Olle Ljungqvist MD PhD

Past Chairman ERAS®Society

Professor of Surgery

Örebro University Hospital & Karolinska Institutet

Sweden

Improving Perioperative Care Worldwide

ERAS worldwide August 2022

Disclosure for Olle Ljungqvist

In compliance with COI policy, ESCRS requires the following disclosures to the session audience:

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Presentation does not include discussion of off-label use of a drugs or medical devices

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8^th ERAS World Congress

2

www.erassociety.org

Share some thoughts

What ERAS®Society has done

• Guidelines that works
• New way of working
• Congresses
• International Network
• Research

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• Improved outcomes for patients
• Saved costs for care & society

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Complications Hospital stay

Guideline compliance

50%

100%

ERAS and Survival?

Recent Review

Variability in ERAS protocol items

Pang et al, W J Surg Oncol 2021: 19: 191

ERAS and long term survival

What is available?

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ERAS vs Non ERAS Prospective cohorts 8 studies ≈ 1000 pats, 6 surgeries

ERAS vs Non ERAS RCT 2 studies ≈350 pats 4 different operations

ERAS vs Non ERAS 7 Retrospective cohorts ≈ 4450 pats, 6 surgeries

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1 – 10 year follow up

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Summary: 12 studies NS

5 studies improved survival

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Pang et al, W J Surg Oncol 2021: 19: 191

Adherence to guidelines and survival

Summary: OS 3 studies improved survival

3 studies NS

CSS 1 study improved survival

DFS 1 study improved survival

1 study NS

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Prospective cohort ≈750 pats, 2 surgeries

Retrospective cohort ≈ 1325 pats, 4 surgeries

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Pang et al, W J Surg Oncol 2021: 19: 191

Return to Intended Oncologic Treatment (RIOT)

Delayed RIOT: Complications or poor performance

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Risk factors: Hypertension

Mutiple preop chemo

Postop complications

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MIS more and faster RIOT vs open surgery

Return to Intended Oncologic Treatment (RIOT)

Pang et al, W J Surg Oncol 2021: 19: 191

ERAS and long term survival after cancer surgery

• Methodological issues
• Relatively low evidence reports available
• Mostly retrospective before/after implementation
• Variable protocols reported, compliance data scarce
• Many different operations
• Findings
• No report showing worse outcomes
• Better outcomes or no difference
• Compliance data speaks in favor of ERAS
• RIOT may be a factor

ERAS survival effect mainly in advanced CR cancer

Factor ERAS Traditional

n = 70 n = 279

Complications 17% 31%

Length of stay 5d 10d

Colorectal cancer surgery

1 ERAS trained surgeon

4 ”traditional” surgeons

5 year follow up

Lohsiriwat V et al Updates Surgery 2021: 73: 2169-2179

Controlling stress metabolism with ERAS�Insulin resistance

Insulin sensitvity

Bowel prep

No nutrition

Dinner, normal sleep

Carbohydrate treatment

Overnight fasting

Thoracic Epidural

Preoperative sedation

Surgery

Immediate feeding & mobilisation

NPO iv low caloric fluids

Oral feeding & mobilisation

Slow return to feeding and mobilisation

Days - weeks

ERAS Care

Traditional care

Ljungqvist JPEN 2012

Insulin reistance

Catabolism

Anabolic

Can ERAS affect residual tumor cells?

Horowitz et al, Nat Rev Clin Onc 2015; 12:213-226

Long term outcomes cancer surgery

Where is surgical care today?�And why?

21st century surgery �World Health Organization

Complications 1 in 4

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Death 1 in 20 – 200

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Surgery cause 1 in 2 adverse events

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Half preventable

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https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery

Variation in complications - Sweden

Complications (%)

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Nat’l 25%

38%

13%

Why different?

Standardized

Little standardised

Different worlds?

Control a machine, best practice established, weather

No standard of care, many unknowns, human variation

What we learned about�”Standard of care”

Standard of care?

PRE

INTRA

POST

What is failing?

Antibiotics

PONV

Thrombosis

NG tubes

Fluids

Fasting guidelines

Temperature control

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DRinking EAting Mobilising

It is not

the care you believe is being delivered

It is

knowing you deliver the right care

ERAS startingpoint�Finding the knowledge for a standard of care

Data in surgery world wide

Meaningful data

Helps improves outcomes

Use data correctly

Fearon et al, Clin Nutr 2005

All care that Improve Recovery

Multi disciplinary Entire patient journey Multi professional

Anesthesia

Bariatric*

Breast reconstruction*

Cardiac°

Cesarean delivery

Colorectal and small bowel*

Cystectomy*

Cytoreductive Surgery

Esophagectomy

Gastrectomy

Gastrointestinal

Gynecology* Head & Neck*

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ERAS^® Society Guidelines

* Guideline is currently supported in the ERAS® Interactive Audit System

°Guideline is currently in progress to be supported in the new ERAS® Interactive Audit System

Hip replacement°

Liver*

Neonatal intestinal

Pancreaticoduodenectomy*

Thoracic°

Emergency laparotomy Part 1

2022

AAA open surgery

ERAS for LMIC

ERAS Liver Transplantation

Emergency Laparotomy part 2-3

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Surgical care evidence for guidence

Experience

Science

A common probelm world wide

Staff are leaving

Factors that keep staff on the job

• Young nurses:
• Praise & recognition
• Support
• Joy in work

• Experienced nurses:
• Efficient processes
• Staffing
• Schedules

ERAS®Society Regional Networks

39

ERAS^®USA

ERAS^®Canada

ERAS^®LaTAM

ERAS^®Africa

ERAS^®Asia

ERAS^®Society

The Future of ERAS

Wish List

• Faster spread
• ERAS is needed more than ever
• Research faster & better
• Unique platform available
• Gov’t support to drive change

Challenges

• Traditions rule
• COVID ”opportunity”
• Data protection legislation
• Sharing of data limited
• Reaching decision makers
• Finding the right people

Approach to the challenges ahead

Respect

Curiosity

Sharing

Trust