Implementation of enhanced recovery after surgery (ERAS) in gynaecological oncology

Incisional infiltration versus transversus abdominis plane block of liposomal bupivacaine after midline vertical laparotomy for suspected gynecologic malignancy: a pilot study

Background

To evaluate whether incisional infiltration of liposomal bupivacaine would decrease opioid requirement and pain scores after midline vertical laparotomy for suspected or known gynecologic malignancy compared with transversus abdominis plane (TAP) block with liposomal bupivacaine.

Methods

A prospective, single blind randomized controlled trial compared incisional infiltration of liposomal bupivacaine plus 0.5% bupivacaine versus TAP block with liposomal bupivacaine plus 0.5% bupivacaine. In the incisional infiltration group, patients received 266 mg free base liposomal bupivacaine with 150 mg bupivacaine hydrochloride. In the TAP block group, 266 mg free base bupivacaine with 150 mg bupivacaine hydrochloride was administered bilaterally. The primary outcome was total opioid use during the first 48-hour postoperative period. Secondary outcomes included pain scores at rest and with exertion at 2, 6, 12, 24 and 48 h after surgery.

Results

Forty three patients were evaluated. After interim analysis, a three-fold higher sample size than originally calculated was required to detect a statistically significant difference. There was no clinical difference between the two arms in mean opioid requirement (morphine milligram equivalents) for the first 48 h after surgery (59.9 vs. 80.8, p = 0.13). There were no differences in pain scores at rest or with exertion between the two groups at pre-specified time intervals.

Conclusion

In this pilot study, incisional infiltration of liposomal bupivacaine and TAP block with liposomal bupivacaine demonstrated clinically similar opioid requirement after gynecologic laparotomy for suspected or known gynecologic cancer. Given the underpowered study, these findings cannot support the superiority of either modality after open gynecologic surgery.

Pushing the DIEP Envelope with ERAS: 24 Hour Discharge is Safe in Appropriately Selected Patients

Enhanced recovery after surgery protocols have become increasingly adopted for autologous breast reconstruction, demonstrating improved quality of care and reduced hospital stays. Despite this, average length of stay remains over 3 days. We have found, in appropriately selected patients, hospital length of stay can be safely reduced to less than 48 hours.

Methods

Retrospective review was performed of patients who underwent microsurgical breast reconstruction by the senior author (M.H.) from April 2019 to December 2021. Demographics, operative details, length of stay, and postoperative complications are reported to assess for safety of discharge within 48 hours, with the primary outcome measure being flap loss.

Results

In total, 188 flaps were performed on 107 patients. Average age was 51.4 years (SD 10.1 years) with average BMI 26.6 kg/m² (SD 4.8 kg/m²). Average length of stay was 1.97 days (SD 0.61 days), and 96 patients (89.7%) were discharged within 48 hours. Six flaps (3.2%) required operative takebacks. Five of the six (83.3%) takebacks occurred on postoperative days zero or one, and all five of these flaps were salvaged. There were four breast hematomas (2.1%), four breast seromas (2.1%), eight breast infections (4.3%), 13 breasts (6.9%) with wound dehiscence, four flaps (2.1%) with partial flap loss, and 24 breasts (12.8%) with mastectomy flap necrosis. One hundred fifty flaps (79.8%) had no complications. Overall success rate of flap reconstruction was 99.5%.

Conclusion

Hospital discharge in 24-48 hours is safe in appropriately selected patients undergoing autologous tissue breast reconstruction.

Enhanced Recovery after Surgery (ERAS) Program for Patients with Peritoneal Surface Malignancies Undergoing Cytoreductive Surgery with or without HIPEC: A Systematic Review and a Meta-Analysis

Enhanced recovery after surgery (ERAS) program refers to a multimodal intervention to reduce the length of stay and postoperative complications; it has been effective in different kinds of major surgery including colorectal, gynaecologic and gastric cancer surgery. Its impact in terms of safety and efficacy in the treatment of peritoneal surface malignancies is still unclear. A systematic review and a meta-analysis were conducted to evaluate the effect of ERAS after cytoreductive surgery with or without HIPEC for peritoneal metastases. MEDLINE, PubMed, EMBASE, Google Scholar and Cochrane Database were searched from January 2010 and December 2021. Single and double-cohort studies about ERAS application in the treatment of peritoneal cancer were considered. Outcomes included the postoperative length of stay (LOS), postoperative morbidity and mortality rates and the early readmission rate. Twenty-four studies involving 5131 patients were considered, 7 about ERAS in cytoreductive surgery (CRS) + HIPEC and 17 about cytoreductive alone; the case histories of two Italian referral centers in the management of peritoneal cancer were included. ERAS adoption reduced the LOS (-3.17, 95% CrI -4.68 to -1.69 in CRS + HIPEC and -1.65, 95% CrI -2.32 to -1.06 in CRS alone in the meta-analysis including 6 and 17 studies respectively. Non negligible lower postoperative morbidity was also in the meta-analysis including the case histories of two Italian referral centers. Implementation of an ERAS protocol may reduce LOS, postoperative complications after CRS with or without HIPEC compared to conventional recovery.

Effect of Enhanced Recovery After Surgery Protocol on Postoperative Outcomes of Women Undergoing Abdominal Hysterectomy

Background

Enhanced recovery after surgery protocol is a standardized, multidisciplinary approach for shorter hospital stay without negatively affecting patient outcomes. The aim of this research was to evaluate the effect of enhanced recovery after surgery protocol on postoperative outcomes of women undergoing abdominal hysterectomy.

Design

A quasi-experimental design was adopted to fulfil the aim of this research.

Setting

The research was conducted at Obstetric and Gynecological Department in Benha University Hospital.

Sample

A purposive sample of 148 women undergoing abdominal hysterectomy divided into two groups.

Data collection

Three tools were used: Tool (I) structured questionnaire sheet. Tool (II) post-operative pain assessment scale (numerical rating scale). Tool (III) post-operative outcomes assessment sheet.

Results

There was a highly statistically significant difference between the studied groups regarding all postoperative outcomes (p = .000). The women in the study group experienced less mean score of pain compared to those in control group on both 2nd and 3rd day after surgery. Also, there was a statistically significant difference between the studied groups regarding postoperative complication and readmission (p = .000).

Conclusion

Women undergoing abdominal hysterectomy who received enhanced recovery after surgery protocol had better postoperative outcomes than women who received routine perioperative care.

The impact of enhanced recovery after gynaecological surgery: A systematic review and meta-analysis

BACKGROUND

Enhanced Recovery After Surgery programs have become the gold standard of care in many surgical specialities.

OBJECTIVES

This updated systematic review and meta-analysis aims to evaluate how an ERAS program can impact outcomes across both benign and oncological gynaecological surgery to inform standard surgical practice.

SEARCH STRATEGY

An electronic search of the SCOPUS, Embase and PubMed Medline databases was performed for relevant studies assessing the use of ERAS in patients undergoing gynaecological surgery compared with those without ERAS.

SELECTION CRITERIA

The studies included were all trials using ERAS programs in gynaecological surgery with a clearly outlined protocol which included at least four items from the most recent guidelines and recorded one primary outcome.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed on two primary endpoints; post-operative length of stay and readmission rate and one secondary endpoint; rates of ileus. Further subgroup analyses was performed to compare benign and oncological surgeries.

MAIN RESULTS

Forty studies (7885 patients) were included in the meta-analysis; 15 randomised controlled trials and 25 cohort studies. 21 studies (4333 patients) were included in meta-analyses of length of stay. Patients in the ERAS group (2351 patients) had a shortened length of stay by 1.22 days (95% CI: -1.59 - -0.86, P < 0.00001) compared to those in the control group (1982 patients). Evaluation of 27 studies (6051 patients) in meta-analysis of readmission rate demonstrated a 20% reduction in readmission rate (OR: 0.80, 95% CI: 0.65-0.97). Analysis of our secondary outcome, demonstrated a 47% reduction in rate of ileus compared to the control group.

CONCLUSIONS

ERAS pathways significantly reduce length of stay without increasing readmission rates or rates of ileus across benign and oncological gynaecological surgery.

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.

Perioperative enhanced recovery programmes for women with gynaecological cancers

BACKGROUND

Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015.

OBJECTIVES

To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes.

SEARCH METHODS

We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty.

MAIN RESULTS

We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants).

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.

Design and Implementation of an Enhanced Recovery After Surgery Protocol in Elective Lumbar Spine Fusion by Posterior Approach: A Retrospective, Comparative Study

STUDY DESIGN

Retrospective, comparative.

OBJECTIVE

The aim of this study was to design an enhanced recovery after surgery (ERAS) protocol for elective lumbar spine fusion by posterior approach, and to compare the results after ERAS implementation in patients undergoing elective lumbar spine fusion with conventional perioperative care.

SUMMARY OF BACKGROUND DATA

Despite wide adoption in other surgical disciplines, ERAS has only been recently implemented in spine surgery. The integrated multidisciplinary approach of ERAS aims to reduce surgical stress to achieve better outcomes.

METHODS

Hospital records of adult patients who underwent one- to three-level elective lumbar spine fusion by posterior approach at a single center were retrospectively studied. An ERAS protocol was designed based on the prevalent hospital practices, local resources and supportive evidence from literature. The ERAS protocol was implemented at our institute in December 2016-dividing patients into pre-ERAS and post-ERAS groups. The outcome measures for comparison were: length of hospital stay (LOS), postoperative complications, 60-day readmission rate, 60-day reoperation rate, and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score) at stipulated time intervals.

RESULTS

A total of 812 patients were included - 496 in the pre-ERAS group and 316 in the post-ERAS group. There was no significant difference between the two groups in baseline demographic, clinical, and surgery-related variables. Patients in the post-ERAS group had a significantly shorter LOS (2.94 vs. 3.68 days). The rate of postoperative complications (13.5% vs. 11.7%), 60-day readmission (1.8% vs. 2.2%), and 60-day reoperation (1.2% vs. 1.3%) did not differ significantly between the pre-ERAS and post-ERAS groups. The VAS and ODI scores, similar at baseline, were significantly lower in the post-ERAS group (VAS: 49.8 ± 12.0 vs. 44 ± 10.8, ODI: 31.6 ± 14.2 vs. 28 ± 12.8) at 4 weeks after surgery. This difference however was not significant at intermediate-term follow-up (6 months and 12 months).

CONCLUSION

Implementation of an ERAS protocol is feasible for elective lumbar spine fusion, and leads to shorter LOS and improved early pain and functional outcome scores.Level of Evidence: 3.

Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway

STUDY OBJECTIVE

Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m² undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP.

DESIGN

A retrospective cohort study.

SETTING

An academic teaching hospital.

PATIENTS

A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m²) undergoing robotic hysterectomy.

INTERVENTIONS

The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls.

MEASUREMENTS AND MAIN RESULTS

Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room).

CONCLUSION

The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.

Prospective study of patient satisfaction with enhanced recovery after surgery (ERAS) protocol in the immediate post-operative period in gynaecological oncology

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal protocol which aims to facilitate faster discharge from hospital and recovery after surgery by minimising physiological and physical stress on the body before, during and after surgery.

AIMS

The aim of this study is to evaluate patient satisfaction while being managed with the ERAS pathway and to determine whether it is an acceptable model of care in this respect.

MATERIALS AND METHODS

The study is an observational study of patient satisfaction in ERAS in gynaecological oncology. Patients who underwent laparoscopy or laparotomy for malignancy or suspected malignancy were asked to complete a validated questionnaire (EORTC IN-PATSAT32) prior to discharge from hospital after surgery.

RESULTS

There were 113 (75.33%) patients recruited out of 150 patients who were approached. There were 68 cases of laparotomy and 45 cases of laparoscopy. There were no statistically significant differences between baseline characteristics of responders and non-responders in both the laparotomy and the laparoscopy group. Patients reported high levels of satisfaction, with a mean score for general satisfaction of 92.2 (SD 11.44 ± 1.387) in the laparotomy group and 92.4 (SD 10.69 ± 1.594) for the laparoscopy group.

CONCLUSIONS

The results of our study reflect high levels of patient satisfaction in both the laparotomy and laparoscopy groups. This could be attributed to a strong focus on discharge planning through a multi-disciplinary approach, specifically addressing key aspects to recovery from initial consultation. The study reflects the successful implementation of an ERAS protocol with gynaecological oncological surgery in this unit.

Enhanced recovery after surgery in laparoscopic distal gastrectomy: Protocol for a prospective single-arm clinical trial

BACKGROUND

The enhanced recovery after surgery (ERAS) programme is feasible and effective in reducing the length of hospital stay, overall complication rates and medical costs when applied to cases involving colonic and rectal resections. However, a recent prospective, randomised, open, parallel-controlled trial (Chinese Laparoscopic Gastrointestinal Surgery Study-01 trial), initiated by our team, indicated that under conventional peri-operative management, the reduction of the post-operative hospital stay of laparoscopic distal gastrectomy (LDG) is quite limited compared with open gastrectomy. Thus, if we could provide valuable clinical evidence for demonstrating the efficacy of the ERAS programme for gastric cancer patients undergoing LDG, it would significantly enhance the peri-operative management of gastrectomy and benefit the patients.

METHODS

In this prospective single-arm trial, patients who are 18-75 years of age with gastric adenocarcinoma diagnosed with cT1-4aN0-3M0 and expected to undergo curative resection through LDG, are considered eligible for this study. All participants underwent LDG with peri-operative management under the ERAS programme. The primary outcome measures included the post-operative hospital stays and rehabilitative rate of the post-operative day 4. The secondary outcome measures are morbidity and mortality (time frame: 30 days), post-operative recovery index (time frame: 30 days), post-operative pain intensity (time frame: 3 days) and the medical costs from surgery to discharge.

CONCLUSION

With reasonable and scientific designing, the trial may be a great help to further discuss the benefit of ERAS programme and thus improving the peri-operative management of patients with gastrectomy.

Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - A systematic review and meta-analysis

OBJECTIVE

To assess the benefit of Enhanced Recovery After Surgery (ERAS) on length of stay (LOS), postoperative complications, 30-day readmission, and cost in gynecologic oncology.

METHODS

A systematic literature search was performed in MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and Web of Science for all peer-reviewed cohort studies and controlled trials on ERAS involving gynecologic oncology patients. Abstracts, commentaries, non-controlled studies, and studies without specific data on gynecologic oncology patients were excluded. Meta-analysis was performed on the primary endpoint of LOS. Subgroup analyses were performed based on risk of bias of the studies included, number of ERAS elements, and ERAS compliance. Secondary endpoints were readmission rate, complications, and cost.

RESULTS

A total of 31 studies (6703 patients) were included: 5 randomized controlled trials, and 26 cohort studies. Meta-analysis of 27 studies (6345 patients) demonstrated a decrease in LOS of 1.6 days (95% confidence interval, CI 1.2-2.1) with ERAS implementation. Meta-analysis of 21 studies (4974 patients) demonstrated a 32% reduction in complications (OR 0.68, 95% CI 0.55-0.83) and a 20% reduction in readmission (OR 0.80, 95% CI 0.64-0.99) for ERAS patients. There was no difference in 30-day postoperative mortality (OR 0.61, 95% CI 0.23-1.6) for ERAS patients compared to controls. No difference in the odds of complications or reduction in LOS was observed based on number of included ERAS elements or reported compliance with ERAS interventions. The mean cost savings for ERAS patients was $2129 USD (95% CI $712 - $3544).

CONCLUSIONS

ERAS protocols decrease LOS, complications, and cost without increasing rates of readmission or mortality in gynecologic oncology surgery. This evidence supports implementation of ERAS as standard of care in gynecologic oncology.

Early Prediction of Length of Stay After Pancreaticoduodenectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) is an evidence-based clinical pathway designed to standardize and optimize care. We studied the impact of ERAS and sought to identify the most important recommendations to predict shorter length of stay (LOS) after pancreaticoduodenectomy (PD).

METHODS

We retrospectively reviewed all patients undergoing PD at our institution between January 2014 and June 2018. We compared clinicopathologic outcomes for patients before and after ERAS implementation. We defined "A-recommendations" as those that were graded "strong" and had "moderate" or "high" levels of evidence. We then compared outcomes of the ERAS group with adherence to "A-recommendations" and performed a subset analysis of "A-recommendations" over the first 72 h after surgery, which we termed "early factors".

RESULTS

A total of 191 patients underwent PD during the study period. We excluded 87 patients who had minimally invasive PD (22), vascular reconstruction (53), or both (12). Of the 104 patients studied, 56 (54%) were pre-ERAS and 48 (46%) were ERAS. There were no differences in comorbidities or demographics between these groups, and morbidity, mortality, and readmission rates were also similar (P > 0.6). Median LOS was 3.5 d shorter in the ERAS group (7 versus 10.5 d, P < 0.001). Adherence to "A-recommendations" within ERAS was associated with a decreased LOS (r = -0.52 P = 0.0001). Patients with >5 "early factors" had a median LOS of 6 d, whereas patients with <5 "early factors" had a median LOS of 9 d (P = 0.008).

CONCLUSIONS

ERAS is an effective protocol that standardizes care and reduces LOS after PD. Implementation of ERAS resulted in a 3.5-day reduction in our LOS with no change in morbidity, mortality, or readmissions. Adherence to ERAS protocol "A-recommendations" and ≥5 "early factors" may be predictive of shortened LOS.

Enhanced Recovery After Surgery in Pediatric and Adolescent Gynecology: A Pilot Study

STUDY OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in adult gynecology as well as adult and pediatric colorectal and urologic surgery with reduction in narcotic use, complications, return to the system (RTS), length of stay (LOS), and improved patient satisfaction. There are no studies evaluating the use of ERAS in pediatric and adolescent gynecology (PAG). The goals of this study are to present initial patient outcomes using ERAS in PAG patients undergoing intra-abdominal gynecologic surgery to prove efficacy, patient satisfaction, and decreased narcotic use.

DESIGN

As a quality improvement measure in perioperative care, an ERAS protocol including preoperative, intraoperative, and postoperative components and a follow-up patient telephone call for pain assessment was implemented for all intra-abdominal gynecologic procedures. A retrospective study on implementation of ERAS components, outcomes, and patient satisfaction was then performed in participants meeting inclusion criteria.

SETTING

Large academic children's hospital.

PARTICIPANTS

Patients <25 years of age who underwent laparoscopic (LSC) or open abdominal (XLAP) gynecologic surgery using an ERAS protocol by the PAG service over a 12-month period.

INTERVENTIONS

An ERAS protocol including preoperative, intraoperative, and postoperative components and follow-up patient telephone call for pain assessment was implemented for all major gynecologic surgeries performed by the PAG service.

MAIN OUTCOME MEASURES

Patient satisfaction with the perioperative ERAS protocol along with components including pain management, narcotic use, LOS, RTS, and postoperative complications for various intra-abdominal gynecologic procedures.

RESULTS

A total of 40 participants met inclusion criteria for the study. Thirty-four (85%) participants underwent LSC procedures and six (15%) underwent XLAP. Of the LSC patients, 95% were discharged on postoperative day 0, and all XLAP patients and one LSC patient were discharged on postoperative day 1. In all, 95% of patients were discharged from the hospital requiring only non-narcotic ERAS medications. There were no readmissions or postoperative complications. All patients were satisfied with their postoperative pain control at their follow-up telephone call and clinic visit.

CONCLUSION

Implementation of a pediatric-specific ERAS protocol in children and adolescents undergoing gynecologic surgery is feasible and safe, and leads to less narcotic use without an increase in complications or decrease in patient satisfaction.

Robotic Surgery in Gynecology

The robotic-assisted laparoscopic surgical approach has improved complex gynecologic surgeries. It has the advantages of excellent visualization through the high-resolution 3-dimensional view, a wrist-like motion of the robotic arms and improved ergonomics. Similar to conventional laparoscopic surgeries, it is associated with a decrease in long-term surgical morbidity, early recovery and return to work, and improved esthetics. We discuss preoperative planning, surgical techniques, and some of the latest clinical results of robotic-assisted laparoscopic gynecologic surgery.

Enhanced recovery versus conventional care in gastric cancer surgery: a meta-analysis of randomized and non-randomized controlled trials

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols have been successfully integrated into peri-operative management of different cancer surgeries such as colorectal cancer. Their value for gastric cancer surgery, however, remains uncertain.

METHODS

A search for randomized and observational studies comparing ERAS versus conventional care in gastric cancer surgery was performed according to PRISMA guidelines. Random-effects meta-analyses with inverse variance weighting were conducted, and quality of included studies was assessed using the Cochrane risk-of-bias tool and Newcastle-Ottawa scale (PROSPERO: CRD42017080888).

RESULTS

Twenty-three studies involving 2686 patients were included. ERAS was associated with reduced length of hospital stay (WMD-2.47 days, 95% CI - 3.06 to - 1.89, P < 0.00001), time to flatus (WMD-0.70 days, 95% CI - 1.02 to - 0.37, P < 0.0001), and hospitalization costs (WMD-USD$ 4400, 95% CI - USD$ 5580 to - USD$ 3210, P < 0.00001), with consistent results across open and laparoscopic surgery. Postoperative morbidity and 30-day mortality were similar, although a higher rate of readmission was observed in the ERAS group (RR = 1.95, 95% CI 1.03-3.67, P = 0.04). Patients in the ERAS arm had significantly attenuated C-reactive protein levels on days 3/4 and 7, interleukin-6 levels on days 1, and 3/4, and tumor necrosis factor-α levels on days 3/4 postoperatively.

CONCLUSION

Compared to conventional care, ERAS reduces hospital stay, costs, surgical stress response and time to return of gut function, without increasing post-operative morbidity in gastric cancer surgery. However, precaution is necessary to reduce the increased risk of hospital readmission when adopting ERAS.

Enhanced Recovery after Surgery Pathway for Microsurgical Breast Reconstruction: A Systematic Review and Meta-Analysis

BACKGROUND

The enhanced recovery after surgery pathway was introduced in 1997 as a multimodal approach to reduce preventable postoperative harm and shorten hospital length of stay. However, there is yet no widely accepted enhanced recovery after surgery protocol for microsurgical breast reconstruction. The authors conducted a systematic review and meta-analysis of the current literature on enhanced recovery after surgery for microsurgical breast reconstruction with regard to postoperative length of stay and morbidity.

METHODS

The PubMed, Embase, Cochrane, Scopus, and Web of Science databases were searched for all studies published before June of 2016 containing original data on enhanced recovery after surgery in microsurgical breast reconstruction in relation to postoperative length of stay and morbidity. Studies were screened using eligibility criteria. Meta-analysis, odds ratio, and 95 percent confidence interval were used to pool acquired data.

RESULTS

The initial search identified 86 studies. Two independent screeners identified four original articles with a total of 676 patients. Length of stay was significantly shorter for patients on an enhanced recovery after surgery pathway (mean difference, -1.23; 95 percent CI, -1.50 to -0.96; p < 0.001; I = 0 percent; random effects model). Enhanced recovery was not associated with changes in 30-day postoperative morbidity; specifically, no significant difference was observed in rates of partial flap loss (p = 0.44), total flap loss (p = 0.91), breast hematoma (p = 0.69), donor-site infection (p = 0.53), urinary tract infection (p = 0.29), and pneumonia (p = 0.42).

CONCLUSION

The authors' review suggests that enhanced recovery after surgery in microsurgical breast reconstruction is associated with a reduced length of stay, and is not associated with increased postoperative morbidity.

[Perioperative care of epithelial ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

The following recommendations cover the perioperative management of ovarian, Fallopian tube and primary peritoneal cancers. Five questions related to pre-habilitation and enhanced recovery after surgery were evaluated. The conclusions and recommendations are based on an analysis of the level of evidence available in the literature. These recommendations are part of the overall recommendations for improving the management of ovarian, fallopian or primary peritoneal cancer, made with the support of INCa (Institut National du Cancer). The main preoperative measures are screening for nutritional deficiencies (Grade B) and for anaemia (GradeC) in patients with ovarian cancer. It is not possible to make recommendations on the correction of malnutrition and/or anemia or on the contribution of pre-operative immuno-nutrition due to the absence of data in ovarian cancer, tube cancer or primary peritoneum cancer. For the same reasons, no recommendation can be made on the value of preoperative digestive preparation in ovarian, fallopian tube or primary peritoneum cancer. During surgery, goal-directed fluid therapy for patients with advanced ovarian cancer is recommended (Grade B). A single dose infusion of tranexamic acid is recommended for patients with ovarian, fallopian tube or primary peritoneal cancer (GradeC). For postoperative analgesia, epidural analgesia is recommended for patients undergoing cyto-reduction surgery by laparotomy (Grade B). In the absence of epidural analgesia, patient controlled analgesia with morphine without continuous infusion (Grade B) is recommended. No recommendation can be given regarding intravenous administration of lidocaine and/or ketamine during surgery, or, regarding peri-operatively prescription of gabapentin or pregabalin. In the absence of studies on the impact of different non-opiate analgesic combinations for ovarian cancer surgery, no recommendations can be made. Early oral feeding is recommended, including in cases of digestive resection (Grade B). The implementation of enhanced recovery programs, including early mobilization, is recommended (GradeC).

The Impact of an Enhanced Recovery After Surgery Program on Patients Treated for Gynecologic Cancer in the Community Hospital Setting

Objectives

The purpose of this study was to compare the outcomes of gynecologic oncology patients treated in the community hospital setting either under the auspices of an enhanced recovery after surgery (ERAS) protocol or in accordance with physician discretion.

Methods

We retrospectively evaluated a series of consecutive gynecologic oncology patients who were managed via open surgery in coincident with an ERAS pathway from January 2015 to December 2016. They were compared with a historical open surgery cohort who was treated from November 2013 to December 2014. The primary clinical end points encompassed hospital length of stay, hospital costs, and patient readmission rates.

Results

There were 86 subjects accrued in the ERAS group and 91 patients in the historical cohort. The implementation of ERAS occasioned a greater than 3-day mean reduction in hospital stay (8.04 days for the historical group vs 4.88 days for the ERAS subjects; P = 0.001) and correspondingly diminished hospital costs ($11,877.47/patient vs $9305.26/patient; P = 0.04). Moreover, there were 2 readmissions (2.3%) in the ERAS group compared with 4 (4.4%) in the historical cohort (P = 0.282).

Conclusions

The results from our investigation suggest that adhering to an ERAS protocol confers beneficial hospital length of stay and hospital cost outcomes, without compromising patient readmission rates. Additional investigation scrutinizing the impact of ERAS enactment with more defined study variables in a larger, randomized setting is warranted.