28.1 Introduction

Enhanced Recovery After Surgery (ERAS) is a multimodal multidisciplinary pathway aiming to provide the best evidence-based care to the patient with the involvement of a multidisciplinary team [1]. The aim of enhanced recovery is not only to shorten patient’s length of stay, which was initially named “fast-track”, but mainly to restore patient’s preoperative function allowing the patient to get back to his baseline condition early [2]. ERAS focuses on “Enhanced” not on “fast”, meaning general improvement of patient’s condition is the key that may as secondary (positive) effect speed up the entire perioperative process. The principles of ERAS have been successfully applied in many surgical disciplines, including hepatobiliary and pancreatic surgery. The implementation of ERAS into clinical practice is a new way of conceive the perioperative period with new organization. To apply successfully an ERAS pathway is demanding and requires the full involvement and training of a dedicated multidisciplinary team (MDT), as illustrated on Fig. 28.1.

Fig. 28.1
figure 1

Organization chart of an Enhanced Recovery After Surgery (ERAS) multidisciplinary team

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Specific ERAS guidelines were first published in 2016 for liver surgery [3] and were updated in 2019 for pancreatoduodenectomy [4]. These recommendations were based on a systematic review and processed by a modified Delphi process and detailed the associated evidence and recommendation for each ERAS items (23 for liver, 27 for pancreas). The present chapter will go through the practical implementation of an ERAS program and the current evidence supporting ERAS for liver and pancreas surgery, with focus on the multidisciplinary management of the patient and the active involvement of the patient himself.

28.2 ERAS: Moving from Evidence-Based into Clinical Practice

The evidence-based items included in ERAS is a continuous process covering the entire patient’s journey, starting from the pre-admission until home-discharge and follow-up. The main areas of focus are preoperative counselling and optimization, normovolemia, multimodal opioid sparing analgesia, as well as early scheduled nutrition and mobilization. According to the latest available guidelines, ERAS items for liver and pancreatic surgery are summarized in Table 28.1. The translation of evidence-based elements of enhancement into clinical practice represent a proper challenge. Simply elaborating and establishing a protocol is not enough [5] and much more efforts and changes in organization are required to improve the perioperative outcome.

Table 28.1 Enhanced Recovery After Surgery (ERAS) items for liver and pancreas surgery
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A MDT must be gathered first under the initiative of a project leader or “ERAS champion”. In our experience, the surgeons in charge of the respective units were designed as leaders of the team and were supported by two to three designated surgeons. In other hospitals anesthesiologists are the champions but the process remain the same: surgeons, anesthesiologists, nurses and patients working together. An optimal MDT should include at least a nurse, an anesthesiologists, an administrator and a surgeon. Other health care workers like physiotherapists or nutritionists as part of the team. A dedicated and specifically trained ERAS nurse is of uttermost importance. The support of the administration is essential from the beginning, to obtain the required resources and monitor the financial benefits. The team should then undergo training to implement an enhanced recovery pathway in their own unit or hospital. ERAS implementation process is a systematic training program provided by ERAS academic experts and conducted over a 8 to 10 months structured period. Following the definition of measurable goals, actions and plans are put into practice, then observation and measurement are taken, and finally adequate adjustments are made. Regular multidisciplinary audit, also including nutritionists and physiotherapists, are conducted in order to monitor compliance and sustainability of changes achieved following the implementation process. The use of a systematic interactive audit system allows standardization of outcomes reporting and continuous data analysis [6]. Long term follow-up studies acknowledged the sustainability of such multidisciplinary implementation and maintenance of ERAS program [7]. With the Covid pandemic, the way to implement ERAS program is about to evolve and e-learning platforms will be used instead of in person meetings.

28.3 ERAS Benefits in Hepato-Biliary and Pancreatic Surgery

Following successful ERAS implementation, clinical benefits in liver surgery were consistently reported. At least five meta-analysis [8,9,10,11,12], with the latest published in 2020 reported a significant reduction in length of stay as well as 30%–50% reduction of postoperative complications, without increasing mortality or readmission. When reported, the functional recovery as well as the quality of life was also improved with ERAS [8]. ERAS compliance was ranging from 65% to 74% [10] and the rate of liver specific complications was not reduced by ERAS implementation [9]. Less than 20% of included studies in the latest metanalysis [10], reported a systematic audit. Therefore, significant improvement in the reporting of compliance as well as the application of systematic audit are awaited in ERAS for hepato-biliary surgery.

Regarding pancreatic surgery, the effect of ERAS on clinical outcome was frequently reported from 2007 until now in many studies. Their results were gathered in five main meta-analysis [13,14,15,16,17], which reported a significant reduction of overall morbidity and length of stay without any increase in readmission rate when an enhanced recovery protocol was applied. Concerning pancreatic surgery specific complications, such as delayed gastric emptying and pancreatic fistula, three of the five abovementioned meta-analysis [14, 15, 17] described a reduction of delayed gastric emptying and a similar rate of clinically significant pancreatic fistula with ERAS compared to historical care. However, the high variability of the number of ERAS items used in each study leads to heterogeneity in the included study.

A recent multicenter cohort study including 404 patients undergoing pancreateoduodenectomy within ERAS assessed the application of the guidelines in daily clinical practice [18]. The number of items applied divided the total number, also called “compliance”, was 62%, with the postoperative period being the most challenging part. Each item of an enhanced recovery protocol is of importance, but it is mainly their cumulative proportion, expressed as overall compliance, was a major factor for clinical outcome as an overall compliance of more than 70% was associated with a significant reduction of overall complications and length of stay. When looking at the impact of each element, the avoidance of postoperative nasogastric tube and early mobilization were independent factors associated with improved outcome after pancreatoduodenectomy.

The long-term outcome after pancreatic and liver surgery is also correlated with the multidisciplinary oncological treatment, including adjuvant chemotherapy. As postoperative complications might increase the interval between the surgical procedure and the start of chemotherapy, the potential role of ERAS compliance on this interval was evaluated in a retrospective analysis [19]. An overall compliance equal or more than 67% was associated with a significant decrease of the interval between surgery and chemotherapy for patients >65 years old.

As already mentioned, economical resources are a frequently raised issue when considering implementing ERAS, as it requires specific resources such as an enhanced recovery dedicated nurse, information’s booklet and database [20]. These investments may lead to resistance to enhanced recovery implementation [21]. However, these initial costs are quickly overwhelmed by the in-hospital cost reduction induced not only by the reduction of length of stay, but also by the decrease of complications. In hepato-biliary and pancreatic surgery, a recent systematic review [22] described among the five included studies in pancreas surgery, a mean cost reduction in favor of the ERAS of USD 7020. In liver surgery, only three studies were found, which precluded a systematic cost analysis. However, a cost-minimization analysis for liver surgery showed a total mean cost reduction of € 3080 per patient following ERAS implementation [23].

28.4 ERAS as a Multidisciplinary Team Approach

A multidisciplinary team (MDT) approach provides comprehensive patient-centered care by gathering a range of different health care professionals sharing a common objective. As ERAS is a multimodal multidisciplinary approach in order to improve patient outcome, the multidisciplinary work is essential, not only during the implementation period but also in the crucial period of sustainability.

Understanding barriers and enablers to ERAS implementation is a key process to improve collaboration within the MDT. An interesting study assessed qualitative barriers and enables across nurses, surgeons and anesthesiologists [24]. Nurses identified patient’s reluctance to early mobilization and feeding, which could be overcome by patient education. Lack of manpower and time was also identified. From the surgeons’ perspective, nursing culture and lack of nursing time, as well as personal preferences and resistance to change were potential barriers. Anesthesiologists expressed concerns that changing nursing culture and surgeon’s behavior would be difficult, and this could be overwhelmed by improved communication and collaboration. A systematic review [25] included studies with focus on health professionals’ experiences of ERAS implementation and identified five main themes: communication and collaboration, resistance to change, role and significance of protocol-based care, and knowledge and expectation. This review concluded that communication among partners and with patients, as well provision of comprehensive information to health professionals and patients, in addition with Identifying a local ERAS champions could improve ERAS implementation.

28.5 Conclusion

ERAS is a powerful improvement tool for the patient’s perioperative course. But application of ERAS in hepato-biliary and pancreatic surgery requires multidisciplinary communication and collaboration in order to deliver evidence-based best practice in a setting of patient-centered care. Under these circumstances, ERAS leads to improved patient outcome, with reduced complications and improved functional outcome associated with reduced length of stay for hepato-biliary and pancreatic surgery. In addition, implementation of ERAS pathway is a cost-effective intervention, allowing support from healthcare administration. Patient education and involvement, as well as multidisciplinary communication and collaboration are essential to reach high compliance to ERAS items, resulting in improved outcome.