Patient outcomes following implementation of an enhanced recovery after surgery pathway for patients with metastatic spine tumors

Abstract

Background Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence‐based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center. Methods The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0–5 cumulative opioid use (morphine milligram equivalent [MME]). Results A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre‐ERAS patients. Although the mean case durations were similar in the ERAS and pre‐ERAS cohorts (265 vs. 274 min; p = .22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p = .003), decreased postoperative day 0–5 cumulative mean opioid use (178 vs. 396 MME; p < .0001), earlier ambulation (mean, 34 vs. 57 h; p = .0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p < .001), and shorter LOS (5.4 vs. 7.5 days; p < .0001). Conclusions The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption.

What enhanced recovery means for patients with cancer undergoing surgery

“…One key limitation of this article is that Chakravarthy et al 9 . do not address the impact of their ERAS pathway on oncologic outcomes.…”

“…Their findings echo those of previous ERAS studies conducted for other cancer types such as gastric, breast, and peritoneal malignancies. 8,10,11 One key limitation of this article is that Chakravarthy et al 9 do not address the impact of their ERAS pathway on oncologic outcomes. For oncologists of all disciplines, it is vital to understand how these improvements in what seem to be relatively transient, perioperative metrics translate into cancer-specific outcomes.…”

“…What all of the aforementioned evidence demonstrates is that the physiological stress and impact of surgery for patients with cancer are important components of their overall oncologic treatment plan. Chakravarthy et al 9 . have demonstrated that an ERAS protocol improves key postoperative for patients undergoing surgery for spine metastases that, at least hypothetically, should lead to a more expeditious return to their planned additional oncologic therapy.…”

“…3,8 Although ERAS pathways provide clear and well-cited advantages for patients, surgeons, and hospitals in the immediate postoperative period, the impact of enhanced recovery programs on patients with cancer and their long-term oncologic outcomes is less known. In this issue of Cancer, Chakravarthy et al 9 report the implementation and study of an ERAS protocol for a novel population of patients undergoing surgery for spine metastases. Their study demonstrated a significant reduction in postoperative opioid utilization and hospital LOS as well as improvements in other secondary outcomes such as early mobilization, introduction of an enteral diet, and Foley removal.…”

“…Although ERAS pathways provide clear and well‐cited advantages for patients, surgeons, and hospitals in the immediate postoperative period, the impact of enhanced recovery programs on patients with cancer and their long‐term oncologic outcomes is less known. In this issue of Cancer , Chakravarthy et al 9 . report the implementation and study of an ERAS protocol for a novel population of patients undergoing surgery for spine metastases.…”