Download PDF
Aktuelle Ernährungsmedizin 2013; 38(06): 424-428
DOI: 10.1055/s-0033-1349669
Standpunkt
© Georg Thieme Verlag KG Stuttgart · New York

“Enhanced Recovery After Surgery” – leichter gesagt als getan!

Zum Problem der Implementierung von Leitlinien und Standards im klinischen Alltag“Enhanced Recovery After Surgery” – Easier Said than Done!The Problem of Implementation of Guidelines and Standards into Clinical Practice
M. Hübner
Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Switzerland
,
D. Roulin
Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Switzerland
,
N. Demartines
Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Switzerland
› Author Affiliations
Further Information

Publication History

Publication Date:
04 December 2013 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Beinahe 20 Jahre sind seit den ersten sensationellen Berichten über die sogenannte „Schnellspur-Chirurgie“ (Fast Track) vergangen. Was zunächst erbittert bekämpft oder zumindest belächelt wurde, ist heutzutage fester Bestandteil des Behandlungskonzepts in vielen chirurgischen Abteilungen. Dies liegt allerdings daran, dass das Ziel der perioperativen Behandlungspfade von schneller zu besser weiterentwickelt wurde.

Oberstes Ziel dieser multimodalen Behandlungspfade ist eine Reduzierung der Stressantwort, die mit dem chirurgischen Eingriff einhergeht. Mehrere randomisierte Studien haben mittlerweile eindrucksvoll belegt, dass in der Folge die postoperativen Komplikationen in etwa halbiert werden und die Krankenhausverweildauer um mehrere Tage gesenkt wird. Daher wurde die Bezeichnung Fast Track inzwischen durch den Terminus Enhanced Recovery After Surgery (ERAS®) ersetzt. Es geht also primär um eine Verbesserung (enhanced) der postoperativen Erholung und nicht um eine Verkürzung (fast) der postoperativen Verweildauer um jeden Preis.

Das ERAS®-Protokoll beinhaltet über 20 verschieden Einzelmaßnahmen in der prä-, intra- und postoperativen Phase. Je vollständiger der Behandlungspfad eingehalten wird, umso besser sind die klinischen Resultate.

Eine erfolgreiche Einführung von ERAS ist mit einer grundlegenden Änderung der traditionellen Behandlung verbunden und erfordert daher nicht nur einen erheblichen personellen, logistischen und finanziellen Aufwand, sondern auch die Bereitschaft umzudenken. Rückgrat für den dauerhaften Erfolg ist ein prospektives Monitoring des Protokolls und der klinischen Resultate. Die Einführung dauert 6 – 12 Monate und ist kosteneffektiv.

Abstract

Nearly 20 years have passed by since the first sensational reports were published on “fast track” surgery. Initial polemic and scepticism have faded away. The clinical pathways have been developed further from “faster to better” and are meanwhile integral part of perioperative care in many surgical units.

The ultimate goal of those multimodal pathways is a reduction of the surgical stress response. Several randomized trials have shown a reduction of complications and hospital stay by 50 % and several days, respectively. “Fast Track” was replaced by “Enhanced Recovery After Surgery” (ERAS®) as the main focus is an improvement of postoperative recovery and not its shortening at any price.

The current ERAS® protocol consists of more than 20 individual measures in the pre-, intra- and postoperative period. The clinical outcome depends largely on the compliance with the protocol: the higher the compliance the better the outcome!

Successful implementation of ERAS® goes along with radical changes of the traditional care schemes; it requires therefore not only considerable personal, logistic and financial efforts but also a shift in mindset. A prospective monitoring of compliance and clinical outcome is the backbone for sustained success. The systematic implementation takes 6 – 12 months and is cost-effective.

Schlüsselwörter

ERAS® - perioperative Behandlung - Viszeralchirurgie

Keywords

ERAS® - perioperative care - visceral surgery
 

  • Literatur

  • 1 Andersen J, Hjort-Jakobsen D, Christiansen PS et al. Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery. Br J Surg 2007; 94: 890-893
    CrossrefPubMedGoogle Scholar
  • 2 Bardram L, Funch-Jensen P, Jensen P et al. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation. Lancet 1995; 345: 763-764
    CrossrefPubMedGoogle Scholar
  • 3 Kehlet H, Mogensen T. Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme. Br J Surg 1999; 86: 227-230
    CrossrefPubMedGoogle Scholar
  • 4 Kehlet H, Buchler MW, Beart Jr RW et al. Care after colonic operation – is it evidence-based? Results from a multinational survey in Europe and the United States. Journal of the American College of Surgeons 2006; 202: 45-54
    CrossrefPubMedGoogle Scholar
  • 5 Adamina M, Kehlet H, Tomlinson GA et al. Enhanced recovery pathways optimize health outcomes and resource utilization: A meta-analysis of randomized controlled trials in colorectal surgery. Surgery 2011; 149: 830-840
    CrossrefPubMedGoogle Scholar
  • 6 Muller S, Zalunardo MP, Hubner M et al. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009; 136: 842-847
    CrossrefPubMedGoogle Scholar
  • 7 Varadhan KK, Neal KR, Dejong CH et al. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010; 29: 434-440
    CrossrefPubMedGoogle Scholar
  • 8 Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. American journal of surgery 2002; 183: 630-641
    CrossrefPubMedGoogle Scholar
  • 9 Wind J, Polle SW, Fung Kon Jin PH et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006; 93: 800-809
    CrossrefPubMedGoogle Scholar
  • 10 Fearon KC, Ljungqvist O, Von Meyenfeldt M et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24: 466-477
    CrossrefPubMedGoogle Scholar
  • 11 Gustafsson UO, Scott MJ, Schwenk W et al. Enhanced Recovery After Surgery Society fPC, European Society for Clinical N, Metabolism, International Association for Surgical M, Nutrition. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg 2013; 37: 259-284
    CrossrefPubMedGoogle Scholar
  • 12 Gustafsson UO, Hausel J, Thorell A et al. Enhanced Recovery After Surgery Study G. Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 2011; 146: 571-577
    CrossrefPubMedGoogle Scholar
  • 13 Ahmed J, Khan S, Lim M et al. Enhanced recovery after surgery protocols – compliance and variations in practice during routine colorectal surgery. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland 2012; 14: 1045-1051
    CrossrefPubMedGoogle Scholar
  • 14 Roulin D, Donadini A, Gander S et al. Cost-effectiveness of the implementation of an enhanced recovery protocol for colorectal surgery. Br J Surg 2013; 100: 1108-1114
    CrossrefPubMedGoogle Scholar
  • 15 Maessen J, Dejong CH, Hausel J et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 2007; 94: 224-231
    CrossrefPubMedGoogle Scholar