Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part I. Gynecol Oncol. 2016;140:313-322. [PMID: 26603969 DOI: 10.1016/j.ygyno.2015.11.015]

Gender bias in shared decision-making among cancer care guidelines: A systematic review

BACKGROUND

In cancer care, the promotion and implementation of shared decision-making in clinical practice guidelines (CPG) and consensus statements may have potential differences by gender.

OBJECTIVE

To systematically analyse recommendations concerning shared decision-making in CPGs and consensus statements for the most frequent cancers exclusively among males (prostate) and females (endometrial).

SEARCH STRATEGY

We prospectively registered the protocol at PROSPERO (ID: RD42021241127). MEDLINE, EMBASE, Web of Science, Scopus and online sources (8 guideline databases and 65 professional society websites) were searched independently by two reviewers, without language restrictions.

INCLUSION CRITERIA

CPGs and consensus statements about the diagnosis or treatment of prostate and endometrial cancers were included from January 2015 to August 2021.

DATA EXTRACTION AND SYNTHESIS

Quality assessment deployed a previously developed 31-item tool and differences between the two cancers analysed.

MAIN RESULTS

A total of 176 documents met inclusion criteria, 97 for prostate cancer (84 CPGs and 13 consensus statements) and 79 for endometrial cancer (67 CPGs and 12 consensus statements). Shared decision-making was recommended more often in prostate cancer guidelines compared to endometrial cancer (46/97 vs. 13/79, 47.4% vs. 16.5%; p < .001). Compared to prostate cancer guidelines (mean 2.14 items, standard deviation 3.45), compliance with the shared-decision-making 31-item tool was lower for endometrial cancer guidelines (mean 0.48 items, standard deviation 1.29) (p < .001). Regarding advice on the implementation of shared decision-making, it was only reported in 3 (3.8%) endometrial cancer guidelines and in 16 (16.5%) prostate cancer guidelines (p < .001).

DISCUSSION AND CONCLUSIONS

We observed a significant gender bias as shared decision-making was systematically more often recommended in the prostate compared to endometrial cancer guidelines. These findings should encourage new CPGs and consensus statements to consider shared decision-making for improving cancer care regardless of the gender affected.

PATIENT OR PUBLIC CONTRIBUTION

The findings may inform future recommendations for professional associations and governments to update and develop high-quality clinical guidelines to consider patients' preferences and shared decision-making in cancer care.

Evaluation of Peri-Operative Management in Women with Deep Endometriosis Who are Candidates for Bowel Surgery: A Survey from the Italian Society of Gynecologic Endoscopy

STUDY OBJECTIVE

There is great consensus that the implementation of the enhanced recovery after surgery (ERAS) approach is beneficial for surgical patients, but there is a paucity of data concerning its application in women with deep endometriosis (DE) who are candidates for bowel surgery. The survey described herein was aimed at gathering detailed information on perioperative management of DE patients who were undergoing sigmoid/rectal (discoid or segmental) resection within the Italian Society of Gynecologic Endoscopy (SEGI) group.

DESIGN

Baseline survey.

SETTING

National survey conducted within the main Italian cooperative group in minimally invasive gynecologic surgery (SEGI).

PATIENTS

The study did not involve patients.

INTERVENTIONS

A 63-item questionnaire covering ERAS items for gynecologic/elective colorectal surgery was sent to SEGI centers. Only questionnaires from centers that reported performing ≥10 sigmoid/rectal resections per year were considered for this analysis.

MEASUREMENTS AND MAIN RESULTS

Thirty-three of 38 (86.8%) of the questionnaires were analyzed. The rates of concordance with the ERAS guidelines were 40.4%, 64.4%, and 62.6% for preoperative, intraoperative, and postoperative items, respectively. The proportion of overall agreement was 56.6%. Preoperative diet, fasting and bowel preparation, correction of anemia, avoidance of peritoneal drains, postoperative feeding, and early mobilization were the most controversial items. Comparative analysis revealed that the referred rates of complete disease removal and conversion to open surgery were significantly different depending on case volume (p = .044 and p = .003, respectively) and gynecologist's/surgeon's experience (p = .042 and p = .022, respectively), with higher chances of obtaining a complete laparoscopic/robotic excision of endometriosis in centers that reported ≥30 DE surgeries performed per year and/or ≥90% of bowel resections performed by a gynecologist/general surgeon specifically dedicated to DE management. In contrast, the rates of concordance with the ERAS guidelines were not significantly different according to case volume (p = .081) or gynecologist's/surgeon's experience (p = .294).

CONCLUSION

This is the first study on DE conducted on a national scale. The current survey results revealed suboptimal compliance with the ERAS recommendations and underline the need to improve the quality of perioperative care in DE patients undergoing sigmoid/rectal resection. This study is a first step toward building a consistent, structured reporting platform for the SEGI units and facilitating wide implementation and standardization of the ERAS protocol for DE patients in Italy.

Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update

BACKGROUND

Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges.

METHODS

Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.

The effect of preoperative scopolamine patch use on postoperative urinary retention in urogynecologic surgeries

INTRODUCTION AND HYPOTHESIS

This study aims to determine whether the use of preoperative transdermal scopolamine is associated with an increased risk of postoperative urinary retention in urogynecologic surgeries.

METHODS

This is a retrospective chart review study of women who underwent surgery between January 1, 2018, and December 31, 2020. Patients who received a scopolamine patch versus those who did not were compared using demographic and perioperative variables utilizing Pearson's chi-squared test and t-test of Wilcoxon rank-sum. A logistic regression was performed to evaluate the effect of scopolamine on the patients' postoperative voiding trial results, controlling for confounders. P-value < 0.05 was considered statistically significant.

RESULTS

A total of 449 women underwent a vaginal or laparoscopic hysterectomy, midurethral sling placement, uterosacral or sacrospinous ligament suspension, sacrocolpopexy, anterior/posterior colporrhaphy, or other urogynecologic surgeries with 109 (24.2%) having received transdermal scopolamine. A significantly higher number of women with preoperative scopolamine [n = 50 (45.9%)] failed their voiding trial compared to those without scopolamine [n = 100 (29.4%), p = 0.0016]. The adjusted model yielded an odds ratio of 1.75 (95% CI: 1.08-2.85) of a failed voiding trial in the scopolamine group. When comparing the odds of failing voiding trial by surgery type, those with a midurethral sling placed during surgery had an adjusted odds ratio of 3.12 (95% CI: 2.01-4.87), as compared to those without a midurethral sling.

CONCLUSIONS

Use of a transdermal scopolamine patch for nausea and vomiting prophylaxis is associated with increased risk of postoperative urinary retention across all urogynecologic surgeries.

Enhanced Recovery after Cesarean Section (ERAC): Where are We in Austria?

OBJECTIVE

Enhanced recovery after surgery (ERAS) recommendations for cesarean section (ERAC), likely the most common reason for laparotomy in women, were issued in 2018-19. We examined how current perioperative management at cesarean section in Austrian hospitals aligns with ERAS recommendations.

STUDY DESIGN

We surveyed the 21 largest public obstetric units in Austria for alignment with 20 of the 31 strong ERAS recommendations regarding perioperative maternal care at cesarean section. We also looked at how the German-language clinical guideline for cesarean section (AWMF Guideline Sectio caesarea) aligns with ERAS recommendations.

RESULTS

The 21 obstetric units cared for about 51% of all births in Austria in 2019. Cesarean section rates ranged from 17.7% to 50.4%. All 21 units implemented the five strong recommendations regarding patient information and counselling, regional anesthesia, euvolemia and multimodal analgesia. The least implemented strong recommendation was the one for the use of pneumatic compression stockings to prevent thromboembolic disease (0/21 units). Overall, all 21 units implemented ≥11 and 13 (62%) implemented ≥15 (≥75%) of the 20 strong recommendations; no unit implemented all 20 strong recommendations. There were no differences in the implementation of strong recommendations according to hospital volume.

CONCLUSIONS

Even in the absence of formal adoption of ERAS program for cesarean section many perioperative ERAS recommendations are already implemented in Austria. The least implemented recommendations were the use of pneumatic compression stockings (0 of 21 units) and immediate catheter removal (4 of 21 units). Only 10 of the 20 ERAS recommendations we looked at are included in the current German-language clinical guideline for cesarean section.

Comparison of Enhanced Recovery After Surgery (ERAS) metrics by race among gynecologic oncology patients: Ensuring equitable outcomes

OBJECTIVES

Race and ethnicity are not routinely audited in Enhanced Recovery After Surgery (ERAS) pathways. Given known racial disparities in outcomes in gynecologic oncology, the purpose of this study was to compare differences in ERAS implementation and outcomes by race.

METHODS

A cohort study was performed among gynecologic oncology patients enrolled in an ERAS pathway at one academic institution from March 2017 to December 2021. Compliance with ERAS metrics, postoperative complications, 30-day survival, reoperations, intensive care unit (ICU) transfers, and readmissions within 30 days were compared by race.

RESULTS

Of 1083 patients (17.0% non-white), non-white women were younger (54.2 years ±13.1 vs. 60.7 years ±13.6, p < 0.001) and proportionally fewer spoke English (75.0% vs. 97.8%, p < 0.001). Fewer non-white women received preadmission ERAS education (73.4% vs. 79.9%, p = 0.05). There were no differences in ERAS implementation by race, including similar rates of preoperative nutritional assessment, carbohydrate loading, antibiotic and thrombosis prophylaxis, and unplanned surgeries by race. There were no differences in complications, reoperations, ICU transfers, or readmissions by race on univariate and multivariate analysis. Four non-white (2.2%) and two white women (0.2%, p = 0.009) died within 30 days of surgery.

CONCLUSIONS

Fewer non-white women received preadmission education, possibly due to language barriers. ERAS compliance, postoperative complications, readmissions, reoperations, and ICU transfers did not differ by race. There were two additional deaths within 30 days postoperatively among non-white women compared to white women - which is difficult to interpret given the rarity of perioperative mortality - but appeared unlikely to be related to differences in ERAS protocol implementation. ERAS programs should ensure educational materials are translated into various languages and audit metrics by race to ensure equitable outcomes.

The Application of Enhanced Recovery After Surgery Protocols in Patients With Perforated Duodenal Ulcer

Background Enhanced recovery after surgery (ERAS) protocols are nowadays considered the standard of care for various elective surgical procedures. However, its utilization remains low in tier-two and tier-three cities of India, and there exists a significant variation in the practice. In the present study, we have investigated the safety and feasibility of these protocols or pathways in emergency surgery for perforated duodenal ulcer disease. Methods A total of 41 patients with perforated duodenal ulcers were randomly divided into two groups. All the patients across the study were treated surgically with the open Graham patch repair technique. Patients in group A were managed with ERAS protocols, while patients in group B were managed with conventional peri-operative practices. A comparison was established between the two groups in terms of the duration of hospital stay and other postoperative parameters. Results The study was conducted on 41 patients who presented during the study period. Group A patients (n=19) were managed with standard protocols, and group B patients (n=22) were managed with conventional standard protocols. As compared to the standard care group, patients in the ERAS group showed quicker postoperative recovery and lesser complications. The need for nasogastric (NG) tube reinsertion, postoperative pain, postoperative ileus, and surgical site infections (SSI) were all significantly lower in the patients of the ERAS group. A significant reduction in the length of hospital stay (LOHS) was found in the ERAS group when compared to the standard care group (relative risk {RR}=61.2; p=0.000). Conclusions The application of ERAS protocols with certain modifications in the management of perforated duodenal ulcers yields significant outcomes in terms of reduced duration of hospital stay and fewer postoperative complications in a selected subgroup of patients. However, the application of ERAS pathways in an emergency setup needs to be further evaluated to develop standardized protocols for a surgical emergency group of patients.

RACCE Study: Impact of an enhanced recovery after surgery program (ERAS) in the management of endometrial cancer: A single-center retrospective study

OBJECTIVE

This study evaluates the implementation of an ERAS program in the gynecological surgery department of Caen University Hospital and its impact on the management of endometrial cancer. The objective was to show its impact on the length of hospitalization of patients before and after its implementation.

PATIENTS AND METHOD

We conducted a retrospective study including all women treated surgically for endometrial cancer at Caen University Hospital between January 1, 2015 and December 31, 2021. The ERAS program started in September 2017. We compared the pre-, intra- and postoperative characteristics of two groups: the first one concerning the period before the implementation of ERAS called « prior ERAS group » and the second one after implementation called « post ERAS group ».

RESULTS

A total of 198 patients were included in our study. 139 patients were included after ERAS implementation. Our study shows that there is a significant reduction in median length of stay between the post ERAS and prior ERAS groups respectively 3 and 4 days (p = 0.004). There was also a reduction of time to resume ambulation (p < 0.001) and re-feeding (p < 0.001) for the post ERAS group compared to the prior ERAS group. Complication rates (p = 0.87) and readmission rates (p = 0.28) were not significant. Overall survival was not significant (p = 0.28).

CONCLUSION

ERAS is a safe and effective method in the overall management of patients allowing an improvement in the quality of patient care and accelerating recovery to a previous physiological state. Finally, this results in a reduction in the patient's length of stay, without impacting morbidity and readmission rate.

Safety and feasibility of same-day discharge following minimally invasive hysterectomy in the morbidly obese patient population

OBJECTIVES

To determine whether morbid obesity should serve as an independent factor in the decision for same day discharge following minimally invasive hysterectomy.

METHODS

Retrospective review was performed of patients with BMI ≥ 40 who underwent minimally invasive hysterectomy within a single comprehensive cancer center between January 2018 - August 2020. Demographics, perioperative factors, post-operative monitoring, complications, and readmissions were compared between patients who underwent same day discharge and overnight observation using Fisher's exact tests and Wilcoxon rank-sum tests.

RESULTS

374 patients with BMI ≥ 40 were included. Eighty-three (22.2%) patients underwent same day discharge, and 291 (77.8%) patients underwent overnight observation. Factors associated with increased likelihood of same day discharge included younger age (median age 53 vs 58; p = 0.001), lower BMI (median BMI 45 vs 47; p = 0.005), and fewer medical co-morbidities (Charlson Co-Morbidity Index 2 vs 3; p < 0.001). On multivariate regression analysis, frailty (OR 2.16 [1.14-4.11], p = 0.019) and surgical completion time after 12 PM (OR 3.67 [2.16-6.24], p < 0.001) were associated with increased risk of overnight observation. Few patients admitted for routine overnight observation required medical intervention (n = 14, 4.8%); most of these patients were frail (64.3%). The overall hospital readmission rate within 30 days of discharge was 3.2% (n = 12), with no patients discharged on the day of surgery being readmitted.

CONCLUSIONS

Morbid obesity alone should not serve as a contraindication to same day discharge following minimally invasive hysterectomy. Admission for observation was associated with low rates of clinically meaningful intervention, and patients who underwent same day discharge were not at increased risk of adverse outcome.

Real-World Evidence: How Long Do Our Patients Fast?-Results from a Prospective JAGO-NOGGO-Multicenter Analysis on Perioperative Fasting in 924 Patients with Malignant and Benign Gynecological Diseases

BACKGROUND

Despite the key role of optimized fasting in modern perioperative patient management, little current data exist on perioperative fasting intervals in routine clinical practice.

METHODS

In this multicenter prospective study, the length of pre- and postoperative fasting intervals was assessed with the use of a specifically developed questionnaire. Between 15 January 2021 and 31 May 2022, 924 gynecology patients were included, from 13 German gynecology departments.

RESULTS

On average, patients remained fasting for about three times as long as recommended for solid foods (17:02 ± 06:54 h) and about five times as long as recommended for clear fluids (9:21 ± 5:48 h). The average perioperative fasting interval exceeded one day (28:23 ± 14:02 h). Longer fasting intervals were observed before and after oncological or extensive procedures, while shorter preoperative fasting intervals were reported in the participating university hospitals. Smoking, treatment in a non-university hospital, an increased Charlson Comorbidity Index and extensive surgery were significant predictors of longer preoperative fasting from solid foods. In general, prolonged preoperative fasting was tolerated well and quality of patient information was perceived as good.

CONCLUSION

Perioperative fasting intervals were drastically prolonged in this cohort of 924 gynecology patients. Our data indicate the need for better patient education about perioperative fasting.

Application of ERAS protocols in esophagogastric emergency surgery: is it feasible and does it make sense?

Management and treatment of esophagogastric diseases have been evolving in terms of multimodal approach and quality of care. The recent introduction of standardized perioperative protocols has represented the opportunity to homogenize the multiple factors enhancing patients' recovery after surgery worldwide. A further optimization would lead to the extension of the ERAS program to upper GI emergencies. This review provides a comprehensive collection of scientific basis, current supporting evidence, and potential applicative limitations.

Prevention of Postoperative Constipation in Urogynecology Patients: A Systematic Review

IMPORTANCE

Constipation is common after pelvic surgery, and studies suggest that surgeons underestimate the negative impact of constipation on patients. Patients undergoing pelvic reconstructive surgery are a unique population requiring special consideration in the prevention and management of constipation.

OBJECTIVE

This study aimed to systematically review the literature to identify evidence for prevention of postoperative constipation with medications or fiber in patients undergoing reconstructive pelvic surgery.

STUDY DESIGN

A structured literature search was performed of five databases (MEDLINE, Embase, Scopus, Web of Science, the Cochrane Library) from inception to June 2022 for studies of postoperative laxative or fiber use in adult patients undergoing benign pelvic reconstructive surgery. Studies of preoperative bowel preparation and nonsurgical patients were excluded. Data on postoperative constipation were extracted for a qualitative analysis of the literature. Grading of Recommendations Assessment, Development, and Evaluation methodology was applied to assess the quality of evidence.

RESULTS

We identified 86 references after deduplication. Only 4 studies with a total of 344 patients were eligible for inclusion in the review. The included studies were all randomized controlled trials assessing time to first bowel movement with the earliest published in 2010. Laxative use decreased constipation more than placebo. Multiple-agent laxative use appeared to decrease bothersome constipation more than single-agent docusate. Preoperative fiber did not decrease constipation. By Grading of Recommendations Assessment, Development, and Evaluation criteria, all four studies provide moderate-quality evidence.

CONCLUSIONS

Few studies have investigated laxative regimens in patients after urogynecologic surgery. The available literature is moderate quality and suggests benefit of multiple-agent treatment over docusate only or no treatment.

Impact of Enhanced Recovery After Surgery (ERAS) program in gynecologic oncology and patient satisfaction

OBJECTIVE

The primary objective of this study was to compare lengths of stay since ERAS program implementation. We also evaluated ERAS protocol compliance, compared the outpatient rate, the complication rate and the readmission rate within 30 days after surgery and performed a satisfaction study.

METHODS

This is a monocentric comparative study with a historical control group, performed in the gynecological surgery department of the University Hospital of Saint-Etienne. We compared a group of patients who underwent surgery in 2016, before the implementation of ERAS program, with a group of patients who underwent surgery from July 2021 to July 2022, for whom ERAS program was applied.

RESULTS

187 patients were included in this study, including 84 patients in the historical group before ERAS and 103 in the group with ERAS. Considering all approaches, the average length of stay decreased by 2 days (p<0.0001). Considering minimally invasive surgery, the outpatient rate increased from 5% to 50% (p<0.0001) and complication rate decreased from 23 to 11% (p = 0,04). The readmissions rate was similar. Satisfaction score for patients managed with ERAS program was 8.9/10.

CONCLUSION

The implementation of ERAS program in gynecological oncology surgery allowed a reduction in length of stay, with a high outpatient rate, decreasing complications in case of minimally invasive surgery, without increasing the readmission rate, and was associated with good patient satisfaction.

Comparison of Single Target-Controlled Infusion Pump-Delivered Mixed Propofol and Remifentanil with Two Target-Controlled Infusion Pumps-Delivered Propofol and Remifentanil in Patients Undergoing Breast Cancer Surgery-A Prospective Study

Total intravenous anesthesia (TIVA) with remifentanil and propofol (RP) is considered to be an ideal type of general anesthesia (GA) for pediatric and adult patients undergoing medical procedures. However, delivery of an RP mixture by target-controlled infusion (TCI) for GA in surgical procedures has not been described. We investigated the merit of this approach for breast cancer surgery. Eighty-four patients (n = 42 per group) were randomly allocated to propofol and remifentanil either delivered by separate TCI pumps (S group) or in an RP mixture by a single TCI pump (M group). Dosages were adjusted based on the bispectral index (BIS) and the analgesia nociception index (ANI). The primary outcomes were adequate anesthesia (BIS 40-60 and ANI 50-70, respectively), acceptable hemodynamic fluctuations (<30% of baseline) with less frequent TCI pump adjustments, bolus injections of anesthetics, and total consumption of anesthetics during the procedure. The secondary endpoints included time of emergence from anesthesia, patient satisfaction, postoperative pain, rescue with opioids, and adverse events. The characteristics of patients, hemodynamic parameters, BIS and ANI scores, duration of surgery, anesthesia, and emergence were not significantly different between groups. The adjustment frequency of TCI was significantly higher in the S group (3 (range 0-6) vs. 2 (0-6) times; p = 0.005). The total dosage of anesthetics, pain rating, patient satisfaction, need for opioids postoperatively, and incidence of adverse events were not significantly different. We have demonstrated that this RP mixture provided adequate hypnotic and analgesic effects under BIS and ANI monitoring in patients undergoing breast cancer surgery within 1 h.

Evaluating outcomes of patient-centered enhanced recovery after surgery (ERAS) in percutaneous nephrolithotomy for staghorn stones: An initial experience

Objective

To evaluate the outcomes of patient-centered enhanced recovery after surgery (ERAS) in -percutaneous nephrolithotomy (PCNL) for staghorn stones.

Patients and methods

A retrospective analysis of 106 patients with staghorn calculi who underwent PCNL treatment at the Third Xiangya Hospital from October 01, 2018 to September 30, 2021 was performed. The patients were divided into the ERAS group (n = 56) and traditional group (n = 50). The ERAS program focused on a patient-centered concept, with elaboration on aspects, such as patient education, nutritional support, analgesia, body warming, early mobilization, nephrostomy tube removal, and strict follow-up.

Results

The total stone free rate and total complication rate were similar in both groups. The visual analogue scale (VAS) 6 h after surgery, ambulation off bed time, indwelling fistula time, indwelling catheter time, and postoperative hospital stays were lower in the ERAS group than in the traditional group (P < 0.05). The multiple session rate in the ERAS group (19, 28.57%) was lower than that in the traditional group (30, 60%) (P = 0.007). The 1-year stone recurrence rate in the ERAS group (7, 17.5%) was lower than that in the traditional group (14, 38.9%) (P = 0.037).

Conclusion

The patient-centered ERAS in PCNL for staghorn stones accelerated rehabilitation by relieving postoperative pain, shortening hospitalization time, accelerating early ambulation, and reducing multiple session rate and 1-year stone recurrence rate, which have socioeconomic benefits.

European Enhanced Recovery After Surgery (ERAS) gynecologic oncology survey: Status of ERAS protocol implementation across Europe

OBJECTIVE

To acquire a comprehensive assessment of the current status of implementation of Enhanced Recovery After Surgery (ERAS) protocols across Europe.

METHODS

The survey was launched by The European Network of Young Gynecologic Oncologists (ENYGO). A 45-item survey was disseminated online through the European Society of Gynecological Oncology (ESGO) Network database.

RESULTS

A total of 116 ESGO centers participated in the survey between December 2020 and June 2021. Overall, 80 (70%) centers reported that ERAS was implemented at their institution: 63% reported a length of stay (LOS) for advanced ovarian cancer surgery between 5 and 7 days; 57 (81%) centers reported a LOS between 2 and 4 days in patients who underwent an early-stage gynecologic cancer surgery. The ERAS items with high reported compliance (>75% "normally-always") included deep vein thrombosis prophylaxis (89%), antibiotic prophylaxis (79%), prevention of hypothermia (55%), and early mobilization (55%). The ERAS items that were poorly adhered to (less than 50%) included early removal of urinary catheter (33%), and avoidance of drains (25%).

CONCLUSION

This survey shows broad implementation of ERAS protocols across Europe; however, a wide variation in adherence to the various ERAS protocol items was reported.

Effect of nurse-led telephone follow-up on postoperative symptoms and analgesics consumption after benign hysterectomy: a randomized, single-blinded, four-arm, controlled multicenter trial

PURPOSE

The study aimed to determine if planned telephone follow-up, especially when adding structured, oriented coaching, reduces the intensity of postoperative symptoms and decreases analgesics consumption after benign hysterectomy.

METHODS

A randomized, single-blinded, four-armed, controlled multicenter trial of 525 women scheduled for hysterectomy was conducted in 5 hospitals in the southeast health region of Sweden. The women were allocated 1:1:1:1 into four follow-up models: (A) no telephone follow-up (control group); (B) one planned, structured, telephone follow-up the day after discharge; (C) as B but with additional telephone follow-up once weekly for 6 weeks; and (D) as C but with oriented coaching telephone follow-up on all occasions. Postoperative symptoms were assessed using the Swedish Postoperative Symptoms Questionnaire. Analgesic consumption was registered. Unplanned telephone contacts and visits were registered during the 6 weeks of follow-up.

RESULTS

In total, 487 women completed the study. Neither pain intensity, nor symptom sum score or analgesic consumption differed between the intervention groups. Altogether, 224 (46.0%) women had unplanned telephone contacts and 203 (41.7%) had unplanned visits. Independent of intervention, the women with unplanned telephone contacts had higher pain intensity and symptom sum scores, particularly if an unplanned telephone contact was followed by a visit, or an unplanned visit was preceded by an unplanned telephone contact.

CONCLUSION

Telephone follow-up did not seem to affect recovery regarding symptoms or analgesic consumption after benign hysterectomy in an enhanced recovery after surgery (ERAS) setting. Unplanned telephone contacts and visits were associated with more postoperative symptoms, especially pain. Trial registration The study is registered in ClinicalTrial.gov: NCT01526668 retrospectively from January 27; 2012. Date of enrolment of first patient: October 11; 2011.

The effect of adding chewing gum to oral carbohydrates on preoperative anxiety scores in women undergoing gynecological surgery: A randomized controlled study

BACKGROUND

Preoperative anxiety is an unpleasant experience that can adversely affect perioperative outcomes. Although clinical benefits of preoperative oral carbohydrate is well reported, the effect of adding chewing gum to carbohydrate loading has never been studied. We aimed to investigate the effect of adding gum-chewing to oral carbohydrates on preoperative anxiety and gastric volume in patients undergoing gynecologic surgery.

METHODS

One hundred and four patients were enrolled and randomized either into a carbohydrate drink group (CHD group) or CHD with gum group. The CHD group was instructed to drink 400 mL of oral carbohydrate the evening before and 200-400 mL 3 hours before surgery. The CHD with gum group was encouraged to chew gum freely during preanesthetic fasting in addition to consuming oral carbohydrates in the same manner. The primary endpoint was preoperative anxiety assessed using the Amsterdam preoperative anxiety and information scale (APAIS). The degree of patient-reported quality of recovery after surgery and gastric volume prior to general anesthesia were also compared as secondary outcomes.

RESULTS

Preoperative APAIS was lower in the CHD with gum group compared with the CHD group (16 [11.5, 20] vs. 20 [16.5, 23], p = 0.008). Patient-rated quality of recovery after surgery was also higher in the CHD with gum group and showed a significant negative correlation with preoperative APAIS score (correlation coefficient: -0.950, p = 0.001). Gastric volume were not different between the groups (0 [0-0.45] vs. 0 [0-0.22], p = 0.158).

CONCLUSION

The addition of gum chewing to oral carbohydrate loading during preoperative fasting was more effective in relieving preoperative anxiety than oral carbohydrate alone in women patients undergoing elective gynecologic surgery.

TRIAL REGISTRATION

Clinical Research Information Services, CRIS identifier: KCT0005714, https://cris.nih.go.kr/cris/index.jsp.

Ameliyat Öncesi ve Sonrası Dönemde Yapılan Uygulamaların ERAS Protokolüne Uygunluğunun Değerlendirilmesi

Amaç: Bu çalışma, ameliyat öncesi ve sonrası dönemde yapılan uygulamaların ERAS (Enhanced Recovery After Surgery) protokolüne uygunluğunun değerlendirilmesi amacıyla yapılmıştır.Yöntem: Tanımlayıcı-kesitsel nitelikte tasarlanan araştırma, Ocak – Temmuz 2019 tarihleri arasında bir üniversitenin Sağlık Araştırma ve Uygulama Merkezinin cerrahi kliniklerinde yürütülmüştür. Ameliyatı planlanan, çalışmaya katılmayı kabul eden 863 hasta araştırma örneklemini oluşturmuştur. Veriler, araştırmacılar tarafından literatür doğrultusunda hazırlanan anket formu, Vizüel Analog Skala ve Bulantı Sayısal Ölçeği ile yüz yüze görüşme yöntemiyle toplanmıştır. Veriler, SPSS 20.0 paket programında tanımlayıcı istatistikler kullanılarak değerlendirilmiştir.Bulgular: Çalışmadaki hastaların tamamının ameliyat öncesi dönemde oral karbonhidrat almadığı, ameliyat öncesi aç kalma sürelerinin 10,55±6,91 saat olduğu ve hastalara premedikasyon uygulanmadığı belirlenmiştir. Hastaların ameliyat sonrası; ilk sıvı alma zamanı ortalamasının 10,45±15,44 saat, ilk katı gıda alma zamanı ortalamasının 18,70±29,23 saat olduğu, ilk mobilizasyon süresinin 19,02±21,39 saat, nazogastrik sonda kalış süresi ortalamasının 29,33±28,80 saat, drenin kalış süresi ortalamasının 54,30±28,06 saat, üriner kateter kalış süresi ortalamasının 49,51±27,40 saat olduğu saptanmıştır.Sonuç: Çalışma sonucunda ERAS protokollerine uyumun istenilen düzeyde olmadığı ve sağlık çalışanlarına ERAS’la uyumlu olmayan uygulamalarla ilgili eğitim verilmesi önerilebilir.

Non invasive hemodynamic monitoring for fluids and blood resuscitation during placenta praevia accreta cesarean delivery: a retrospective observational study

BACKGROUND

We carry out a retrospective observational analysis of clinical records of patients with major placenta praevia who underwent cesarean section surgery over a period of 20 months in our hospital. Out of a total of 40 patients, 20 were subjected to Goal-Directed Therapy (GDT) implemented with non-invasive hemodynamic monitoring using the EV1000 ClearSight system (Group I) and 20 to standard hemodynamic monitoring (Group II). Given the risk of conspicuous blood loss, this study evaluate the impact on maternal and fetal health of GDT relative to standard hemodynamic monitoring.

RESULTS

Average total infusion of fluids was 1600 +/- 350 ml. Use of blood products occurred in 29 patients (72,5%), of which 11 had a hysterectomy and 8 were treated with Bakri Balloons. For 2 patients > 1000 mL of concentrated red blood cells were used. When stroke volume index SVI dropped below 35 mL/m2/beat, it responded well to the infusion of at least 2 crystalloid boluses (5 ml/kg) in 7 patients. Cardiac index (CI) increased in 8 patients in concomitance with a reduction in medium arterial pressure (MAP), but the use of ephedrine (10 mg iv) re-established acceptable baseline values. Group I means are higher than Group II means for MAP, lower for RBC usage, end-of-surgery maternal lactates and fetal pH, and for LOS. Statistical analysis determines that the null hypotheses of equalities between Groups I and II can be rejected for all measures apart from MAP at baseline and induction. Proportions of serious complications in Groups I and II are respectively 10% and 32% and Boschloo's test rejects the null of equality of proportions against the alternative hypothesis of lower proportion of occurrence in Group I than in Group II.

CONCLUSIONS

Hypovolemia can lead to vasoconstriction and inadequate perfusion with decreased oxygen delivery to organs and peripheral tissues and ultimately cause organ dysfunction. Despite the small sample size due to the rarity of the pathology, our statistical analysis finds evidence in favor of more favorable clinical outcomes for patients who received GDT implemented with non-invasive hemodynamic monitoring infusion relative to patients who received standard hemodynamic monitoring.

Anastomotic Leakage after Colorectal Surgery in Ovarian Cancer: Drainage, Stoma Utility and Risk Factors

Objective: to evaluate the incidence of anastomotic leakage (AL), risk factors and utility of drainage and stoma in patients undergoing intestinal surgery for ovarian cancer in a single institution and in a review of the literature. Methods: retrospective study that includes consecutive patients undergoing debulking surgery with en bloc pelvic resection with rectosigmoid colectomy for ovarian cancer between 1 November 2011 and 31 December 2021. Data regarding patient and tumour characteristics, surgical procedure, hospitalisation, complications and follow-up were recorded and analysed. The PubMed database was explored for recent publications on this topic. Results: Seventy-five patients were enrolled in the study. All anastomoses were performed at a distance of >6 cm from the anal margin, with negative leak tests and tension-free anastomosis. Diverting stoma were performed in just three patients (4%). At least one perianastomotic pelvic drain was positioned in 71 patients (94.7%) and was removed on average on postoperative day 7. Four patients (5.3%) experienced AL. In all cases, the drain content was not the only sign of complication, as the clinical signs were also highly suggestive. Just one patient received conservative treatment. Average postoperative hospitalisation was 14.6 days (SD: ±9.7). There were no deaths at 30 and 60 days after surgery. Between the AL and non-AL groups, statistically significant differences were observed for age, Charlson Comorbidity Index, length of the intestinal resection and fitness for chemotherapy at 30 days. In ovarian cancer, rectosigmoid resection is a standardised procedure with comparable results for AL, and risk factors for AL are discretely homogeneous. What is neither homogeneous nor standardised according to the literature is the use of stomas and/or drains. Conclusion: use in the future of protective stoma and/or intra-abdominal drains is to be explored in selected and standardised situations to verify their preventive role.

Enhanced recovery after gynecological surgery: A meta-analysis of randomized controlled trials

Enhanced recovery after surgery protocol is a multidisciplinary and multimodal approach designed to improve perioperative outcomes for patients. This meta-analysis aimed to identify and elaborate on the efficacy of this protocol in women undergoing gynecologic surgery. Four databases were searched for randomized controlled trials from inception to December 2021. A total of 14 studies met the inclusion criteria and were analyzed. There was a significant reduction in the length of stay, the time to first flatus and first defecation, complications, and readmission rates in patients undergoing enhanced recovery after surgery when compared to routine care. The rate of discharge on the first postoperative day significantly increased in patients from the enhanced recovery group. There was no significant difference in the surgery time and blood loss. In conclusion, the enhanced recovery after surgery protocol might have a positive effect on patients undergoing gynecologic surgery. However, there is still heterogeneity between the included studies, and we need more research to draw reliable conclusions that enhanced recovery after surgery is favorable.

Use and misuse of opioid after gynecologic surgery

Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.

ERAS implementation in an urban patient population undergoing gynecologic surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols improve outcomes. We investigated ERAS implementation in a population with comorbid conditions, inadequate insurance, and barriers to healthcare undergoing gynecologic surgery.

OBJECTIVE

To investigate ERAS implementation in publicly insured/uninsured patients undergoing gynecologic surgery on hospital length of stay (LOS), 30-day hospital readmission rates, opioid administration, and pain scores.

STUDY DESIGN

Data were obtained pre- and post-ERAS implementation. Patients undergoing gynecologic surgery with private insurance, public insurance, and uninsured were included (N = 589). LOS, readmission <30 days, opioid administration, and pain scores were assessed.

RESULTS

Implementation of ERAS led to shorter LOS 1.75 vs. 1.49 days (p = 0.008). Average pain scores decreased from 3.07 pre-ERAS vs. 2.47 post-ERAS (p = <0.001). Opioid use decreased for ERAS patients (67.22 vs. 33.18, p = <0.001). Hospital readmission rates were unchanged from 8.2% pre-ERAS vs. 10.3% post-ERAS (p = 0.392).

CONCLUSIONS

ERAS decreased pain scores and opioid use without increasing LOS or readmissions.

Association Between Experimental Pain Thresholds and Trajectories of Postoperative Recovery Measures After Benign Hysterectomy

Purpose

Quantitative sensory testing (QST) can be applied to quantify the sensitivity to different painful stimuli. This study aims to evaluate the association between preoperative pressure and thermal pain thresholds and trajectories of measurements of postoperative recovery (patient-reported daily maximum and average pain intensity, sum score of symptoms, and analgesic consumption) after benign hysterectomy.

Patients and Methods

A prospective, longitudinal single-blinded, observational multicenter study was conducted in five hospitals in the southeast of Sweden between 2011 and 2017. A total of 406 women scheduled for abdominal or vaginal hysterectomy for benign conditions were enrolled in the study. QST measuring pressure (PPT), heat (HPT), and cold pain thresholds (CPT) were performed preoperatively. The cut-off levels for dichotomizing the pain thresholds (low/high) were set at the 25-percentile for PPT and HPT and the 75-percentile for CPT. The Swedish Postoperative Symptom Questionnaire was used to measure postoperative pain and other symptoms of discomfort (symptom sum score) on 13 occasions for six weeks postoperatively. Daily analgesic consumption of opioids and non-opioids was registered.

Results

A CPT above the 75-percentile was associated with high postoperative maximum pain intensity (p = 0.04), high symptom sum score (p = 0.03) and greater consumption of non-opioids (p = 0.03). A HPT below the 25-percentile was only associated with greater consumption of non-opioids (p = 0.02). PPT was not associated with any of the outcome measures.

Conclusion

CPT seemed to be predictive for postoperative pain and symptoms of discomfort after benign hysterectomy. Preoperative QST may be used to individualize the management of postoperative recovery for low pain threshold individuals.

Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience

OBJECTIVES

To evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes.

METHODS

This retrospective cohort study was conducted between November 2014 and December 2020. Two groups were defined based on compliance level (<80% vs ≥80%). The primary outcome was to analyze overall compliance since implementation of the ERAS protocol. The secondary endpoint was to assess the relationship between compliance and 30-day re-admission, length of stay, re-operation, opioid-free rates, and post-operative complications. We also assessed compliance with each ERAS element over three time periods (P1: 2014-2016, P2: 2017-2018, P3: 2019-2020), categorizing patients according to the date of surgery. Values were compared between P1 and P3.

RESULTS

A total of 1879 patients were included. Overall compliance over the period of 6 years was 74% (95% CI 71.9% to 78.2%). Mean overall compliance increased from 69.7% to 75.8% between P1 and P3. Compliance with ERAS ≥80% was associated with lower Clavien-Dindo complication rates (grades III (OR 0.55; 95% CI 0.33 to 0.93) and V (OR 0.08, 95% CI 0.01 to 0.60)), 30-day re-admission rates (OR 0.61; 95% CI 0.43 to 0.88), and length of stay (OR 0.59; 95% CI 0.47 to 0.75). No difference in opioid consumption was seen. Pre-operatively, there was increased adherence to counseling by 50% (p=0.01), optimization by 21% (p=0.02), and carbohydrate loading by 74% (p=0.02). Intra-operatively, compliance with use of short-acting anesthetics increased by 37% (p=0.01) and avoidance of abdominal drainage increased by 7% (p=0.04). Use of goal-directed fluid therapy decreased by 16% (p=0.04). Post-operatively, there was increased compliance with avoiding salt and water overload (8%, p=0.02) and multimodal analgesia (5%, p=0.02).

CONCLUSIONS

Over the time period of the study, overall compliance increased from 69.7% to 75.8%. Compliance (≥80%) with ERAS is associated with lower complication rates, fewer 30-day re-admissions, and shorter length of stay without impacting re-operation rates and post-operative opioid use.

Evaluation of perioperative management of advanced ovarian (tubal/peritoneal) cancer patients: a survey from MITO-MaNGO Groups

OBJECTIVE

The European Society of Gynaecological Oncology (ESGO)-quality indicators (QIs) for advanced ovarian cancer (AOC) have been assessed only by few Italian centers, and data are not available on the proportion of centers reaching the score considered for a satisfactory surgical management. There is great consensus that the Enhanced Recovery After Surgery (ERAS) approach is beneficial, but there is paucity of data concerning its application in AOC. This survey was aimed at gathering detailed information on perioperative management of AOC patients within MITO-MaNGO Groups.

METHODS

A 66-item questionnaire, covering ESGO-QIs for AOC and ERAS items, was sent to MITO/MaNGO centers reporting to operate >20 AOC/year.

RESULTS

Thirty/34 questionnaires were analyzed. The median ESGO-QIs score was 31.5, with 50% of centers resulting with a score ≥32 which provides satisfactory surgical management. The rates of concordance with ERAS guidelines were 46.6%, 74.1%, and 60.7%, respectively, for pre-operative, intra-operative, and post-operative items. The proportion of overall agreement was 61.3%, and with strong recommendations was 63.1%. Pre-operative diet, fasting/bowel preparation, correction of anaemia, post-operative feeding and early mobilization were the most controversial. A significant positive correlation was found between ESGO-QIs score and adherence to ERAS recommendations.

CONCLUSION

This survey reveals a satisfactory surgical management in only half of the centers, and an at least sufficient adherence to ERAS recommendations. Higher the ESGO-QIs score stronger the adherence to ERAS recommendations, underlining the correlations between case volume, appropriate peri-operative management and quality of surgery. The present study is a first step to build a structured platform for harmonization within MITO-MaNGO networks.

The Canadian Gynecologic Oncology Peri-operative Management Survey: re-examining Enhanced Recovery After Surgery (ERAS) recommendations

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) is a global surgery quality improvement program associated with improved clinical outcomes across the spectrum of disciplines, including gynecologic oncology. The objective of this study was to re-survey the practice of ERAS Gynecologic Oncology guidelines across Canada, after the initial guidelines publication (2016), subsequent guidelines update (2019), and Society of Gynecologic Oncology of Canada (GOC) education events.

METHODS

A survey was created and developed through the GOC Communities of Practice ERAS section and distributed to all members between March and November 2021. The results of this survey were compared with the survey performed in 2015 RESULTS: The initial GOC survey in 2015 included 77/92 active gynecologic oncologists (84%) representing all provinces in Canada. The current updated survey had responses from 59/118 active gynecologic oncologists (51%) also from every province. Compared with the original survey there was a statistically significant improvement in uptake of 10 ERAS recommendations: smoking/alcohol cessation, modern fasting guidelines (allowance of clear fluids and solid food pre-operatively), carbohydrate loading, pre-operative warming, early feeding, post-operative laxative use, avoidance of nasogastric tubes and abdominal drains, foley catheter removal at 6 hours, and active mobilization (all p<0.003). Only two fields (stopping oral contraceptive medications pre-operatively and foley catheter removal post-operative day 1) showed worsening uptake across the two surveys (p<0.01). The ERAS recommendations that did not change in the examined time frame included routine use of mechanical bowel preparation, venous thromboembolism prophylaxis, pre-operative antibiotics, and additional antibiotic dosing for prolonged surgery.

CONCLUSIONS

This survey demonstrates increased uptake of 10 of the ERAS guideline recommendations among Canadian gynecologic oncology providers. These findings may translate to improvements in clinical outcomes and healthcare system-level benefits including increased hospital capacity and cost savings.

The effect of preoperative oral carbohydrate on the time to colostrum and amount of vaginal bleeding after elective cesarean section

OBJECTIVE

To investigate the effect of oral carbohydrate at 2 h before elective cesarean section on postoperative recovery indicators such as the time to colostrum and vaginal bleeding.

METHODS

Women undergoing elective cesarean section under spinal-epidural anesthesia, aged 20-40 years, with a body mass index (BMI) of 19-30 kg/m² and an American Society of Anesthesiology (ASA) score of II were randomized to the oral carbohydrate group (the OC group), the oral placebo group (the OP group), or the control group (the C group). The OC group underwent oral carbohydrate preloading (300 mL/bottle), the OP group orally consumed 300 mL of distilled water, and the C group was forbidden from drinking or eating on the day of the operation. The time to colostrum, vaginal bleeding, time to exhaust, and complications were recorded.

RESULTS

A total of 38 participants in the OC group, 37 in the OP group, and 37 in the C group completed the study. Compared with the OP group and the C group, the OC group produced colostrum significantly earlier, had a lower amount of 24-h vaginal bleeding, and had a higher 24-h consumption of analgesics. Compared with OP and OC groups, the C group took longer to exhaust. No significant intergroup difference was observed for any other indicator.

CONCLUSION

Oral carbohydrates loading 2 h before elective cesarean section significantly reduces the time to produce colostrum and the amount of vaginal bleeding, which contributes to postoperative recovery.

A Scientometric Analysis and Visualization Discovery of Enhanced Recovery After Surgery

Background

Enhanced recovery after surgery (ERAS), a new clinical surgical concept, has been applied in many surgical disciplines with good clinical results for the past 20 years. Bibliometric analysis is an effective method to quantitatively evaluate the academic productivity. This report aimed to perform a scientometric analysis of the ERAS research status and research hotspots.

Methods

Comprehensive scientific mapping analysis of a wide range of literature metadata using the scientometric tools, including the Bibliometrix R Package, Biblioshiny, and CiteSpace. Data were retrieved from the Web of Science Core Collection database of original articles from 2001 to 2020. Specific indicators and maps were analyzed to show the co-authorship, co-institute, co-country, co-citation, and international cooperation. Automatic literature screening, unsupervised cluster filtering, and topic cluster identification methods were used to display the conceptual framework and thematic evolution.

Results

A total of 1,403 research projects drafted by 6,966 authors and published in 413 sources were found. There was an exponential growth in the number of publications on ERAS. There were 709 collaborations between authors from different countries, and the US, China, and the UK had the greatest number of publications. The WORLD JOURNAL OF SURGERY, located in Bradford’s Law 1, had the highest number of published articles (n = 1,276; total citations = 3,193). CiteSpace network analysis revealed 15 highly correlated cluster ERAS studies, and the earliest study was on colonic surgery, and ERAS was recently applied in cardiac surgery. The etiology of ERAS is constantly evolving, with surgery and length of hospital as the main topics. Meta-analyses and perioperative care have tended to decline.

Conclusion

This is the first scientometric analysis of ERAS to provide descriptive quantitative indicators. This can provide a better understanding of how the field has evolved over the past 20 years, help identify research trends, and provide insights and research directions for academic researchers, policymakers, and medical practitioners who want to collaborate in these areas in the future.

Implementation of the ERAS (Enhanced Recovery After Surgery) protocol for hysterectomy in the Piedmont Region with an audit&feedback approach: Study protocol for a stepped wedge cluster randomized controlled trial. A study of the EASY-NET project

Introduction

ERAS (Enhanced Recovery After Surgery) is a perioperative program combining multiple evidence-based interventions designed to reduce the surgical stress response. Despite the publication of dedicated guidelines, ERAS application to gynecologic surgery outside clinical studies has been slow and fragmented. To promote the systematic adoption of the ERAS program in the entire regional hospital network in Piedmont an Audit-and-Feedback approach (A&F) has been adopted within a cluster randomized controlled trial, aiming to estimate the true impact of the protocol on a large, unselected population.

Methods

The study protocol provides for a multicenter stepped wedge cluster randomized trial, focused on women undergoing an hysterectomy, for comparison between standard perioperative management and perioperative management according to the ERAS protocol. The primary outcome is the length of hospital stay (LOS). Secondary outcomes are: post-operative complications, quality-of-recovery at 24-hours after surgery, 30-day readmissions, patients’ satisfaction, healthcare costs. The compliance to all the ERAS items is monitored with an A&F approach. All the gynecologic units of Piedmont hospitals are involved and all the patients hospitalized for elective hysterectomy in the period of the study are included. Centers, stratified by surgical volume and randomly assigned to four groups, are randomly ordered to activate the ERAS protocol in four periods, every three months. The planned calendar and the total duration of the study have been extended for six months due to the COVID-19 pandemic. The expected sample size of about 2400 patients has a high statistical power (99%) to detect a reduction of LOS of 1 day (effect size 0.5) and to estimate clinically meaningful changes in the other study endpoints. The study protocol has been approved by the Ethical Committee of all participating centers. Study results will be timely circulated within the hospital network and published in peer-reviewed journals.

Conclusion

Results are expected to demonstrate positive clinical outcomes of the ERAS protocol even when its implementation is directed towards an entire regional network of gynecologic units, and not only towards selected and highly motivated centers.

Trial registration

NCT04063072

Effectiveness of enhanced recovery after surgery protocol in open gynecologic oncology surgery: A randomized controlled trial

OBJECTIVE

To examine the effectiveness of applying the recommended enhanced recovery after surgery (ERAS) protocol compared with our usual care in women with gynecologic malignancy undergoing elective laparotomy.

METHODS

From June 2020 to May 2021, 93 women with gynecologic cancers (cervix, endometrium, and ovary) undergoing elective laparotomy at our institution were randomly assigned into an intervention group (ERAS protocol, 46 women) or control group (usual care, 47 women). For the intervention group, each woman was brought through the pre-specified ERAS protocol starting from preoperative counseling to postoperative management. For the control group, participants underwent routine standard care. The primary outcomes were length of hospital stay and postoperative pain.

RESULTS

The intervention group demonstrated shorter hospital stay by 20 h (47.48 h vs 67.17 h, P = 0.02) with lower postoperative pain score at postoperative day 0 (1.58 vs 4.00, P < 0.01) and day 1 (1.00 vs 2.67, P < 0.01) while having decreased opioid consumption (P < 0.01). The intervention group also had faster recovery of gastrointestinal function. Overall, good compliance to most of the ERAS pathway domains was obtained.

CONCLUSION

The ERAS protocol demonstrates benefits on shortening hospital stay, reducing pain, and bowel function recovery without increasing complications in our population.

CLINICAL TRIAL REGISTRATION

The present study was registered at clinicaltrials.gov (NCT04201626) on December 3, 2019. Initial participant enrollment began on June 1, 2020. Access through URL of the registration site: https://clinicaltrials.gov/ct2/show/NCT04201626?cond=ERAS&cntry=TH&draw=2&rank=3.

To what extent is enhanced recovery in surgery used in French obstetrics and gynecology departments?: use of enhanced recovery in gynecologic and obstetric surgery in France

The objective of the present study was to evaluate the implementation of Enhanced Recovery in Surgery (ERS) in French obstetrics and gynecology departments. To achieve this objective, we drafted an online questionnaire about ERS protocols for caesarean sections and hysterectomies with a benign indication and put a hyperlink on the 'French National College of Gynecologists and Obstetricians' (Collège National des Gynécologues et Obstétriciens Français) website. We obtained 112 analyzable responses. Respectively 66% and 34% of the surveyed departments had established ERS protocols for cesarean sections and for hysterectomies with a benign indication. However, not all of the key ERS items were sufficiently implemented: despite the establishment of written protocols, the degree of compliance with the guidelines issued by the French-Speaking Group for Enhanced Recovery After Surgery (Groupement Francophone de Réhabilitation Améliorée Après Chirurgie) was variable. There are few published data on the implementation of ERS in obstetrics and gynecology departments worldwide. In 2010, the Enhanced Recovery After Surgery® Society issued guidelines and a checklist for an ERS protocol. The literature data suggest that for most surgical disciplines, the main ERS criteria are not well known or not widely applied. ERS protocols are still not widespread in French gynecologic surgery departments. Moreover, the application of some of the major ERS items differs markedly from one ERS program to other, which is likely to reduce the level of effectiveness. It therefore appears to be essential to formalize and promote ERS protocols in gynecological surgery.

Enhanced recovery after minimally invasive gynecologic oncology surgery to improve same day discharge: a quality improvement project

OBJECTIVES

Same day discharge after minimally invasive hysterectomy has been shown to be safe and feasible. We designed and implemented a quality improvement perioperative program based on early recovery after surgery principles to improve the rate of same day discharge from 30% to 75% after minimally invasive gynecologic oncology surgery over a 12 month period.

METHODS

We enrolled 102 consecutive patients undergoing minimally invasive hysterectomy at a single cancer center during a 12 month period. A pre-intervention cohort of 100 consecutive patients was identified for comparison of clinicodemographic variables and perioperative outcomes. A multidisciplinary team developed a comprehensive perioperative care program and followed quality improvement methodology. Patients were followed up for 30 days after discharge. A statistical process chart was used to monitor the effects of our interventions, and a multivariate analysis was conducted to determine factors associated with same day discharge.

RESULTS

Same day discharge rate increased from 29% to 75% after implementation (p<0.001). The post-intervention cohort was significantly younger (59 vs 62 years; p=0.038) and had shorter operative times (180 vs 211 min; p<0.001) but the two groups were similar in body mass index, comorbidity, stage, and intraoperative complications. There was no difference in 30 day perioperative complications, readmissions, reoperations, emergency department visits, or mortality. Overnight admissions were secondary to nausea and vomiting (16%), complications of pre-existing comorbidities (12%), and urinary retention (8%). On multivariate analysis, longer surgery, timing of surgery, and narcotic use on the ward were significantly associated with overnight admission. Overall, 89% of patients rated their experience as 'very good' or 'excellent', and 87% felt that their length of stay was adequate.

CONCLUSIONS

Following implementation of a perioperative quality improvement program targeted towards minimally invasive gynecologic oncology surgery, our intervention significantly improved same day discharge rates while maintaining a low 30 day perioperative complication rate and excellent patient experience.

Usefulness of criteria for intraoperative Management of Postoperative Nausea and Vomiting

Background

Postoperative nausea and vomiting (PONV) delays postoperative recovery, prolongs hospital stays, and hinders patients’ return to society, thus making it a major cause of increased healthcare costs. It is also the most troubling postoperative complication in female patients undergoing surgery. However, in Japan, guidelines for the management of PONV have not been established, and the management protocol for PONV is left to each institution and anesthesiologist. Therefore, we developed criteria for intraoperative management of PONV.

Methods

In female surgical patients, the usefulness of the criteria was evaluated by comparing the implementation rate of intraoperative management and PONV incidence before and after the establishment of the criteria. An Apfel simplified score (Apfel score) ≥2 was set as an indication for intraoperative management of PONV.

Results

The implementation rate of intraoperative management increased from 91.2 to 96.0% after the introduction of the criteria. In patients with an Apfel score of 2, the intraoperative management implementation rate significantly increased from 81.1 to 94.7% (p = 0.016), while PONV incidence significantly decreased from 44.6 to 34.1% after the introduction of the criteria (p = 0.040).

Conclusions

The criteria for intraoperative management of PONV increased the implementation rate of intraoperative management and decreased PONV incidence, indicating the usefulness of the criteria.

Protein Supplement and Enhanced Recovery After Posterior Spine Fusion Surgery: A Randomized, Double-blind, Placebo-controlled Trial

STUDY DESIGN

This was a randomized, double-blind clinical trial study.

OBJECTIVE

The objective of this study was to evaluate the effect of protein supplementation on vertebral fusion and enhanced recovery after posterior spine fusion (PSF) surgery.

SUMMARY OF BACKGROUND DATA

Nonfusion is one of the most common complications of lumbar spine surgery. It has been shown that protein plays an important role in bone repair; however, its correlation to vertebral fusion following PSF surgery is unknown.

PATIENTS AND METHODS

In this randomized, double-blind clinical trial study, the intervention group received a diet with 1.2 g of protein plus high-protein supplement (36 g whey protein), and the control group received a similar diet, except for starch as a placebo from 48 hours before to 1 month after surgery.

RESULTS

The intervention group showed a significantly higher rate of vertebral fusion compared with the control group (P=0.019). Surgical site infection and pain were significantly lower in the intervention group. A significant difference was found in the wound healing rate in favor of the intervention group. The rates of decrease in serum high-sensitivity C-reactive protein levels and increase in serum levels of insulin-like growth factor 1, albumin, total protein, and alkaline phosphatase were greater in the intervention group than in the control group (P<0.001).

CONCLUSIONS

Increased protein intake improves vertebral fusion and enhances recovery in patients undergoing PSF. This was the first study to investigate the effect of protein on fusion and healing factors; as a result, further clinical trials are needed to confirm the current results.

A Randomised Study To Compare Palonosetron With Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting (PONV) Following Laparoscopic Gynecological Surgeries

Background

Incidence of postoperative nausea and vomiting (PONV) in susceptible patients can be unacceptably high (70-80% reported incidence). This study was designed to evaluate the effect of palonosetron and ondansetron in preventing PONV in high-risk patients undergoing gynecological laparoscopic surgery.

Methodology

In this randomized, controlled, double-blind trial, non-smoking females aged 18-70 years, weighing 40-90 kg, and posted for elective laparoscopic gynecological surgeries were enrolled into ondansetron (Group A, n = 65) and palonosetron (Group B, n = 65) groups. Palonosetron (1 mcg/kg IV) or ondansetron (0.1 mg/kg IV) were administered just before induction. Postoperatively, the incidence of nausea, vomiting, PONV (scored on a scale of 0-3), need for rescue antiemetic, complete response, patient satisfaction, and adverse effects were evaluated up to 48 h following surgery. Normally distributed continuous variables were compared using Student’s t-test. In addition, the Chi-squared test or Fisher’s exact test were used to compare nominal categorical data as deemed appropriate. P-value <0.05 was observed as statistically significant.

Results

The overall PONV scores and postoperative nausea scores during 0-2 and 24-48 hours were comparable, but PONV scores (p = 0.023) and postoperative nausea scores (p = 0.010) during 2-24 hours were significantly lesser in Group B compared to Group A. There was no statistically significant difference in the postoperative vomiting score or retching during 0-48 hours. The amount of first-line rescue antiemetic used during 2-24 hours was significantly higher in Group A (56%) than in Group B (31%) (p = 0.012; p <0.05). A complete response to the drug during 2-24 hours was significantly higher (p = 0.023) in Group B (63%) compared to Group A (40%), whereas response was comparable during 0-2 and 24-48 hours. Both groups had a comparable incidence of adverse effects and patient satisfaction scores.

Conclusion

Palonosetron has a superior anti-nausea effect, less need for rescue antiemetics, and lesser incidence of total PONV compared to ondansetron during 2-24h and comparable effect to ondansetron during 0-2h and 24-48h postoperative period in high-risk patients undergoing gynecological laparoscopic surgery.

Transcutaneous Electrical Acupoint Stimulation Decreases the Incidence of Postoperative Nausea and Vomiting After Laparoscopic Non-gastrointestinal Surgery: A Multi-Center Randomized Controlled Trial

Importance

Postoperative nausea and vomiting (PONV) gives patients a bad experience and negates their good recovery from surgery.

Objective

This trial aims to assess the preventive effectiveness of transcutaneous electrical acupoint stimulation (TEAS) on the incidence of PONV in high-risk surgical patients.

Design

The large sample size, multicenter, evaluator-blinded, and randomized controlled study was conducted between September 3, 2019 to February 6, 2021.

Setting

The 12 hospitals were from different Chinese provinces.

Participants

After obtaining ethics approval and written informed consent, 1,655 patients with Apfel score ≥ 3 points were enrolled for selective laparoscopic non-gastrointestinal surgery under general anesthesia.

Interventions

Patients were randomly allocated into the TEAS and Sham group with a 1:1 ratio. The TEAS group was stimulated on bilateral Neiguan and Zusanli acupoints after recovery from anesthesia on the surgical day and the next morning for 30 min, while the Sham group received an identical setting as TEAS but without currents delivered. Electronic patient self-reported scale was used to evaluate and record the occurrence of PONV.

Main Outcomes and Measures

Primary clinical end point is the incidence of PONV which was defined as at least one incidence of nausea, retching, or vomiting after operation within postoperative 24 h.

Results

Compared with the Sham treatment, the TEAS lowered the PONV incidence by 4.8% (29.4 vs. 34.2%, P = 0.036) and vomiting incidence by 7.4% (10.4 vs. 17.8%, P < 0.001). TEAS also lowered persistent nausea incidence and PONV scores and decreased PONV related complications and Quality of Recovery−40 scores (P < 0.05). TEAS lowered the 24 h PONV risk by 20% (OR, 0.80, 95% CI, 0.65 −0.98; P = 0.032), and lowered hazard ratio by 17% (HR, 0.83, 95% CI, 0.70–0.99; P = 0.035). Both TEAS and palonosetron were the independent PONV risk protective factors for 24 h PONV incidence and cumulative PONV incidence. The combination of TEAS and palonosetron was the most effective strategy to reduce the PONV incidence (P < 0.001).

Conclusions and Relevance

TEAS attenuated the PONV incidence and severity in high-risk surgical patients and may be applied clinically as a complement therapy to prevent PONV.

Clinical Trial Registration

https://clinicaltrials.gov/ct2/show/NCT04043247, identifier: NCT04043247.

Implementation of an enhanced recovery after surgery program in the treatment of uterine fibroids with focused ultrasound ablation surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) can reduce the length of hospital stay, incidence of surgery-related complications, and postoperative pain. We aimed to demonstrate the implementation of an ERAS pathway in the treatment of uterine fibroids with focused ultrasound ablation surgery (FUAS).

MATERIALS AND METHODS

A retrospective data analysis was performed on clinical outcomes encompassing the following three phases: before ERAS (pre-ERAS), during adjustment of ERAS (interim-ERAS), and after the introduction of an ERAS program (post-ERAS). The purpose of describing the interim-ERAS was to provide references for the formulation of the program during the course of FUAS by describing the adjustment processes. Data from patients admitted to the hospital from September 2019 to December 2019 and April 2020 to November 2020 and who met the criteria for FUAS in the treatment of their uterine fibroids were examined. Length of stay, cost of surgery, postoperative pain score, utilization of postoperative analgesics, and incidence of postoperative adverse events were compared across the abovementioned three phases.

RESULTS

Compared with the pre-phase, the cost of treatment and length of stay were reduced after the implementation of ERAS. The use of analgesics before leaving the operating room, as well as the incidence of postoperative nausea and vomiting, were also reduced.

CONCLUSION

The implementation of an ERAS protocol might benefit patients with uterine fibroids treated with FUAS in terms of requiring a shorter hospitalization period, lower costs, and reduced opioid use.

Updates in Enhanced Recovery Pathways for Gynecologic Surgery

Gynecologic surgery encompasses over a quarter of inpatient surgical procedures for US women, and current projections estimate an increase of the US female population by nearly 50% in 2050. Over the last decade, US hospitals have embraced enhanced recovery pathways in many specialties. They have increasingly been used in multiple institutions worldwide, becoming the standard of care for patient optimization. According to the last updated enhanced recovery after surgery (ERAS) guideline published in 2019, there are several new considerations behind each practice in ERAS protocols. This article discusses the most updated evidence regarding ERAS programs for gynecologic surgery.

Enhanced Recovery after Surgery (ERAS) Protocol for Early Discharge within 12 Hours after Robotic Radical Hysterectomy

To evaluate safety of quick discharge after robotic radical hysterectomy (RRH) in a tertiary hospital which has the enhanced recovery after surgery (ERAS) protocol. Among 94 consecutive cervical cancer patients who had undergone RRH, operative outcomes and the rate of unexpected visit after surgery were analyzed retrospectively. Patients were categorized as a surgery-to-discharge time of ≤12 h (early discharge [ED]) or >12 h (late discharge [LD]). About 77% (n = 72) of analyzed 94 patients discharged within 12 h after RRH. The ED group had significant correlation with shorter duration for urinary catheter required, less operative blood loss, and less voiding difficulty after long-term follow up compared to the LD group. There was no difference of perioperative complications and unexpected visit between the two groups. Performing nerve sparing (NS) RRH was only independent predictor for ED (p = 0.043, hazard ratio for LD = 0.22, confidence interval = 0.05–0.95). In conclusion, the ED within 12 h after RRH was safe in the setting of ERAS protocol. The NS-RRH could avoid the delay of genitourinary function recovery after surgery which caused LD. It can become the reasonable clinical pathway to discharge early patients who undergo NS-RRH with ERAS protocol.

PROPER-PRehabilitatiOn Plus Enhanced Recovery after surgery versus enhanced recovery after surgery in gynecologic oncology: a randomized clinical trial

BACKGROUND

Prehabilitation is a process that occurs before surgery and aims to improve patient functional capacity and enhance surgical recovery. This process includes medical, nutritional, physical, and psychological interventions that may reduce the duration of hospital stay and provide postoperative physical benefits.

PRIMARY OBJECTIVE

To evaluate the impact of a prehabilitation program on postoperative recovery time for patients who will undergo gynecological surgery following the Enhanced Recovery After Surgery (ERAS) guidelines.

STUDY HYPOTHESIS

A multidisciplinary, preoperative prehabilitation program for patients who will undergo gynecological surgery leads to a reduction in the length of hospital stay and improves patient functional capacity.

TRIAL DESIGN

Prospective, interventionist, and randomized controlled trial in a 1:1 ratio, open to multidisciplinary team and patients, blinded to surgeons and anesthesiologists. The control group will undergo ERAS standard preoperative care while the intervention group will have ERAS standard preoperative care plus prehabilitation.

MAJOR INCLUSION CRITERIA

Patients scheduled to undergo gynecologic surgery performed by laparotomy with a preoperative schedule that allows prehabilitation intervention for 2 to 3 weeks.

PRIMARY ENDPOINT

To compare time between surgery and the day the patient is ready for discharge in patients who underwent the prehabilitation process versus those who did not. Readiness for discharge is defined as the ability to take care of one's-self, to walk alone, and to ingest at least 75% of daily recommended calorie intake.

SAMPLE SIZE

194 participants ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: At present, 30 patients have been recruited. Accrual should be completed by 2023-24.

TRIAL REGISTRATION

The study is approved by the IBCC - São Camilo Oncologia ethics committee (reference number 4.256.553) and is registered at clinicaltrials.gov (NCT04596800).