Treatments

Patients Love A Gentler Approach To Surgery, But Surgeons Balk

We know you'd rather skip the fasting and bowel prep. But that's the way we've always done it.

We know you'd rather skip the fasting and bowel prep. But that's the way we've always done it. iStockphoto.com hide caption

itoggle caption iStockphoto.com

Surgery can be a necessary misery, endured in hope of health.

But what if you took away the misery, and kept the benefits?

When hospitals quit subjecting patients to prolonged fasting, nasogastric tubes, abdominal drains, and other commonplaces of surgical care, a study finds, patients feel less pain and recover faster.

Women who had major abdominal surgery at the Mayo Clinic under a protocol to enhance recovery went home sooner and needed less pain medication than women who had the surgery the usual way. And 95 percent of the women in the group whose treatment emphasized recovery rated their care as excellent or very good.

The enhanced recovery approach, which was pioneered in Europe about a decade ago, abandons many of the standard steps for patient care before, during and after surgery. It turns out there was no evidence of benefit for many of these practices, even though they're used worldwide. So this protocol chucks them.

So patients aren't asked to slurp down quarts of medication to clean the gastrointestinal tract, so-called bowel prep, or told to shun food and drink before surgery. Instead, they can eat up till midnight the day before, and drink water up till four hours before surgery.

Anesthesia and pain management changed, too. The goal is to avoid using intravenous opioids, because they make people nauseated, constipated and generally feeling crummy. Instead, the Mayo doctors gave patients nonnarcotic painkillers, such as acetaminophen, before, during and after surgery.

People who still had pain after surgery were given oral opioids. Only if that didn't work would they get an opioid IV. Overall, patients' use of opioids dropped 80 percent in the first two days after surgery, and they didn't report more pain.

And there wasn't much lying in bed. Once patients left the operating room, they were encouraged to start eating and drinking four hours after surgery — and to be up and walking that evening.

"The early feeding makes a big difference" in how people feel, says Dr. Sean Dowdy, a professor in obstetrics and gynecology at Mayo who led the study. But he told Shots it's not just that. "Whether it's the early feeding or the lack of bowel preps or the change in anesthesia delivery, regardless, patients are happier."

Happier, OK. But what about their health? The Mayo doctors compared the 241 women who had the enhanced recovery approach to surgery in 2011 to women who had similar surgery using conventional management the year before. The enhanced recovery group's hospital stays were shorter, with women who had surgery for ovarian cancer going home four days earlier. Patient care cost $7,600 less, on average, with the new protocol. The results were published in the journal Obstetrics & Gynecology.

"What we didn't want was to have all these interventions and perhaps dismiss [patients] from the hospital early and have their satisfaction going down," Dowdy says. Indeed, hospitals long ago figured out that kicking patients out sooner is one way to reduce costs. But sometimes the early discharges increase complications and readmissions.

That wasn't the case in this study. "We don't have an increase in readmissions or anything like that," Dowdy says.

Now all inpatient gynecological surgery at Mayo uses the enhanced recovery pathway. Mayo and other hospitals also have adopted this approach for colorectal surgery, too, including the seemingly counterintuitive steps of skipping bowel prep and allowing food before surgery. Studies find it to be as safe and effective as conventional surgical management. Mayo doctors say their patients come out of surgery stronger, less dehydrated and feeling better.

That quicker recovery is especially important for women with ovarian cancer, Dowdy says, because they're almost certainly going to have chemotherapy after surgery. "They really have to recover to the extent that they're healthy enough for chemotherapy," Dowdy says. "We're not going to hit them when they're down."

Sounds good. Can I get this kinder, gentler approach to surgery at my local hospital? Probably not.

Though this protocol has been discussed and studied for at least a decade, very few hospitals offer it. "People are just not willing to accept that this is a better way to manage patients," Dowdy says.

That's people as in surgeons. "I'm a surgeon," Dowdy says. "Surgeons are typically pretty set in their ways. There are traditional and strongly held beliefs that you have to manage patients in a certain way or they'll do badly. This challenges that doctrine."

Partly for that reason, Dowdy assembled a team of surgeons, oncologists and anesthesiologists to customize the protocol. They decided not to use epidural anesthesia, for instance, though it has been used in other enhanced recovery protocols. The anesthesiologists on the team were concerned that it could cause dangerous drops in blood pressure.

The Mayo team is continuing to fine-tune their system, including experimenting with a drug that can be injected into a surgical incision to reduce pain for three days. "This was kind of our first stab at this," Dowdy concludes.

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