Seventeen years is the average amount of time it takes for research to reach the patient bedside. But this is not always the case, as a team of clinician researchers in gynecological surgery are showing. “It shouldn’t take 17 years for new discoveries to reach patients,” says Sean C. Dowdy, M.D., deputy director for practice in the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery and chair, Division of Gynecologic Surgery, “One of our goals at the Kern Center is to not only discover new ways of delivering quality health care, but to improve the interface between discovery and translation to facilitate wide-spread dissemination. This is the only way to truly transform our practice, and the practice world-wide.”
Dr. Dowdy practices what he preaches. His team began looking at enhanced recovery after surgery (ERAS) for patients undergoing gynecologic surgeries, publishing their findings in 2013. The team studied the effects of a protocol designed to improve perioperative recovery for patients undergoing major operations for gynecologic cancer, and later published international guidelines (Part I and Part II) on best practices. The guidelines addressed elements including preoperative and postoperative diet, intraoperative and post-operative pain control, nausea and vomiting prophylaxis, fluid balance, and activity.
The study team of ERAS 1.0 reported that, “Implementation of enhanced recovery was associated with excellent pain management with reduced opioid requirements, reduced length of stay with stable readmission and complication rates, excellent patient satisfaction, and substantial cost reductions.”
After ERAS 1.0 was fully implemented throughout the division, ERAS 2.0 was designed to continue the cycle of improvement, says Dr. Dowdy. In ERAS 1.0, opioid use was reduced by 80% in the first 48 hours. For ERAS 2.0, “We wanted to determine if using an extended release form of bupivacaine injected into the surgical incision [standard bupivacaine was used in ERAS 1.0] would improve pain control and further reduce opioid requirements.”
The team’s findings, published in November 2016, showed that, “Substituting liposomal bupivacaine [extended release form] for the standard preparation resulted in an additional 50 percent reduction in opioid requirements. Furthermore, patient-controlled anesthesia requirements decreased from 30 percent to less than 5 percent without an increase in pharmacy costs.”
“These findings are important for improving patient recovery after laparotomy, but also positively impact the opioid epidemic. The goal is to have acceptable pain relief, while trying to prevent long-term opioid dependence.” says Dr. Dowdy.
Beyond suffering caused by nausea, vomiting, and pain after surgery, opioids combined with anesthesia reduces the ability of to move contents through the gastrointestinal tract, and may result in a common and unpleasant complication, called ileus. ERAS 2.0 resulted in a nearly 50 percent reduction in adynamic ileus, from 20% to 11%.
Dr. Dowdy and his team continue to work to disseminate the team’s findings and bring best practices to those outside of Mayo Clinic so patients all over the world can benefit. As part of an Agency for Healthcare Research and Quality contract, Dr. Dowdy will be the content expert for gynecologic surgery with the goal of disseminating enhanced recovery to 1000 service lines in 5 surgical specialties over the next 5 years.
Considering that each version of ERAS spanned the discovery-translation-application cycle over approximately 3 years in comparison to the average of 17 years, we can use this as a learning opportunity to accelerate the speed at which research is adopted into practice. As such, he and the team are preparing to initiate ERAS 3.0 in coming months to further improve perioperative recovery by fine-tuning elements of the prior ERAS pathways. In addition, they hope to increase standardization across surgeons to reduce variations in length of stay and decrease readmission rates.