Surgery is always a bit worrying. We fear the pain, the time spent in hospital, possible complications, the number of medications to take… For around ten years, the device Enhanced Recovery After Surgery (ERAAC) precisely brings together “a set of measures before, during and after an operation, with the aim of minimizing the physical and psychological trauma experienced by the patient“, summarizes Dr. Benjamin François, orthopedic surgeon. With, as a result, less stress, reduced pain and shorter hospitalization. Focus on the main areas of application of this “new philosophy of care”, as the specialist defines it.
In oncology, adapted psychological preparation
In oncology (gynecological, digestive, urological cancers, etc.), the RAAC program is deployed through a multitude of measures: in addition to the use of outpatient surgery as often as possible and minimally invasive samples, “Particular attention is paid to the patient’s concerns: we seek to ease pre-operative anxiety in order to facilitate anesthesia and reduce the risk of postoperative complications”, indicates Dr Thomas Jalle, gynecological surgeon and oncologist*. To this end, we emphasize therapeutic education, by explaining to the patient the progress of his procedure to help him plan for the post-surgical period. Then, we encourage him to benefit from supportive care before the intervention: “pre-operatively, he can meet a psychologist, a sophrologist, etc.., which helps to relieve tension in the body and mind.”, continues the specialist. Finally, “he arrives standing at the block and places himself on the table. This may seem anecdotal, but it is very important that the patient does not feel “passive” regarding their care.”. And it works: in 2016, a study showed that the chances of 5-year survival of patients operated on for cancerous tumors were almost doubled when 70% of the RAAC recommendations were applied.
* At the Argonay clinic, in Haute-Savoie (Ramsay Santé group).
In gynecology, special attention to pain
In gynecopelvic surgery, the key to the RAAC program is post-operative pain management. “During the operation, multimodal anesthesia is used.explains Dr. Thomas Jalle. Clearly, besides general anesthesiawe will realize regional anesthesia under ultrasound, in order to put specific nerve endings to sleep, which considerably reduces pain upon waking up. Finally, before the end of the intervention, the surgeon infiltrates the scars with a local anesthetic. As a result, thanks to these three levels of analgesia, the patient often leaves the hospital with a simple prescription for paracetamol.” For certain major interventions, specific operating protocols have also been developed within the framework of the RAAC. “For hysterectomy (removal of the uterus), we use vNOTES surgery, a technique which consists of passing through the vaginal route: there are no scars and there is less disruption to the internal organswhich reduces post-operative pain and speeds recovery”concludes the doctor.
In digestive surgery, dietary support
In digestive surgery (liver, kidney, stomach operations, bariatric surgery, etc.), the RAAC includes a “nutrition” section. “Before being operated on, the patient benefits from appropriate preparation, aimed at reducing the risk factors for complications as much as possible.announces Professor Benoît Romain, visceral and digestive surgeon*. If he is affected byobesityFor example, a weight loss process, possibly as part of a Spa treatment, can be engaged. We also realize screening for diabetes, iron deficiency anemia and malnutrition.“After the operation,”the patient is encouraged to quickly return to a normal diet: no nasogastric tube or morphinebecause it slows down the resumption of transit, and causes nausea and vomiting”. Shortly after the intervention, he’s starting to eat again.”through the mouth and in a seated position, which promotes healing and an early return to a good quality of life. At the same time, the patient is invited to keep a logbook, in which he notes what he eats, how he feels, etc., in order to be an actor in his care.“.
*At the university hospitals of Strasbourg.
In orthopedics, a return to early walking
In orthopedics, RAAC is mainly applied in the context of major interventions, such as prosthetic hip and knee replacements, as well as cruciate ligament surgery. ” The number one issue is a resumption of support as quickly as possible.says Dr. Benjamin François. Early rise of the patient in fact allows a reduction in the risk of complications linked to prolonged bed rest, such as phlebitis, for example. But this early rising is also facilitated by so-called “pre-habilitation” work. “Before the intervention, we will optimize the patient’s physical condition. The latter will be able to follow, in particular, a muscle strengthening program (buttock and hip muscles, quadriceps, hamstrings, etc.) and benefit from physical preparation adapted to what awaits them. He will be taught, for example, to use crutches before he needs them. It’s very reassuring to be prepared in advance for the aftermath of the operation!” After the surgery, mobilization physiotherapy is put in place.with walking routes of varying length, more or less difficulty, which the patient is encouraged to approach as challenges”. In parallel, “pain management is crucial because the less pain the hospitalized person has, the sooner we can ask them to get up “.
Why prescribe respiratory physiotherapy after certain operations?
After orthopedic, thoracic or abdominal surgery, the RAAC protocol includes respiratory physiotherapy sessions. Odd ? Not so much: in the post-operative phase, pulmonary complications (pneumonia, bronchitis, collapse of the pulmonary alveoli, etc.) remain the main causes of mortality. Through simple exercises (inhaling, holding your breath, exhaling in a controlled manner through a straw, etc.), the physiotherapist prevents bronchial congestion helping the patient to effectively eliminate their secretions. Finally, he ensures the recovery of lung volume, because the latter can be reduced by anesthesia and medications that were administered before the operation.
Does the hospital you have chosen apply the RAAC?
In France, around forty hospitals and clinics have obtained the Grace Center label, issued by the French-speaking Group for Improved Rehabilitation After Surgery. This qualification, re-evaluated each year, guarantees that the establishment offers an RAAC program to patients in at least one specialty. Concerned establishments listed on grace-asso.fr/centres-grace.
The RAAC program has proven effectiveness
In 2016, the High Authority for Health (HAS) published a report which dissects the benefits of RAAC. Thus, for each type of surgery (colorectal, orthopedic, thoracic, gynecological and urological), the application of a RAAC program reduces the length of hospitalization by almost a day. The best results are obtained in colorectal surgery (–3 days on average). In terms of complications, RAAC is also effective: in gastroesophageal surgery, for example, this protocol reduces mortality by around 30%.
The patient better included in his medical journey
“These pre-, intra- and post-operative measures invite the patient to participate in therapeutic decisions concerning them and to become an actor in your recovery. Thus, it is no longer a medical object. This management philosophy has been shown to reduce the risk of complications (including nosocomial infections). It is therefore not a question of “putting patients out”, but just of supporting their recovery, without pressure.”
Thanks to Dr Benjamin François, orthopedic surgeon at the Pays de Savoie private hospital, in Annemasse, in Haute-Savoie (Ramsay Santé group).