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Vargiu V, Santullo F, Scambia G, Naldini A, Giannarelli D, Gallotta V, Lodoli C, Abatini C, Quagliozzi L, Esposito G, Iasevoli M, Pacelli F, Fagotti A. STOMA study SToma-leak ratio in advanced ovarian cancer surgery: Results of a restrictive policy on the use of protective stoMAs. Gynecol Oncol 2025; 196:92-98. [PMID: 40184714 DOI: 10.1016/j.ygyno.2025.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2024] [Revised: 03/20/2025] [Accepted: 03/22/2025] [Indexed: 04/07/2025]
Abstract
OBJECTIVE Assessemnet of anastomotic leak rates following recto-sigmoid resection in advanced ovarian cancer surgery after implementing a restrictive stoma policy. Secondary objectives include identifying predictive factors for stoma creation, analyzing anastomotic leak management, and perioperative outcomes. SUMMARY BACKGROUND DATA Recto-sigmoid resection is essential in advanced ovarian cancer treatment but carries risks like anastomotic dehiscence. The role of protective stomas remains uncertain, highlighting the need for targeted strategies. METHODS This retrospective study includes data from 722 patients who underwent recto-sigmoid resection between January-2020 and December-2023 at Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. Patients were classified under liberal (2020-2021) or restrictive (2022-2023) stoma policies. The liberal approach relied on general surgeon preference without predefined criteria, while the restrictive policy introduced a systematic evaluation of risk factors by the gynecologic oncologist and the general surgeon in the surgical team before proceeding with ostomy creation. RESULTS The restrictive policy significantly reduced stoma rates from 38.8 % to 11.1 % (p < 0.001) without increasing anastomotic leaks (stable at 2.5 %, p = 1.000). Predictive factors for stoma included multiple bowel resections, inferior mesenteric artery closure, low anastomosis, and residual tumor. Patients with stomas experienced more severe postoperative complications (p = 0.007), prolonged hospital stays (p < 0.001), and delayed chemotherapy (p = 0.018). No differences in anastomotic leak management were recorded among patients with and without ostomy. CONCLUSIONS A restrictive stoma policy reduced ostomy rates without affecting leak rates or mortality, supporting individualized surgical decision-making in ovarian cancer. Prospective studies are needed to clarify risk factors for leaks and validate the necessity of protective stomas.
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Affiliation(s)
- Virginia Vargiu
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Santullo
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Angelica Naldini
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Diana Giannarelli
- Facility of Epidemiology and Biostatistics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Claudio Lodoli
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carlo Abatini
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lorena Quagliozzi
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | | | - Fabio Pacelli
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Fagotti
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy.
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Lago V, Novillo-Del Álamo B, Arnáez M, Rey I, Padilla-Iserte P, Matute L, Gurrea M, Domingo S. Impact of surgical complexity on disease-free survival and overall survival in newly diagnosed advanced ovarian cancer. Int J Gynecol Cancer 2025; 35:101821. [PMID: 40319539 DOI: 10.1016/j.ijgc.2025.101821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2024] [Revised: 03/29/2025] [Accepted: 04/06/2025] [Indexed: 05/07/2025] Open
Abstract
OBJECTIVE Ovarian cancer surgery and the complexity of the procedure may be measured with the standardized Aletti score. The main objective of this study was to establish the influence of surgical complexity using the Aletti score on disease-free survival and overall survival. METHODS A retrospective observational study was conducted in a reference gynecologic oncology department, including advanced ovarian cancer patients, newly diagnosed who underwent a primary debulking surgery or interval debulking surgery between January 2010 and December 2019 (stage IIB-IV International Federation of Gynecology and Obstetrics classification), and epithelial histology. Incomplete medical records, loss to follow-up patients, and borderline histologies were excluded. Survival analysis and multivariate analysis were performed. RESULTS A total of 399 patients were included in the study. Regarding Aletti score complexity, no differences were observed in disease-free survival (median: 25 vs 24 months, p = .5) or overall survival (median: 56 vs 49 months, p = .6). Complete cytoreduction was associated with better disease-free survival (median: complete 26 vs optimal 14 vs sub-optimal 9 months, p < .0001) and overall survival (p < .0001). Furthermore, primary debulking surgery showed statistically better disease-free survival (median: 25 vs 16 months, p < .0001) and overall survival (median: 72 vs 38 months, p < .0001) compared to interval debulking surgery. The multivariable analysis showed that disease-free survival, overall survival, International Federation of Gynecology and Obstetrics classification, CA125 level at diagnosis, cytoreduction classification achieved after surgery, and the Clavien-Dindo complications did not significantly associate with the Aletti score. CONCLUSIONS Disease-free survival and overall survival were not influenced by the surgical complexity in patients undergoing cytoreduction after the first diagnosis of advanced ovarian cancer. A higher Aletti score was not associated with a higher rate of complications.
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Affiliation(s)
- Víctor Lago
- University Hospital La Fe, Gynecologic Oncology Unit, Valencia, Spain; La Fe Health Research Institute (IIS La Fe), Valencia, Spain; CEU Cardenal Herrera University, Valencia, Spain
| | | | - Marta Arnáez
- University Hospital La Fe, Gynecologic Oncology Unit, Valencia, Spain
| | - Iria Rey
- University Hospital La Fe, Gynecologic Oncology Unit, Valencia, Spain; La Fe Health Research Institute (IIS La Fe), Valencia, Spain
| | - Pablo Padilla-Iserte
- University Hospital La Fe, Gynecologic Oncology Unit, Valencia, Spain; CEU Cardenal Herrera University, Valencia, Spain
| | - Luis Matute
- University Hospital La Fe, Gynecologic Oncology Unit, Valencia, Spain
| | - Marta Gurrea
- University Hospital La Fe, Gynecologic Oncology Unit, Valencia, Spain
| | - Santiago Domingo
- University Hospital La Fe, Gynecologic Oncology Unit, Valencia, Spain
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Acosta Ú, Catalán S, Luzarraga A, Míguez M, Pamies M, Pérez-Benavente A, Sánchez-Iglesias JL. Impact of enhanced recovery after surgery programs in the return to adjuvant chemotherapy in patients with advanced ovarian cancer. Int J Gynecol Cancer 2025; 35:101627. [PMID: 39979166 DOI: 10.1016/j.ijgc.2024.101627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2024] [Revised: 12/30/2024] [Accepted: 12/31/2024] [Indexed: 02/22/2025] Open
Abstract
OBJECTIVE Advanced ovarian cancer treatment comprises cytoreductive surgery followed by chemotherapy. There is no established optimal time between surgery and chemotherapy initiation; however, delays can affect patient survival. Enhanced recovery after surgery (ERAS) programs aim to optimize post-operative recovery and may reduce delays in adjuvant treatment. This study investigated whether the implementation of the ERAS protocol reduces the time to chemotherapy after surgery for advanced ovarian cancer or influences the completion of planned chemotherapy cycles, evaluated the factors causing delays in chemotherapy, and examined the association between adherence to the ERAS protocol and the time to chemotherapy. METHODS This retrospective cohort study included patients with ovarian, tubal, or primary peritoneal cancer, International Federation of Gynecology and Obstetrics stages IIB to IV, who underwent debulking surgery and adjuvant chemotherapy at Vall d'Hebron Hospital. We compared the patients within the ERAS protocol with those under conventional management. The times from surgery to chemotherapy and completion of treatment were compared, in addition to the impact of ERAS adherence on the time to chemotherapy. Time to chemotherapy was measured both quantitatively and qualitatively (50 days cutoff). RESULTS A total of 137 and 46 patients were included in the ERAS and conventional groups, respectively. Chemotherapy started at a median of 44.5 days in the ERAS and 48.5 in the conventional group (p = .63) and was completed in 81.8% and 89.1% of patients, respectively, without differences by type of surgery. Compliance with the ERAS protocol did not correlate with earlier initiation of chemotherapy. Surgical morbidity, including complications, small bowel re-section, and intensive care unit admission, was identified as an independent risk factor for delayed chemotherapy. CONCLUSIONS Although ERAS programs improved post-operative recovery, they did not significantly reduce the time to chemotherapy or improve chemotherapy cycle completion in patients with advanced ovarian cancer, irrespective of adherence to the protocol.
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Affiliation(s)
- Úrsula Acosta
- Vall d'Hebron University Hospital, Department of Gynecologic Oncology, Barcelona, Spain.
| | - Sara Catalán
- Vall d'Hebron University Hospital, Department of Gynecology and Obstetrics, Barcelona, Spain
| | - Ana Luzarraga
- Vall d'Hebron University Hospital, Department of Gynecologic Oncology, Barcelona, Spain
| | - Marta Míguez
- Vall d'Hebron University Hospital, Department of Gynecology and Obstetrics, Barcelona, Spain
| | - Mónica Pamies
- Vall d'Hebron University Hospital, Nursing Unit for Gynecologic Oncology, Barcelona, Spain
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Prakash Bhandoria G, Guru A, Pawar A, Bhatt A, Kumar N, Kumar R, Patel S, Lal Solanki S, Sukumar V, Rajagopal AK, Somashekhar S. INDEPSO-ISPSM consensus on peritoneal malignancies - Enhanced recovery after surgery in cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC). Gynecol Oncol Rep 2025; 57:101662. [PMID: 39811827 PMCID: PMC11732209 DOI: 10.1016/j.gore.2024.101662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 10/28/2024] [Accepted: 12/11/2024] [Indexed: 01/03/2025] Open
Abstract
Background The role of enhanced recovery after surgery (ERAS) in cytoreductive surgery and/or Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is evolving, with promising results that improve patient outcomes. This consensus exercise was carried out to address and standardize components of the ERAS protocol pertinent to the Indian context. Method The modified Delphi method was employed with two rounds of voting. All fifty invited specialists agreed to vote. There were 30 questions addressing the key elements of ERAS protocols. They were broadly distributed across four sections: Prehabilitation, Preoperative, Intraoperative, and Postoperative elements. A consensus was achieved if any one option received > 70 % votes (strong consensus > 90 %). If consensus was not achieved in round 1, the question was moved to round 2. Results After rounds I and II, 48/50 (95.8%) of invited panelists voted for the questions. The highest rate of 'skipped question' was 6% in both rounds. A consensus was obtained for 28/30 (93.33%) questions, and strong consensus was obtained for 5/30 (16.6%) questions. No consensus was obtained for two questions. Some of the panelists' recommendations contradicted the standard ERAS guidelines, such as using intraperitoneal drains in all patients and mechanical bowel preparation for left-sided colonic or rectal resections. Conclusion Despite some limitations, this consensus exercise represents a significant step toward advancement and pioneering efforts to improve patient outcomes by implementing and standardizing ERAS protocols in CRS and/or HIPEC tailored for India.
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Affiliation(s)
| | - Arvind Guru
- Dept of Surgical Oncology, Homi Babha Cancer Hospital and Research Centre (HBCHRC), New Chandigarh, Punjab, India
| | - Ajinkya Pawar
- Dept of Surgical Oncology, The Gujarat Cancer & Research Institute, Ahmedabad, Gujarat, India
| | - Aditi Bhatt
- Dept of Surgical Oncology, Shalby Cancer and Research Institute, Ahmedabad, India
| | - Neha Kumar
- Dept of Gynaecologic Oncology, Amrita Hospital, Faridabad, India
| | - Rohit Kumar
- Dept of Surgical Oncology, Aster International Institute of Oncology, Bangalore, India
| | - Swapnil Patel
- Dept of Surgical Oncology, Upkar Hospital and Cancer Institute, Varanasi, India
| | | | - Vivek Sukumar
- Dept of Surgical Oncology, Specialty Surgical Oncology, Mumbai, India
| | - Ashwin K. Rajagopal
- Dept of Surgical Oncology, Aster International Institute of Oncology, Bangalore, India
| | - S.P. Somashekhar
- Dept of Surgical Oncology, Aster International Institute of Oncology, Bangalore, India
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Míguez Medina M, Luzarraga A, Catalán S, Acosta Ú, Hernández-Fleury A, Bebia V, Monreal-Clua S, Angeles MA, Bonaldo G, Gil-Moreno A, Pérez-Benavente A, Sánchez-Iglesias JL. Incisional Hernia in Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: A Single-Center Retrospective Study. Cancers (Basel) 2025; 17:418. [PMID: 39941787 PMCID: PMC11816242 DOI: 10.3390/cancers17030418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2024] [Revised: 01/16/2025] [Accepted: 01/24/2025] [Indexed: 02/16/2025] Open
Abstract
BACKGROUND/OBJECTIVES An incisional hernia (IH) is a frequent postoperative complication after cytoreductive laparotomic surgery for advanced ovarian cancer (AOC). It occurs in 2-22% of patients in the first two years of follow-up, depending on the series. Although different risk factors have been described for various types of malignancies and surgeries, few studies have analyzed the risk factors for hernia development in ovarian cancer (OC). However, none have examined the role of enhanced recovery after surgery (ERAS) programs. METHODS We performed a retrospective study that included patients with AOC and primary or interval debulking surgery through a median laparotomic approach. This study was conducted in Vall d'Hebron Hospital, Barcelona, Spain, between January 2015 and December 2022. Univariate and multivariate regression analyses were conducted. RESULTS Of the 156 patients included, 30 (19.2%) presented with an IH. The patients with IHs were smokers in a higher proportion to non-smokers (53.9% vs. 16.1%, p = 0.003) and more frequently presented with wound dehiscence (34.4% vs. 15.0%, p = 0.026). Patients in whom negative pressure wound therapy was applied had a hernia less frequently than those who had not had it (12.5% vs. 26.7%, p = 0.043). Similarly, the incidence of hernia decreased when patients went through an ERAS protocol (10.1% vs. 28.8%, p = 0.008). In the multivariate analysis, smoking was the only independent risk factor (RR 10.84, CI 2.76-42.64), and applying an ERAS protocol was seen to be the sole protective factor (RR 0.22, CI 0.08-0.61) against the development of an IH. CONCLUSIONS The implementation of ERAS is highly recommended due to its numerous benefits, most notably the reduction in hernia incidence. Additionally, the preoperative identification of current smokers provides an opportunity for smoking cessation and targeted respiratory prehabilitation, both of which further contribute to IH reduction.
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Affiliation(s)
- Marta Míguez Medina
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Ana Luzarraga
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Sara Catalán
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Úrsula Acosta
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Alina Hernández-Fleury
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Vicente Bebia
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
- Gynecologic Oncology Division, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Sonia Monreal-Clua
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Martina Aida Angeles
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
- Gynecologic Oncology Division, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Giulio Bonaldo
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | - Antonio Gil-Moreno
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
- Gynecologic Oncology Division, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Asunción Pérez-Benavente
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
- Gynecologic Oncology Division, Vall d’Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Jose Luis Sánchez-Iglesias
- Gynecologic Oncology Unit, Department of Gynecology, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
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Heutlinger O, Acharya N, Tedesco A, Ramesh A, Smith B, Nguyen NT, Wischmeyer PE. Nutritional Optimization of the Surgical Patient: A Narrative Review. Adv Nutr 2025; 16:100351. [PMID: 39617150 PMCID: PMC11784791 DOI: 10.1016/j.advnut.2024.100351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2024] [Revised: 11/13/2024] [Accepted: 11/14/2024] [Indexed: 12/18/2024] Open
Abstract
An increasing body of literature supports the clinical benefit of nutritional assessment and optimization in surgical patients; however, this data has yet to be consolidated in a practical fashion for use by surgeons. In this narrative review, we concisely aggregate emerging data to highlight the role of nutritional optimization as a promising, practical perioperative intervention to reduce complications and improve outcomes in surgical patients. This review of the surgical nutrition literature was conducted via large database review. There were no distinct inclusion/exclusion criteria for this review; however, we focused on adult populations using up-to-date literature from high-quality systematic reviews or randomized controlled trials when available. Current perioperative management focuses on the mitigation of intraoperative and immediate postoperative complications. Well-defined risk calculators attempt to stratify patient surgical risk preoperatively to reduce adverse events directly related to surgical procedures, such as hemorrhage, cardiopulmonary compromise, or infection. However, there is a lack of standardization of prognostic tools, nutritional protocols, and guidelines governing the assessment, composition, and administration of nutritional supplementation. Substantial data exist demonstrating the clinical benefit in the operative setting. In this work, we provide a fundamental primer for surgeons to understand the clinical importance of nutritional optimization along with practical prognostic tools and recommendations for use in their practice. While the extent to which nutritional optimization improves patient outcomes is debatable, the evidence clearly demonstrates a clinically meaningful benefit. Evaluating nutritional status differs based on disease severity and etiology of presentation, thus surgeons must select the appropriate prognostic tools to assess their patients during the perioperative period. This information will catalyze subsequent work with a multidisciplinary team to provide personalized dietary plans for patients and spark research to establish protocols for specific presentations.
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Affiliation(s)
- Olivia Heutlinger
- School of Medicine, University of California-Irvine, Irvine, California, United States.
| | - Nischal Acharya
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Amanda Tedesco
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Ashish Ramesh
- School of Medicine, University of California-Irvine, Irvine, California, United States
| | - Brian Smith
- Department of Surgery, University of California-Irvine, Irvine, California, United States
| | - Ninh T Nguyen
- Department of Surgery, University of California-Irvine, Irvine, California, United States
| | - Paul E Wischmeyer
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, United States; Department of Surgery, Duke University School of Medicine, Durham, North Carolina, United States
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Piovano E, Puppo A, Camanni M, Castiglione A, Delpiano EM, Giacometti L, Rolfo M, Rizzo A, Zola P, Ciccone G, Pagano E. Implementing Enhanced Recovery After Surgery for hysterectomy in a hospital network with audit and feedback: A stepped-wedge cluster randomised trial. BJOG 2024; 131:1207-1217. [PMID: 38404145 DOI: 10.1111/1471-0528.17797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of implementing the Enhanced Recovery After Surgery (ERAS) protocol in patients undergoing elective hysterectomy in a network of regional hospitals, supported by an intensive audit-and-feedback (A&F) approach. DESIGN A multi-centre, stepped-wedge cluster randomised trial (ClinicalTrials.gov NCT04063072). SETTING Gynaecological units in the Piemonte region, Italy. POPULATION Patients undergoing elective hysterectomy, either for cancer or for benign conditions. METHODS Twenty-three units (clusters), stratified by surgical volume, were randomised into four sequences. At baseline (first 3 months), standard care was continued in all units. Subsequently, the four sequences implemented the ERAS protocol successively every 3 months, after specific training. By the end of the study, each unit had a period in which standard care was maintained (control) and a period in which the protocol, supported by feedback, was applied (experimental). MAIN OUTCOME MEASURES Length of hospital stay (LOS), without outliers (>98th percentile). RESULTS Between September 2019 and May 2021, 2086 patients were included in the main analysis with an intention-to-treat approach: 1104 (53%) in the control period and 982 (47%) in the ERAS period. Compliance with the ERAS protocol increased from 60% in the control period to 76% in the experimental period, with an adjusted absolute difference of +13.3% (95% CI 11.6% to 15.0%). LOS, moving from 3.5 to 3.2 days, did not show a significant reduction (-0.12 days; 95% CI -0.30 to 0.07 days). No difference was observed in the occurrence of complications. CONCLUSIONS Implementation of the ERAS protocol for hysterectomy at the regional level, supported by an A&F approach, resulted in a substantial improvement in compliance, but without meaningful effects on LOS and complications. This study confirms the effectiveness of A&F in promoting important innovations in an entire hospital network and suggests the need of a higher compliance with the ERAS protocol to obtain valuable improvements in clinical outcomes.
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Affiliation(s)
- Elisa Piovano
- Obstetrics and Gynaecology Unit 2U, Sant'Anna Hospital, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Andrea Puppo
- Obstetrics and Gynaecology Unit, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Marco Camanni
- Obstetrics and Gynaecology Unit, Martini Hospital, ASL Città di Torino, Turin, Italy
| | - Anna Castiglione
- Clinical Epidemiology Unit, AOU Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Elena Maria Delpiano
- Obstetrics and Gynaecology Unit, Martini Hospital, ASL Città di Torino, Turin, Italy
| | - Lisa Giacometti
- Clinical Epidemiology Unit, AOU Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Monica Rolfo
- Healthcare Services Direction, Humanitas Gradenigo, Torino, Italy
| | - Alessio Rizzo
- General Surgery and Oncology Unit, Mauriziano Hospital, Turin, Italy
| | - Paolo Zola
- Department of Surgical Sciences, Sant'Anna Hospital, University of Turin, Turin, Italy
| | - Giovannino Ciccone
- Clinical Epidemiology Unit, AOU Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - Eva Pagano
- Clinical Epidemiology Unit, AOU Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
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Sánchez‐Iglesias JL, Morales‐Coma C, Minig L, Lago V, Domingo S, Mancebo G, Siegrist J, Fidalgo García MS, Llueca A, Serra A, Cobas Lozano P, Lekuona Artola A, Gómez‐Hidalgo NR, Acosta Ú, Ferrer‐Costa R, Bradbury M, Pérez‐Benavente A, Gil‐Moreno A, the SEGO Spain‐GOG Group. Procalcitonin and C-reactive protein as early markers of anastomotic leakage in intestinal resections for advanced ovarian cancer (EDMOCS). Acta Obstet Gynecol Scand 2024; 103:1302-1310. [PMID: 38532280 PMCID: PMC11168259 DOI: 10.1111/aogs.14834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Serum levels of procalcitonin and C-reactive protein (CRP) have been used to predict anastomotic leakage after colorectal surgery, but information is scarce in advanced ovarian cancer (AOC) surgery with bowel resection. This study aimed to assess the predictive value of procalcitonin and CRP in detecting anastomotic leakage after AOC surgery with bowel resection. The study also aimed to determine the optimal postoperative reference values and the best day for evaluating these markers. MATERIAL AND METHODS This prospective, observational and multicentric trial included 92 patients with AOC undergoing debulking surgery with bowel resection between 2017 and 2020 in 10 reference hospitals in Spain. Procalcitonin and CRP levels were measured at baseline and on postoperative days 1-6. Receiver operating characteristic analysis was performed to evaluate the predictive value of procalcitonin and CRP at each postoperative day. Sensitivity, specificity, positive and negative predictive values were calculated. RESULTS Anastomotic leakage was detected in six patients (6.5%). Procalcitonin and CRP values were consistently higher in patients with anastomotic leakage at all postoperative days. The maximum area under the curve (AUC) for procalcitonin was observed at postoperative day 1 (AUC = 0.823) with a cutoff value of 3.8 ng/mL (83.3% sensitivity, 81.3% specificity). For CRP, the maximum AUC was found at postoperative day 3 (AUC = 0.833) with a cutoff level of 30.5 mg/dL (100% sensitivity, 80.4% specificity). CONCLUSIONS Procalcitonin and C-reactive protein are potential biomarkers for early detection of anastomotic leakage after ovarian cancer surgery with bowel resection. Further prospective studies with a larger sample size are needed to confirm these findings.
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Affiliation(s)
- José Luis Sánchez‐Iglesias
- Department of Gynecologic OncologyVall d'Hebron University HospitalBarcelonaSpain
- Biomedical Research Group in Gynecology, Vall d'Hebron Research Institute (VHIR)Universitat Autònoma de BarcelonaBarcelonaSpain
| | | | - Lucas Minig
- Department of Gynecologic OncologyIMED HospitalValenciaSpain
- Department of GynecologyCEU Cardenal Herrera UniversityValenciaSpain
| | - Víctor Lago
- Department of GynecologyCEU Cardenal Herrera UniversityValenciaSpain
- Department of Gynecologic OncologyLa Fe University HospitalValenciaSpain
| | - Santiago Domingo
- Department of Gynecologic OncologyLa Fe University HospitalValenciaSpain
| | - Gemma Mancebo
- Gynecological Cancer Multidisciplinary UnitHospital del MarBarcelonaSpain
- Department of GynecologyUniversitat Pompeu FabraBarcelonaSpain
| | - Jaime Siegrist
- Oncologic Gynecology Unit, Department of GynecologyLa Paz University HospitalMadridSpain
| | | | - Antoni Llueca
- Multidisciplinary Unit of Abdominal Pelvic Oncology SurgeryHospital General Universitario de CastellonCastellónSpain
- Department of MedicineUniversidad Jaume ICastellónSpain
| | - Anna Serra
- Multidisciplinary Unit of Abdominal Pelvic Oncology SurgeryHospital General Universitario de CastellonCastellónSpain
- Department of MedicineUniversidad Jaume ICastellónSpain
| | - Paloma Cobas Lozano
- Department of Gynecologic OncologyHospital Universitario Donostia, OSI DonostialdeDonostiaSpain
| | - Arantza Lekuona Artola
- Department of Gynecologic OncologyHospital Universitario Donostia, OSI DonostialdeDonostiaSpain
| | | | - Úrsula Acosta
- Department of Gynecologic OncologyVall d'Hebron University HospitalBarcelonaSpain
| | - Roser Ferrer‐Costa
- Department of BiochemistryVall d'Hebron University HospitalBarcelonaSpain
| | - Melissa Bradbury
- Department of Gynecologic OncologyVall d'Hebron University HospitalBarcelonaSpain
| | - Assumpció Pérez‐Benavente
- Department of Gynecologic OncologyVall d'Hebron University HospitalBarcelonaSpain
- Biomedical Research Group in Gynecology, Vall d'Hebron Research Institute (VHIR)Universitat Autònoma de BarcelonaBarcelonaSpain
| | - Antonio Gil‐Moreno
- Department of Gynecologic OncologyVall d'Hebron University HospitalBarcelonaSpain
- Biomedical Research Group in Gynecology, Vall d'Hebron Research Institute (VHIR)Universitat Autònoma de BarcelonaBarcelonaSpain
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Sauro KM, Smith C, Ibadin S, Thomas A, Ganshorn H, Bakunda L, Bajgain B, Bisch SP, Nelson G. Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials. JAMA Netw Open 2024; 7:e2417310. [PMID: 38888922 PMCID: PMC11195621 DOI: 10.1001/jamanetworkopen.2024.17310] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/17/2024] [Indexed: 06/20/2024] Open
Abstract
Importance A comprehensive review of the evidence exploring the outcomes of enhanced recovery after surgery (ERAS) guidelines has not been completed. Objective To evaluate if ERAS guidelines are associated with improved hospital length of stay, hospital readmission, complications, and mortality compared with usual surgical care, and to understand differences in estimates based on study and patient factors. Data Sources MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central were searched from inception until June 2021. Study Selection Titles, abstracts, and full-text articles were screened by 2 independent reviewers. Eligible studies were randomized clinical trials that examined ERAS-guided surgery compared with a control group and reported on at least 1 of the outcomes. Data Extraction and Synthesis Data were abstracted in duplicate using a standardized data abstraction form. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Risk of bias was assessed in duplicate using the Cochrane Risk of Bias tool. Random-effects meta-analysis was used to pool estimates for each outcome, and meta-regression identified sources of heterogeneity within each outcome. Main Outcome and Measures The primary outcomes were hospital length of stay, hospital readmission within 30 days of index discharge, 30-day postoperative complications, and 30-day postoperative mortality. Results Of the 12 047 references identified, 1493 full texts were screened for eligibility, 495 were included in the systematic review, and 74 RCTs with 9076 participants were included in the meta-analysis. Included studies presented data from 21 countries and 9 ERAS-guided surgical procedures with 15 (20.3%) having a low risk of bias. The mean (SD) Reporting on ERAS Compliance, Outcomes, and Elements Research checklist score was 13.5 (2.3). Hospital length of stay decreased by 1.88 days (95% CI, 0.95-2.81 days; I2 = 86.5%; P < .001) and the risk of complications decreased (risk ratio, 0.71; 95% CI, 0.59-0.87; I2 = 78.6%; P < .001) in the ERAS group. Risk of readmission and mortality were not significant. Conclusions and Relevance In this meta-analysis, ERAS guidelines were associated with decreased hospital length of stay and complications. Future studies should aim to improve implementation of ERAS and increase the reach of the guidelines.
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Affiliation(s)
- Khara M. Sauro
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Oncology and Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Christine Smith
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Seremi Ibadin
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abigail Thomas
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Heather Ganshorn
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Linda Bakunda
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bishnu Bajgain
- Department of Community Health Sciences and O’Brien Institute of Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven P. Bisch
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Ariadne Labs, Brigham and Women’s Hospital, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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10
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Nelson G. Enhanced Recovery in Gynecologic Oncology Surgery-State of the Science. Curr Oncol Rep 2023; 25:1097-1104. [PMID: 37490193 DOI: 10.1007/s11912-023-01442-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/26/2023]
Abstract
PURPOSEOF REVIEW The purpose of this review is to describe the state of the science of enhanced recovery after surgery (ERAS) in gynecologic oncology. RECENT FINDINGS Over the last 5 years, there is mounting evidence supporting ERAS in gynecologic oncology surgery. Despite this, surveys have found suboptimal uptake of ERAS, and stakeholders have highlighted the difficulty of ERAS implementation as a major barrier. To address this, the core components required for a successful ERAS implementation program (protocol, ERAS team, audit system) are reviewed. ERAS developments specific to gynecologic oncology are also discussed, including same-day discharge initiatives for minimally invasive surgery, implications of telemedicine, and methods to increase uptake of ERAS in low- and middle-income countries. ERAS is a surgical quality improvement program with strong evidence supporting its effectiveness in gynecologic oncology. Efforts are required to address ERAS implementation barriers to increase uptake globally, especially in low-income settings.
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Affiliation(s)
- Gregg Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, 1331 29 St NW, Calgary, Alberta, T2N 4N2, Canada.
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11
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Lindemann K, Kleppe A, Eyjólfsdóttir B, Heimisdottir Danbolt S, Wang YY, Heli-Haugestøl AG, Walcott SL, Mjåland O, Navestad GA, Hermanrud S, Juul-Hansen KE, Kongsgaard U. Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer. Int J Gynecol Cancer 2023; 33:1279-1286. [PMID: 37451690 PMCID: PMC10423533 DOI: 10.1136/ijgc-2023-004355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/18/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts. METHODS Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed. RESULTS Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS. CONCLUSIONS ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.
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Affiliation(s)
- Kristina Lindemann
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Andreas Kleppe
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | | | | | - Yun Yong Wang
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Sara L Walcott
- Department of Clinical Service, Oslo University Hospital, Oslo, Norway
| | - Odd Mjåland
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
| | - Gerd-Anita Navestad
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Silje Hermanrud
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Knut Erling Juul-Hansen
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
| | - Ulf Kongsgaard
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
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12
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Lönnerfors C, Persson J. Can robotic-assisted surgery support enhanced recovery programs? Best Pract Res Clin Obstet Gynaecol 2023; 90:102366. [PMID: 37356336 DOI: 10.1016/j.bpobgyn.2023.102366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 06/03/2023] [Indexed: 06/27/2023]
Abstract
Enhanced recovery after surgery (ERAS) protocols comprise a multimodal approach to optimize patient outcome and recovery. ERAS guidelines recommend minimally invasive surgery (MIS) when possible. Key components in MIS include preoperative patient education and optimization; multimodal and narcotic-sparing analgesia; prophylactic measures regarding nausea, infection, and venous thrombosis; maintenance of euvolemia; and promotion of the early activity. ERAS protocols in MIS improve outcome mainly in terms of reduced length of stay and subsequently reduced cost. In addition, ERAS protocols in MIS reduce postoperative pain and nausea, increase patient satisfaction, and might reduce the rate of postoperative complications. Robotic surgery supports ERAS through facilitating MIS in complex procedures where laparotomy is an alternative approach.
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Affiliation(s)
- Celine Lönnerfors
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Skåne University Hospital, Lund, Sweden; Lund University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology, Lund, Sweden.
| | - Jan Persson
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Skåne University Hospital, Lund, Sweden; Lund University, Faculty of Medicine, Department of Clinical Sciences, Obstetrics and Gynecology, Lund, Sweden.
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13
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Chen Y, Zhang G, Xu J, Zhang S, Zou J, Wu Y, Jiang Y, Xu Y. Initial Clinical Application of Enhanced Recovery After Transoral Robotic Thyroidectomy. J Laparoendosc Adv Surg Tech A 2023; 33:763-767. [PMID: 37366863 DOI: 10.1089/lap.2023.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Background: The enhanced recovery after surgery (ERAS) protocol has been widely adopted across various surgical subspecialties. Transoral robotic thyroidectomy (TORT) has grown in popularity in the past decade. Therefore, this study aimed to discuss the initial application of ERAS in TORT. Methods: We retrospectively analyzed the clinical data of 95 patients who had undergone TORT in our department from April 2020 to March 2022. All patients were treated using the ERAS protocol. Results: TORT was successfully performed in all 95 patients. Postoperative histopathological examination revealed papillary carcinoma. The average operative time, hemorrhage volume, length of postoperative stay, and pain score (24 hours after surgery) were 227.32 ± 44.37 minutes, 35.81 ± 23.45 mL, 1.37 ± 0.62 days, and 2.11 ± 0.54, respectively. Sixty patients received an analgesia pump, with no significant difference in pain scores between the patients with and without the pump (P > .05). Eight patients experienced transient mandibular numbness, and two experienced transient hoarseness postoperatively. Of the 24 cases of total thyroidectomy/bilateral subtotal thyroidectomy (ST) or lobectomy with isthmusectomy plus contralateral ST patients, 8 developed transient hypoparathyroidism. No common complications, such as incision infection, hematoma/effusion formation, coughing while drinking, or permanent hoarseness/hypocalcemia, were reported. Conclusion: Our initial outcomes demonstrate that implementing an ERAS protocol in TORT is safe and feasible.
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Affiliation(s)
- Yi Chen
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China
| | - Gang Zhang
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China
| | - Jing Xu
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China
| | - Shu Zhang
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China
| | - Jiaqun Zou
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China
| | - Yan Wu
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China
| | - Yan Jiang
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China
| | - Yan Xu
- Department of Breast and Thyroid Surgery, Daping Hospital, Army Medical University, Chongqing, P.R. China
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14
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Deshler BJ, Rockenbach E, Patel T, Monahan BV, Poggio JL. Current update on multimodal analgesia and nonopiate surgical pain management. Curr Probl Surg 2023; 60:101332. [PMID: 37302814 DOI: 10.1016/j.cpsurg.2023.101332] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Bailee J Deshler
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Emily Rockenbach
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Takshaka Patel
- Department of Surgery, General Surgery Resident Physician, Temple University Hospital, Philadelphia, PA
| | - Brian V Monahan
- Department of Surgery, General Surgery Resident Physician, Temple University Hospital, Philadelphia, PA
| | - Juan Lucas Poggio
- Division and System Chief, Colorectal Surgery, Department of Surgery, Professor of Surgery, Temple University Health System, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
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15
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Nelson G, Dowdy SC. Surgeon-administered transversus abdominis plane block in gynecologic surgery-is it time to tap out? Am J Obstet Gynecol 2023; 228:491-493. [PMID: 36967370 DOI: 10.1016/j.ajog.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, University of Calgary, Calgary, Alberta, Canada.
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN
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16
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Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
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.
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Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
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17
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Gayet I, Foulon A, Turck M, Jamard E, Morello R, Simonet T, Fauvet R. RACCE Study: Impact of an enhanced recovery after surgery program (ERAS) in the management of endometrial cancer: A single-center retrospective study. J Gynecol Obstet Hum Reprod 2023; 52:102543. [PMID: 36702400 DOI: 10.1016/j.jogoh.2023.102543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/06/2023] [Accepted: 01/20/2023] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Inès Gayet
- Service de Gynécologie et d'Obstétrique, CHU Caen, 1 avenue de la côte de Nacre, F-14033 Caen, France
| | - Arthur Foulon
- Centre de Gynécologie et d'Obstétrique, Université Picardie Jules Verne, CHU Amiens Picardie, 1 rue du Professeur Christian Cabrol, F-80054 Amiens, France
| | - Mélusine Turck
- Service de Gynécologie et d'Obstétrique, CHU Caen, 1 avenue de la côte de Nacre, F-14033 Caen, France
| | - Estelle Jamard
- Service de Gynécologie et d'Obstétrique, CHU Caen, 1 avenue de la côte de Nacre, F-14033 Caen, France
| | - Rémy Morello
- Unit of Biostatistics and Clinical Research, University of Caen Hospital, Caen, France
| | - Thérèse Simonet
- Département d'Anesthésie et de Réanimation, CHU Caen, Avenue de la Côte de Nacre, Caen F-14033, France
| | - Raffaèle Fauvet
- Service de Gynécologie et d'Obstétrique, CHU Caen, 1 avenue de la côte de Nacre, F-14033 Caen, France; Université Caen Normandie, Esplanade de la Paix, CS 14032, F-14032 Caen, France; Unité INSERM ANTICIPE, Centre François Baclesse, 3 Ave du Général Harris, BP 5026, F-14076 Caen, France.
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18
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Kengsakul M, Nieuwenhuyzen-de Boer GM, Udomkarnjananun S, Kerr SJ, van Doorn HC, van Beekhuizen HJ. Clinical validation and comparison of the Comprehensive Complication Index and Clavien-Dindo classification in predicting post-operative outcomes after cytoreductive surgery in advanced ovarian cancer. Int J Gynecol Cancer 2023; 33:263-270. [PMID: 36600504 DOI: 10.1136/ijgc-2022-003998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The Comprehensive Complication Index (CCI) is an instrument used to measure cumulative post-operative complications. Our study aimed to validate the CCI after cytoreductive surgery for primary advanced-stage epithelial ovarian cancer, and to compare its diagnostic performance with the Clavien-Dindo classification. METHODS This prospective cohort study classified post-operative complications according to the Clavien-Dindo classification and the CCI. Logistic regression was used to determine the association between both classifications with intensive care unit admission, prolonged length of hospital stay (defined as stays longer than the 75th percentile of all stays in this study), 30-day readmission, and time to initiating chemotherapy after surgery >42 days. Area under the receiver operating characteristic curves (AUC) were used to assess the discriminative performance of each classification. RESULTS A total of 300 patients were included in the analysis. Most patients (n=255, 85%) underwent interval cytoreductive surgery. Complete cytoreduction was achieved in 235 (78%) patients. Overall, 30-day post-operative complications classified by the Clavien-Dindo classification occurred in 147 (49%) patients. Severe complications (grade ≥3a) occurred in 51 (17%) patients. Approximately 30% (n=82) had multiple complications. The CCI showed an excellent correlation with the Clavien-Dindo classification (r=0.906, p<0.001). In comparison with the Clavien-Dindo classification, the proportion of patients classified with severe complications increased from 17% to 30% when stratified with the CCI, and 20% of patients were diagnosed with a CCI score that correlated with a higher Clavien-Dindo classification grade. On regression analysis, both Clavien-Dindo classification and CCI had associations with intensive care unit admission, prolonged length of hospital stay, 30-day readmission, and time to chemotherapy >42 days (all p<0.05). AUC demonstrated that CCI (0.842, 95% CI 0.792 to 0.893) and Clavien-Dindo classification (0.813, 95% CI 0.762 to 0.864, p<0.001) had a good diagnostic performance for prolonged length of hospital stay. CONCLUSIONS Both the Clavien-Dindo classification and CCI showed significant associations with all surgical outcomes. However, the cumulative complications score of the CCI demonstrated a more superior discriminative performance than the Clavien-Dindo classification for prolonged length of hospital stay in advanced-stage epithelial ovarian cancer.
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Affiliation(s)
- Malika Kengsakul
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Srinakharinwirot University Panyananthaphikkhu Chonprathan Medical Center, Nonthaburi, Thailand
| | - Gatske M Nieuwenhuyzen-de Boer
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Stephen J Kerr
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Helena C van Doorn
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Heleen J van Beekhuizen
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Robella M, Tonello M, Berchialla P, Sciannameo V, Ilari Civit AM, Sommariva A, Sassaroli C, Di Giorgio A, Gelmini R, Ghirardi V, Roviello F, Carboni F, Lippolis PV, Kusamura S, Vaira M. 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. Cancers (Basel) 2023; 15:cancers15030570. [PMID: 36765534 PMCID: PMC9913706 DOI: 10.3390/cancers15030570] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/02/2023] [Accepted: 01/09/2023] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Manuela Robella
- Unit of Surgical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Torino, Italy
- Correspondence: ; Tel.: +39-338-382-4104
| | - Marco Tonello
- Advanced Surgical Oncology Unit, Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Paola Berchialla
- Center for Biostatistics, Epidemiology and Public Health (C-BEPH), Deptartment of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
| | - Veronica Sciannameo
- Center for Biostatistics, Epidemiology and Public Health (C-BEPH), Deptartment of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
| | | | - Antonio Sommariva
- Advanced Surgical Oncology Unit, Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Cinzia Sassaroli
- Abdominal Oncology Department, Fondazione Giovanni Pascale, IRCCS, 80131 Naples, Italy
| | - Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Roberta Gelmini
- SC Chirurgia Generale d’Urgenza ed Oncologica, AOU Policlinico di Modena, 41125 Modena, Italy
| | - Valentina Ghirardi
- UOC Ovarian Carcinoma Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Franco Roviello
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery, and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Fabio Carboni
- Peritoneal Tumours Unit, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | | | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit, Fondazione Istituto Nazionale Tumori IRCCS Milano, 20133 Milano, Italy
| | - Marco Vaira
- Unit of Surgical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Torino, Italy
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Gómez-Hidalgo NR, Pletnev A, Razumova Z, Bizzarri N, Selcuk I, Theofanakis C, Zalewski K, Nikolova T, Lanner M, Kacperczyk-Bartnik J, El Hajj H, Perez-Benavente A, Nelson G, Gil-Moreno A, Fotopoulou C, Sanchez-Iglesias JL. European Enhanced Recovery After Surgery (ERAS) gynecologic oncology survey: Status of ERAS protocol implementation across Europe. Int J Gynaecol Obstet 2023; 160:306-312. [PMID: 35929452 DOI: 10.1002/ijgo.14386] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 07/19/2022] [Accepted: 07/28/2022] [Indexed: 12/31/2022]
Abstract
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.
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Affiliation(s)
- Natalia R Gómez-Hidalgo
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
| | - Andrei Pletnev
- Department of Gynecology and Obstetrics, University of Zielona, Góra, Poland
| | - Zoia Razumova
- Department of Women's and Children's Health, Division of Neonatology, Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A Gemelli (IRCCS), Rome, Italy
| | - Ilker Selcuk
- Gynaecological Oncology, Maternity Hospital, Ankara City Hospital, Ankara, Turkey
| | | | - Kamil Zalewski
- Gynecological Oncology, Świętokrzyskie Cancer Center, Kielce, Poland
| | - Tanja Nikolova
- Klinikum Mittelbaden, Academic Teaching Hospital of Heidelberg University, Baden-Baden, Germany
| | - Maximilian Lanner
- Department of Obstetrics and Gynecology, Kardinal Schwarzenberg Klinikum, Schwarzach im Pongau, Austria
| | | | - Houssein El Hajj
- Department of Surgical Oncology, Oscar Lambret Cancer Center, Lille, France
| | - Assumpció Perez-Benavente
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Antonio Gil-Moreno
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Madrid, Spain
| | - Christina Fotopoulou
- West London Gynecological Cancer Centre; Hammersmith Hospital, Imperial College, London, UK
| | - Jose Luis Sanchez-Iglesias
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
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21
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O'Neill AM, Calpin GG, Norris L, Beirne JP. The impact of enhanced recovery after gynaecological surgery: A systematic review and meta-analysis. Gynecol Oncol 2023; 168:8-16. [PMID: 36356373 DOI: 10.1016/j.ygyno.2022.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Alice M O'Neill
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Gavin G Calpin
- Department of Surgery, University Hospital Galway, Newcastle Road, Galway, Ireland
| | - Lucy Norris
- Department of Obstetrics and Gynaecology, Trinity St. James' Cancer Institute, Trinity Centre for Health Sciences, St. James' Hospital, Dublin 8, Ireland
| | - James P Beirne
- Department of Gynaecological Oncology, Trinity St. James' Cancer Institute, St. James' Hospital, Dublin 8, Ireland
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22
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Cao S, Zhang Y, Lin B, Chen J, Chen X, Zhuang C. Enhanced recovery after gynecological surgery: A meta-analysis of randomized controlled trials. Nurs Health Sci 2022; 25:30-43. [PMID: 36464803 DOI: 10.1111/nhs.13000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 11/23/2022] [Accepted: 12/01/2022] [Indexed: 12/10/2022]
Abstract
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.
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Affiliation(s)
- SuFen Cao
- Department of Obstetrics, Haikou Hospital of The Maternal And Child Health, Haikou, China
| | - YuQiang Zhang
- Department of Obstetrics, Haikou Hospital of The Maternal And Child Health, Haikou, China
| | - BaiLang Lin
- Department of Nursing, Haikou Hospital of The Maternal And Child Health, Haikou, China
| | - JiaCheng Chen
- Department of Liver and Gallbladder Surgery, Hainan Provincial People's Hospital, Haikou, China
| | - XiaoJing Chen
- Medical Department, Haikou Hospital of The Maternal And Child Health, Haikou, China
| | - ChunYu Zhuang
- Department of Nursing, Haikou Hospital of The Maternal And Child Health, Haikou, China
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23
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Sánchez-Iglesias JL, Bebia V, Gimenez E, Aller MB, Bradbury M, Pérez-Benavente MA, Gil-Moreno A, Cossio-Gil Y. Cost analysis of the enhanced recovery after surgery protocol applied in advanced ovarian cancer: A secondary outcome of the PROFAST trial. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2545-2550. [PMID: 35922279 DOI: 10.1016/j.ejso.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION A randomised trial implementing Enhanced Recovery After Surgery (ERAS) for high complexity advanced ovarian cancer (AOC) surgery (PROFAST) demonstrated a reduction of median length of stay and hospital readmissions when compared to patients managed conventionally. One secondary objective was to determine if an ERAS pathway in the perioperative management of advanced ovarian cancer patients led to cost savings. MATERIAL AND METHODS Secondary objective of a prospective randomised trial of patients with suspected or diagnosed advanced ovarian cancer allocated to conventional or ERAS perioperative management, carried out at a referral centre from June 2014 to March 2018. Treatment was determined by a computer-generated random allocation system. METHODS Gross counting was employed to estimate the cost of hospitalisation in wards, intensive care unit (ICU) and surgical care, while micro-costing was used to obtain image and laboratory test costs. Mean costs between trial arms were considered. Sensitivity analyses were performed. RESULTS Ninety-nine patients (n = 50 ERAS group, n = 49 Conventional group) were included. Mean costs per patient were 10,719€ in the ERAS group and 11,028€ in the conventional group, leading to an average saving of 309€ per patient. These results were based on 96 patients, excluding 3 extreme outliers mainly related with very high ICU costs. Savings, which were significant for hospital ward costs (-33% total; 759€ per patient in first hospitalisation, and 914€ per partient/day of readmission) were found as robust in the sensitivity analysis. CONCLUSIONS Implementation of an ERAS pathway leads to cost savings when compared to conventional management after AOC surgery.
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Affiliation(s)
| | - V Bebia
- Gynaecologic Oncology Unit, Vall d'Hebron University Hospital, Barcelona, Spain.
| | - E Gimenez
- Health Services Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Information Systems, Vall d'Hebron University Hospital, Barcelona, Spain
| | - M B Aller
- Health Services Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Information Systems, Vall d'Hebron University Hospital, Barcelona, Spain
| | - M Bradbury
- Gynaecologic Oncology Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - M A Pérez-Benavente
- Gynaecologic Oncology Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - A Gil-Moreno
- Gynaecologic Oncology Unit, Vall d'Hebron University Hospital, Barcelona, Spain; Biomedical Research Group in Gynaecology, Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, CIBERONC, Barcelona, Spain
| | - Y Cossio-Gil
- Health Services Research Group, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain; Information Systems, Vall d'Hebron University Hospital, Barcelona, Spain
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24
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Stratification of Length of Stay Prediction following Surgical Cytoreduction in Advanced High-Grade Serous Ovarian Cancer Patients Using Artificial Intelligence; the Leeds L-AI-OS Score. Curr Oncol 2022; 29:9088-9104. [PMID: 36547125 PMCID: PMC9776955 DOI: 10.3390/curroncol29120711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/11/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
(1) Background: Length of stay (LOS) has been suggested as a marker of the effectiveness of short-term care. Artificial Intelligence (AI) technologies could help monitor hospital stays. We developed an AI-based novel predictive LOS score for advanced-stage high-grade serous ovarian cancer (HGSOC) patients following cytoreductive surgery and refined factors significantly affecting LOS. (2) Methods: Machine learning and deep learning methods using artificial neural networks (ANN) were used together with conventional logistic regression to predict continuous and binary LOS outcomes for HGSOC patients. The models were evaluated in a post-hoc internal validation set and a Graphical User Interface (GUI) was developed to demonstrate the clinical feasibility of sophisticated LOS predictions. (3) Results: For binary LOS predictions at differential time points, the accuracy ranged between 70-98%. Feature selection identified surgical complexity, pre-surgery albumin, blood loss, operative time, bowel resection with stoma formation, and severe postoperative complications (CD3-5) as independent LOS predictors. For the GUI numerical LOS score, the ANN model was a good estimator for the standard deviation of the LOS distribution by ± two days. (4) Conclusions: We demonstrated the development and application of both quantitative and qualitative AI models to predict LOS in advanced-stage EOC patients following their cytoreduction. Accurate identification of potentially modifiable factors delaying hospital discharge can further inform services performing root cause analysis of LOS.
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25
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Gauci PA, Deluche E, Azais H, Zaccarini F, Guani B, Balaya V, Kerbage Y, Jochum F, Sanson C, Guyon F, Akladios C, Bendifallah S, Dabi Y. Surgical management of patients with advanced ovarian cancer: Results of a French National Survey. J Gynecol Obstet Hum Reprod 2022; 51:102463. [DOI: 10.1016/j.jogoh.2022.102463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/18/2022] [Accepted: 08/23/2022] [Indexed: 11/30/2022]
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26
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Noh JJ, Lee YY. Where is ERAS in the management of advanced ovarian cancer?: between myths and truths. J Gynecol Oncol 2022; 33:e79. [PMID: 36032026 PMCID: PMC9428295 DOI: 10.3802/jgo.2022.33.e79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 07/31/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Joseph J Noh
- Gynecologic Cancer Center, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoo-Young Lee
- Gynecologic Cancer Center, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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27
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Kengsakul M, Nieuwenhuyzen-de Boer GM, Udomkarnjananun S, Kerr SJ, van Doorn HC, van Beekhuizen HJ. Factors Predicting 30-Day Grade IIIa-V Clavien-Dindo Classification Complications and Delayed Chemotherapy Initiation after Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: A Prospective Cohort Study. Cancers (Basel) 2022; 14:4181. [PMID: 36077721 PMCID: PMC9454550 DOI: 10.3390/cancers14174181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: The aim of this study was to evaluate factors associated with 30-day postoperative Clavien−Dindo classification (CDC) grade IIIa or greater complications and delayed initiation of chemotherapy after cytoreductive surgery (CRS) for primary advanced-stage epithelial ovarian cancer (AEOC). Methods: This was a prospective study involving 300 patients who underwent primary or interval CRS for AEOC between February 2018 and September 2020. Postoperative complications were graded according to the CDC. Logistic regression analysis was used to evaluate factors predicting CDC grade ≥IIIa and time to chemotherapy (TTC) >42 days. Results: Interval CRS was performed in 255 (85%) patients. CDC grade ≥IIIa occurred in 51 (17%) patients. In multivariable analysis, age (p = 0.036), cardiovascular comorbidity (p < 0.001), diaphragmatic surgery (p < 0.001), intraoperative urinary tract injury (p = 0.017), and upper-abdominal visceral injury (e.g., pancreas, stomach, liver, or spleen) (p = 0.012) were associated with CDC grade ≥IIIa. In 26% of cases, TTC was >42 days (median (IQR) 39 (29−50) days) in patients with CDC grade ≥IIIa versus 33 (25−41) days in patients without CDC grade ≥ IIIa (p = 0.008). The adjusted odds ratio of developing TTC >42 days was significantly higher in patients associated with WHO performance grade ≥2 (p = 0.045), intraoperative bowel injury (p = 0.043), upper-abdominal visceral injury (p = 0.008), and postoperative CDC grade ≥IIIa (p = 0.032). Conclusions: Patients with advanced age, with cardiovascular comorbidity, and who required diaphragmatic surgery had an increased adjusted odds ratio of developing CDC grade ≥IIIa complications. CDC grade ≥IIIa complications were independently associated with TTC >42 days. Proper patient selection and prevention of intraoperative injury are essential in order to prevent postoperative complications and delayed initiation of chemotherapy.
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Affiliation(s)
- Malika Kengsakul
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi 11120, Thailand
| | - Gatske M. Nieuwenhuyzen-de Boer
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Albert Schweitzer Hospital, 3318 AT Dordrecht, The Netherlands
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
| | - Stephen J. Kerr
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Helena C. van Doorn
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Heleen J. van Beekhuizen
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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Sun L, Li H, Wei S, Yang M, Deng S. Successful secondary radical operation on unretractable metastatic platinum-sensitive recurrent ovarian cancer by immunotherapy: a case report. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:718. [PMID: 35845511 PMCID: PMC9279770 DOI: 10.21037/atm-22-2128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/20/2022] [Indexed: 11/15/2022]
Abstract
Background Although rechallenge with platinum-based chemotherapy is effective for most platinum-sensitive recurrent ovarian cancer (ROC) patients, there is still a subset of patients who have no responses to the standard care. Overcoming multidrug resistance (MDR) is a top priority in oncology clinics, but it remains intricate. It is difficult for clinicians to manage unretractable ROC when conventional therapy yields no results. The rational and effective use of immunotherapy will contribute to the clinical benefit of these patients, especially in patients without approved immunotherapy biomarkers. Here we present a case of successful secondary radical surgery for unretractable metastatic MDR ROC by immunotherapy based on her immune-infiltrating tumor microenvironment signatures. Case Description A 57-year-old woman, diagnosed with IC2 stage high-grade serous ovarian cancer in 2015, underwent immediate ultra-radical cytoreductive surgery followed by 6 cycles of platinum-containing adjuvant chemotherapy. After nearly 37 months of disease-free status, the woman complained of spontaneous pain from the right subcostal margin for 1 month and was diagnosed with ROC accompanied by multiple unretractable colorectal and hepatic metastases. Standard chemotherapies were ineffective and quickly resulted in disease progression and grade IV myelosuppression followed impaired gastrointestinal function. Notably, after standard chemotherapy, the patient was tested negative for all immune biomarkers, but multiple fluorescence immunohistochemistry indicated that her tumor tissue was significantly infiltrated with the cluster of differentiation 8 (CD8) T cells and natural killer (NK) cells, implying potential benefits of immunotherapy. Then changed to 3 cycles of intravenous pembrolizumab, the main pelvic tumor and hepatic metastases showed significant shrinkage and achieved partial response, but the disease progressed after 8.7 months. Subsequently, arterial perfusion with pembrolizumab was performed combined with the chemotherapy. A comfortingly partial response was achieved again that enabled the patient to successfully undergo a secondary radical surgery for colorectal and liver metastases. Since that time the patient’s postoperative course has been favorable, and she remains disease-free at present for at least 17 months. Conclusions Immune infiltration signatures of the tumor microenvironment could serve as an indication for immunotherapy in patients with unretractable platinum-sensitive ROC with MDR. In addition, the introduction of immunotherapy might bring some degree of chemotherapy resensitization.
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Affiliation(s)
- Li Sun
- National Cancer Center/National Clinical Research Center for Cancer/Department of Gynecology, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China.,National Cancer Center/National Clinical Research Center for Cancer/Department of Gynecology, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hua Li
- National Cancer Center/National Clinical Research Center for Cancer/Department of Gynecology, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Sulan Wei
- National Cancer Center/National Clinical Research Center for Cancer/Department of imaging, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Meng Yang
- National Cancer Center/National Clinical Research Center for Cancer/Department of Gynecology, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Shaoqiong Deng
- National Cancer Center/National Clinical Research Center for Cancer/Department of Gynecology, Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
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29
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Costantini B, Vargiu V, Santullo F, Rosati A, Bruno M, Gallotta V, Lodoli C, Moroni R, Pacelli F, Scambia G, Fagotti A. Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery: A Large Single-Center Experience. Ann Surg Oncol 2022; 29:4791-4802. [PMID: 35435561 PMCID: PMC9246984 DOI: 10.1245/s10434-022-11686-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/08/2022] [Indexed: 12/23/2022]
Abstract
Background Cytoreductive surgery is currently the main treatment for advanced epithelial ovarian cancer (OC), and several surgical maneuvers, including colorectal resection, are often needed to achieve no residual disease. High surgical complexity carries an inherent risk of postoperative complications, including anastomosis leakage (AL). Albeit rare, AL is a life-threatening condition. The aim of this single-center retrospective study is to assess the AL rate in patients undergoing colorectal resection and anastomosis during primary surgery for advanced epithelial OC through a standardized surgical technique and to evaluate possible pre/intra- and postoperative risk factors to identify the population at greatest risk. Methods A retrospective analysis of clinical and surgical characteristics of 515 patients undergoing colorectal resection and anastomosis during primary or interval debulking surgery between December 2011 and October 2019 was performed. Several pre/intra- and postoperative variables were evaluated by multivariate analysis as potential risk factors for AL. Results The overall anastomotic leakage rate was 2.9% (15/515) with a significant negative impact on postoperative course. Body mass index < 18 kg/m2, preoperative albumin value lower than 30 mg/dL, section of the inferior mesenteric artery at its origin, and medium–low colorectal anastomosis (< 10 cm from the anal verge) were identified as independent risk factors for AL on multivariate analysis. Conclusions AL is confirmed to be an extremely rare but severe postoperative complication of OC surgery, being responsible for increased early postoperative mortality. Preoperative nutritional status and surgical characteristics, such as blood supply and anastomosis level, appear to be the most significant risk factors. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-022-11686-y.
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Affiliation(s)
- Barbara Costantini
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Virginia Vargiu
- Department of Oncology, Gemelli Molise Spa, Campobasso, Italy
| | - Francesco Santullo
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Rosati
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Matteo Bruno
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valerio Gallotta
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudio Lodoli
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rossana Moroni
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Fabio Pacelli
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy. .,Università Cattolica del Sacro Cuore, Rome, Italy.
| | - Anna Fagotti
- Division of Gynecologic Oncology, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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Vargiu V, Santullo F, Rosati A, Costantini B, Gallotta V, Lodoli C, Pacelli F, Scambia G, Fagotti A. ASO Author Reflections: Risk Factors for Anastomotic Leakage in Advanced Ovarian Cancer Surgery—What We Know and Future Perspectives. Ann Surg Oncol 2022; 29:4803-4804. [DOI: 10.1245/s10434-022-11690-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 12/21/2022]
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Chiewhatpong P, Charoenkwan K, Smithiseth K, Lapisatepun W, Lapisatepun P, Phimphilai M, Muangmool T, Cheewakriangkrai C, Suprasert P, Srisomboon J. Effectiveness of enhanced recovery after surgery protocol in open gynecologic oncology surgery: A randomized controlled trial. Int J Gynaecol Obstet 2022; 159:568-576. [PMID: 35396709 DOI: 10.1002/ijgo.14211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Phasawee Chiewhatpong
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kittipat Charoenkwan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kannika Smithiseth
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Warangkana Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Panuwat Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Mattabhorn Phimphilai
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tanarat Muangmool
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chalong Cheewakriangkrai
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Prapaporn Suprasert
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jatupol Srisomboon
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Chau JPC, Liu X, Lo SHS, Chien WT, Hui SK, Choi KC, Zhao J. Perioperative enhanced recovery programmes for women with gynaecological cancers. Cochrane Database Syst Rev 2022; 3:CD008239. [PMID: 35289396 PMCID: PMC8922407 DOI: 10.1002/14651858.cd008239.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Janita Pak Chun Chau
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Xu Liu
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai Tong Chien
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Sze Ki Hui
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong, China
| | - Kai Chow Choi
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Jie Zhao
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Morrison J, Balega J, Buckley L, Clamp A, Crosbie E, Drew Y, Durrant L, Forrest J, Fotopoulou C, Gajjar K, Ganesan R, Gupta J, Hughes J, Miles T, Moss E, Nanthakumar M, Newton C, Ryan N, Walther A, Taylor A. British Gynaecological Cancer Society (BGCS) uterine cancer guidelines: Recommendations for practice. Eur J Obstet Gynecol Reprod Biol 2022; 270:50-89. [DOI: 10.1016/j.ejogrb.2021.11.423] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/19/2021] [Indexed: 12/24/2022]
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Kim YN, Kim JC, Chung YS, Park J, Lee YJ, Lee JY, Nam EJ, Kim SW, Kim S, Kim YT. Incidence of postoperative thrombotic events in ovarian cancer patients with a de-escalated prophylactic strategy: A retrospective cohort study. Gynecol Oncol 2022; 165:75-81. [PMID: 35216810 DOI: 10.1016/j.ygyno.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/03/2022] [Accepted: 02/06/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE This study aimed to determine the incidence of thrombotic events in ovarian cancer patients following a de-escalated prophylactic strategy and to stratify risk groups. METHODS We reviewed the records of patients who underwent debulking surgery for ovarian cancer at a single institution between January 2007 and May 2019. We identified clinically diagnosed and radiologically confirmed cases of thrombotic events-classified as pulmonary thromboembolism (PE), deep vein thrombosis (DVT), and other thrombotic events-within 6 months of debulking surgery. RESULTS After excluding 13 patients diagnosed with thromboembolism at the baseline or during neoadjuvant chemotherapy, 799 were analyzed. Since the introduction of medical prophylaxis at our institution in 2009, 482 patients (60%) received medical prophylaxis with subcutaneous injection of low molecular weight heparin for 5 days with mechanical prophylaxis, whereas 317 (40%) received mechanical prophylaxis only. After debulking surgery, thrombotic events occurred in 28 patients (3.5%) including PE (n = 11), DVT (n = 10), and other thrombotic events (n = 7). Multivariable analysis identified age, body mass index (BMI), and operative duration as independent risk factors associated with thrombotic events. A thrombotic event was an independent prognostic factor for overall survival (HR 2.17, 95% CI 1.16-4.1). A cut-off analysis for pre-operative identifiable risk factors showed age < 57 years and BMI < 21 could help define low-risk groups. One patient from 172 low-risk patients (0.58%) experienced a thrombotic event. CONCLUSIONS The thrombotic event incidence was low in our cohort. A de-escalated prophylaxis strategy may be considered in young (age < 57 years) and lean (BMI < 21) patients.
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Affiliation(s)
- Yoo-Na Kim
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Chul Kim
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Shin Chung
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Junsik Park
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Jae Lee
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung-Yun Lee
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Eun Ji Nam
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Wun Kim
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sunghoon Kim
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Tae Kim
- Department of Obstetrics and Gynecology, Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
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Analgesia for Gynecologic Oncologic Surgeries: A Narrative Review. Curr Pain Headache Rep 2022; 26:1-13. [PMID: 35118596 DOI: 10.1007/s11916-022-00998-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Gynecologic oncologic malignancies are amongst the most common cancers affecting women across the world. This narrative review focuses on the current state of evidence around optimal perioperative pain management of patients undergoing surgeries for gynecologic malignancies with a specific focus on cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). RECENT FINDINGS Recent improvements in postoperative pain management following all types of gynecologic procedures, including minimally invasive, open-abdominal, or CRS + HIPEC, have been implemented through enhanced recovery after surgery (ERAS) protocols. These protocols encompass the use of preemptive analgesia, neuraxial and regional techniques, local anesthetic infiltration, and multimodal analgesia. The severity of postoperative pain varies for minimally invasive cancer surgery to open debulking procedures. Therefore, an individualized perioperative analgesic plan is critical depending on the surgical approach. For CRS + HIPEC, neuraxial techniques such as thoracic epidurals and opioid sparing multimodal analgesics have shown efficacy in the perioperative period. However, future research is needed as many of these patients develop chronic pain with very limited research done in this realm.
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Outcomes of Enhanced Recovery after Surgery (ERAS) in Gynecologic Oncology: A Review. Curr Oncol 2022; 29:631-640. [PMID: 35200556 PMCID: PMC8870666 DOI: 10.3390/curroncol29020056] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/12/2022] [Accepted: 01/26/2022] [Indexed: 11/17/2022] Open
Abstract
Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement program that started in colorectal surgery and has now expanded to numerous specialties, including gynecologic oncology. ERAS guidelines comprise multidisciplinary, evidence-based recommendations in the preoperative, intraoperative, and postoperative period; these interventions broadly encompass patient education, anesthetic choice, multimodal pain control, avoidance of unnecessary drains, maintenance of nutrition, and prevention of emesis. Implementation of ERAS has been shown to be associated with improved clinical outcomes (length of hospital stay, complications, readmissions) and cost. Marx and colleagues first demonstrated the feasibility of ERAS in gynecologic oncology in 2003; since then, over 30 comparative studies and 4 guidelines have been published encompassing major gynecologic surgery, cytoreductive surgery, and vulvar/vaginal surgery. Implementation of ERAS in gynecologic oncology has been demonstrated to provide improvements in length of stay, complications, cost, opioid use, and patient satisfaction. Increased compliance with ERAS guidelines has been associated with greater improvement in outcomes.
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Yan X, Zhang S, Jia J, Yang J, Song Y, Duan H. Total Parenteral Nutrition Treatment Improves the Nutrition Status of Gynecological Cancer Patients by Improving Serum Albumin Level. Front Med (Lausanne) 2022; 8:759387. [PMID: 35127741 PMCID: PMC8810638 DOI: 10.3389/fmed.2021.759387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022] Open
Abstract
Background Malnutrition is often observed in gynecological cancer patients, however its prevalence in these patients remains largely unexplored. Total parenteral nutrition (TPN) is a nutritional intervention method that has controversial treatment outcome on gynecological cancer patients. The present retrospective study is designed to evaluate the nutrition status and TPN treatment outcome on patients diagnosed with endometrial, cervical or ovarian malignant tumors. Methods Medical records of a total of 263 patients treated at the First Hospital of Shanxi Medical University, China were included. Nutrition status was assessed by patient-generated subjective global assessment (PG-SGA). Patients were grouped based on nutrition status, cancer type or treatment strategy for clinical characteristic comparison. Multivariable logistic regression analysis was used to identify predictors for malnutrition status and hospital stay duration. Results Presence of endometrial and cervical cancer, body weight before nutritional intervention and serum albumin level (P < 0.001 for all) were found to be significant predictors for malnutrition status in gynecological cancer patients. In the malnourished patients, those who were treated with TPN had significantly lower serum albumin levels before and after treatment (P < 0.001) and PG-SGA scores after treatment. Also, TPN treatment could significantly increase the serum albumin levels in these patients after 1 week. In addition, shorter hospitalization period was needed for TPN-treated endometrial (P = 0.019) and ovarian (P < 0.001) patients. Moreover, serum albumin levels (P < 0.001), use of TPN treatment (P = 0.025) and nutrition status (P = 0.010) were identified to be independent predictors for hospital stay duration. Conclusion Our results suggest that malnutrition is a significant clinical manifestation in gynecological cancer patients who may benefit from TPN treatment for reduced hospitalization and improved serum albumin levels.
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Affiliation(s)
- Xin Yan
- Department of Drug Clinical Trial, First Hospital of Shanxi Medical University, Taiyuan, China
- *Correspondence: Xin Yan
| | - Sanyuan Zhang
- Department of Gynecology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Junmei Jia
- Department of Oncology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Jiaolin Yang
- Department of Gynecology, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Yilai Song
- Department of Drug Clinical Trial, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Haoran Duan
- School of Nursing, Shanxi Medical University, Taiyuan, China
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Reuter S, Woelber L, Trepte CC, Perez D, Zapf A, Cevirme S, Mueller V, Schmalfeldt B, Jaeger A. The impact of Enhanced Recovery after Surgery (ERAS) pathways with regard to perioperative outcome in patients with ovarian cancer. Arch Gynecol Obstet 2021; 306:199-207. [PMID: 34958401 PMCID: PMC9300507 DOI: 10.1007/s00404-021-06339-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/15/2021] [Indexed: 12/12/2022]
Abstract
Purpose Major surgery for ovarian cancer is associated with significant morbidity. Recently, guidelines for perioperative care in gynecologic oncology with a structured “Enhanced Recovery after Surgery (ERAS)” program were presented. Our aim was to evaluate if implementation of ERAS reduces postoperative complications in patients undergoing extensive cytoreductive surgery for ovarian cancer. Methods 134 patients with ovarian cancer (FIGO I-IV) were included. 47 patients were prospectively studied after implementation of a mandatory ERAS protocol (ERAS group) and compared to 87 patients that were treated before implementation (pre-ERAS group). Primary endpoints of this study were the effects of the ERAS protocol on postoperative complications and length of stay in hospital. Results Preoperative and surgical data were comparable in both groups. Only the POSSUM score was higher in the ERAS group (11.8% vs. 9.3%, p < 0.001), indicating a higher surgical risk in the ERAS group. Total number of postoperative complications (ERAS: 29.8% vs. pre-ERAS: 52.8%, p = 0.011), and length of hospital stay (ERAS: 11 (6–23) vs pre-ERAS: 13 (6–50) days; p < 0.001) differed significantly. A lower fraction of patients of the ERAS group (87.2%) needed postoperative admission to the ICU compared to the pre-ERAS group (97.7%), p = 0.022). Mortality within the ERAS group was 0% vs. 3.4% (p = 0.552) in the pre-ERAS group. Conclusion The implementation of a mandatory ERAS protocol was associated with a lower rate of postoperative complications and a reduced length of stay in hospital. If ERAS has influence on long-term outcome needs to be further evaluated.
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Affiliation(s)
- Susanne Reuter
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Martinistraße 52, 20246, Hamburg, Germany.
| | - Linn Woelber
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Martinistraße 52, 20246, Hamburg, Germany
| | - Constantin C Trepte
- Department of Anaesthesiology, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
| | - Daniel Perez
- Department of General, Visceral and Thoracic Surgery, Hamburg-Eppendorf University Medical Center, Hamburg, Germany
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Sinan Cevirme
- Institute of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Volkmar Mueller
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Martinistraße 52, 20246, Hamburg, Germany
| | - Barbara Schmalfeldt
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Martinistraße 52, 20246, Hamburg, Germany
| | - Anna Jaeger
- Department of Gynecology, Hamburg-Eppendorf University Medical Center, Martinistraße 52, 20246, Hamburg, Germany
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Nelson G, Wang X, Nelson A, Faris P, Lagendyk L, Wasylak T, Bathe OF, Bigam D, Bruce E, Buie WD, Chong M, Fairey A, Hyndman ME, MacLean A, McCall M, Pin S, Wang H, Gramlich L. Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada. JAMA Netw Open 2021; 4:e2119769. [PMID: 34357394 PMCID: PMC8346943 DOI: 10.1001/jamanetworkopen.2021.19769] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. OBJECTIVE To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. INTERVENTIONS Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. MAIN OUTCOMES AND MEASURES Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. RESULTS A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). CONCLUSIONS AND RELEVANCE The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.
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Affiliation(s)
- Gregg Nelson
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Xiaoming Wang
- Analytics, Data Integration, Measurement, and Reporting, Alberta Health Services, Calgary, Alberta, Canada
| | - Alison Nelson
- Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Peter Faris
- Analytics, Data Integration, Measurement, and Reporting, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Tracy Wasylak
- Strategic Clinical Networks, Alberta Health Services, Calgary, Alberta, Canada
| | - Oliver F. Bathe
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Erin Bruce
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - W. Donald Buie
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael Chong
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Fairey
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - M. Eric Hyndman
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anthony MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael McCall
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sophia Pin
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Haili Wang
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Harji D, Mauriac P, Bouyer B, Berard X, Gille O, Salut C, Rullier E, Celerier B, Robert G, Denost Q. The feasibility of implementing an enhanced recovery programme in patients undergoing pelvic exenteration. Eur J Surg Oncol 2021; 47:3194-3201. [PMID: 34736803 DOI: 10.1016/j.ejso.2021.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/06/2021] [Accepted: 07/14/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pelvic exenteration (PE) is a complex operative procedure, reserved for patients with locally advanced and recurrent pelvic malignancies. PE is associated with a high index of post-operative morbidity. Enhanced Recovery After Surgery (ERAS) programmes have been successful in improving postoperative outcomes, however, its application in PE has not been studied. The aim of our study is to assess the feasibility and short-term impact of ERAS on PE. METHODS A dedicated PE ERAS programme was developed reflecting the complexity of differing subtypes of PE. A prospective cohort study was undertaken to evaluate the feasibility of implementing our PE ERAS between 2016 and 2020. The primary endpoint of this study was overall compliance with the ERAS programme. RESULTS 145 patients were enrolled into our PE ERAS programme, with 86 (56.2%) patients undergoing a soft tissue PE, 27 (17.6%) a vascular PE and 32 (20.9%) a bony PE. The median overall compliance to the PE ERAS programme was 70% (IQR 55.5-88.8). There were no observed differences between overall compliance to the PE ERAS programme between different subtypes of PE (p = 0.60). Patients with higher compliance with the PE ERAS programme had a shorter LoS (p < 0.001), less post-operative morbidity (p < 0.001), reduced severity of Clavien-Dindo grade of morbidity (p < 0.001) and fewer readmissions (p = 0.03). CONCLUSIONS The principles of ERAS can be readily applied to patients undergoing PE, with high adherence to the ERAS programme associated with improved clinical outcomes.
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Affiliation(s)
- Deena Harji
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France
| | - Paul Mauriac
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Benjamin Bouyer
- Département de Chirurgie Rachidienne, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Xavier Berard
- Département de Chirurgie Vasculaire, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France
| | - Olivier Gille
- Département de Chirurgie Rachidienne, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Cécile Salut
- Département D'imagerie Diagnostique et Interventionnelle, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Eric Rullier
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Bertrand Celerier
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
| | - Grégoire Robert
- Département D'urologie, Hôpital Pellegrin, Place Amélie Raba Léon, 33076, Bordeaux, CHU Bordeaux, France.
| | - Quentin Denost
- Département de Chirurgie Colorectal, Hôpital Haut-Lévèque, 1 Avenue Magellan, 33604, Pessac, CHU Bordeaux, France.
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Sánchez-Iglesias JL, Gómez-Hidalgo NR, Pérez-Benavente A, Carbonell-Socias M, Manrique-Muñoz S, Serrano MP, Gutiérrez-Barceló P, Bradbury M, Nelson G, Gil-Moreno A. Importance of Enhanced Recovery After Surgery (ERAS) Protocol Compliance for Length of Stay in Ovarian Cancer Surgery. Ann Surg Oncol 2021; 28:8979-8986. [PMID: 34091804 DOI: 10.1245/s10434-021-10228-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/10/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Enhanced Recovery After Surgery (ERAS) programs include multiple perioperative care elements, which when implemented together are designed to improve recovery after surgery with subsequent reduction in hospital length of stay (LOS). The aim of this study is to examine the impact of ERAS protocol compliance on LOS in patients undergoing advanced ovarian cancer surgery within the context of a randomized clinical trial. METHODS Patients were enrolled in a prospective, consecutive, interventional randomized clinical trial between June 2014 and March 2018. Women with either suspected or confirmed advanced ovarian cancer with International Federation of Gynecology and Obstetrics (FIGO) stages IIB-IVA and recurrent ovarian cancer, who underwent cytoreduction surgery, were randomly assigned to either a conventional management (CM) protocol or an ERAS protocol. Demographic items, preoperative clinical data, and surgical characteristics of patients were recorded, as were LOS and ERAS protocol compliance. Negative binomial regression was used to model the relation between length of stay and ERAS protocol compliance. RESULTS We included 49 patients in the CM group and 50 patients in the ERAS group. The overall rate of ERAS compliance was 92%. We observed that increasing ERAS protocol compliance was associated with shorter median LOS, and in patients who underwent higher complex surgeries, the length of stay reduction was greater. CONCLUSION This study identifies a correlation between increasing ERAS protocol compliance and decreasing LOS in ovarian cancer surgery. This finding underlines the necessity to implement as many ERAS protocol elements as possible to achieve optimal clinical outcome improvements.
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Affiliation(s)
- Jose Luis Sánchez-Iglesias
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain.
| | - Natalia R Gómez-Hidalgo
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain.
| | - Asunción Pérez-Benavente
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain
| | - Melchor Carbonell-Socias
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain
| | | | | | - Pilar Gutiérrez-Barceló
- Nursing Unit for Gynecologic Oncology and Breast Diseases, Vall d'Hebron Hospital, Barcelona, Spain
| | - Melissa Bradbury
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Antonio Gil-Moreno
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Madrid, Spain
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Hasselgren E, Hertzberg D, Camderman T, Björne H, Salehi S. Perioperative fluid balance and major postoperative complications in surgery for advanced epithelial ovarian cancer. Gynecol Oncol 2021; 161:402-407. [PMID: 33715894 DOI: 10.1016/j.ygyno.2021.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/25/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Appropriate fluid balance in the perioperative period is important as both hypo- and hypervolemia are associated with increased risk of complications. Women undergoing cytoreductive surgery (CRS) for advanced epithelial ovarian cancer (EOC) may have major fluid shifts. The optimal perioperative fluid balance in these women is yet to be determined. Our objective was to investigate the association between perioperative fluid balance and major postoperative complications. METHODS Women with advanced stage EOC who underwent surgery at Karolinska University Hospital, Stockholm, Sweden were identified from the institutional database. Women subjected to surgery with curative intent were included in the analysis. Additional data were retrieved from medical records. The association between perioperative fluid balance and major postoperative complications was investigated by multivariable regression and adjusted for predefined confounders. RESULTS Of the 270 women identified in the institutional database during 2014-2017, 184 women were included in the analyses. Of these women, 22% (n = 40) experienced a major postoperative complication. The fully adjusted odds of major postoperative complications increased when perioperative fluid balance exceeded >3000 mL, (Odds Ratio (OR) 4.85, 95% Confidence Interval (CI) 1.23-19.2, p = 0.02) and > 5000 mL (OR 33.7, 95% CI 4.13-275, p < 0.01). There was no association between negative fluid balance and major postoperative complications (OR 3.33, 95% CI 0.25-44.1, p = 0.36). CONCLUSIONS Fluid balance >3000 mL perioperatively during surgery for advanced EOC increased the odds of major postoperative complications. Management of perioperative fluid balance in advanced EOC surgery remains a challenge.
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Affiliation(s)
- Emma Hasselgren
- Department of Physiology and Pharmacology, Division of Anaesthesiology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.
| | - Daniel Hertzberg
- Department of Physiology and Pharmacology, Division of Anaesthesiology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Tina Camderman
- Department of Physiology and Pharmacology, Division of Anaesthesiology, Karolinska Institutet, Stockholm, Sweden
| | - Håkan Björne
- Department of Physiology and Pharmacology, Division of Anaesthesiology, Karolinska Institutet, Stockholm, Sweden; Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Sahar Salehi
- Department of Women's and Children's Health, Division of Obstetrics and Gynaecology, Karolinska Institutet, Stockholm, Sweden; Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
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Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - A systematic review and meta-analysis. Gynecol Oncol 2020; 161:46-55. [PMID: 33388155 DOI: 10.1016/j.ygyno.2020.12.035] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/22/2020] [Indexed: 12/16/2022]
Abstract
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.
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Bisch S, Nelson G. Randomised controlled trial confirms benefit of enhanced recovery after surgery on length of stay in ovarian cancer: How low can we go? Eur J Cancer 2020; 139:90-91. [PMID: 32979646 DOI: 10.1016/j.ejca.2020.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Steven Bisch
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada.
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