Construction and development of enhanced recovery after surgery system under LEER model

To the Editor: The concept of enhanced recovery after surgery (ERAS) has garnered attention worldwide, and received robust recognition and support from numerous governments, owing to its impressive outcomes and expanding application areas.[1,2] The development of a surgical system for accelerated recovery under the less pain, early move, early eat, and reassuring (LEER) model represents a goal-oriented, integrated methodology designed to address the lack of a systematic and standardized workflow in current accelerated recovery surgical practices, aiming to standardize and systematize ERAS procedures comprehensively. Utilizing the successes of the LEER model, our team has established a multidisciplinary, integrated ward for accelerated rehabilitation, which has not only innovated the ERAS multidisciplinary team (MDT) in form and content, but also sparked new approaches for broadening its application across all clinical settings.[3] This letter discusses the establishment of the LEER model application system and the concept of its clinical expansion. With the ultimate aim of enhancing postoperative recovery, our team identified the most critical factors influencing accelerated postoperative recovery from a broad set of ERAS requirements, setting them as milestone goals. These were identified as less pain, early move, early eat, and reassuring—collectively forming the acronym “LEER”. The LEER model, pronounced [lɪr], is defined as a methodology guided by the goal of “less pain, early move, early eat, and reassuring”. It integrates various elements, measures, and methods of accelerated recovery surgery, relying on a unified approach to information systems integration, and promotes systematic, standardized, and cohesive thinking, methods, and processes. Less pain evaluates the effects of treatment on disease-induced pain, traumatic pain from the treatment, and the body’s subsequent stress response, forming the core component of the ERAS program’s implementation. Early movement encompasses all bodily motor functions, including the internal motion of cells, tissues, organs, and external movements such as limb motion, breathing, and coughing; crucially, it supports the swift recovery of organ function in postoperative patients. Early eating considers food as the essential energy source for all bodily activities and the primary maintainer of gastrointestinal barrier function, providing either early enteral nutrition (EN) or total parenteral nutrition (TPN) to those unable to eat, vital for rapid post-surgical recovery. Reassuring the patient addresses the psychological impacts of trauma, anxiety, fear, and other crises, significantly influencing recovery smoothness. The workflow, designed around the integrated goals of the LEER framework, is implemented throughout the patient’s admission, pre-surgery, intra-surgery, post-surgery, and post-discharge stages. A collaborative team comprising the attending physicians, intraoperative anesthesiologists, operating room nursing staff, and the department’s multi-target nursing group (MTNG) delivers precise treatment and management to enhance the patient’s perioperative care.[4] The benefits of this approach include as follows: (1) establishment of a LEER model promoting accelerated recovery surgery at its core; (2) development of an ERAS standardized workflow and quality control system under the LEER framework; (3) creation of an MTNG for precise goal implementation; (4) construction of the LEER-ERAS information system to ensure the safe execution, grassroots promotion, and application of the ERAS work system, standards, and quality control. The clinical application and practical effects include significant improvements during the pancreaticoduodenal perioperative period, with the postoperative pain score decreasing from an average of 4.59 to 3.12, the postoperative hospital stay reducing from 15.76 days to 11.52 days, and hospitalization costs falling from RMB 70,167.7 Yuan to 61,610.92 Yuan.[5] In laparoscopic anatomical hepatectomy, bowel function recovery time was shortened from 2.54 days to 1.98 days, the postoperative hospital stay was reduced from 9.93 days to 8.26 days, and hospitalization costs decreased from RMB 45,562.24 Yuan to 43,772.34 Yuan. The multi-objective MTNG workflow, based on the ERAS methoology and the LEER model, was applied to 107 cases of hepatobiliary and pancreatic malignancies in the perioperative period. Following surgery, the time to resume normal eating was reduced from 4.21 days to 3.62 days, the length of the postoperative hospital stay was shortened from 9.81 days to 8.31 days, score of patient understanding of their disease improved from 78.6 to 86.79, medical compliance increased from 80.01% to 85.93%, and total satisfaction with nursing services rose from 89.1% to 98.6%.[4] Building on the concept of ERAS in the early stage of the LEER model, the team further explored how to mobilize internal medicine resources in clinical practice to collaborate with surgical teams. This collaboration aimed to enhance the surgical rate and postoperative rehabilitation of elderly patients and those with critical illnesses or chronic conditions. Efforts focus on reducing preoperative waiting times and postoperative recovery durations, minimizing postoperative complications and mortality, thereby speeding up ward turnover and expediting recovery. The All in One (AO) ward model was developed to address these challenges. This model represents a new approach within an MDT framework, specifically designed for accelerated recovery surgery (ERAS-MDT). The AO ward consists of three components: the main ward, the auxiliary ward, and the support ward. The main ward comprises all professional departments within the surgical system and internal medicine, featuring comprehensive specialties such as geriatrics and general medicine. The auxiliary ward includes related internal medicine specialties that provide additional treatment support to enhance the main ward’s specialty care. The support ward involves specialties directly related to surgical diagnosis and treatment. The “All” in AO encompasses the “Main Ward + Auxiliary Ward + Support Ward”, while “One” denotes the unified processes and standards employed across this integrated ward to achieve the collective goal of accelerated recovery. This integrated approach is termed the “LEAO” ward (LEER mode accelerated rehabilitation All-in-One ward [LEAO], pronounced “Leo” in Galician). The workflow of the AO ward is detailed in Figure 1. Our team’s initial application of the AO ward model to elderly patients with gallstones demonstrated significant benefits: a higher surgical treatment rate, reduced preoperative hospital stays, lower postoperative pain scores, shorter times for postoperative gastrointestinal function recovery, decreased postoperative hospital stays, reduced costs of surgical hospitalization, and increased patient satisfaction (P <0.05).Figure 1: Workflow diagram of AO ward. Main ward consists of hepatobiliary and pancreatic surgery and general medicine, and is responsible for perioperative management and surgical treatment in the main ward. Adjunctive treatment ward consists of the Department of Respiratory Intensive Care, the Department of Gastroenterology, the Department of Endocrinology, the Department of Cardiovascular Medicine, and the Department of Neurology. Specialized treatment is provided to patients in the main ward who require related specialist treatment. Supportive care ward consists of the Department of Anesthesiology, the Department of Nutrition, and the Department of Rehabilitation, and it provodes anesthesia support, nutritional support and rehabilitation support for surgical patients in the main ward. AO: All in One.The construction of the surgical system under the LEER model aims to enhance the implementation of the ERAS concept. Its workflow is systematic, standardized, and easily comprehensible, enabling straightforward memorization and execution by doctors and nurses. After clinical application, this model has not only yielded expected outcomes in treating specific diseases but has also gained recognition across various medical specialties. The results demonstrate that establishing the AO ward for accelerated recovery in the perioperative treatment of elderly patients with gallstones not only facilitates patient treatment and rapid recovery but also promotes resource integration within the hospital. Furthermore, it provides a strategic direction to alleviate the constraints of surgical resources. Building on this foundation, the ERAS concepts and measures beneficial to patients have been expanded into the enhanced recovery after treatment (ERAT) concept. This expansion aims to foster accelerated recovery across all clinical specialties post-treatment, explore new operational modes and deeper meanings within the ERAS-MDT framework, and identify innovative approaches for the treatment and management of chronic diseases. It is anticipated that an independent sub-discipline of accelerated rehabilitation medicine may be established based on the ERAT concept in the future to address the increasing clinical demands.