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

Impact of the Enhanced Recovery After Surgery Program on Outcomes After Cardiac Surgery: One-Year Results

BACKGROUND

To evaluate the clinical impact of enhanced recovery after surgery (ERAS) protocols implementation in the cardiac surgery department at Lausanne University Hospital (CHUV) comparing outcomes between a prospective ERAS cohort and a retrospective cohort from 2019.

PATIENTS AND METHODS

A prospective cohort of 228 patients undergoing elective cardiac surgery with ERAS protocols between May 2023 and August 2024 was compared to a retrospective cohort of 162 patients from 2019. Inclusion criteria included on-pump adult elective cardiac surgery patients via median sternotomy. Propensity score matching was applied based on six variables: age, sex, EuroSCORE II, type of surgery, previous cardiac surgery, and cardiopulmonary by-pass duration, resulting in two matched groups of 125 patients each.

RESULTS

After matching, the ERAS group showed a significant reduction in median hospital length of stay from 11.0 to 9.0 days (p = 0.002). The proportion of patients free from any of the defined complications increased in the ERAS group from 43.2% to 61.7% (p = 0.006), indicating an overall reduction in postoperative morbidity. ERAS implementation independently increased odds of being complication-free (OR 2.88 and p < 0.001). Opioid use on postoperative day 2 decreased from 9.90 to 3.30 morphine milligram equivalents (MME) (p < 0.001) and mobilization rates on postoperative day 1 improved from 65.3% to 81.4% (p = 0.048).

CONCLUSIONS

ERAS protocols implementation in cardiac surgery at CHUV resulted in reduced hospital length of stay, decreased opioid use, improved early mobilization, and a lower overall complication rate. These findings demonstrate the effectiveness of adapting international ERAS guidelines to local practices in cardiac surgery.

Impact of enhanced recovery after surgery programs in the return to adjuvant chemotherapy in patients with advanced ovarian cancer

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.

Interventions to support caregivers of older adults undergoing surgery: A systematic review

INTRODUCTION

Increasing numbers of caregivers provide support to older adults after surgery, which is associated with stress and negative impacts on their health. Our review questions were: METHODS: The databases searched included PubMed, OVID MEDLINE, OVID PsycINFO, EBSCO CINAHL, OVID EMBASE, Web of Science Core Collection, Wiley Cochrane CENTRAL on February 14, 2024. Studies eligible for inclusion were randomized controlled trial (RCT) or quasi-experimental design with control groups, published in English, Dutch, German, French and Persian, included any unpaid caregiver, and the intervention must include a component specifically designed to meet the caregivers' needs.

RESULTS

in total 27,845 were screened and 45 full texts were reviewed. Seven RCTs, two pilot RCTS, and four quasi RCTs were included. Only five interventions had any positive impact and included self-management, telehealth, education and a family-centered care model.

CONCLUSION

Few effective interventions were identified and more engagement with caregivers may identify interventions that better target the caregivers' needs.

PROSPERO REGISTRATION NUMBER

CRD42024519637.

Effect of Enhanced Recovery After Surgery compliance on postoperative venous thromboembolism

BACKGROUND

Implementing Enhanced Recovery After Surgery (ERAS) guidelines has been demonstrated to reduce complications; however, it is unknown if ERAS may influence incidence of postoperative venous thromboembolism, a particularly challenging complication. The objective of this study was to examine the association between ERAS compliance and venous thromboembolism across multiple surgery types.

METHODS

This retrospective cohort study included adult patients undergoing one of seven ERAS-guided surgeries between 2017 and 2021 at nine hospitals in Alberta, Canada, that implemented ERAS guidelines. The exposure was overall ERAS compliance (categorized as low, moderate, high) and compliance with each ERAS element. The primary outcome was venous thromboembolism within 30 days of surgery. Secondary outcomes included 30-day hospital readmission, emergency department visits and healthcare costs.

RESULTS

Of the 8118 included patients, most had colorectal (52.8%) and gynaecologic (26.1%) surgery. There were 118 (1.5%) patients who experienced a postoperative venous thromboembolism. ERAS compliance was associated with developing a venous thromboembolism; each unit increase in the ERAS compliance score was associated with a 23% decrease in the occurrence of venous thromboembolism. More patients with venous thromboembolism had low (11.0%) or moderate (44.1%) overall ERAS compliance compared with those with no venous thromboembolism (5.6% and 34.5% respectively, P = 0.001). Using logistic regression analysis, the overall ERAS compliance score and American Society of Anesthesiologists class remained significant risk factors for developing a venous thromboembolism.

CONCLUSIONS

ERAS compliance was associated with decreased odds of postoperative venous thromboembolism across multiple surgical disciplines, highlighting the importance of improving ERAS compliance to decrease postoperative venous thromboembolism.

Effectiveness of Enhanced Recovery After Surgery protocol in pancreatic surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The Enhanced Recovery After Surgery (ERAS) protocol represents an advancement in perioperative care to reduce surgical stress and accelerate recovery. This meta-analysis aimed to evaluate the effectiveness of ERAS in pancreatic surgery and to assess the effect of the ERAS protocol vs conventional hospital care on postoperative outcomes, including length of stay (LOS) in the hospital, hospital costs, readmission rates, and infection rates in patients undergoing pancreatic surgery.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane Central Register of Controlled Trials, and Embase were searched to identify relevant RCTs. Data were extracted and analyzed using a random effects model. Statistical analyses were performed using RStudio.

RESULTS

A total of 7 RCTs involving 731 patients were included. The meta-analysis showed a statistically significant reduction in LOS by 2.49 days (mean difference, -2.49; 95% CI, -4.20 to -0.79; P <.01) with considerable heterogeneity (I2 = 86%). Hospital costs were significantly reduced (standardized mean difference, -0.36; 95% CI, -0.65 to -0.06; P =.02) with moderate heterogeneity (I2 = 52%). The readmission and infection rates showed no statistically significant differences between the ERAS and control groups. The Egger test indicated no significant publication bias.

CONCLUSION

The ERAS protocol significantly reduced LOS and hospital costs in patients who underwent pancreatic surgery. Our findings support the implementation of ERAS protocols to enhance recovery and optimize outcomes. To the best of our knowledge, our study is the first to demonstrate these results using an RCT-only meta-analysis approach in pancreatic surgery, highlighting the value of ERAS in improving perioperative care.

Wound Infiltration With Local Anesthetics Versus Transversus Abdominis Plane Block for Postoperative Pain Management in Gynecological Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Postoperative pain management significantly influences recovery speed, hospital stay duration, and healthcare costs. In light of inconsistencies in clinical trial outcomes, we conducted a systematic review and meta-analysis to assess the efficacy of the Transversus Abdominis Plane (TAP) block compared to local anesthetic wound infiltration (WI) for postoperative pain management in gynecological surgery.

DATA SOURCES

Systematic searches were conducted across PubMed/MEDLINE, ScienceDirect, the Cochrane Library, and Web of Science databases to identify all randomized controlled trials comparing TAP block and WI in adult patients undergoing gynecological surgical procedures. Additionally, the reference lists of the identified studies were manually reviewed. Only studies published in English were eligible for inclusion in the analysis.

METHODS OF STUDY SELECTION

The Population, Intervention, Comparison, and Outcome framework for the review included: (1) adult patients who underwent gynecological surgical procedures; (2) postoperative TAP block as the intervention; (3) comparison with local anesthetic WI; (4) primary outcome: postoperative pain at 1, 4, 12, and 24 hours; secondary outcomes: postoperative opioid consumption, opioid-related side effects, and patient satisfaction. STATA software, version 18 (Stata Corp, College Station, TX, USA), was used for the analysis.

TABULATION, INTEGRATION, AND RESULTS

A total of 213 papers were initially identified. Of these, 10 randomized controlled trials encompassing a total of 604 patients met the inclusion criteria. The meta-analysis studying minimally invasive surgery showed that TAP block was associated with lower pain scores at rest and 1, 4, 12, and 24 hours compared to the WI group. Furthermore, the TAP block resulted in a reduction in opioid consumption at 24 hours, although there was no significant difference in opioid-related adverse effects. Two studies presented data on patient-reported satisfaction, and a pooled analysis was not feasible due to heterogeneity.

CONCLUSION

TAP block seems to provide better postoperative pain control after laparoscopic gynecologic procedures and reduces opioid use compared to WI in gynecologic surgery.

All Wales Ovarian Cancer Prehabilitation Project (AWOCPP)

Over 50% of patients with ovarian cancer are diagnosed with advanced disease (stage 3+) in Wales when treatment typically involves chemotherapy, combined with cytoreductive surgery. Postoperative morbidity is common resulting in prolonged hospital stays and delays in returning to chemotherapy. Patients with advanced ovarian cancer commonly have modifiable risk factors that can be targeted for improvement with personalised prehabilitation. Multimodal personalised prehabilitation has been shown to have a positive impact on perioperative outcomes and length of stay (LOS).Quality improvement methods were used to implement a multimodal prehabilitation programme for all patients with advanced ovarian cancer planned for surgery in Wales. A unique approach to determining an individual patient's modifiable risk factors was devised that enabled a personalised prehabilitation programme to be created including exercise, smoking cessation, medical and nutritional optimisation and emotional support. Data were collected to enable future health economic evaluation of the programme in anticipation of national role out as standard of care. To evaluate if the prehabilitation intervention was impacting the quality of care, the following outcome measures were assessed: LOS, postoperative complications and surgery to chemotherapy interval (SCI). These measures were compared with a historical Welsh data set from 2018 to 2019 when access to prehabilitation was not available.Following the implementation of prehabilitation for ovarian cancer, the median LOS reduced from 6 to 5 days (p=0.29). There was a reduction in postoperative complications: from 16.9% to 12.7% (Grade 2), 4.4% to 1.8% (Grade 3), 0.6% to 0% (Grade 4+5). The median SCI following prehabilitation was 43.5 days (range 27-91) compared with 40 days (range 15-182 (p=0.65)).Prehabilitation has had a positive impact on the treatment pathways for advanced ovarian cancer in Wales. Means of improving patient engagement and establishing cost-effective delivery need to be developed to make this intervention standard of care.

Pre-operative impact of multimodal prehabilitation in gynecologic oncology patients

OBJECTIVE

Multimodal prehabilitation is a multi-disciplinary program that includes exercise, nutrition, and psychological intervention before surgery to improve pre-operative functional capacity. This study aims to assess the impact of a prehabilitation program on the pre-operative functional status of gynecologic oncology patients.

METHODS

This single-center, prospective observational study included all consecutive patients diagnosed with gynecologic cancer who were scheduled for surgery and enrolled in a structured prehabilitation program from January 2018 to May 2024. Only patients with both baseline and pre-operative evaluations were included. Functional status data were compared before (baseline) and after (pre-operative) the prehabilitation intervention. The primary outcome measured was functional capacity, as determined by the 6-minute walk test (6MWT). Secondary outcomes included hand grip strength, the Malnutrition Universal Screening Tool (MUST) score, and the Hospital Anxiety and Depression Scale score. The type of training and adherence were also evaluated.

RESULTS

A total of 77 patients underwent both baseline and pre-operative evaluation at the prehabilitation unit. The median duration of the program was 25.2 days (range; 9-63). Significant pre-operative improvements were observed in 6MWT (baseline: 435.7 m, standard deviation [SD] = 115.9 vs pre-operative: 455.7 m, SD = 118.9, p < .001), hand grip strength (baseline: 19.0 kg, SD = 5.5 vs pre-operative: 20.4 kg, SD = 5.9, p = .012), MUST score (baseline MUST ≥2 in 14.3% patients vs pre-operative 3.9%, p = .03), and Hospital Anxiety and Depression Scale score (baseline anxiety score: 7.4, SD = 4.3 vs pre-operative: 6.3, SD = 3.6, p < .001; and baseline depression score: 5.5, SD = 4.2 vs pre-operative: 4.3, SD = 3.6, p < .001). Among the different training programs, patients participating in supervised CrossFit training showed greater improvement in the 6MWT (33.4 m), compared to the hospital-supervised group (27.1 m), and the non-supervised home training group (14.0 m).

CONCLUSIONS

A structured multimodal prehabilitation program improves pre-operative functional capacity in gynecologic oncology patients, with the greatest improvements seen in those who participated in supervised high-intensity training, such as CrossFit.

Determination of Comfort Levels and Spiritual Care Needs of Gynecologic Cancer Patients with Abdominal Drains: A Cross-Sectional Descriptive Study in Turkey

This study was conducted to determine the comfort levels and spiritual care needs of gynecologic cancer patients with abdominal drains. The study was conducted with 61 gynecologic cancer patients with abdominal drains at the gynecologic oncology surgery clinic of a state hospital in Turkey. Data were collected using the "Participant Information Form," "Perianesthesia Comfort Questionnaire (PCQ)", and "Spiritual Care Needs Inventory". Kolmogorov-Smirnov test and Mann-Whitney U test were used to analyze the data. It was found that the postoperative comfort of the patients in this study was above a moderate level. Patients who did not need spiritual care, did not fulfil religious rituals regularly and did not receive social support had a high level of comfort in the early postoperative period. Patients with gynecologic cancer were found to have high spiritual care needs. Patients without chronic diseases, possessing a single abdominal drain, familiar with the concept of spiritual care, expressing a need for spiritual care, engaging in regular religious rituals, and enjoying social support were identified as having elevated spiritual care needs. Within the framework of holistic nursing care provided to gynecologic cancer patients with abdominal drains, the results reveal the necessity of spiritual care and the importance of comfort.

2024 critical review of the patient blood management (PBM) recommendations of the Spanish enhanced recovery after major surgery (via RICA)

The Spanish enhanced recovery in adult surgery strategy, the "RICA pathway", was published in 2021 and includes 19 specific recommendations and more than 20 indirect recommendations for patient blood management (PBM). After reviewing these recommendations, and in the context of the new clinical evidence available, we propose the following updates: First: Detection and treatment of any preoperative anemia status in ALL patients who are candidates for major surgery with hematinic deficiencies. Second: Universal use of tranexamic acid in major surgery, bedside monitoring of intraoperative hemoglobin levels, restrictive transfusion criteria, and monitoring of patient well-being in terms of hydration, coagulability, normothermia and analgesia. Third: Restrictive transfusion criteria, single-unit blood transfusion and diagnosis/treatment of postoperative anemia. Real, universal implementation and integration of PBM in the RICA program is urgently needed.

Enhanced recovery pathway in adult patients with spinal deformity undergoing open thoracolumbar surgery

PURPOSE

The poor prognosis of adult patients with spinal deformity following long-segment spinal fusion surgery remains a major concern. Our study aims to investigate the impact of an Enhanced Recovery After Surgery (ERAS) protocol on the prognosis of adult patients with spinal deformity.

METHODS

This study focused on a retrospective review of a database of previous adult spinal deformity. Adult patients with spinal deformity who underwent long-segment fusion surgery from July 2016 to July 2022 were evaluated, from July 2016 to July 2019 for the pre-ERAS patient group and from July 2019 to July 2022 for the ERAS group. Demographic data, radiological sagittal parameters, and intraoperative data were collected from all patients. The length of hospital stay, postoperative complications, and 90-day readmission rates were compared between the two groups. Additionally, multivariate regression models were used to analyze the predictors of postoperative length of stay, postoperative complications, and 90-day readmission rates.

RESULTS

A total of 215 patients were included in this study, 102 patients in the pre-ERAS group and 113 patients in the ERAS group. Postoperative outcomes in the ERAS group included significantly lower postoperative length of stay (LOS) (13.09 ± 4.57 vs. 11.13 ± 4.16, P = 0.001); significantly lower rate of postoperative complications (52.0% vs. 29.2%, P < 0.001) and significantly lower 90-day readmission rates (14.7% vs. 6.19%, P = 0.040). Multivariate linear regression showed that fewer ERAS (P = 0.022), later drain placement (P = 0.027), and more complications (P = 0.002) were significantly associated with longer postoperative LOS. Multivariate logistic regression showed that fewer ERAS (P = 0.015) and later drain removal (P = 0.041) were significantly associated with more complications, and more ERAS (P = 0.009), earlier postoperative LOS (P = 0.020), and earlier urinary catheter removal (P = 0.034) were significantly associated with the 90-day readmission rates.

CONCLUSIONS

According to the results of our study, it is necessary to implement an ERAS protocol for adult patients with spinal deformity undergoing long-segment fusion surgery. The ERAS protocol is effective in reducing postoperative hospital length of stay, incidence of surgical complications, and 90-day readmission rates.

Implementation of enhanced recovery protocol did not increase rates of acute kidney injury in open gynecologic oncology surgery: A single-institution experience

OBJECTIVE

To compare the incidence of acute kidney injury (AKI) among patients undergoing gynecologic surgery before and after implementing an Enhanced Recovery After Surgery (ERAS) pathway.

METHODS

We conducted a retrospective review of medical records from Mayo Clinic during three time periods when ERAS was used, focusing on patients who underwent open gynecologic surgery. AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) criteria. We used inverse-probability of treatment weighting (IPTW) to adjust for baseline covariates between pre-ERAS (135 patients) and post-ERAS (486 patients) cohorts. Statistical comparisons were made using t-test, Wilcoxon rank-sum, chi-square or Fisher's exact test, and univariate logistic regression with odds ratio (OR) and 95 % confidence interval (CI).

RESULTS

Pre-IPTW, the AKI incidence was similar between cohorts (10.4 % vs 8.4 %, p = 0.48), and the odds of AKI for post-ERAS patients compared to pre-ERAS was not significant (OR 0.80, 95 % CI 0.42-1.51). After IPTW-adjustment, the AKI incidence remained comparable (10.3 % vs 8.1 %, p = 0.41), with the odds ratio unchanged (OR 0.76, 95 % CI 0.40-1.45). AKI patients were older (mean 67.0 vs 62.4 years, p < 0.01), had higher ASA scores (61.8 % vs 45.2 %, p = 0.02), lower preoperative hemoglobin (median 10.8 vs 12.5 g/dL, p < 0.01), longer surgeries (median 331 vs 222 min, p < 0.01), greater intraoperative blood loss (median 800 vs 500 mL, p < 0.01), more transfusions (56.4 % vs 29.3 %, p < 0.01), and higher fluid volumes (median 5750 vs 4165 mL, p < 0.01).

CONCLUSION

The ERAS pathway did not significantly impact AKI incidence in gynecologic surgery patients. AKI remains associated with increased postoperative complications, highlighting the need for improved risk prediction and preventive strategies.

Comparison of the Efficacy of Indwelling Gastric Tubes in Preoperative and Postoperative Patients With Oral and Maxillofacial Malignancies

PURPOSE

To explore the optimal plan for the timing of indwelling gastric tube placement in oral and maxillofacial malignant tumor patients.

DESIGN

A prospective randomized controlled trial.

METHODS

80 patients with oral and maxillofacial tumor were selected, and 40 patients were Pre-operative group. The remaining 40 patients were the control group, called Postoperative group. The body weight and hospital stay of the two groups were observed before and after surgery. Blood samples were taken before surgery and 1, 3 and 7 days after surgery to detect hemoglobin and plasma albumin.

FINDINGS

The number of postoperative hospitalization days in the pre-operative group was significantly lower than that in the post-operative group; postoperative hemoglobin and plasma albumins were lower in both groups compared with the preoperative level.

CONCLUSIONS

Preoperative nasogastric tube ensured early postoperative administration of gastrointestinal nutrition, promoted postoperative plasma albumin recovery, and shortened the days of hospitalization.

Implementation of enhanced recovery protocols in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for metastatic ovarian cancer following neoadjuvant chemotherapy. A feasibility study

Objective

The aim of this study is to evaluate the implementation of the elements of enhanced recovery (ERAS) protocols in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for metastatic ovarian cancer. ERAS protocols have shown improvement in the perioperative outcomes of patients who underwent cytoreductive surgery for metastatic ovarian cancer by reducing the length of stay as well as the postoperative complications and by improving patients' postoperative experience.

Methods

This is a feasibility study involving retrospective analysis from (31) patients who underwent cytoreductive surgery and HIPEC versus (35) a control group that underwent cytoreductive surgery only, prior to the introduction of the HIPEC programme for metastatic ovarian cancer. All patients had undergone neoadjuvant chemotherapy prior to surgery. We compared the compliance for each element of the ERAS protocol between the two study groups.

Results

We analyzed data from 66 patients, 31 in HIPEC group and 35 in the control goup. We found no significant difference in the patients' characteristics between the two groups and there were no differences in the implementation of 8 elements of the ERAS protocols (100 % for both groups). The use of nasogastric tube was more frequently observed in patients undergoing surgery and HIPEC compared to those undergoing surgery alone (42 % vs 0 %, respectively; p < 0.001). The number of patients who were mobilized on the first postoperative day was higher in the group undergoing surgery and HIPEC (87.1 % vs 57.1 %, respectively; p = 0.007), however there was no significant difference in the percentage of patients that had early removal of the urinary catheter (p = 0.12), nor in the percentage of patients that received early feeding (p = 0.18). Finally, there were no statistically significant differences in the complication rates, the length of hospital stay and the re-admission rates between the two groups.

Conclusion

Enhanced recovery protocols can be implemented safely in patients undergoing cytoreductive surgery and HIPEC for ovarian cancer.

Optimizing prehabilitation in gynecologic malignancies: Improving acceptance, overcoming barriers, and managing program complexity

Prehabilitation aims to improve patients' physical condition before a stressful event, such as surgery, and enhance recovery. Despite its potential benefits, many emerging prehabilitation programs face challenges in enrolling or retaining patients. In our prehabilitation study PHOCUS, which aims to prepare ovarian cancer patients for surgery, we have also encountered lower acceptance and retention rates. Particularly the most vulnerable patients, who are old and frail, and may benefit the most from the prehabilitation, decline participation due to the complexity of the proposed program. In our review we discussed obstacles and barriers that prevent patients' participation based on both literature and our experience. Among the main reasons are patient's low motivation, high intensity of the program and a lack of social support. To overcome these challenges, we suggest increasing the program's flexibility, adapting the program according to individual patient's needs and enhancing patients' education about the benefits of prehabilitation.

Defining optimal perioperative analgesia in patients undergoing laparotomy for advanced gynecologic malignancy: A randomized controlled trial

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways utilize multimodal analgesia. In pathways already utilizing incisional injection of liposomal bupivacaine (ILB), we assessed the benefit of adding intrathecal opioid analgesia (ITA).

METHODS

In this randomized controlled non-inferiority trial in patients undergoing laparotomy for gynecologic malignancy, we allocated patients 1:1 to ILB alone versus ITA + ILB with 150 μg intrathecal hydromorphone. The primary endpoint was the Overall Benefit of Analgesia Score (OBAS) at 24 h following surgery. Secondary endpoints included pain scores, intravenous opioid use, and cost of care.

RESULTS

Demographic and surgical factors were balanced for 105 patients. For the primary endpoint, ILB alone was non-inferior to ITA + ILB (median OBAS at 24 h of 4 vs 4; p = 0.70). We observed a significant reduction in the need for intravenous opioids (26% vs 71%; p < 0.001) and total opioid requirements (median 7.5 vs 39.3 mg morphine equivalents, p < 0.001) in the first 24 h. Clinically relevant improvements in pain scores were identified in the first 16 h after surgery favoring ITA + ILB. Total cost of the index episode, pharmacy costs, and costs at 30 days were not statistically different.

CONCLUSIONS

Using OBAS as the primary endpoint, ILB alone was non-inferior to ITA + ILB. However, important cost-neutral benefits for ITA + ILB in the first 24 h post-operatively included lower pain scores and reduced need for intravenous opioids. These early, incremental benefits of adding ITA to ERAS bundles already utilizing ILB should be considered to optimize immediate post-operative pain.

Enhanced recovery after fetal spina bifida surgery: global practice

OBJECTIVES

Enhanced recovery after surgery (ERAS) protocols are multimodal evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aimed to explore whether worldwide fetal therapy centers offering prenatal myelomeningocele repair implement the ERAS principles and to provide recommendations for improved perioperative management of patients.

METHODS

In this survey study, a total of 53 fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for Cesarean section, gynecological oncology and colorectal surgery. Each item was awarded a score of 1 or 0, depending, respectively, on whether the center did or did not comply with that principle, with a maximum score of 20.

RESULTS

The questionnaire was completed by 46 centers in 17 countries (response rate, 87%). In total, 22 (48%) centers performed exclusively open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offered both open and fetoscopic procedures and 10 (22%) used only fetoscopy. The perioperative management of patients undergoing fetoscopic and open surgery was very similar. The median ERAS score was 12 (range, 8-17), with a mean ± SD of 12.5 ± 2.4. Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%) and thromboprophylaxis (96%), while the lowest compliance was observed for preoperative carbohydrate loading (15%), a 2-h fasting period for clear fluids (20%), postoperative nausea and vomiting prevention (33%) and early feeding (35%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥ 11 days) hospital stay (mean ± SD, 12.9 ± 2.4, 12.1 ± 2.0 and 10.3 ± 3.2, respectively, P = 0.15). Furthermore, there was no significant association between ERAS score and surgical technique or case volume.

CONCLUSIONS

The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardized protocols integrating ERAS principles may improve patient recovery, reduce maternal morbidity and shorten the hospital stay after fetal spina bifida surgery. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Reducing Opioid Consumption and Length of Stay After Bariatric Surgery: A Nonpharmacologic ERAS Intervention Bundle

PURPOSE

To reduce opioid consumption and decrease length of stay (LOS) in bariatric surgical patients by implementing an evidence-based, nonpharmacologic enhanced recovery after surgery (ERAS) intervention bundle.

DESIGN

Evidence-based practice project.

METHODS

We developed and implemented a nonpharmacologic ERAS bundle from existing American Society of PeriAnesthesia Nurses Standards and bariatric and subspecialty surgical ERAS protocols to standardize the postoperative nursing care of bariatric patients. The bundle consisted of early ambulation, immediate initiation and prolonged use of oxygenation, prevention of nausea and vomiting, frequent use of incentive spirometry, and application of ice packs to surgical sites. The two project outcomes were opioid consumption and patient LOS. We used descriptive statistics to summarize opioid consumption and LOS among surgical bariatric patients at baseline and post intervention and independent samples t tests to determine the statistical significance of pre- or post-LOS changes.

FINDINGS

After implementing the ERAS bundle in 31 bariatric surgical patients, we found that the percentage of patients given an opioid substantially decreased by 13.8%, with both fentanyl and hydromorphone (Dilaudid) consumption meaningfully decreasing by 11.0% and 25.6%, respectively. The average LOS significantly decreased (P = .015) by 23 minutes per patient following the intervention, from 1 hour and 58 minutes to 1 hour and 35 minutes, representing a 19.5% reduction in total patient time in the PACU.

CONCLUSIONS

Use of a nonpharmacologic ERAS bundle and standardizing postoperative care decreased overall PACU bariatric surgical patient opioid consumption and significantly reduced PACU LOS. Optimizing pain management for bariatric patients in the PACU could lead to improved pain control and reduced reliance on opioids during their entire hospital stay, enhancing health care outcomes and improving patient safety. Perioperative leaders and educators can use our example to develop initiatives that decrease opioid use and LOS to improve care for the high-acuity bariatric patient population.

Perioperative outcomes in gynecologic pelvic exenteration before and after implementation of an enhanced recovery after surgery program

OBJECTIVES

To compare perioperative outcomes in patients undergoing pelvic exenteration for gynecologic malignancies before and after implementation of Enhanced Recovery After Surgery (ERAS) protocols.

METHODS

We performed an institutional retrospective cohort study of patients undergoing pelvic exenteration for gynecologic malignancies before (1/1/2006-12/30/2014) and after (1/1/2015-6/30/2023) ERAS implementation. We described ERAS compliance rates. We compared outcomes up to 60 days post-exenteration. Complication grades were defined by the Clavien-Dindo system.

RESULTS

Overall, 105 women underwent pelvic exenteration; 74 (70.4%) in the pre-ERAS and 31 (29.5%) in the ERAS cohorts. There were no differences between cohorts in age, body mass index, race, primary disease site, type of exenteration, urinary diversion, or vaginal reconstruction. All patients had complications, with at least one grade II+ complication in 94.6% of pre-ERAS and 90.3% of ERAS patients. The ERAS cohort had more grade I-II gastrointestinal (61.3% vs 21.6%, p < 0.001) and hematologic (61.3% vs 36.5%, p = 0.030) and grade III-IV renal (29.0% vs 12.2%, p = 0.048) and wound (45.2% vs 18.9%, p = 0.008) complications compared to the pre-ERAS cohort. ERAS patients had a higher rate of ileus (38.7% vs 10.8%, p = 0.002), urinary leak (22.6% vs 5.4%, p = 0.014), pelvic abscess (35.5% vs 10.8%, p = 0.005), postoperative bleeding requiring intervention (61.3% vs 28.4%, p = 0.002), and readmission (71.4% vs 46.5%, p = 0.025). Median ERAS compliance was 60%.

CONCLUSIONS

Pelvic exenteration remains a morbid procedure, and complications were more common in ERAS compared to pre-ERAS cohorts. ERAS protocols should be optimized and tailored to the complexity of pelvic exenteration compared to standard gynecologic oncology ERAS pathways.

Enhanced recovery after surgery (ERAS) guided gynecologic/oncology surgery - The patient's perspective

Objective

Enhanced recovery after surgery (ERAS) pathways have demonstrated improvements in outcomes following benign gynecologic and gynecologic oncology surgery. However, there is limited data reporting the benefit of ERAS from the patient's perspective. This study aimed to explore patient knowledge of and experience with ERAS-guided surgery.

Methods

This interpretive descriptive study included participants who had undergone ERAS-guided gynecologic and gynecologic oncology surgery in Alberta, Canada using convenience sampling. Semi-structured interviews explored patient knowledge of ERAS, overall experience with surgery and recommended changes for surgical care. An inductive thematic analysis was conducted.

Results

Eight females aged 26-76 years old participated in the study who had gynecologic (n = 4) and gynecologic oncology (n = 4) surgery. Six themes central to participant experience of ERAS-guided surgery were identified: patient expectations, individual motivation, values and support, healthcare provider communication, trust in healthcare providers, COVID-19 and care co-ordination. Overall, specific knowledge of ERAS was low. Expectations were set by previous experience of healthcare (previous surgery or occupation), as well as information provided by healthcare professionals. Participants whose expectations aligned with physical experience of ERAS provided favourable perspectives. Participants recommended improving the quality, relevance and availability of information and establishing accessible follow up strategies.

Conclusion

Based on the finding that knowledge about ERAS was minimal, we advocate for improved education pertaining to ERAS recommendations. Acknowledging patients' expertise and motivation to engage in their care maybe one strategy to improve compliance with ERAS guidelines and improve outcomes for both patients and the healthcare system.

Perioperative liberal drinking management promotes postoperative gastrointestinal function recovery after gynecological laparoscopic surgery: A randomized controlled trial

STUDY OBJECTIVE

This study aims to evaluate the effect of perioperative liberal drinking management, including preoperative carbohydrate loading (PCL) given 2 h before surgery and early oral feeding (EOF) at 6 h postoperatively, in enhancing postoperative gastrointestinal function and improving outcomes in gynecologic patients. The hypotheses are that the perioperative liberal drinking management accelerates the recovery of gastrointestinal function, enhances dietary tolerance throughout hospitalization, and ultimately reduces the length of hospitalization.

DESIGN

A prospective randomized controlled trial.

SETTING

Operating room and gynecological ward in Wuhan Union Hospital.

PATIENTS

We enrolled 210 patients undergoing elective gynecological laparoscopic surgery, and 157 patients were included in the final analysis.

INTERVENTIONS

Patients were randomly allocated in a 1:1:1 ratio into three groups, including the control, PCL, and PCL-EOF groups. The anesthetists and follow-up staff were blinded to group assignment.

MEASUREMENTS

The primary outcome was the postoperative Intake, Feeling nauseated, Emesis, Examination, and Duration of symptoms (I-FEED) score (range 0 to 14, higher scores worse). Secondary outcomes included the incidence of I-FEED scores >2, and other additional indicators to monitor postoperative gastrointestinal function, including time to first flatus, time to first defecation, time to feces Bristol grade 3-4, and time to tolerate diet. Additionally, we collected other ERAS recovery indicators, including the incidence of PONV, complications, postoperative pain score, satisfaction score, and the quality of postoperative functional recovery at discharge.

MAIN RESULTS

The PCL-EOF exhibited significantly enhanced gastrointestinal function recovery compared to control group and PCL group (p < 0.05), with the lower I-FEED score (PCL: 0[0,1] vs. PCL-EOF: 0[0,0] vs. control: 1[0,2]) and the reduced incidence of I-FEED >2 (PCL:8% vs. PCL-EOF: 2% vs. control:21%). Compared to the control, the intervention of PCL-EOF protected patients from the incidence of I-FEED score > 2 [HR:0.09, 95%CI (0.01-0.72), p = 0.023], and was beneficial in promoting the patient's postoperative first flatus [PCL-EOF: HR:3.33, 95%CI (2.14-5.19),p < 0.001], first defecation [PCL-EOF: HR:2.76, 95%CI (1.83-4.16), p < 0.001], Bristol feces grade 3-4 [PCL-EOF: HR:3.65, 95%CI (2.36-5.63), p < 0.001], first fluid diet[PCL-EOF: HR:2.76, 95%CI (1.83-4.16), p < 0.001], and first normal diet[PCL-EOF: HR:6.63, 95%CI (4.18-10.50), p < 0.001]. Also, the length of postoperative hospital stay (PCL-EOF: 5d vs. PCL: 6d and control: 6d, p < 0.001), the total cost (PCL-EOF: 25052 ± 3650y vs. PCL: 27914 ± 4684y and control: 26799 ± 4775y, p = 0.005), and postoperative VAS pain score values [POD0 (PCL-EOF: 2 vs. control: 4 vs. PCL: 4, p < 0.001), POD1 (PCL-EOF: 1 vs. control: 3 vs. PCL: 2, p < 0.001), POD2 (PCL-EOF: 1 vs. control:2 vs. PCL: 1, p < 0.001), POD3 (PCL-EOF: 0 vs. control: 1 vs. PCL: 1, p < 0.001)] were significantly reduced in PCL-EOF group.

CONCLUSIONS

Our primary endpoint, I-FEED score demonstrated significant reduction with perioperative liberal drinking, serving as a protective intervention against I-FEED>2. Gastrointestinal recovery metrics, such as time to first flatus and defecation, also showed substantial improvements. Furthermore, the intervention enhanced postoperative dietary tolerance and expedited early recovery.

TRIAL REGISTRATION

ChiCTR2300071047(https://www.chictr.org.cn/).

Hospital-level variation in costs of elective nonruptured abdominal aortic aneurysm repair

BACKGROUND

With the aging population in the United States, the incidence of abdominal aortic aneurysms is shifting to older ages. Given changing demographic characteristics and increasing health care expenditures, the present study evaluated the degree of center-level variation in the cost of elective abdominal aortic aneurysm repair.

METHODS

We identified all adult (≥18 years) hospitalizations for elective repair of nonruptured abdominal aortic aneurysms in the 2017 to 2020 Nationwide Readmissions Database. Hierarchical mixed-effects models were used to rank hospitals based on risk-adjusted costs. The interclass coefficient was used to calculate the amount of variation attributable to hospital-level characteristics. High-cost hospitals were classified as centers in the top decile of costs. The association of high-cost hospitals status with outcomes of interest was examined.

RESULTS

An estimated 62,626 patients underwent abdominal aortic aneurysm repair, and 5,011 (8.0%) were managed at high-cost hospitals. Compared with non-high-cost hospitals, high-cost hospitals were more commonly large (52.6% vs 48.3%) metropolitan (78.3% vs 66.9%) teaching centers (all P < .001). The interclass coefficient found that 28% of the observed variation in cost is attributable to hospital factors. After adjustment, high-cost hospitals were associated with increased odds of gastrointestinal (adjusted odds ratio = 1.42; 95% CI, 1.05-1.90) and infectious (adjusted odds ratio = 1.35; 95% CI, 1.14-1.59) complications. Finally, the Elixhauser index (β = +$2,700/unit; 95% CI, $2,500-$3,000) and open repair (β = +$4,100; 95% CI, $3,100-$5,200) were associated with increased costs.

CONCLUSION

We observed significant variation in cost attributable to center-level differences. Our findings have implications for reimbursement paradigms and the establishment of quality and cost benchmarks in the elective repair of abdominal aortic aneurysm.

Enhanced recovery after surgery (ERAS) implementation in cytoreductive surgery (CRS) and hyperthermic IntraPEritoneal chemotherapy (HIPEC): Insights from Italian peritoneal surface malignancies expert centers

BACKGROUND

Cytoreductive surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a complex procedure that involves extensive peritoneal and visceral resections followed by intraperitoneal chemotherapy. The Enhanced Recovery After Surgery (ERAS) program aims to achieve faster recovery by maintaining pre-operative organ function and reducing the stress response following surgery. A recent publication introduced dedicated ERAS guidelines for CRS and HIPEC with the aim of extending the benefits to patients with peritoneal surface malignancies.

METHODS

A survey was conducted among 21 Italian centers specializing in peritoneal surface malignancies (PSM) treatment to assess adherence to ERAS guidelines. The survey covered pre/intraoperative and postoperative ERAS items and explored attitudes towards ERAS implementation.

RESULTS

All centers completed the survey, demonstrating expertise in PSM treatment. However, less than 30 % of centers adopted ERAS protocols despite being aware of dedicated guidelines. Preoperative optimization was common, with variations in bowel preparation methods and fasting periods. Intraoperative normothermia control was consistent, but fluid management practices varied. Postoperative practices, including routine abdominal drain placement and NGT management, varied greatly among centers. The majority of respondents expressed an intention to implement ERAS, citing concerns about feasibility and organizational challenges.

CONCLUSIONS

The study concludes that Italian centers specialized in PSM treatment have limited adoption of ERAS protocols for CRS ± HIPEC, despite being aware of guidelines. The variability in practice highlights the need for standardized approaches and further evaluation of ERAS applicability in this complex surgical setting to optimize patient care.

Oncology Intensive Care Units: Distinguishing Features and Clinical Considerations

The rapidly advancing field of cancer therapeutics has led to increased longevity among cancer patients as well as increasing complexity of cancer-related illness and associated comorbid conditions. As a result, institutions and organizations that specialize in the in-patient care of cancer patients have similarly evolved to meet the constantly changing needs of this unique patient population. Within these institutions, the intensive care units that specialize in the care of critically ill cancer patients represent an especially unique clinical resource. This article explores some of the defining and distinguishing characteristics associated with oncology ICUs.

Enhanced Recovery After Surgery versus Conventional Care in Cholecystectomy: A Systematic Review and Meta-Analysis

Objectives: The primary objective of this study was to evaluate the safety and efficacy of the enhanced recovery after surgery (ERAS) protocol in cholecystectomy, comparing it with standard care. Methods: A comprehensive literature search was conducted in December 2023, using globally recognized databases such as PubMed, Embase, and the Cochrane Library. Various parameters were compared using Review Manager software. This study was duly registered with PROSPERO (CRD420223). Results: The meta-analysis included nine studies, encompassing a total of 1920 patients. The findings revealed that the ERAS group, in comparison to traditional care, experienced shorter hospitalization periods (weighted mean difference [WMD]: -1.23, 95% confidence interval [CI]: -1.98 to -0.47; P = .001), lower visual analog scale at 24 hours (WMD: -1.10, 95% CI: -1.30 to -0.90; P < .00001), faster time to first flatus (WMD: -4.48, 95% CI: -4.50 to -4.46; P < .00001), and reduced operative times (WMD: -9.94, 95% CI: -17.88 to -0.96; P = .03). In addition, there was a notable decrease in instances of postoperative nausea and vomiting (odds ratio [OR]: 0.46, 95% CI: 0.28 to 0.74; P = .002). No significant differences were observed in readmission rates, blood loss, postoperative complications, or bile leakage between the two care methods. Conclusions: This study substantiates that the ERAS protocol is an advantageous perioperative care strategy for patients undergoing cholecystectomy. It significantly outperforms traditional care in reducing the length of stay, decreasing the likelihood of postoperative nausea/vomiting, alleviating postoperative pain, and accelerating the time to the first flatus. These findings highlight the effectiveness of ERAS in enhancing patient outcomes in cholecystectomy.

Implementing Enhanced Recovery After Surgery for hysterectomy in a hospital network with audit and feedback: A stepped-wedge cluster randomised trial

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.

Enhanced recovery after surgery versus conventional postoperative care in patients undergoing hysterectomy: a systematic review and meta-analysis

PURPOSE

Hysterectomy is a common gynecological surgery associated with significant postoperative discomfort and extended hospital stays. Enhanced recovery after surgery (ERAS), a multidisciplinary approach, has emerged as a strategy aimed at improving perioperative outcomes and promoting faster patient recovery and satisfaction. This meta-analysis aimed to evaluate the impact of ERAS protocols on clinical outcomes, such as hospital stay length, readmission rates, and postoperative complications, in patients undergoing gynecological hysterectomy.

METHODS

Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis were conducted. Databases including PubMed, Embase, and Cochrane library were searched for relevant studies published up to January 31, 2023. A total of seventeen studies were selected based on predefined eligibility and exclusion criteria. Meta-analysis was carried out using a random-effects model with the STATA SE 14.0 software, focusing on outcomes like length of hospital stay, postoperative complications, and readmission rates.

RESULTS

ERAS protocols significantly reduced the length of hospital stays and incidence of postoperative complications such as ileus, without increasing readmission rates or the level of patient-reported pain. Notable heterogeneity was observed among included studies, attributed to the variation in patient populations and the specificity of the documented study protocols.

CONCLUSION

The findings underscore the effectiveness of ERAS protocols in enhancing recovery trajectories in gynecological hysterectomy patients. This reinforces the imperative for broader, standardized adoption of ERAS pathways as an evidence-based approach, fostering a safer and more efficient perioperative care paradigm.

Enhanced Recovery After Surgery Guidelines and Hospital Length of Stay, Readmission, Complications, and Mortality: A Meta-Analysis of Randomized Clinical Trials

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.

Adapting Enhanced Recovery After Surgery (ERAS) Protocols to Promote Equity in Cancer Care and Outcomes

MINI ABSTRACT

Equity-focused evaluations of existing healthcare system-level policies, clinical practices, and interventions are needed to identify factors that may narrow, or unintentionally widen, the racial disparity in cancer outcomes. We focus here on the evaluation of enhanced recovery after surgery (ERAS) protocols and their potential to promote equity in cancer care and outcomes.

Implementation of a surgical site infection prevention bundle in gynecologic oncology patients: An enhanced recovery after surgery initiative

OBJECTIVE

To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway.

METHODS

Patients undergoing laparotomy for a gynecologic oncology surgery between January-June 2017 (pre-SSIPB) and between January 2018-December 2020 (post-SSIPB) were compared using t-tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors.

RESULTS

Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders.

CONCLUSION

Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients.

Clinical Impact of an Enhanced Recovery Program for Lower-extremity Bypass

OBJECTIVE

To determine the association of Enhanced Recovery Program (ERP) implementation with length of stay (LOS) and perioperative outcomes after lower-extremity bypass (LEB).

BACKGROUND

ERPs have been shown to decrease hospital LOS and improve perioperative outcomes, but their impact on patients undergoing vascular surgery remains unknown.

METHODS

Patients undergoing LEB who received or did not receive care under the ERP were included; pre-ERP (January 1, 2016-May 13, 2018) and ERP (May 14, 2018-July 31, 2022). Clinicopathologic characteristics and perioperative outcomes were analyzed.

RESULTS

Of 393 patients who underwent LEB [pre-ERP: n = 161 (41%); ERP: n = 232 (59%)], most were males (n = 254, 64.6%), White (n = 236, 60%), and government-insured (n = 265, 67.4%). Pre-ERP patients had higher Body Mass Index (28.8 ± 6.0 vs 27.4 ± 5.7, P = 0.03) and rates of diabetes (52% vs 36%, P = 0.002). ERP patients had a shorter total [6 (3-13) vs 7 (5-14) days, P = 0.01) and postoperative LOS [5 (3-8) vs 6 (4-8) days, P < 0.001]. Stratified by indication, postoperative LOS was shorter in ERP patients with claudication (3 vs 5 days, P = 0.01), rest pain (5 vs 6 days, P = 0.02), and tissue loss (6 vs 7 days, P = 0.03). ERP patients with rest pain also had a shorter total LOS (6 vs 7 days, P = 0.04) and lower 30-day readmission rates (32%-17%, P = 0.02). After ERP implementation, the average daily oral morphine equivalents decreased [median (interquartile range): 52.5 (26.6-105.0) vs 44.12 (22.2-74.4), P = 0.019], while the rates of direct discharge to home increased (83% vs 69%, P = 0.002).

CONCLUSIONS

This is the largest single-center cohort study evaluating ERP in LEB, showing that ERP implementation is associated with shorter LOS and improved perioperative outcomes.

Sustainability of an enhanced recovery pathway after minimally invasive gynecologic oncology surgery

OBJECTIVE

Same day discharge is safe after minimally invasive gynecology oncology surgery. Our quality improvement peri-operative program based on enhanced recovery after surgery principles led to an increase in same day discharge from 30% to 75% over a 12 month period. Twelve months after program implementation, we assessed the sustainability of same day discharge rates, determined post-operative complication rates, and evaluated factors affecting same day discharge rates.

METHODS

A retrospective chart review was conducted of 100 consecutive patients who underwent minimally invasive surgery at an academic cancer center from January to 2021 to December 2021. This cohort was compared with the active intervention cohort (n=102) from the implementation period (January 2020 to December 2020). Same day discharge rates and complications were compared. Multivariable analysis was performed to assess which factors remained associated with same day discharge post-intervention.

RESULTS

Same day discharge post-intervention was 72% compared with 75% during active intervention (p=0.69). Both cohorts were similar in age (p=0.24) and body mass index (p=0.27), but the post-intervention cohort had longer operative times (p=0.001). There were no significant differences in 30-day complications, readmission, reoperation, or emergency room visits (p>0.05). There was a decrease in 30-day post-operative clinic visits from 18% to 5% in the post-intervention cohort (p=0.007), and unnecessary bowel prep use decreased from 35% to 14% (p<0.001). On multivariable analysis, start time (second case of the day) (OR 0.06; 95% CI 0.01 to 0.35), and ward narcotic use (OR 0.12; 95% CI 0.03 to 0.42) remained associated with overnight admission.

CONCLUSION

Same day discharge rate was sustained at 72%, 12 months after the implementation of a quality improvement program to optimize same day discharge rate after minimally invasive surgery, while maintaining low post-operative complications and reducing unplanned clinic visits. To maximize same day discharge, minimally invasive gynecologic oncology surgery should be prioritized as the first case of the day, and post-operative narcotic use should be limited.

Analgesic efficacy of erector spinae plane block in patients undergoing major gynecologic surgery: A randomized controlled study

STUDY OBJECTIVE

To investigate the analgesic efficacy of erector spinae plane block (ESPB) in major gynecologic surgery, expressed as cumulative opioid consumption 24 h after surgery.

DESIGN

A single-center, patient-assessor blinded, randomized controlled study.

SETTING

Samsung medical center (tertiary university hospital), between February 2022 to January 2023.

PATIENTS

Eighty-eight females undergoing major surgery with long midline incision for gynecologic malignancy.

INTERVENTIONS

Patients were randomly assigned to receive standard systemic analgesia (Control group) or ESPB (ESPB group). ESPB was performed bilaterally at the level of the 9th thoracic vertebra with a mixture of 20 mL of 0.5% ropivacaine and 100 μg of epinephrine.

MEASUREMENTS

The primary outcome was cumulative opioid consumption at 24 h postoperatively. Secondary outcomes included opioid consumption and pain severity during the 72 h after surgery. The variables regarding postoperative recovery and patient-centered outcomes were compared.

MAIN RESULTS

The mean cumulative opioid consumption 24 h after surgery was 35.8 mg in the ESPB group, which was not significantly different from 41.4 mg in the control group (mean difference, 5.5 mg; 95% CI -1.7 to 12.8 mg; P = 0.128). However, patient satisfaction regarding analgesia was significantly higher in the ESPB group compared with the control group at 24 h postoperative (median difference, -1; 95% CI -3 to 0; P = 0.038). There were no significant differences in the variables associated with postoperative recovery.

CONCLUSION

ESPB did not reduce opioid consumption during the 24 h postoperative but attenuated pain intensity during the early period after surgery.

Improving the Rate of Same-Day Discharge in Gynecologic Oncology Patients Undergoing Minimally Invasive Surgery-An Enhanced Recovery After Surgery Quality Improvement Initiative

OBJECTIVES

The objectives of our quality improvement (QI) initiative were (1) to increase the rate of same-day discharge (SDD) in eligible gynecologic oncology (GO) patients to 70% and (2) to evaluate the ease with which QI methods demonstrated in one study could be applied at another center.

DESIGN

A pre-/postintervention design was used (50 patients/group).

SETTING

SDD in patients undergoing minimally invasive GO surgery is a recent trend aligned with Enhanced Recovery After Surgery (ERAS) principles. SDD in GO is safe and feasible based on several recent studies, including a QI initiative in Edmonton, Alberta, which resulted in SDD rates >70%.

PATIENTS

A baseline audit of GO patients at our center (Calgary, Alberta) found the SDD rate to be 14%. Given that Edmonton and our center are within the same province, they have similar patient populations and available resources-suggesting that interventions from the Edmonton QI initiative may be translatable.

INTERVENTIONS

Four interventions were designed to address root causes for failed SDD identified after QI diagnostics: (1) SDD as the default discharge plan, including a "Day Surgery" surgical booking; (2 and 3) development and implementation of ERAS SDD preoperative and postoperative order sets; and (4) patient education SDD-specific documents.

MEASUREMENTS AND MAIN RESULTS

Rate of SDD was measured together with patient demographics and surgical outcomes. Process and balancing measures were defined and tracked. SDD in GO increased from 14% (7 of 50) to 82% (41 of 50) after the implementation of the above-mentioned interventions (odds ratio [OR], 28; p <.001; 95% confidence interval [CI], 9.54-82.11). Improved SDD was achieved without negatively affecting postoperative rates of emergency department visits: 8% pre- and 4% postintervention within 7 days (OR, 0.48; p = .678; 95% CI, 0.09-2.74) and 12% pre- and 10% postintervention within 30 days (OR, 0.8148; p = 1.001; 95% CI, 0.2317-2.86).

CONCLUSION

This ERAS QI initiative resulted in a substantial increase in SDD in GO, without a negative impact on balancing measures. We demonstrate that the "spread" of simple, clearly defined QI interventions across centers (where the patient population is similar) is feasible. This suggests that an ERAS SDD program for GO could be a realistic goal for other centers with similar characteristics.

Impacts of enhanced recovery after surgery nursing interventions on wound infection and complications following bladder cancer surgery: A meta-analysis

A meta-analysis was executed to comprehensively examine the impacts of enhanced recovery after surgery (ERAS) care interventions on complications and wound infections following bladder cancer (BCa) surgery. Computer searches were carried out in Embase, Google Scholar, Cochrane Library, PubMed, Wanfang and CNKI, from their inception to November 2023, for RCTs regarding perioperative ERAS nursing interventions in patients with BCa. Two independent researchers performed literature screening, extracted data and carried out quality evaluations. Stata 17.0 software was utilized for the analysis of the data. Ultimately, 16 RCTs, involving 1190 patients, were included. The analysis showed that, in comparison with conventional nursing methods, perioperative ERAS nursing application in patients with BCa remarkably decreased the occurrence of wound infections (OR: 0.31, 95% CI: 0.16-0.59) and complications (OR: 0.19, 95% CI: 0.13-0.28). Our study indicates that perioperative care based on the ERAS concept remarkably decreased the occurrence of wound infections and complications following BCa surgery, demonstrating notable nursing efficacy and meriting widespread clinical promotion.

Impact of pharmacogenomic profiles on post-surgical pain following laparotomy for gynecologic pathology

OBJECTIVES

The aim of this prospective study was to compare perioperative opioid use in women by status of CYP2D6, a highly polymorphic pharmacogene relevant to opioid metabolism.

METHODS

Patients undergoing laparotomy were prospectively recruited and provided a preoperative saliva swab for a pharmacogenomic (PGx) gene panel. Postoperative opioid usage and pain scores were evaluated via chart review and a phone survey. Pharmacogenes known to be relevant to opioid metabolism were genotyped, and opioid metabolizing activity predicted by CYP2D6 genotyping. Patient and procedural factors were compared using Fisher's exact and Kruskal-Wallis tests.

RESULTS

The 96 enrolled patients were classified as ultra-rapid (N = 3, 3%), normal (58, 60%), intermediate (27, 28%), and poor (8, 8%) opioid metabolizers. There was no difference in surgical complexity across CYP2D6 categories (p = 0.61). Morphine Milligram Equivalents (MME) consumed during the first 24 h after peri-operative suite exit were significantly different between groups: ultrarapid metabolizers had the highest median MME (75, IQR 45-88) compared to the other three groups (normal metabolizers 23 [8-45], intermediate metabolizers 48 [20-63], poor metabolizers 31 [12-53], p = 0.03). Opioid requirements were clinically greater in ultrarapid metabolizers during the second 24 h and last 24 h but were statistically similar (p = 0.07). There was no difference in MME prescribed at discharge (p = 0.22) or patient satisfaction with pain control (p = 0.64) between groups.

CONCLUSIONS

A positive association existed between increased CYP2D6 activity and in-hospital opioid requirements, especially in the first 24 h after surgery. This provides important information to further individualize opioid prescriptions for patients undergoing laparotomy for gynecologic pathology.

Protocolized care pathways in emergency general surgery: a systematic review and meta-analysis

BACKGROUND

Emergency abdominal surgery is associated with significant postoperative morbidity and mortality. The delivery of standardized pathways in this setting may have the potential to transform clinical care and improve patient outcomes.

METHODS

The OVID SP versions of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were searched between January 1950 and October 2022. All randomized and non-randomized cohort studies comparing protocolized care streams with standard care protocols in adult patients (>18 years old) undergoing major emergency abdominal surgery with 30-day follow-up data were included. Studies were excluded if they reported on standardized care protocols in the trauma or elective setting. Outcomes assessed included length of stay, 30-day postoperative morbidity, 30-day postoperative mortality and 30-day readmission and reoperations rates. Risk of bias was assessed using ROBINS-I for non-randomized studies and RoB-2 for randomized controlled trials. Meta-analysis was performed using random effects modelling.

RESULTS

Seventeen studies including 20 927 patients were identified, with 12 359 patients undergoing protocolized care pathways and 8568 patients undergoing standard care pathways. Thirteen unique protocolized pathways were identified, with a median of eight components (range 6-15), with compliance of 24-100%. Protocolized care pathways were associated with a shorter hospital stay compared to standard care pathways (mean difference -2.47, 95% c.i. -4.01 to -0.93, P = 0.002). Protocolized care pathways had no impact on postoperative mortality (OR 0.87, 95% c.i. 0.41 to 1.87, P = 0.72). A reduction in specific postoperative complications was observed, including postoperative pneumonia (OR 0.42 95% c.i. 0.24 to 0.73, P = 0.002) and surgical site infection (OR 0.34, 95% c.i. 0.21 to 0.55, P < 0.001).

DISCUSSION

Protocolized care pathways in the emergency setting currently lack standardization, with variable components and low compliance; however, despite this they are associated with short-term clinical benefits.

Hospital-level variation in hospitalization costs for spinal fusion in the United States

BACKGROUND

With a growing emphasis on value of care, understanding factors associated with rising healthcare costs is increasingly important. In this national study, we evaluated the degree of center-level variation in the cost of spinal fusion.

METHODS

All adults undergoing elective spinal fusion were identified in the 2016 to 2020 National Inpatient Sample. Multilevel mixed-effect models were used to rank hospitals based on risk-adjusted costs. The interclass coefficient (ICC) was utilized to tabulate the amount of variation attributable to hospital-level characteristics. The association of high cost-hospital (HCH) status with in-hospital mortality, perioperative complications, and overall resource utilization was analyzed. Predictors of increased costs were secondarily explored.

RESULTS

An estimated 1,541,740 patients underwent spinal fusion, and HCH performed an average of 9.5% of annual cases. HCH were more likely to be small (36.8 vs 30.5%, p<0.001), rural (10.1 vs 8.8%, p<0.001), and located in the Western geographic region (49.9 vs 16.7%, p<0.001). The ICC demonstrated 32% of variation in cost was attributable to the hospital, independent of patient-level characteristics. Patients who received a spinal fusion at a HCH faced similar odds of mortality (0.74 [0.48-1.15], p = 0.18) and perioperative complications (1.04 [0.93-1.16], p = 0.52), but increased odds of non-home discharge (1.30 [1.17-1.45], p<0.001) and prolonged length of stay (β 0.34 [0.26-0.42] days, p = 0.18). Patient factors such as gender, race, and income quartile significantly impacted costs.

CONCLUSION

The present analysis identified 32% of the observed variation to be attributable to hospital-level characteristics. HCH status was not associated with increased mortality or perioperative complications.

Enhanced Recovery after Surgery (ERAS) Implementation and Barriers among Healthcare Providers in France: A Cross-Sectional Study

The implementation of Enhanced Recovery After Surgery (ERAS) is a challenge for healthcare systems, especially in case of patients undergoing major surgery. Despite a proven significant reduction in postoperative complications and hospital lengths of stay, ERAS protocols are inconsistently used in real-world practice, and barriers have been poorly described in a cohort comprising medical and paramedical professionals. This study aims to assess the proportion of French healthcare providers who practiced ERAS and to identify barriers to its implementation amongst those surveyed. We conducted a prospective cross-sectional study to survey healthcare providers about their practice of ERAS using an online questionnaire. Healthcare providers were contacted through hospital requests, private hospital group requests, professional corporation requests, social networks, and personal contacts. The questionnaire was also designed to explore barriers to ERAS implementation. Identified barriers were allocated by two independent assessors to one of the fourteen domains of the Theoretical Domains Framework (TDF), which is an integrative framework based on behavior change theories that can be used to identify issues relating to evidence on the implementation of best practice in healthcare settings. One hundred and fifty-three French healthcare providers answered the online questionnaire (76% female, median age 35 years (IQR: 29 to 48)). Physiotherapists, nurses, and dieticians were the most represented professions (31.4%, 24.2%, and, 14.4%, respectively). Amongst those surveyed, thirty-one practiced ERAS (20.3%, 95%CI: 13.9 to 26.63). Major barriers to ERAS practice were related to the "Environmental context and resources" domain (57.6%, 95%CI: 49.5-65.4), e.g., lack of professionals, funding, and coordination, and the "Knowledge" domain (52.8%, 95%CI: 44.7-60.8), e.g., ERAS unawareness. ERAS in major surgery is seldom practiced in France due to the unfavorable environment (i.e., logistics issues, and lack of professionals and funding) and a low rate of procedure awareness. Future studies should focus on devising and assessing strategies (e.g., education and training, collaboration, institutional support, the development of healthcare networks, and leveraging telehealth and technology) to overcome these barriers, thereby promoting the wider implementation of ERAS.

[Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]

BACKGROUND

Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals.

METHODS

Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay.

RESULTS

Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ.

CONCLUSION

Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.

Exploring perioperative risk factors for poor recovery of postoperative gastrointestinal function following gynecological surgery: A retrospective cohort study

Purpose

To investigate perioperative risk factors that affect the recovery of postoperative gastrointestinal function in patients undergoing gynecological surgery and to establish a preoperative risk prediction scoring system.

Methods

In this retrospective cohort study, characteristics and perioperative factors of patients who underwent elective gynecological surgery at Union Hospital from January 2021 to March 2022 were extracted from electronic medical records. Patients were grouped according to the Intake, Feeling nauseated, Emesis, physical Exam, and Duration of symptoms (I-FEED) scoring system to compare collected data.

Results

In total, clinical data from 208 gynecological patients were extracted. The incidence of poor postoperative gastrointestinal recovery was 7.21 %. The number of previous abdominal surgeries (0.73 ± 0.06 vs 1.20 ± 0.24, p = 0.044), the incidence of malignant disease (20.2 % vs 53.3 %, p = 0.003), postoperative maximum WBC count (9.15 vs 12.44, p = 0.005) and postoperative minimum potassium (3.97 ± 0.36 vs 3.76 ± 0.37, p = 0.036) were not only associated with poor postoperative gastrointestinal recovery, but also malignant disease (p = 0.000), postoperative maximum WBC count (p = 0.027) and postoperative minimum potassium (p = 0.024) were significantly associated with the severity of postoperative gastrointestinal function. An increased number of previous abdominal surgeries and malignant primary disease could increase the risk of an I-FEED score >2 as independent risk factors.

Conclusion

Patients with poor postoperative GI function had poorer postoperative recovery outcomes. A preoperative score prediction system was established, in which patients with ≥2 points had a 19.4 % risk of poor postoperative gastrointestinal recovery. Higher-quality prospective studies should be performed to achieve more precise risk stratification and to construct a more accurate prediction system.

Reduced length of intensive care unit stay and early mechanical ventilator weaning with enhanced recovery after surgery (ERAS) in free fibula flap surgery

This study aimed to evaluate the effects of the enhanced recovery after surgery (ERAS) program on postoperative recovery of patients who underwent free fibula flap surgery for mandibular reconstruction. This retrospective study included 188 patients who underwent free fibula flap surgery for complex mandibular and soft tissue defects between January 2011 and December 2022. We divided them into two groups: the ERAS group, consisting of 36 patients who were treated according to the ERAS program introduced from 2021 to 2022. Propensity score matching was used for the non-ERAS group, which comprised 36 cases selected from 152 patients between 2011 and 2020, based on age, sex, and smoking history. After propensity score matching, the ERAS and non-ERAS groups included 36 patients each. The primary outcome was the length of intensive care unit (ICU) stay; the secondary outcomes were flap complications, unplanned reoperation, 30-day readmission, postoperative ventilator use length, surgical site infections, incidence of delirium within ICU, lower-limb comorbidities, and morbidity parameters. There were no significant differences in the demographic characteristics of the patients. However, the ERAS group showed the lower length of intensive care unit stay (ERAS vs non-ERAS: 8.66 ± 3.90 days vs. 11.64 ± 5.42 days, P = 0.003) and post-operative ventilator use days (ERAS vs non-ERAS: 1.08 ± 0.28 days vs. 2.03 ± 1.05 days, P < 0.001). Other secondary outcomes were not significantly different between the two groups. Additionally, patients in the ERAS group had lower postoperative morbidity parameters, such as postoperative nausea, vomiting, urinary tract infections, and pulmonary complications (P = 0.042). The ERAS program could be beneficial and safe for patients undergoing free fibula flap surgery for mandibular reconstruction, thereby improving their recovery and not increasing flap complications and 30-day readmission.

The efficacy of preoperative low-residue diet on postoperative ileus following cesarean section

OBJECTIVE

To evaluate the efficacy of preoperative low-residue diet on postoperative ileus in women undergoing elective cesarean section (CS).

METHODS

This is a surgeon-blind, randomized controlled trial enrolling pregnant women at ≥39 weeks of gestation undergoing elective CS. Patients were preoperatively randomized to receive either low-residue diet (arm A) or free diet (arm B) starting from three days before surgery. The primary outcome was the postoperative ileus. The secondary outcomes were the postoperative pain (assessed through VAS scale), the quality of the surgical field (scored using a 5-point scale, from poor to excellent), postoperative complications, and the length of hospital stay. Perioperative data were collected and compared between groups.

RESULTS

A total of 166 patients were enrolled and randomized in arm A (n = 83) and arm B (n = 83). Postoperative ileus over 24 h was significantly shorter in arm A, compared to arm B (19.3% vs 36.2%). The surgical evaluation of small intestine was scored ≥3 in 96.4% of arm A patients versus 80.7% in arm B, while evaluation of large intestine, respectively, in 97.7% and 81.9%. Postoperative pain after 12 h from CS was significantly lower in arm A (VAS, 3.4 ± 1.7) compared to arm B (VAS, 4.1 ± 1.8). There were no significant differences as regards postoperative pain at 24 and 48 h, nausea/vomit, surgical complications, and hospital stay.

CONCLUSIONS

Implementation of a preoperative low-residue diet for women scheduled for elective CS would reduce postoperative ileus and pain. Further large-scale studies are required before translating these research findings into routine obstetrical practice.

Efficacy of Enhanced Recovery after Surgery (ERAS) protocol in maxillofacial trauma: A randomized controlled trial

INTRODUCTION

Enhanced Recovery after surgery (ERAS) guidelines have been formulated in the literature for various different specialties but none is present for maxillofacial trauma patients. Hence, we have formulated ERAS protocol for maxillofacial trauma (ERAS-MT) patients and compared with the patients receiving the standard traditional care for post trauma outcomes.

METHODOLOGY

A randomized controlled trial included 74 patients divided into two groups: Group 1 (ERAS group:37 patients) and Group II (Control group:37 patients). ERAS group were intervened according to the formulated ERAS protocol based on the previous literature and the control group received the standard of care. The both groups were compared for various post trauma outcomes.

RESULTS

Baseline demographic data was non-significant between both the groups. There was significant decrease in pre-operative IV fluid use and total number of IV analgesics used till 72 h as well as in the immediate post operative period in the ERAS group(p = 0.001). ERAS group started oral feeds within 6 h and they were significantly compliant for oral carbohydrates in the pre-operative phase(p = 0.001). PONV episodes, swelling and infections were insignificantly less in the ERAS group(p > 0.05), however a significant difference was seen throat pain and decreased anxiety as well as Oral Hygiene Index(p = 0.001). At two weeks, a significant difference was seen in overall patient's satisfaction and cost analysis in the ERAS group (p = 0.001).

CONCLUSION

Our study suggested that ERAS protocol was associated with shorter hospital stay, early recovery with better overall satisfaction of the patients, lesser post-operative complications and significantly decreased cost analysis.

Thoracic epidural analgesia as part of an enhanced recovery program in gynecologic oncology: a prospective cohort study

OBJECTIVE

To evaluate the safety and the effectiveness of thoracic epidural analgesia as part of the enhanced recovery after surgery (ERAS) multimodal analgesic protocol in patients with gynecologic oncology who have undergone laparotomy for suspected or confirmed malignancy.

METHODS

We conducted a prospective cohort study, following an enhanced recovery after surgery pathway, among patients who had undergone laparotomy for confirmed or suspected gynecological malignancy between January 2020 and September 2021. All patients who underwent laparotomy at the gynecologic oncology department for the aforementioned reason during that time were considered eligible. Patients (n=217) were divided into two groups: epidural (n=118) and non-epidural (n=99) group. Both groups were treated with the standard ERAS departmental analgesic protocol. The primary outcomes were length of hospital stay, complications, and readmission rates.

RESULTS

Data from 217 patients (epidural group, n=118 vs non-epidural group, n=99) with median age of 61 years (IQR 53-68) were analyzed. The most common type of cancer was of ovarian origin (85/217, 39.2%, p=0.055) and median (Aletti) surgical complexity score was 3 (p=0.42). No differences were observed in the patients' demographics, clinical, and surgical characteristics. Primarily, median length of stay was 4 days in both groups with statistically significant lower IQR in the epidural group (3-5 vs 4-5, p=0.021). Complication rates were more common in the non-epidural group (38/99, 38.3% vs 36/118, 30.5%, p<0.001) with similar rates of grade III (p=0.51) and IV (0%) complications and readmission rates (p=0.51) between the two groups. Secondarily, the epidural group showed lower pain scores (p<0.001) on the day of surgery and in the first post-operative day (p<0.001), higher mobilization rates on the day of surgery (94.1% vs 57.6%, p<0.001), faster removal of urinary catheter (p<0.001), shorter time to flatus (p<0.001), and less nausea on the day of surgery (p<0.001).

CONCLUSION

In this study we showed that thoracic epidural analgesia, when used as part of an ERAS protocol, is safe and offers more favorable pain relief along with a number of additional benefits, improving the peri-operative experience of patients with gynecologic cancer.

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.

Benefits of the Enhanced Recovery After Surgery (ERAS) Pathway With Quadratus Lumborum Blocks for Minimally Invasive Gynecologic Surgery Patients: A Retrospective Cohort Study

STUDY OBJECTIVE

This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery.

DESIGN AND SETTING

This retrospective cohort study was performed in a tertiary care hospital.

PATIENTS

A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck Hospital of University of Southern California (USC), California, USA, from 2016 to 2020 were included in this study.

INTERVENTIONS

The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared toward a satisfactory, safe, and expeditious discharge.

MEASUREMENTS AND MAIN RESULTS

The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block.

CONCLUSIONS

The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.

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.