Enhanced recovery after surgery (ERAS®) in gynecologic oncology – Practical considerations for program development

Enhanced Recovery after Surgery - Evidence and Practice

AbstractEnhanced Recovery After Surgery (ERAS) is a global initiative comprised of a series of evidence-based interventions in the preoperative, intraoperative, and postoperative surgical phases. When implemented as a bundle, ERAS interventions both improve clinical outcomes and provide cost savings to the health care system. This review provides an update on the current evidence for individual ERAS elements to improve quality of care as well as practical recommendations for multidisciplinary teams to implement their own ERAS programs.

Real-world study on the application of enhanced recovery after surgery protocol in video-assisted thoracoscopic day surgery for pulmonary nodule resection

OBJECTIVE

This study aims to evaluate the real-world effectiveness of applying different levels of Enhanced Recovery After Surgery (ERAS) guidelines to video-assisted thoracic day surgery (VATS). The goal is to determine the optimal degree of ERAS protocols and management requirements to improve postoperative recovery outcomes.

METHODS

It was designed as a single-centre, prospective pragmatic randomized controlled trial (PRCT), including patients who underwent VATS at the Day Surgery Center of West China Hospital, between January 2021 and November 2022. Patients were divided into Group A and Group B through convenience sampling to implement different levels of ERAS management protocols. Data collection included the baseline characteristics (gender, age, marital status, education level, BMI, PONV risk score, ASA classification), surgery-related indicators (type of surgery, pathological results, hospitalization costs, duration of surgery, intraoperative blood loss, intraoperative rehydration volume), postoperative recovery indicators (postoperative chest tube duration time, time to first postoperative ambulation and urination, postoperative complications, follow-up condition), pain-related indicators (pain threshold score, pain score at 6 h postoperatively, bedtime, and predischarge), psychological state indicators (anxiety level), Athens Insomnia Scale (AIS) scores, and social support scores. Propensity score matching (PSM) was utilized and statistical analyses were conducted using R version 4.4.1. Comparisons of categorical variables were performed using the χ² test, while comparisons of continuous variables were conducted using ANOVA or the Kruskal-Wallis rank-sum test. A significance level of α = 0.05 was set for statistical tests.

RESULT

A total of 340 patients were included, with 187 in Group A and 153 in Group B. After propensity score matching (PSM), there were 142 patients in Group A and 105 in Group B, with no significant baseline differences. Group A had a significantly higher proportion of chest tube removals within 24 h postoperatively (P < 0.001) and earlier mobilization (P < 0.001). Despite a higher pain threshold in Group A (P = 0.016), their postoperative pain scores were not higher than those in Group B. Additionally, Group A had a lower incidence of postoperative complications.

CONCLUSION

The more comprehensive ERAS protocol significantly improved postoperative recovery, confirming its value in day-case VATS and supporting its clinical adoption. However, the study has limitations; future research should focus on standardizing ERAS protocols and expanding their application to a broader patient population to validate these findings further.

TRAIL REGISTRATION

This study underwent review by the Ethics Committee of West China Hospital of Sichuan University under No. 2020 (1001). It has been officially registered with the China Clinical Trial Registry, TRN: ChiCTR2100051372 and registration date is Sept. 22, 2021.

Cost impact analysis of enhanced recovery after minimally invasive gynecologic oncology surgery

OBJECTIVE

The implementation of a peri-operative care program based on enhanced recovery after surgery principles for minimally invasive gynecologic oncology surgery led to an improvement in same day discharge from 29% to 75% at our center. This study aimed to determine the program's economic impact.

METHODS

Our initial enhanced recovery quality improvement program enrolled consecutive patients undergoing minimally invasive hysterectomy at a single center during a 12-month period and compared them to a pre-intervention cohort. The primary outcome was overall costs. The secondary outcomes were surgical and post-operative visit costs. The surgical visit costs included pre-operative and operating room, post-operative stay, pharmacy, and interventions costs. The 30-day post-operative visit costs included clinic and emergency room, and readmission costs. The costs for every visit were collected from the case-cost department and expressed in 2020 Canadian dollars (CAD).

RESULTS

A total of 96 and 101 patients were included in the pre- and post-intervention groups, respectively. The median total cost per patient for post-intervention was $7252 compared with $8381 pre-intervention (p=0.02), resulting in a $1129 cost reduction per patient. The total cost for the program implementation was $134 per patient for a total cost of $13 106. The median post-operative stay cost was $816 post-intervention compared with $1278 pre-intervention (p<0.05). Statistically significant savings for the post-intervention group were also found for operative visit, operating room costs, and pharmacy (p<0.05). On multivariate analysis, surgical approach was the only factor associated with operating room costs, whereas both surgical approach and group (pre- vs post-intervention) impacted the total and post-operative stay costs (p<0.05).

CONCLUSION

In addition to increasing the same day discharge rate after minimally invasive gynecologic oncology surgery, an enhanced recovery-based peri-operative care program led to significant reductions in cost.

Effect of transversus abdominis plane block on postoperative outcomes in gynecologic oncology patients managed on an Enhanced Recovery After Surgery pathway

OBJECTIVES

To characterize the effect of transversus abdominis plane (TAP) blocks on post-operative outcomes in patients undergoing laparotomy for gynecologic malignancy.

METHODS

This retrospective cohort study assessed patients undergoing laparotomy in 2016-2017 and 2020 in Alberta, Canada. The primary outcome was opioid consumption in oral morphine milligram equivalent (MME). Secondary outcomes included maximum pain scores, length of stay, and patient-controlled analgesia (PCA) use. Outcomes were compared using t-test with subgroup analysis by NSAID use. Multivariate regression modelling was performed for potential confounders.

RESULTS

Data was collected on 956 patients; 828 received a TAP block, 128 did not. Opioid use in the first 24 h was lower in the TAP block group (35.9 mg MME vs 44.5 mg MME, p = 0.0294), without any increase in pain scores, this did not remain significant after regression analysis. Patients with TAP blocks had significant reduced mean length of stay (3.2 days vs. 5.0 days, p < 0.0001), and PCA use (19.9% vs. 56.25%, p < 0.0001). On subgroup analysis of patients that did not receive NSAIDs (n = 160), mean opioid use was decreased in those patients with TAP blocks compared to those without TAP blocks in the first 24 h (36.1 mg vs. 61.2 mg, p = 0.0017), and at 24 to 48 h (16.3 mg vs. 51.0 mg, p < 0.0001).

CONCLUSIONS

Surgeon-administered TAP blocks were associated with decreased length of stay and post-operative opioid use in patients not receiving scheduled NSAIDs. This decrease in opioid use was not associated with any increase in average or maximum pain scores.

Enhanced Recovery in Gynecologic Oncology Surgery-State of the Science

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.

Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer

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.

Enhanced recovery after surgery in cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: national survey of peri-operative practice by Indian society of peritoneal surface malignancies

Objectives

The Enhanced recovery after surgery (ERAS) program is designed to achieve faster recovery by maintaining pre-operative organ function and reducing stress response following surgery. A two part ERAS guidelines specific for Cytoreductive surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) was recently published with intent of extending the benefit to patients with peritoneal surface malignancies. This survey was performed to examine clinicians' knowledge, practice and obstacles about ERAS implementation in patients undergoing CRS and HIPEC.

Methods

Requests to participate in survey of ERAS practices were sent to 238 members of Indian Society of Peritoneal Surface malignancies (ISPSM) via email. They were requested to answer a 37-item questionnaire on elements of preoperative (n=7), intraoperative (n=10) and postoperative (n=11) practices. It also queried demographic information and individual attitudes to ERAS.

Results

Data from 164 respondents were analysed. 27.4 % were aware of the formal ERAS protocol for CRS and HIPEC. 88.4 % of respondents reported implementing ERAS practices for CRS and HIPEC either, completely (20.7 %) or partially (67.7 %). The adherence to the protocol among the respondents were as follows: pre operative (55.5-97.6 %), intra operative (32.6-84.8 %) and post operative (25.6-89 %). While most respondents considered implementation of ERAS for CRS and HIPEC in the present format, 34.1 % felt certain aspects of perioperative practice have potential for improvement. The main barriers to implementation were difficulty in adhering to all elements (65.2 %), insufficient evidence to apply in clinical practice (32.4 %), safety concerns (50.6 %) and administrative issues (47.6 %).

Conclusions

Majority agreed the implementation of ERAS guidelines is beneficial but are followed by HIPEC centres partially. Efforts are required to overcome barriers like improving certain aspects of perioperative practice to increase the adherence, confirming the benefit and safety of protocol with level I evidence and solving administrative issues by setting up dedicated multi-disciplinary ERAS teams.

Efficacy and Safety of Gabapentin on Postoperative Pain Management After Bariatric Surgery: A Systematic Review and Meta-Analysis

PURPOSE

Examine the efficacy and safety of perioperative gabapentin in bariatric surgical patients.

DESIGN

Systematic Review and Meta-analysis.

METHODS

An exhaustive search was conducted using PubMed, Cochrane Library, MEDLINE, CINAHL, Google Scholar, and other gray literature. Only randomized controlled trials evaluating the use of gabapentin in bariatric surgery were included. Risk ratio (RR) and mean difference (MD) were used to estimate outcomes with suitable effect models. Quality of evidence was assessed using the Risk of Bias and GRADE system.

FINDINGS

Four trials consisting of 283 patients were analyzed. The use of gabapentin significantly lowered the cumulative pain score in the first 24 hours after surgery by an average of 1.04 (MD, -1.04; 95% CI, -1.45 to -0.63; P < .00001). Gabapentin also reduced the overall morphine equivalent consumption by 7.89 mg (MD, -7.89; 95% CI, -13.56 to -2.2; P = .006). However, gabapentin did not affect the incidence of PONV (RR, 0.61; 95% CI, 0.38-1.00; P = .05), somnolence (RR, 1.25; 95% CI, 0.57-2.73; P = .57), dizziness (RR, 1.01; 95% CI, 0.40-2.54; P = .99), and headache (RR, 0.76; 95% CI, 0.25-2.30; P = .62). Substantial heterogeneity, imprecision of the effect size, and potential publication bias were limitations of this review.

CONCLUSIONS

The use of gabapentin is effective in the management of postoperative pain in bariatric surgery. However, there is limited data regarding the opioid-sparing effect and adverse effect profiles of gabapentin in the bariatric surgical population.

Provider compliance with a tailored opioid prescribing calculator in gynecologic surgery

OBJECTIVE

To evaluate the impact a tailored opioid prescription calculator has on meeting individual patient opioid needs while avoiding opioid over prescriptions.

METHODS

Our group previously developed and published an opioid prescribing calculator incorporating patient risk factors (history of depression, anxiety, chronic opioid use, substance abuse disorder, and/or chronic pain) and type of surgery (laparotomy or laparoscopy). This calculator was implemented on 1/1/2021 and its impact on opioid prescriptions was evaluated until 12/31/21. The primary outcome of the present study is to determine prescriber compliance with the calculator (defined as not overprescribing from the number of pills indicated by the calculator). The secondary outcome is to determine the excess prescription rate (defined as proportion of patients reporting more than 3 pills remaining at 30 days post-surgery). Refill rates and pain related patient phone calls were collected. Descriptive statistics were used to summarize the cohort.

RESULTS

Of the 355 patients included, 54.7% (N = 194) underwent laparoscopy and 45.4% (N = 161) underwent laparotomy. One hundred and forty-two patients (40%) had at least one risk factor for opioid usage. The median number of opioid pills prescribed following laparoscopy was 3 (range 0-15) and 6 (0-20) after laparotomy. The prescriber compliance was 88.2% and the excess prescription rate was 25.1% (N = 89 patients).

CONCLUSIONS

Our tailored opioid calculator has a high prescriber compliance. Implementation of this calculator led to a standardization of tailored opioid prescribing, while limiting the number of over prescriptions. A free web version of the calculator can be easily accessed at www.opioidcalculator.org.

Enhanced recovery after surgery program alleviates neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in patients undergoing gynecological surgery

Background

To evaluate the efficacy of the enhanced recovery after surgery (ERAS) programs on the systemic inflammatory response (SIR) of patients following gynecological surgery, a randomized controlled trial was performed to compare the ERAS programs with the conventional perioperative care programs. Furthermore, novel SIR markers could be identified to evaluate the ERAS programs of gynecological surgery.

Methods

Patients undergoing gynecological surgery were randomly allocated to either the ERAS group or the conventional group. The correlations between the elements of ERAS protocols and SIR markers following gynecological surgery were evaluated.

Results

A total of 340 patients who underwent gynecological surgery were enrolled (ERAS = 170; conventional = 170). First, we identified whether the ERAS programs after gynecological surgery reduced the perioperative difference between neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Interestingly, first flatus time postoperatively, visual analog scale (VAS) score of patients was positively correlated with the perioperative difference NLR or PLR. Moreover, we discovered that the perioperative difference NLR or PLR was correlated with elements of ERAS protocol, including first sips of water, first semifluid diet postoperatively, pelvic drain duration, and out-of-bed time of patients.

Conclusion

We originally reveal that certain elements of ERAS programs alleviated SIR to operation. The implementation of ERAS programs enhances postoperative recovery after gynecological surgery via improving system inflammatory status. NLR or PLR could be the novel and inexpensive marker to assess ERAS programs in gynecological surgery.Clinical trial registration:ClinicalTrials.gov, identifier, NCT03629626.

Patient outcomes following implementation of an enhanced recovery after surgery pathway for patients with metastatic spine tumors

BACKGROUND

Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence-based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center.

METHODS

The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0-5 cumulative opioid use (morphine milligram equivalent [MME]).

RESULTS

A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre-ERAS patients. Although the mean case durations were similar in the ERAS and pre-ERAS cohorts (265 vs. 274 min; p = .22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p = .003), decreased postoperative day 0-5 cumulative mean opioid use (178 vs. 396 MME; p < .0001), earlier ambulation (mean, 34 vs. 57 h; p = .0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p < .001), and shorter LOS (5.4 vs. 7.5 days; p < .0001).

CONCLUSIONS

The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Updates in Enhanced Recovery Pathways for Gynecologic Surgery

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

Information needs of women undergoing gynaecological risk reduction surgery: Applying patient-reported findings to improve service delivery

BACKGROUND

Women with genetic mutations including BRCA1, BRCA2 and Lynch syndrome are at increased risk of developing gynaecological cancers with management options including surveillance and/or risk reduction surgery. Little is known about the information women require to inform their decisions around having risk reduction surgery, the implication this surgery has for them and the timing preferences to receive this information.

AIMS

To identify the information needs of women who are considering or who have had risk reduction surgery due to having a diagnosed or suspected genetic mutation with subsequent increased risk of developing gynaecological cancer.

MATERIALS AND METHODS

A pilot survey was undertaken in a tertiary, metropolitan hospital as part of a service improvement project. Women referred to the gynaecology-oncology service for gynaecological risk reduction surgery between January to December 2018 were invited to participate through completing either online or hard copy versions of a 12-item survey.

RESULTS

A response rate of 60% (n = 32) was obtained from women between 27 and 77 years of age. Key information topics included sexuality and intimacy (90.6%; n = 29), the surgery itself (87.5%; n = 28) and surgical menopause (87.5%; n = 28). Over 90% (n = 31) of respondents stated they preferred to receive information about surgery pre-operatively and in written format (81.3%; n = 26). The importance of a multidisciplinary approach was recognised with women wanting information from allied health practitioners such as physiotherapists and social workers.

CONCLUSIONS

Findings have enabled a better understanding of the type, timing and content of information desired by women making complex decisions about risk reduction surgery. Results have contributed to developing an information resource which will more adequately assist women to meet their information needs when considering gynaecological risk reduction surgery in our hospital.

Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians' practice about ERAS in patients undergoing CRS-HIPEC.

METHODS

An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists.

RESULTS

The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76-95%), preoperative (50-94%), and intraoperative (55-90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated.

CONCLUSIONS

Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices.

Optimization of postoperative opioid prescriptions in gynecologic oncology: Striking a balance between opioid reduction and pain control

OBJECTIVE

To implement a quality-improvement initiative to assess the impact various patient and procedural factors have on postoperative opioid use. To develop a tailored opioid prescribing algorithm for gynecologic oncology patients.

METHODS

A retrospective cohort study was performed of patients who underwent a laparoscopy or laparotomy procedure for a suspected or known gynecologic malignancy between 3/2019-9/2020. Patients were assessed preoperatively for the presence of suspected risk factors for opioid misuse (depression, anxiety, chronic pain, current opioid use, or substance abuse). Patients completed a 30-day postoperative questionnaire assessing for total opioid pill use and refills requests. Multivariate models were developed to estimate the independent effect of sociodemographic characteristics, risk factors for opioid misuse and procedural factors on patient reported postoperative opioid use.

RESULTS

A total of 390 patients were analyzed. Thirty-nine percent (N = 151/390) of patients reported not using opioids after discharge and 5% (N = 20/390) received an opioid refill. For both minimally invasive procedures and laparotomy procedures, body mass index, comorbidities, intraoperative or postoperative complications and final diagnosis of malignancy were not associated with the amount of opioid consumption. However, younger age and history of risk factors for opioid misuse significantly impacted postoperative opioid use. In multivariate analysis, age (p = 0.038) and risk factors (p < 0.001) remained significant after controlling for other factors.

CONCLUSIONS

Two out of every five patients did not use opioids after surgery. Younger patients and those with risk factors for opioid misuse need a tailored approach to prescribing opioids to balance the need for adequate pain control with the risk of misuse.

Scaling an Enhanced Recovery Program to an Institution-Wide Initiative: It Takes a Village

BACKGROUND AND OBJECTIVE

With the inclusion of Enhanced Recovery Programs (ERPs) into routine clinical practice, scaling programs across an institution is important to drive sustainable change in a patient-centric care delivery paradigm. A review of ERP implementation within a large institution was performed to understand key components that hinder or facilitate success of scaling an ERP.

METHODS

From January 2018 to March 2018, a needs assessment was completed to review implementation of enhanced recovery across the institution. Implementation progress was categorized into one of 5 phases including Define, Implement, Measure, Analyze, and Optimize.

RESULTS

Only 25% of service line ERPs reached the optimization phase within 5 years. One hundred percent of respondents reported more strengths (n = 41) and opportunities (n = 41) than weaknesses or threats (n = 25 and 14, respectively). Commonly identified strengths included established enhanced recovery pathways, functional team databases, and effective provider education. Weaknesses identified were inconsistencies in data quality/collection and a lack of key personnel participation including buy-in and time availability. Respondents perceived the need for data standardization to be an opportunity, while personnel factors were viewed as key threats.

CONCLUSION

Identification of strengths, weaknesses, opportunities, and threats could prove beneficial in helping scale an ERP across an institution. Successful optimization and expansion of ERPs require robust data management for continuous quality improvement efforts among clinicians, administrators, executives, and patients.

Enhanced Recovery Protocol Enhances Postdischarge Recovery After Laparoscopic Sacrocolpopexy

OBJECTIVE

The objective of this study is to determine if an ERAS (enhanced recovery after surgery) protocol enhanced the patient-perceived postdischarge recovery after laparoscopic sacrocolpopexy.

METHODS

In this prospective cohort study, patients exposed to an ERAS protocol completed a preoperative survey that included established predictors of postdischarge recovery. Postoperatively, they completed the validated Postdischarge Surgical Recovery 13 (PSR-13) scale at 7, 14, and 42 days. A historical cohort of non-ERAS patients who completed similar surveys were included for comparisons. Characteristics between the 2 cohorts were analyzed using the χ2 test, Student t tests, and Mann-Whitney U tests where appropriate. A mixed-design analysis of variance model was constructed to determine if our ERAS protocol affected recovery as measured by the PSR-13 scale.

RESULTS

Eighty-nine ERAS patients were compared with 169 non-ERAS controls. There were no differences in established predictors of recovery between the groups. Length of hospital stay was shorter in the ERAS cohort (33±13.1 hours vs 44.2±25.9 hours; mean difference, 11.2; 95% confidence interval [CI], 6.44-16.0). Postdischarge recovery significantly improved with time (7 days: 52.7; 95% CI, 50.1-55.2; 14 days: 63.4; 95% CI, 60.9-65.8; 42 days: 80.1, 95% CI, 78.1-82.1). The ERAS cohort reported greater postdischarge recovery than the non-ERAS cohort (as measured by the PSR-13 scale) at postoperative days 7, 14, and 42 days (68.4 vs 62.3; mean difference, 6.1; 95% CI, 2.04-10.16).

CONCLUSIONS

Enhanced recovery after surgery protocols reduce length of hospital stay and enhance patient-perceived postdischarge recovery.

Comparison of the Efficacy and Safety of Dinalbuphine Sebacate, Patient-Controlled Analgesia, and Conventional Analgesia After Laparotomy for Gynecologic Cancers: A Retrospective Study

Objective

We aimed to investigate the effects of dinalbuphine sebacate (DNS), fentanyl-based patient-controlled analgesia (PCA), and conventional analgesia (CA) for pain management after laparotomy for gynecologic cancers.

Methods

A total of 137 eligible patients who underwent laparotomy through a midline incision wound for gynecologic cancer between July 2019 and June 2020 were retrospectively evaluated. The patients were divided into three groups as follows: the intramuscular DNS, intravenous PCA, and CA groups. Postoperative pain (POP) intensity as measured with a numerical rating scale (NRS), total consumption of analgesics, and incidence of treatment-emergent adverse events were compared between the three groups.

Results

The DNS group showed significant reduction in NRS pain intensity than the PCA and CA groups on day 1 (4.8 vs 6.2, p < 0.01 and 6.2, p < 0.05, respectively), day 2 (3.0 vs 4.7, p < 0.01 and 4.8, p < 0.001, respectively), day 3 (2.0 vs 3.9, p < 0.001 and 3.5, p < 0.001, respectively), day 4 (1.1 vs 3.1, p < 0.001 and 2.9, p < 0.001, respectively), and day 5 (0.7 vs 2.3, p < 0.001 and 2.4, p < 0.001, respectively). The total consumption of morphine equivalents per day was similar between the DNS and PCA groups (142.8 ± 7.3 mg vs 137.7 ± 70.0 mg, p = 0.8032) and lowest in the CA group (11.7 ± 30.7 mg, p < 0.0001). The overall safety profile was comparable between the DNS, PCA, and CA groups. The patients in the DNS group complained less of dizziness postoperatively than those in the PCA group (27% vs 47%) and had less nausea than those in the CA group (13% vs 33%).

Conclusion

A single DNS injection was more effective for relieving POP than PCA and CA in the patients who had a longitudinal incision for gynecologic cancer surgery. DNS was well tolerated and had less adverse effects than PCA and CA.

The implementation of enhanced recovery after surgery protocols in ovarian malignancy surgery

The enhanced recovery after surgery (ERAS) refers to multimodal interventions to reduce the length of hospital stay and complications at various steps of perioperative care. It was first developed in colorectal surgery and later embraced by other surgical disciplines including gynecologic oncology. The ERAS Society recently published guidelines for gynecologic cancer surgeries to enhance patient recovery. However, limitations exist in the implementation of the guidelines in ovarian cancer patients due to the distinct characteristics of the disease. In the present review, we discuss the results that have been published in the literature to date regarding the ERAS protocols in ovarian cancer patients, and explain why more evidence needs to be specifically assessed in this type of malignancy among other gynecologic cancers.

Women's experiences of an enhanced recovery after surgery program: A qualitative study

The Enhanced Recovery After Surgery Program aims to transfer much of the responsibility for postoperative recovery to the patient and their next of kin. The aim of the study was to identify and describe women's experiences of care within this program in relation to gynecological abdominal surgery. A qualitative approach was used where 16 women were interviewed within 1 to 2 weeks of their surgery. A thematic analysis focusing on interpretation of latent content was performed. Three themes were identified: Empowerment, Self-care, and Participation. Empowerment represents aspects of the recovery program that strengthen self-efficacy, such as being seen, being given information, and continuity of care. Self-care identifies the practical implications of empowerment, namely internal resources, knowledge, and external resources. These two themes were identified as separate but interlinked through the theme Participation. Preoperative information, postoperative encouragement, and follow-up empowered the women in their recovery. Early discharge from hospital was beneficial for recovery if accompanied by social support and sufficient self-care ability. A desire for a person-centered approach in the preoperative meeting and in postoperative care was identified.

Evaluating the importance of routine drainage following laparoscopic pelvic lymph node dissection for gynecological malignancies

OBJECTIVE

To determine the efficacy of drainage following pelvic lymph node (PLN) dissection, especially for cases involving laparoscopic surgery.

METHODS

In this retrospective study, 368 patients with malignant gynecological tumors who underwent systemic PLN dissection at Keio University Hospital between January 2012 and October 2018 were enrolled. Drainage tubes were placed in the retroperitoneal fossa in all patients. Medical records were used for data collection.

RESULTS

Laparoscopy was performed on 81 patients, and laparotomy was performed on 287 patients. In the laparoscopy group, tubes were removed 1 day post surgery. In the laparotomy group, tubes were removed 1 day post surgery in 167 patients and 4 days post surgery in 120 patients. Compared with the laparotomy group, we determined the laparoscopy group to have a significantly lower prevalence of lymphocyst (6.2% vs 20.2%, p = 0.002) but a similar prevalence of lymphedema (4.9% vs 5.2%), and symptomatic lymphocyst (2.5% vs 4.5%). The two laparotomy groups did not differ significantly with respect to the prevalence of lymphedema (4.8% vs 5.8%), lymphocyst (20.4% vs 20.0%), or symptomatic lymphocyst (4.2% vs 5.0%).

CONCLUSION

Our results suggest that routine drainage should be omitted, especially in cases involving laparoscopic surgery.

Unanticipated 30-day readmission following rectosigmoid resection at the time of cytoreductive surgery in patients with advanced stage ovarian cancer

The objective of this study was to examine the rate of and indications for readmission in patients with advanced staged ovarian cancer undergoing rectosigmoid resection and primary anastomosis, an important quality metric. A retrospective review was conducted of patients with primary ovarian cancer who underwent rectosigmoid resection as part of cytoreductive surgery between July 2003 and July 2014. Univariate analysis identified rates and predictors of readmission. Fifty patients were eligible for analysis. The unanticipated 30-day readmission rate was 18% (n = 9). Of those readmitted less than 30 days from date of discharge, 3 were readmitted more than once, making 14 total readmissions. A total of 21 indications for readmission were reported, with the most common being: infection (23.8%, n = 5); thromboembolic events (19%, n = 4); and severe malnutrition (14.3%, n = 3). The median time to readmission was 14 days (range, 2-26). There were no deaths within 30 days of surgery in this cohort.IMPACT STATEMENTWhat is already known about the subject? Unanticipated 30-day readmission rates are reported to be between 12 and 20% among patients undergoing cytoreductive surgery for the management of ovarian cancer. The relative contribution of rectosigmoid resection at the time of cytoreductive surgery to readmission is not well studied.What do the results of this study add? In the examined cohort, the unanticipated 30-day readmission rate following rectosigmoid resection with primary reanastomosis at the time of cytoreductive surgery is 18%, similar to the readmission rate for patients undergoing cytoreductive surgery, in general. While the sample size is limited, the perioperative complications in this cohort appear similar to those of patients undergoing cytoreductive surgery.What are the implications of these findings for clinical practice and/or further research? Efforts to reduce unanticipated 30-day readmission following cytoreductive surgery is warranted. Future studies may benefit from multi-centre approaches and prospective data collection, while simultaneously assessing the impact of enhanced recovery programs. Ultimately, identification of risk factors, and programmatic initiatives to drive down readmission will be important across surgical platforms, and the opportunity exists in patients with advanced stage ovarian cancer.

The impact of implementation of a hysterectomy enhanced recovery pathway on anesthetic medication costs

Aim: To evaluate the effect of implementation of a hysterectomy Enhanced Recovery After Surgery (ERAS) protocol on perioperative anesthetic medication costs. Patients & methods: Historical cohort study of 84 adult patients who underwent a hysterectomy. Forty-two patients who underwent surgery before protocol implementation comprised the pre-ERAS group. Forty-two patients who underwent surgery after protocol implementation comprised the post-ERAS group. Data on anesthetic medication costs and outcomes were analyzed. Results: Compared with the pre-ERAS group, the post-ERAS group's total medication cost was significantly lower (median: 325.20 USD; interquartile range [IQR]: 256.12-430.65 USD vs median: 273.10 USD; IQR: 220.63-370.59 USD, median difference: -40.76, 95% CI: -130.39, 16.99, p = 0.047). Length of stay was significantly longer in pre-ERAS when compared with post-ERAS groups (median: 5.0 days; IQR: 4.0-7.0 days vs median: 3.0 days; IQR: 3.0-4.0 days, median difference: -2.0 days, 95% CI: -2.5581, -1.4419, p < 0.0001). Conclusion: ERAS protocols may reduce perioperative medication costs.

Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: an international survey of peri-operative practice

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) programs have been shown to improve clinical outcomes in gynecologic oncology, with the majority of published reports originating from a small number of specialized centers. It is unclear to what degree ERAS is implemented in hospitals globally. This international survey investigated the status of ERAS protocol implementation in open gynecologic oncology surgery to provide a worldwide perspective on peri-operative practice patterns.

METHODS

Requests to participate in an online survey of ERAS practices were distributed via social media (WhatsApp, Twitter, and Social Link). The survey was active between January 15 and March 15, 2020. Additionally, four national gynecologic oncology societies agreed to distribute the study among their members. Respondents were requested to answer a 17-item questionnaire about their ERAS practice preferences in the pre-, intra-, and post-operative periods.

RESULTS

Data from 454 respondents representing 62 countries were analyzed. Overall, 37% reported that ERAS was implemented at their institution. The regional distribution was: Europe 38%, Americas 33%, Asia 19%, and Africa 10%. ERAS gynecologic oncology guidelines were well adhered to (>80%) in the domains of deep vein thrombosis prophylaxis, early removal of urinary catheter after surgery, and early introduction of ambulation. Areas with poor adherence to the guidelines included the use of bowel preparation, adoption of modern fasting guidelines, carbohydrate loading, use of nasogastric tubes and peritoneal drains, intra-operative temperature monitoring, and early feeding.

CONCLUSION

This international survey of ERAS in open gynecologic oncology surgery shows that, while some practices are consistent with guideline recommendations, many practices contradict the established evidence. Efforts are required to decrease the variation in peri-operative care that exists in order to improve clinical outcomes for patients with gynecologic cancer globally.

Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced Recovery After Surgery (ERAS®) Society Recommendations - Part II: Postoperative management and special considerations

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part II of the guidelines highlights postoperative management and special considerations.

METHODS

The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations.

RESULTS

Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items. No consensus could be reached regarding the preemptive use of fresh frozen plasma.

CONCLUSION

The present ERAS recommendations for CRS ± HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS ± HIPEC and to prospectively evaluate recommendations in clinical practice.

How to Start an Enhanced Recovery After Surgery Cardiac Program

In this review the authors introduce a practical approach to guide the initiation of an enhanced recovery after surgery (ERAS) cardiac surgery program. The first step in implementation is organizing a dedicated multidisciplinary ERAS cardiac team composed of representatives from nursing, surgery, anesthesiology, and other relevant allied health groups. Identifying a program coordinator or navigator who will have responsibilities for developing and implementing educational initiatives, troubleshooting, monitoring progress and setbacks, and data collection is also vital for success. An institution-specific protocol is then developed by leveraging national guidelines and local expertise.

Good clinical practice advice for the management of patients with gynaecological cancer during the COVID-19 pandemic in Nigeria and other resource-constrained countries

The impact of the COVID-19 pandemic on healthcare services in settings with under-resourced health systems such as that of Nigeria is likely to be substantial in the coming months. The gynaecological oncology services still need to be prioritised as an essential core health service. There are increasing concerns from both physicians and patients regarding how to manage patients diagnosed with cancer during this pandemic as evidence suggests a substantial increase in the risk of COVID-19-related deaths amongst patients with cancer. However, we recognise that despite this great challenge, we must continue to provide the highest quality of care to the patients, whereas, at the same time, ensure adequate safety not only for the patients and their families but also for the entire oncology team. We advocate that due to the widespread travel restrictions and inability to refer patients for the highest level of care at this period, centres without radiotherapy facilities as seen in most resource-limited settings should always consider lower level care options such as the use of chemotherapy pending when there is a better access to these facilities. We, therefore, developed this good clinical practice advice to staff of the gynaecological oncology unit in the centre and other resource-constrained settings for the management of patients with gynaecological cancer during the COVID-19 pandemic.

Fast-track- recovery surgery with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively among surgical gynaecological cancer patients: study protocol of an open-labelled, randomised controlled trial

Introduction

There has been growing evidence on the favourable outcomes of fast-track-recovery (FTR) surgery; to expedite recovery, minimise complications, and reduce the length of hospital stay for surgical patients. However, there is lack of evidence on the effectiveness of FTR in surgical gynaecological cancer (GC) patients. Most of the previous studies did not focus on feeding composition in the FTR surgery protocol. This study aims to determine the effectiveness of FTR feeding with a whey-protein-infused carbohydrate-loading drink pre-operatively and early oral feeding post-operatively on post-operative outcomes among surgical GC patients.

Methods/design

This open-labelled, randomised controlled trial (RCT) will randomly allocate patients into intervention and control groups. Ambulated Malaysian aged over 18 years and scheduled for elective surgery for (suspected) GC, will be included in this study. The intervention group will be given whey-protein-infused carbohydrate-loading drinks on the evening before their operation and 3 h before their operation as well as started on early oral feeding 4 h post-operatively. The control group will be fasted overnight pre-operation and only allowed plain water, and return to a normal diet is allowed when bowel sounds return post-operatively. The primary outcomes of study are length of post-operative hospital stay, length of clear-fluid tolerance, solid-food tolerance and bowel function. Additional outcome measures are changes in nutritional status, biochemical profile and functional status. Data will be analysed on an intention-to-treat basis.

Trial registration

ClinicalTrials.gov, ID: NCT03667755. Retrospectively registered on 12 September 2018;

Protocol version: version 3 dated 27 September 2017.

Impact of transversus abdominis plane blocks versus non-steroidal anti-inflammatory on post-operative opioid use in ERAS ovarian cancer surgery

BACKGROUND

Treatment of ovarian cancer often requires extensive surgical resection. The transversus abdominis plane (TAP) block has been utilized in benign gynecologic surgery to decrease post-operative pain and opioid use. We hypothesized that TAP blocks would decrease total opioid use in the first 24 hours and decrease length of stay following staging and cytoreductive surgery for ovarian cancer compared with either no local anesthetic or local wound infiltration alone.

METHODS

All patients undergoing surgery for ovarian cancer from November 2016 to June 2017 were included in this retrospective cohort study. Median opioid use at 24, 48, and 72 hours post-operatively, as well as length of stay, were assessed. Multivariate median regression analysis was performed to adjust for potential confounders: post-operative non-steroidal anti-inflammatory drug (NSAID) usage, pre-operative opioid consumption, and extent of cytoreductive surgery. Length of stay was compared using Cox regression analysis.

RESULTS

One-hundred-and-twenty patients were included in the analysis. Eighty-two patients had a TAP block, while 38 did not. After adjusting for potential confounders there was no difference in median 24 hours opioid consumption (p=0.29) or length of stay (HR 0.95, p=0.78) between patients receiving TAP block compared with those without. After adjusting for potential confounders, patients receiving scheduled NSAIDs had a 2.6-fold greater likelihood of being discharged (p<0.0005) and a significant reduction in median opioid use at 24 hours (23.5 vs 14.5 mg) (p=0.017) compared with those patients without NSAIDs.

DISCUSSION

Post-operative administration of NSAIDs, but not TAP block, was associated with a decrease in post-operative opioid use and length of stay following surgery for ovarian cancer. Further investigation into alternative regional anesthetics for Enhanced Recovery after Surgery (ERAS) protocols is warranted.

The volume of acute normovolemic hemodilution

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A concern about this article is the amount of blood withdrawal during acute normovolemic hemodilution,

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Acute normovolemic hemodilution must be one of the best strategies to prevent perioperative red blood cell transfusion

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Risk of large fluid replacement during acute normovolemic hemodilution should be consider to ensure patients safety.

Opioid Use in the Postoperative Arena: Global Reduction in Opioids After Surgery Through Enhanced Recovery and Gynecologic Surgery

Enhanced recovery programs aim to reduce surgical stress to improve the patient perioperative experience. Through a combination of multimodal analgesia and maintaining a physiological state, postoperative recovery is improved. Many analgesic adjuncts are available that improve postoperative pain control and limit opioid analgesia requirements. Adjuncts are often used in combination, but different interventions may be incorporated for patient-specific and procedure-specific needs. Postoperative pain control can be optimized by continuing nonopioid adjuncts, and prescribing opioid analgesia to address breakthrough pain. Prescribing practices should balance optimizing pain relief, minimizing the risk of chronic pain, while limiting the potential for opioid misuse.

Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

INTRODUCTION

Enhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes.

METHODS

Retrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification.

RESULTS

A total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I-V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001).

CONCLUSIONS

Compliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

Less Is More: Minimally Invasive and Quality Surgical Management of Gynecologic Cancer

Surgery is a cornerstone of gynecologic oncology. Minimally invasive techniques have been adopted rapidly, in lieu of open approaches, in cervical and endometrial cancer staging. In addition, nodal assessment has undergone significant changes with the introduction of SLN biopsies. The movement toward less is more has also been seen with perioperative and postoperative care and the advent of ERAS protocols, which attempt to maintain normal physiology with the goal of improving functional recovery. It is imperative that new technology be critically evaluated to ensure that oncologic outcomes are not compromised.

Clinical pathways of recovery after surgery for advanced ovarian/tubal/peritoneal cancer: an NSGO-MaNGO international survey in collaboration with AGO-a focus on surgical aspects

OBJECTIVES

This survey assessed the implementation of enhanced recovery after surgery (ERAS) for patients undergoing surgery for advanced ovarian cancer in three European cooperative study groups in Scandinavia, Italy, and Austria. The aim was to evaluate the landscape for future trials on ERAS pathways in ovarian cancer, because high-level evidence for such interventions is lacking.

METHODS

In July 2017, a web-based questionnaire (SurveyMonkey Inc, Palo Alto, CA, USA) was sent to centers conducting surgery for advanced ovarian cancer within the Nordic Society of Gynecologic Oncology (NSGO), Mario Negri Gynecologic Oncology Group (MaNGO) and other Italian institutions, and the Association for Gynecologic Oncology Austria (AGO Austria) (n = 100). The survey covered all aspects of an ERAS pathway including surgery, nursing, and anesthesia. We herein report on the survey findings relating to surgery, including nursing care issues; however, anesthesiologic issues will be discussed in a separate report.

RESULTS

The overall response rate was 62%. Only a third of the centers in Italy and Austria follow a written ERAS protocol compared with 60% of the Scandinavian centers. Only a minority of centers have completely abandoned bowel preparation, with the highest proportion in Scandinavia (36%). Two hours of fasting for fluids before surgery is routinely practiced in Scandinavia and Austria (67-57%, respectively), but not in Italy (5%). Carbohydrate loading is routinely administered only in Scandinavia (67%). Peritoneal drainage is used by 22% routinely and by 61% in cases of bowel resection/lymphadenectomy/peritonectomy. Early feeding with a light diet on day 0 or 1 is the standard of care in Scandinavia and Austria, but not in Italy.

CONCLUSIONS

The degree of implementation of ERAS protocols varies across and within cooperative groups. The centralization of ovarian cancer care seems to facilitate standardization of peri-operative protocols. Currently, the high heterogeneity in patterns of care may challenge an international approach to a clinical trial.