Compared with the conventional approach, patients managed with the ERAS approach had significantly shorter median time of ileus (4 vs 5 days; p=0.01) and significantly shorter length of hospital stay (7 vs 10 days; p=0.01).

“A cost reduction of SGD 16,728 was found for each case managed with the ERAS approach vs conventional approach [SGD 23,698 vs 40,426],” highlighted Lee. “No additional manpower cost was required for the implementation of ERAS.”

Lee also noted some difficulties of implementing ERAS at his centre. “Although some components of ERAS are more important than others, they are linked to each other. Therefore, ERAS implementation should be done in one go rather than in a ‘piecemeal’ manner,” he advised. “Moreover, changing the mindset of hospital staff, such as surgeons, anaesthetists and nurses, can be challenging.”

“Implementation of ERAS is easy and intuitive, but it requires customization to fit the practices at different hospitals,” concluded Lee. “Teamwork and continuous evaluation are crucial to its successful implementation.”