Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey

Prehabilitation elements

The majority of the respondent counseled patients to stop smoking (81.6%) and alcohol consumption (80.1%) before surgery, encouraged them to exercise (76.4%), and perform incentive spirometry (95%), before surgery. Preoperative anemia is corrected by most (94%) practitioners, and hypoalbuminemia by 89.7%. Immunonutrition is used only by 26.4% of clinicians in this study. Further details are presented in Supplementary Material 3 (Figure 1).

Figure 1:

Prehabilitation practices among the respondents.

Preoperative and intraoperative elements

MBP was reported used by 84.5% of respondents. Preoperative fasting up to 2 h for liquids was reported by 43.8% of respondents. Half (50.6%) respondents said that patients are kept fasting up to 6–8 h before surgery. The rest of the respondents used longer fasting periods preoperatively. Carbohydrate preloading was reportedly used by 40% of respondents. Thromboprophylaxis was initiated by 92.6% of respondents before surgery. Low molecular weight heparin was the commonest drug used (77.9%) for thromboprophylaxis (Tables 1 and 2).

Multimodal analgesia was used by most (94.8%) respondents. Thoracic epidurals, opioids, and non-steroidal anti-inflammatory drugs were the commonest combination (76.4%) used for multimodal analgesia. Goal-directed fluid therapy was reportedly used by 55% of respondents. Most (86%) respondents reported specific intravenous fluid infusion rates and target urine output during CRS and HIPEC phases, each (Table 2). Core body temperature was monitored by 90.4% of respondents. The majority (80%) respondents reported active measures to maintain normothermia during CRS-HIPEC procedures.

Postoperative elements

Intensive care unit (ICU) admissions were reported by 83.8% of respondents for postoperative care. The majority (83%) reported that patients were not extubated immediately post-surgery, and were ventilated electively. Non-invasive ventilation was used by most (71%) respondents during the period of ventilation. The average length of ICU stay for patients was reported as two days by 49.2%, and four days by 30.8% of respondents. Intravenous fluids were stopped by most (82.3%) when the patient started accepting orally (Table 3).

Most (94.7%) respondents used intraabdominal drains. These drains were removed when the output reduced below a subjectively determined volume (65.4% respondents). Most (77.9%) reported using intercostal drains when diaphragmatic surgery/peritonectomy was performed. Urinary catheters were kept up to 72 h by 32.2% of respondents, 36.7% removed these when the patient became ambulant. The majority (84%) used nasogastric tubes in the postoperative period. Thromboprophylaxis was continued in the postoperative period by most (97%) respondents. The average hospital stay was reported between seven to 10 days by 44.8% of respondents, while 10–12 days was reported by another 30%.

There were some differences in the practices among clinicians working with and without a formal protocol incorporating ERAS practices. The only statistically significant one was the use of preoperative carbohydrate loading that was more in the ERAS group (p=0.002) (Table 4). The ‘commonest choices among responses’ for ERAS elements were compared with the consensus guidelines. The percentage of agreement was low (50–75%) for postoperative practices like avoiding nasogastric drainage, intra-abdominal drains, and thoracic drains, which was similar to the practices of our respondents (Table 4).

Working protocol and checklist

The working protocol (Supplementary Material 4) includes 44 elements that are divided into essential and non-essential elements (Figure 2). Essential elements are those that must be followed in all patients irrespective of the disease extent and nature of surgery. Non-essential elements are those which can be selectively implemented at the discretion of the treating clinicians.

Figure 2:

Essential and non-essential elements in the working protocol for prospective implementation of ERAS practices.

Prehabilitation

Benefits of prehabilitation have been shown in several recent studies, and these form integral initial elements in an ERAS pathway [23], [24], [25], [26]. It was encouraging to see that most clinicians were following prehabilitation practices in their CRS-HIPEC subset of patients (75–95%). Incentive spirometry was initiated by most (95%) when a decision of surgery was made [27]. Our previous report showed a reduction in respiratory complications in patients undergoing CRS-HIPEC with preoperative spirometry and non-invasive ventilation in the postoperative period [28, 29].

Preoperative elements

The current consensus is to avoid mechanical bowel preparation for major abdominal and pelvic surgeries except for rectal surgeries, though bowel preparation with oral antibiotics is recommended [30]. The majority (86%) of respondents still use bowel preparation for their CRS-HIPEC procedures. In the international consensus, 65.2% recommended MBP for patients undergoing rectal resection, which is low considering that these patients have higher rates of bowel resections and multiple anastomoses. Most of our patients present with a high peritoneal cancer index, that merits multiple bowel resections, and most commonly, a rectal resection [28, 31]. There are two theoretical benefits of bowel preparation – reduction in leak rates and wound infections. Anastomotic leaks after CRS-HIPEC are difficult to manage [32, 33]. This and the possibility of unplanned rectal resections are likely reasons for a more conservative approach. The side-effects of mechanical bowel preparation are patient discomfort, dehydration, and prolonged hospital stay [17]. ‘Modern fasting’ practices were reported as 43.8% for liquids (2 h before surgery) and 50.6% for solids (6–8 h before surgery), respectively [34]. There is still a large scope of improvement in these elements. More robust clinical evidence is needed before avoiding bowel preparation can be systematically incorporated into ERAS practices.

Intraoperative elements

Forty-five% respondents reported that they were actively trying to reduce opioid use, usually by alternative regional analgesia techniques like transversus abdominis plane block, wound infiltration, etc. Similarly, the use of epidural analgesia, which has shown advantages for other surgical procedures, was high (>75.0%) [18].

In the recently published ERAS guidelines, there are many other components like measures for preventing surgical site infections, skin preparation, maintenance of normothermia, optimal fluid management using goal-directed fluid therapy that is already part of the perioperative management protocols [14, 17, 35]. Majority of the respondents followed these practices. The SOAPC has published consensus guidelines for the perioperative management of patients undergoing CRS-HIPEC that already address most of these issues [36]. Some specific measures were not included in our survey questionnaire as they represent routine practices like skin preparation and prophylactic oral antibiotics.

Postoperative management

More than 50% of the respondents favored early extubation, if possible, in the operating room, early mobilization, and early initiation of feeding, which concurs with ERAS practices. But extubation in the operating room or elective ventilation depends on many factors like preoperative pulmonary and cardiac comorbidities, resection of the diaphragm, amount of blood loss during surgery, and hemodynamic stability at the end of surgery [37]. The respondents’ approach was more conservative regarding other practices like avoiding nasogastric drainage or early removal, avoiding/early removal of intraabdominal and thoracic drains, and early removal of the urinary catheter. Once again, this could be attributed to the extent of the surgery. It’s been proposed that nasogastric drainage can be avoided in patients who do not undergo resection of the lesser omentum [14]. In our protocol, these practices are optional, and we will prospectively evaluate the results of these practices using the checklist. Another essential aspect that is difficult to replicate in the Indian subcontinent is early discharge [35]. When the cost is borne by patients directly, both clinicians and patients are more comfortable with a few extra days in the hospital than early discharge, which is less than the cost of taking essential supportive care at another medical facility. Patients coming from smaller towns and remote areas do not have access to the supportive care required following these procedures (supportive fluid therapy, drainage of collections). Traveling back and forth is expensive and inconvenient. The postoperative practices are still conservative and need the maximum transition to ERAS pathways. It has been shown that out of several ERAS elements, postoperative elements have the greatest impact on optimal recovery [37]. However few recent studies have demonstrated that postoperative elements are the most difficult ones to implement [38, 39].

Implementation of ERAS protocol and checking compliance

The working protocol comprises essential and non-essential elements (Figure 2). Compliance of 70% is acceptable when evaluating adherence to ERAS protocols. But this may not be applicable for all elements. Some elements like prehabilitation, shorter duration of fasting, carbohydrate loading, multimodal analgesia, and early ambulation can be implemented in all patients, irrespective of disease extent and surgical complexity (Supplementary Material 4), and the compliance for such elements should be nearly 100%. Implementation of these can lead to a reduction in morbidity and length of stay. Others like avoiding MBP, early removal of drains, and early discharge may be difficult to implement in all patients and more evidence is needed to recommend their routine use. Studies reporting the feasibility of ERAS in patients undergoing CRS have also demonstrated lower compliance for the latter [35, 39]. This division into essential and non-essential elements should make it feasible for more teams to follow these practices. The accompanying checklist is a simple and inexpensive tool to both document and evaluates compliance.

Future directives

Implementation of the protocol and check-list will enable us to devise a final protocol that can be implemented with a high level of compliance at our centers. It will be used to analyze the impact of these practices on morbidity and mortality. Based on the results and accumulating evidence from around the world we hope to be able to create an ‘ideal’ protocol for the Indian centers. The results will also be discussed at clinical meetings and conferences to recruit more centers for the study. Members of both societies will be informed thorough emails and social media platforms about the outcomes of the prospective study. The results will also be published in scientific journals.

Our survey was exhaustive considering ERAS practices alone and had a reasonable response rate (>60%). Nearly 100% of the surgeons exclusively involved in the management of peritoneal metastases responded to the survey. This survey serves as a baseline evaluation of the existing practices. The working protocol and checklist can be used by other teams to implement ERAS practices. There are certain weaknesses of our study. Firstly, it is a survey-based study, thus represents clinicians’ opinions. There is always a possible gap between responses and actual practice in a survey-based study. The strengths of our study are that this survey represents the perspectives of anesthesiologists and Intensivists too. Prior surveys have not engaged these practitioners. Our survey is possibly the most exhaustive survey yet on CRS-HIPEC, with 76 questions. We feel this study captures most perioperative elements involved in the CRS-HIPEC subset of patients. The prospective validation of ERAS-CRS-HIPEC guidelines will soon be undertaken, and we would be able to contribute to ever-emerging evidence supporting ERAS.