Surgeons at St. Joseph Mercy Ann Arbor have totally re-engineered the way they treat colorectal cancer— before, during and after surgery–and the results have led to some of the best patient outcomes in the country for a disease that strikes more than 150,000 Americans each year.
By analyzing the entire process from the patient’s perspective, the team at St. Joe has developed a model for treatment that is setting the national standard for colorectal care. Its main components include:
Pioneering use of the minimally invasive da Vinci® Robotic Surgical System for colorectal conditions;
The “Enhanced Recovery Initiative,” (ERI); which includes comprehensive patient education and more effective pre- and post-surgical protocols.
For Robert Cleary, MD, lead physician of da Vinci surgery for colorectal cancer, it is the culmination of a 25- year career that began in general surgical residency at St. Joe and included a colorectal surgical fellowship at Parkland Memorial Hospital in Dallas.
“St. Joe added the da Vinci to our suite of robotic surgical tools in 2006. At the time, it was being used mostly by urologists and gynecologists,” said Dr. Cleary. “I had been fellowship trained in laparoscopy, but I was convinced we could use the da Vinci for colorectal conditions, too. With its 3D imaging, greater flexibility and improved dexterity and control, I thought it would be easier than working with a laparoscope.”
ERI has shortened hospital stays by two to three days with no increase in readmission.
Well informed, well prepared patients are able to participate more fully in their own recovery.
2009 was a signature year for the Colon and RectalSurgery service. Dr. Cleary applied through the American Council for Graduate Medical Education to establish a Colon and Rectal Surgery fellowship at St Joe’s. This fellowship to train future colon and rectal surgeons was approved in 2012. The second fellow is currently enrolled in this program that includes robotic training.
As compared to traditional, open surgery, the da Vinci approach promises less blood loss, smaller scars, shorter hospital stays, lower likelihood of infection or other complications and a faster recovery time. “We also see better clinical outcomes, quicker return to bowel function and normal diet, significantly less pain and faster healing,” he said.
But spectacular as the surgical successes are, what happens before and after surgery is equally important to the overall patient experience. The Enhanced Recovery Initiative (ERI) is a program developed by Dr. Cleary and a host of colleagues in anesthesia, nursing, nutrition, case management and other disciplines.
“We sat around a table and said, ‘ok, we’re going to create an enhanced recovery protocol—much like ones that have been popularized in Sweden,’” he said. “We decided that each of us would research all the literature in our area of expertise and come back every month to discuss our findings.”
The group learned, for example, that the conventional wisdom of no food or drink 12 hours before surgery was not the best approach; that the patients actually did much better if they consumed a high carb sports drink (Gatorade) two hours before the procedure. It decreased nitrogen and protein losses, reduced insulin resistance, helped maintain lean body mass and decreased recovery time and length of stay.
“We also learned about better ways to do bowel prep, anesthetics and pain management, and we found treatments that reduced the incidence of post-surgical blood clots as well as nausea and vomiting,” he said. Other enhancements included better fluid management that speeds up the return to normal bowel function, early removal of urinarycatheters and a quicker return to post-operative feeding and mobilization.
ERI, which went live in February of 2012, has shortened hospital stays by two to three days with no increasein readmission.
Key to the success of the program is patient education that begins with the first office visit. After speaking with the physician, patients are given an information kit that includes hard copy handouts and a DVD with a 15-minute PowerPoint presentation that detail the disease process, treatment options, risks and benefits, milestones and expectations. Well informed, well prepared patients are able to participate better in their own recovery.
Dr. Cleary believes the combination of da Vinci robotic surgery and the Enhanced Recovery Initiative make St. Joe’s colorectal program the most progressive in the region. “Along with our fellowship program, it has put us in prime time and gained us a reputation as a state-of-the-art center,” he added.
Dr. Cleary is setting his sights on the outpatient experience. “We want to bring the same scrutiny to the patients’ healing process once they’ve gone home,” he said. In addition, St. Joe is working with the Michigan Surgical Quality Collaborative, a consortium of 67 hospitals across the state, to share its findings and replicate its successes statewide.