You may have heard of ERAS, it’s very fashionable and combined with the laparoscopic approach should dramatically reduce the length of inpatient stays from 5 to 7 days (and even longer) to 2 or 3 days. It has been popularised in Scandinavia and Holland where it is the normal standard of post operative care.
ERAS is genuinely marvellous, the principle of it being that instead of lying in your bed for a week after we whip out a piece of your colon you are instead up and about, free of catheters, drains, IV fluids, casually chewing some gum in between your 3 small meals a day and leaving the hospital 48 hours later regardless of whether or not you’ve opened your bowels. You take minimal pain killers and get no complications like “hospital acquired thrombosis” as they have somehow renamed deep vein thrombosis on various posters around Bighospital.
It’s great and if you are a healthy person with your own teeth, you cycle everywhere, have a BMI of 21 and are on no medications you can expect it to all work out just like we tell you.
The problem with this idea in practice is that some of the people of Bighospitalburgh are amongst the most deprived people in the country. We are almost at the top of the league tables for low income, poor health, low literacy, crime, access to services, housing and unemployment. You can’t put these people through enhanced recovery and expect it to go well.
The other problem that we have with enhanced recovery is that the patients don’t get “on board” with it. Despite 5mm operating ports and a tiny extraction wound they take to their bed for 3 days and will not get up. They are asked to fill in an ERAS diary, which they don’t and won’t do. They are asked to get up and walk about, which they don’t do when they haven’t had an operation.
They take huge quantities of opiates and bung themselves up so they won’t open their bowels for a fortnight. They don’t like opening their bowels anywhere other than their own toilet anyway.
Most people expect to stay a week at least after we remove some colon. They are adamant that they can’t go home after 2 days.
If I was a 60 year old illiterate, unemployed, alcoholic who lived alone in a council house and lived off tinned corned beef and crisps and couldn’t afford to heat my house, would I be convinced to leave hospital 72 hours post right hemi colectomy? I think I would stay in the warm, clean bed with the nice nurses who help me wash and bring three meals a day.
Interested parties should read the following review: Wind J et al. Systematic review of enhanced recovery programmes in colonic surgery. British Journal of Surgery 2006;93:800-9