The Society for Vascular Surgery (SVS) and the Enhanced Recovery after Surgery (ERAS) Society have released a consensus statement intended to help address perioperative challenges faced by vascular surgery patients.
The ERAS pathways have proven beneficial for a number of surgical specialties, and the application of these pathways will be important to address the needs of patients undergoing open aortic operations, according to a press release.
With the goal of delivering high-quality perioperative care and accelerating recovery, this consensus statement is intended to help address the many perioperative challenges faced by vascular surgery patients, who are often older, frailer and have more comorbidities than the average surgical patient.
This document focuses on both transabdominal and retroperitoneal approaches—including supraceliac, suprarenal and infrarenal clamp sites—for aortic aneurysm and aortoiliac occlusive disease operations.
Recommendations for the defined, universal ERAS elements are described, and include the following:
- Preadmission: Screening, preoperative exercise therapy/prehabilitation, perioperative anti-platelet, anticoagulation plan
- Preoperative: Fasting, carbohydrate loading, venous thromboembolism prophylaxis, pre-anaesthetic sedative and analgesia medication, antimicrobials, nausea/vomiting prevention
- Intraoperative: Anaesthetic protocols, epidural analgesia, body temperature management, drainage of surgical site
- Postoperative: Multimodal analgesia and opioid reduction strategies, nasogastric drainage, oral feeding, fluid therapy, urinary drainage, glycaemic control, early mobilisation strategy, discharge education, audit of outcomes
This document additionally reviews some traditional clinical practices where the literature does not allow firm recommendations, such as, preoperative medical risk assessment, skin preparation and intraoperative fluid therapy. The writing group has summarised the current state of knowledge because of the common use of these practices in many institutions, although they were not included in the formal recommendations in the consensus statement.
The recommendations for elective open aortic surgery are important as they are the first published and have summarised a large volume of heterogeneous studies across all ERAS elements for operations performed for either aortic aneurysm disease or aortoiliac occlusive disease. As a result of this, the existence of numerous research gaps has been demonstrated.
These recommendations support the use of care teams to enhance patient optimisation and shared decision-making in this population. There is a focus on physiologic stress minimisation and reduced variation in postoperative convalescence, which promises to improve the safety and outcomes for patients undergoing open aortic operations.
Katharine McGinigle (University of North Carolina at Chapel Hill, Chapel Hill, USA), chair of the SVS writing group, stated: “The ERAS writing group and I are thrilled to share this consensus statement for perioperative best practices for open aortic surgery, and really believe that our patients have much to gain. Each of these recommendations are really nothing new on their own, but it is the collection of them that makes the group of recommendations novel. They emphasise the coordination and timing of care across disciplines to reduce unnecessary care variation and to give our patients the best chances of an improved convalescence.”
This consensus statement provides a carefully reviewed and graded summary of the existing literature, which can guide vascular surgeons and other specialists from other disciplines who treat patients with aortic disease. It defines current standards enabling multidisciplinary teams to implement these procedures in their practice with the intent of improving patient outcomes.
To read this consensus statement, visit vascular.org/SVSERASdocument.