A care pathway implemented at Vanderbilt University Medical Center has optimized patient recovery following surgery for soft tissue sarcoma, leading to reductions in length of stay and complications.
According to Joshua M. Lawrenz, M.D., assistant professor of VUMC’s Division of Musculoskeletal Oncology, the Enhanced Recovery After Surgery (ERAS) pathway is a model for multimodal perioperative care with four key components: nutritional optimization; pre-operative risk factor mitigation; multimodal pain control with minimal use of opioid medications; and early mobilization.
ERAS protocols implemented since 2014 have been associated with reductions of 20-30 percent in both length of hospital stay and complications, and Vanderbilt has been one of the key institutions to evaluate its clinical merit.
“This pathway has been proven to be very successful in many surgical subspecialties here at Vanderbilt,” said Ginger Holt, M.D., chief of the Division of Musculoskeletal Oncology. “Our patients with sarcoma are often high risk and in need of optimization. They frequently need large surgeries and can have pain throughout the surgical course.”
Working Together on Sarcoma
A multidisciplinary team at Vanderbilt Orthopaedics — including clinicians, clinical coordinators, anesthesiologists, nurses, physical therapists, and IT specialists — has come together under the title of ERASarcoma Workgroup.
“We’ve been tailoring the pathway for patients with sarcoma over the past year,” Lawrenz said, adding that the work may become part of a clinical research trial.
To establish the ERASarcoma pathway, the team partnered with Vanderbilt’s High-Risk Surgical Encounter (Hi-RiSE) Clinic, where patients at higher risk of developing complications — due to conditions such as frailty or anemia, for example — are comprehensively evaluated in order to coordinate interventions in the weeks leading up to surgery.
Since its launch in September 2022, the preoperative regimen for patients with sarcoma has included immuno-nutrition shakes and Hi-RISE clinic visits. All patients have access to a multimodal analgesia, a nerve block combined with predominantly non-narcotic medications. Physical therapists develop individual rapid-recovery and early-mobilization plans for each patient. Lastly, patients receive a regimen of perioperative antibiotics to target wound infections associated with sarcoma surgery.
The comparative clinical trial is designed to prospectively evaluate the efficacy of the ERAS pathway for patients undergoing surgical treatment for extremity soft tissue sarcoma. The primary endpoints of the study will include differences in opioid consumption and pain scores. Secondary endpoints include short-term patient reported outcomes, limb function scores, hospital length of stay, and perioperative complications such as wound complications. Investigators are currently recruiting participants for the trial.
“ERASarcoma is going to allow for more standardization of care, and hopefully improve patient experience,” Lawrenz said. “Patients with sarcoma tend to have baseline nutritional deficiencies, and a wound complication rate of 30 to 40 percent has been documented in patients who have had radiation and surgery for their extremity sarcoma. It would be impactful if this multidisciplinary effort could bring that number down.”