1
|
Torosis M, Fullerton M, Kaefer D, Nitti V, Ackerman AL, Grisales T. Pudendal Block at the Time of Transvaginal Prolapse Repair: A Randomized Controlled Trial. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024:02273501-990000000-00214. [PMID: 38640500 DOI: 10.1097/spv.0000000000001448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
IMPORTANCE The utility of pudendal nerve blocks (PNBs) at the time of transvaginal surgery is mixed in the literature. No published study has evaluated the efficacy of PNB since the widespread adoption of Enhanced Recovery After Surgery (ERAS) pathways. OBJECTIVE This study aimed to determine if PNB, in addition to ERAS measures, at the time of vaginal reconstructive surgery reduces opioid use in the immediate postoperative period. STUDY DESIGN In this randomized, blinded, controlled trial, women scheduled for transvaginal multicompartment prolapse repair were randomized to bilateral PNB before incision with 20 mL of 0.5% bupivacaine versus usual care. Primary outcome was opioid use in morphine milligram equivalents (MME) for the first 24 hours. The study was powered to detect a 5.57-MME difference in opioid use in the first 24 hours between groups. RESULTS Forty-four patients were randomized from January 2020 to April 2022. The PNB and control groups were well matched in demographic and surgical data. There was no difference in opioid use in first 24 hours between the control and PNB groups (8 [0-20] vs 6.7 [0-15]; P = 0.8). Median pain scores at 24 and 48 hours did not differ between groups (4 ± 2 vs 3 ± 3; P = 0.44) and 90% of participants were satisfied with pain control across both groups. Time to return to normal activities (median, 10 days) was also not different between the groups. CONCLUSIONS Because pain satisfaction after transvaginal surgery in the era of ERAS is high, with overall low opioid requirements, PNB provides no additional benefit.
Collapse
Affiliation(s)
- Michele Torosis
- From the Department of Obstetrics and Gynecology, UCLA, Los Angeles, CA
| | - Morgan Fullerton
- Department of Obstetrics and Gynecology, Kaiser Permanente, Panorama City, CA
| | | | | | | | - Tamara Grisales
- From the Department of Obstetrics and Gynecology, UCLA, Los Angeles, CA
| |
Collapse
|
2
|
Ranganathan P, Dare A, Harrison EM, Kingham TP, Mutebi M, Parham G, Sullivan R, Pramesh CS. Inequities in global cancer surgery: Challenges and solutions. J Surg Oncol 2024; 129:150-158. [PMID: 38073139 DOI: 10.1002/jso.27551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 12/17/2023]
Abstract
The disparity in access to and quality of surgical cancer care between high and low resource settings impacts immediate and long-term oncological outcomes. With cancer incidence and mortality set to increase rapidly in the next few decades, we examine the factors leading to inequities in global cancer surgery, and look at potential solutions to overcome these challenges.
Collapse
Affiliation(s)
- Priya Ranganathan
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Anna Dare
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ewen M Harrison
- Centre for Medical Informatics, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Miriam Mutebi
- Department of Surgery, Aga Khan University, Nairobi, Kenya
| | - Groesbeck Parham
- Department of Obstetrics and Gynecology, Charles Drew University of Science and Medicine, Los Angeles, California, USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Zambia, Lusaka, Zambia
| | - Richard Sullivan
- School of Cancer Sciences, Centre for Cancer Society and Public Health, Institute of Cancer Policy, King's College London, London, UK
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| |
Collapse
|
3
|
Yang ST, Kuo SC, Liu HH, Huang KM, Liu CH, Chen SF, Wang PH. Early oral diet may enhance recovery from benign gynecologic surgery: A single center prospective study. J Chin Med Assoc 2023; 86:917-922. [PMID: 37603887 DOI: 10.1097/jcma.0000000000000982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Early dietary intake enhanced recovery after surgery (ERAS). There remains a gap in the recognition and implementation of early diet after surgery in medical institutions in Taiwan. This study aimed to investigate whether early oral intake after benign gynecologic surgery results in favorable outcomes in Taiwanese patients. METHODS This was a prospective controlled nonrandomized cohort study. Patients who underwent benign gynecological surgery were included in the early- and conventional-diet groups. The primary outcome was length of hospital stay, and the secondary outcome was postoperative complications. RESULTS Forty and 38 patients were included in the early and conventional-diet groups, respectively. The early-diet group demonstrated significantly reduced length of hospital stay (the early-diet group, 2.58 ± 0.93 days; conventional-diet group, 4.16 ± 1.13 days; p < 0.001). No increase in postoperative complications was observed in the early-diet group. Laparoscopic surgery reduced the length of hospital stay (β, -0.65; 95% confidence interval [CI], -1.22 to -0.08; p = 0.027), while an increased length of hospital stay was associated with higher visual analog scales (VAS, β, 0.21; 95% CI, 0.03-0.39; p = 0.026) and the conventional-diet group (β, 1.13; 95% CI, 0.65-1.61; p < 0.001) as assessed by multivariate regression analysis. CONCLUSION Patients who underwent benign gynecologic surgery tolerated an early oral diet well without an increase in complications. Laparoscopic surgery and lower pain scores also enhanced postoperative recovery.
Collapse
Affiliation(s)
- Szu-Ting Yang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shu-Chen Kuo
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Hung-Hsien Liu
- Department of Medical Imaging and Intervention, Tucheng Hospital, New Taipei City, Taiwan, ROC
| | - Kuan-Min Huang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chia-Hao Liu
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Shu-Fen Chen
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Female Cancer Foundation, Taipei, Taiwan, ROC
| |
Collapse
|
4
|
Nelson G. Enhanced Recovery in Gynecologic Oncology Surgery-State of the Science. Curr Oncol Rep 2023; 25:1097-1104. [PMID: 37490193 DOI: 10.1007/s11912-023-01442-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 07/26/2023]
Abstract
PURPOSEOF REVIEW The purpose of this review is to describe the state of the science of enhanced recovery after surgery (ERAS) in gynecologic oncology. RECENT FINDINGS Over the last 5 years, there is mounting evidence supporting ERAS in gynecologic oncology surgery. Despite this, surveys have found suboptimal uptake of ERAS, and stakeholders have highlighted the difficulty of ERAS implementation as a major barrier. To address this, the core components required for a successful ERAS implementation program (protocol, ERAS team, audit system) are reviewed. ERAS developments specific to gynecologic oncology are also discussed, including same-day discharge initiatives for minimally invasive surgery, implications of telemedicine, and methods to increase uptake of ERAS in low- and middle-income countries. ERAS is a surgical quality improvement program with strong evidence supporting its effectiveness in gynecologic oncology. Efforts are required to address ERAS implementation barriers to increase uptake globally, especially in low-income settings.
Collapse
Affiliation(s)
- Gregg Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, 1331 29 St NW, Calgary, Alberta, T2N 4N2, Canada.
| |
Collapse
|
5
|
Taiym D, Cowan M, Nakamura B, Azad H, Strohl A, Barber E. Effect of continuous post-operative lidocaine infusion in an enhanced recovery program on opioid use following gynecologic oncology surgery. J Gynecol Oncol 2023; 34:e61. [PMID: 37232055 PMCID: PMC10482581 DOI: 10.3802/jgo.2023.34.e61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/16/2023] [Accepted: 04/16/2023] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVE To determine the effectiveness of implementing an Enhanced Recovery After Surgery (ERAS) program, including continuous intraoperative and postoperative intravenous (IV) lidocaine infusion, on perioperative opioid use. METHODS This was a single-institution retrospective pre- post- cohort study. Consecutive patients undergoing planned laparotomy for known or potential gynecologic malignancy were identified after implementation of an ERAS program and compared to a historical cohort. Opioid use was calculated as morphine milligram equivalents (MMEs). Cohorts were compared using bivariate tests. RESULTS A total of 215 patients were included in the final analysis, 101 patients received surgery before ERAS implementation and 114 received surgery after. A reduction in total opioid use was observed in ERAS patients compared with historical controls (MME 26.5 [9.6-60.8] versus 194.5 [123.8-266.8], p<0.001). Length of stay (LOS) was reduced by 25% in the ERAS cohort (median 3 days, range 2-26, versus 4 days, range 2-18; p<0.001). Within the ERAS cohort, 64.9% received IV lidocaine for the planned 48 hours, and 5.6% had the infusion discontinued early. Within the ERAS cohort, patients who received IV lidocaine infusion used less opioids compared to those who did not (median 16.9, range 5.6-55.1, versus 46.2, range 23.2-76.1; p<0.002). CONCLUSION An ERAS program including a continuous IV lidocaine infusion as the opioid-sparing analgesic strategy was noted to be safe and effective, leading to decreased opioid consumption and LOS compared with a historic cohort. Additionally, lidocaine infusion was noted to decrease opioid consumption even among patients already receiving other ERAS interventions.
Collapse
Affiliation(s)
- Deanna Taiym
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Matthew Cowan
- Albert Einstein College of Medicine, Division of Gynecologic Oncology, Montefiore Medical Center, Department of Obstetrics and Gynecology and Women's Health, Bronx, NY, USA
| | - Brad Nakamura
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
| | - Hooman Azad
- Department of Obstetrics and Gynecology, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Anna Strohl
- Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cleveland, OH, USA
| | - Emma Barber
- Northwestern University, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Chicago, IL, USA
- Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
- Surgical Outcomes and Quality Improvement Center, Institute for Public Health in Medicine, Chicago, IL, USA.
| |
Collapse
|
6
|
Lindemann K, Kleppe A, Eyjólfsdóttir B, Heimisdottir Danbolt S, Wang YY, Heli-Haugestøl AG, Walcott SL, Mjåland O, Navestad GA, Hermanrud S, Juul-Hansen KE, Kongsgaard U. Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer. Int J Gynecol Cancer 2023; 33:1279-1286. [PMID: 37451690 PMCID: PMC10423533 DOI: 10.1136/ijgc-2023-004355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/18/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts. METHODS Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed. RESULTS Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS. CONCLUSIONS ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.
Collapse
Affiliation(s)
- Kristina Lindemann
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Andreas Kleppe
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | | | | | - Yun Yong Wang
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Sara L Walcott
- Department of Clinical Service, Oslo University Hospital, Oslo, Norway
| | - Odd Mjåland
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
| | - Gerd-Anita Navestad
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Silje Hermanrud
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Knut Erling Juul-Hansen
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
| | - Ulf Kongsgaard
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
| |
Collapse
|
7
|
Palm KM, Abrams MK, Sears SB, Wherley SD, Alfahmy AM, Kamumbu SA, Wang NC, Mahajan ST, El-Nashar SA, Henderson JW, Hijaz AK, Mangel JM, Pollard RR, Rhodes SP, Sheyn D, Roberts K. Opioid use following pelvic reconstructive surgery: a predictive calculator. Int Urogynecol J 2023; 34:1725-1742. [PMID: 36708404 DOI: 10.1007/s00192-022-05428-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 11/11/2022] [Indexed: 01/29/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption greater than the median. METHODS This was a prospective cohort study of 18- to 89-year-old women undergoing major urogynecological surgery between 1 November2020 and 15 October 2021. Subjects completed one preoperative questionnaire ("questionnaire 1") that surveyed factors expected to influence postoperative pain and opioid use. At approximately 1 and 2 weeks following surgery, patients completed two additional questionnaires ("questionnaire 2" and "questionnaire 3") about their pain scores and opioid use. Risk factors for opioid use greater than the median were assessed. Finally, a calculator was created to predict the amount of opioid used at 1 week following surgery. RESULTS One hundred and ninety patients were included. The median amount of milligram morphine equivalents prescribed was 100 (IQR 100-120), whereas the median amount used by questionnaire 2 was 15 (IQR 0-50) and by questionnaire 3 was 20 (IQR 0-75). On multivariate logistic regression, longer operative time (aOR 1.64 per hour of operative time, 95% CI 1.07-2.58) was associated with using greater than the median opioid consumption at the time of questionnaire 2; whereas for questionnaire 3, a diagnosis of fibromyalgia (aOR=16.9, 95% CI 2.24-362.9) was associated. A preliminary calculator was created using the information collected through questionnaires and chart review. CONCLUSIONS Patients undergoing surgery for pelvic floor disorders use far fewer opioids than they are prescribed.
Collapse
Affiliation(s)
- Kasey M Palm
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Megan K Abrams
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sarah B Sears
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Susan D Wherley
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Anood M Alfahmy
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stacy A Kamumbu
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Naomi C Wang
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Sangeeta T Mahajan
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sherif A El-Nashar
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Joseph W Henderson
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Adonis K Hijaz
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey M Mangel
- Division of Female Pelvic Medicine and Reconstructive Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Robert R Pollard
- Division of Female Pelvic Medicine and Reconstructive Surgery, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Stephen P Rhodes
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - David Sheyn
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Kasey Roberts
- Division of Female Pelvic Medicine and Reconstructive Surgery, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| |
Collapse
|
8
|
Ljungqvist O. Gynecologic oncology surgery - Ready for the next step in ERAS. Gynecol Oncol 2023; 173:A1-A2. [PMID: 37258003 DOI: 10.1016/j.ygyno.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Olle Ljungqvist
- School of Medical Sciences, Dept of Surgery, Örebro University, Örebro, Sweden.
| |
Collapse
|
9
|
Nelson G, Dowdy SC. Surgeon-administered transversus abdominis plane block in gynecologic surgery-is it time to tap out? Am J Obstet Gynecol 2023; 228:491-493. [PMID: 36967370 DOI: 10.1016/j.ajog.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 05/01/2023]
Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, University of Calgary, Calgary, Alberta, Canada.
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN
| |
Collapse
|
10
|
Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges. METHODS Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.
Collapse
Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| |
Collapse
|
11
|
de Boer HD, Scott MJ, Fawcett WJ. Anaesthesia role in enhanced recovery after surgery: a revolution in care outcomes. Curr Opin Anaesthesiol 2023; 36:202-207. [PMID: 36745085 DOI: 10.1097/aco.0000000000001248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Enhanced recovery after surgery (ERAS) has revolutionized care outcomes. The purpose of this review is to provide an overview of how ERAS changed healthcare outcomes. RECENT FINDINGS Development of multidisciplinary evidence-based ERAS guidelines for specific surgical specialties and systematic implementation of these guidelines resulted in improved healthcare outcomes, reduction in length of stay, reduction in complications and improved survival. The value of audit of the outcomes is essential for implementation and to improve healthcare. Healthcare economics analysis related to the implementation of ERAS showed significant cost savings up to a return to investment ratio of more than seven. SUMMARY ERAS has revolutionized healthcare by developing evidence-based ERAS guidelines and systematic implementation of these guidelines. Audit of outcomes is essential, not only to improve healthcare but also to significantly save healthcare expenditures.
Collapse
Affiliation(s)
- Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
| | - Michael J Scott
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital, Guildford, UK
| |
Collapse
|
12
|
Fernandez S, Trombert-Paviot B, Raia-Barjat T, Chauleur C. Impact of Enhanced Recovery After Surgery (ERAS) program in gynecologic oncology and patient satisfaction. J Gynecol Obstet Hum Reprod 2023; 52:102528. [PMID: 36608803 DOI: 10.1016/j.jogoh.2022.102528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The primary objective of this study was to compare lengths of stay since ERAS program implementation. We also evaluated ERAS protocol compliance, compared the outpatient rate, the complication rate and the readmission rate within 30 days after surgery and performed a satisfaction study. METHODS This is a monocentric comparative study with a historical control group, performed in the gynecological surgery department of the University Hospital of Saint-Etienne. We compared a group of patients who underwent surgery in 2016, before the implementation of ERAS program, with a group of patients who underwent surgery from July 2021 to July 2022, for whom ERAS program was applied. RESULTS 187 patients were included in this study, including 84 patients in the historical group before ERAS and 103 in the group with ERAS. Considering all approaches, the average length of stay decreased by 2 days (p<0.0001). Considering minimally invasive surgery, the outpatient rate increased from 5% to 50% (p<0.0001) and complication rate decreased from 23 to 11% (p = 0,04). The readmissions rate was similar. Satisfaction score for patients managed with ERAS program was 8.9/10. CONCLUSION The implementation of ERAS program in gynecological oncology surgery allowed a reduction in length of stay, with a high outpatient rate, decreasing complications in case of minimally invasive surgery, without increasing the readmission rate, and was associated with good patient satisfaction.
Collapse
Affiliation(s)
- Sara Fernandez
- University Jean Monnet, Department of Gynecologic and Obstetrics, Hôpital Nord, University Hospital of Saint-Etienne, Avenue Albert Raimond, Saint-Priest-en-Jarez 42270, France
| | - Béatrice Trombert-Paviot
- University Jean Monnet, Department of Public Health, University Hospital of Saint-Etienne, France; INSERM, U 1059, Saint-Étienne 42023, France
| | - Tiphaine Raia-Barjat
- University Jean Monnet, Department of Gynecologic and Obstetrics, Hôpital Nord, University Hospital of Saint-Etienne, Avenue Albert Raimond, Saint-Priest-en-Jarez 42270, France; INSERM, U 1059, Saint-Étienne 42023, France
| | - Céline Chauleur
- University Jean Monnet, Department of Gynecologic and Obstetrics, Hôpital Nord, University Hospital of Saint-Etienne, Avenue Albert Raimond, Saint-Priest-en-Jarez 42270, France; INSERM, U 1059, Saint-Étienne 42023, France.
| |
Collapse
|
13
|
Amer A, Scuffell C, Dowen F, Wilson CH, Manas DM. A national survey on enhanced recovery for renal transplant recipients: current practices and trends in the UK. Ann R Coll Surg Engl 2023; 105:166-172. [PMID: 35446720 PMCID: PMC9889185 DOI: 10.1308/rcsann.2021.0365] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2021] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Enhanced recovery after surgery (ERAS) is well established in many specialties but has not been widely adopted in renal transplantation. The aim of this survey was to understand current national practices and sentiment concerning ERAS for renal transplant recipients in the UK. METHODOLOGY A national web-based survey was sent to consultant surgeons at all 23 UK adult renal transplant units. Completed questionnaires were collected between May and July 2020. Data were analysed according to individual responses and grouped according to the existence of formal ERAS pathways within units. RESULTS All transplant units were represented in this survey. Three units had a formal ERAS pathway for all recipients. Of the remaining units, 65.9% considered implementing an ERAS pathway in the near future. The most commonly perceived barrier to ERAS implementation was 'embedded culture within transplant units' (54.8% of respondents). A fifth of respondents insert surgical drains selectively and 11.7% routinely discontinue patient-controlled analgesia on postoperative day 1. Most respondents routinely remove urinary catheters on day 5 (70%) and ureteric stents 4-6 weeks post-transplantation (81.7%). Median length of stay for deceased donor kidney transplant recipients was lower in units with ERAS programmes (5-7 days versus 8-10 days, respectively). The main cited barriers for discharge were 'suboptimal fluid balance' and 'requirement of treatment for rejection'. CONCLUSIONS Despite slow uptake of ERAS in kidney transplantation, appetite appears to be increasing, particularly in the post-COVID-19 era. The current practice and opinions of transplant specialists highlighted in this survey may help to establish nationally agreed ERAS guidelines in this field.
Collapse
|
14
|
Gómez-Hidalgo NR, Pletnev A, Razumova Z, Bizzarri N, Selcuk I, Theofanakis C, Zalewski K, Nikolova T, Lanner M, Kacperczyk-Bartnik J, El Hajj H, Perez-Benavente A, Nelson G, Gil-Moreno A, Fotopoulou C, Sanchez-Iglesias JL. European Enhanced Recovery After Surgery (ERAS) gynecologic oncology survey: Status of ERAS protocol implementation across Europe. Int J Gynaecol Obstet 2023; 160:306-312. [PMID: 35929452 DOI: 10.1002/ijgo.14386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 07/19/2022] [Accepted: 07/28/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To acquire a comprehensive assessment of the current status of implementation of Enhanced Recovery After Surgery (ERAS) protocols across Europe. METHODS The survey was launched by The European Network of Young Gynecologic Oncologists (ENYGO). A 45-item survey was disseminated online through the European Society of Gynecological Oncology (ESGO) Network database. RESULTS A total of 116 ESGO centers participated in the survey between December 2020 and June 2021. Overall, 80 (70%) centers reported that ERAS was implemented at their institution: 63% reported a length of stay (LOS) for advanced ovarian cancer surgery between 5 and 7 days; 57 (81%) centers reported a LOS between 2 and 4 days in patients who underwent an early-stage gynecologic cancer surgery. The ERAS items with high reported compliance (>75% "normally-always") included deep vein thrombosis prophylaxis (89%), antibiotic prophylaxis (79%), prevention of hypothermia (55%), and early mobilization (55%). The ERAS items that were poorly adhered to (less than 50%) included early removal of urinary catheter (33%), and avoidance of drains (25%). CONCLUSION This survey shows broad implementation of ERAS protocols across Europe; however, a wide variation in adherence to the various ERAS protocol items was reported.
Collapse
Affiliation(s)
- Natalia R Gómez-Hidalgo
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
| | - Andrei Pletnev
- Department of Gynecology and Obstetrics, University of Zielona, Góra, Poland
| | - Zoia Razumova
- Department of Women's and Children's Health, Division of Neonatology, Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A Gemelli (IRCCS), Rome, Italy
| | - Ilker Selcuk
- Gynaecological Oncology, Maternity Hospital, Ankara City Hospital, Ankara, Turkey
| | | | - Kamil Zalewski
- Gynecological Oncology, Świętokrzyskie Cancer Center, Kielce, Poland
| | - Tanja Nikolova
- Klinikum Mittelbaden, Academic Teaching Hospital of Heidelberg University, Baden-Baden, Germany
| | - Maximilian Lanner
- Department of Obstetrics and Gynecology, Kardinal Schwarzenberg Klinikum, Schwarzach im Pongau, Austria
| | | | - Houssein El Hajj
- Department of Surgical Oncology, Oscar Lambret Cancer Center, Lille, France
| | - Assumpció Perez-Benavente
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Antonio Gil-Moreno
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Madrid, Spain
| | - Christina Fotopoulou
- West London Gynecological Cancer Centre; Hammersmith Hospital, Imperial College, London, UK
| | - Jose Luis Sanchez-Iglesias
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
| |
Collapse
|
15
|
Sinha R, Verma N, Bana R, Kalidindi N, Sampurna S, Mohanty GS. Intra- and post-operative outcomes in benign gynaecologic surgeries before and after the implementation of enhanced recovery after surgery protocols: A comparison. J Minim Access Surg 2023; 19:112-119. [PMID: 36722536 PMCID: PMC10034813 DOI: 10.4103/jmas.jmas_42_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 01/20/2023] Open
Abstract
Objective To compare intra- and post-operative outcomes in patients undergoing benign gynaecologic surgery before and after the implementation of enhanced recovery after surgery (ERAS) protocols. Introduction ERAS is a multidisciplinary teamwork with the aim to reduce the body's reaction to surgical stress. The key components of ERAS include pre-operative counselling, avoiding prolonged fasting, standardised analgesic and anaesthetic regimes, early mobilisation and early discharge. Materials and Methods Women undergoing hysterectomy and myomectomy were included in the study. The pre-ERAS group had 100 cases and the ERAS group had 104. Demographic data of both the groups were compared. Duration of surgery, amount of blood loss, intra-abdominal drain, oral feed, catheter removal, ambulation, passage of flatus and length of stay were compared. Results The demographic profiles of both the groups were comparable. Time taken to intake of liquids (P < 0.001), solid food (P < 0.001), passage of flatus (P = 0.001), removal of Foley's catheter (P = 0.023), ambulation (P = 0.007), pain score (P = 0.001) and length of stay in hospital (P < 0.001) were statistically significantly shorter in the ERAS group when compared to the pre-ERAS group. A significant difference was seen in the use of intraperitoneal drains in the ERAS group (81% vs. 23.1%), and if used, drains were removed early in the ERAS group (66.66% vs. 28.39%) within 40 h. Both the groups had similar intra- and immediate post-operative complications. Conclusion ERAS helps in reducing length of stay with early feeding and ambulation, leading to early discharge without increase in intra- and post-operative complications in women undergoing benign gynaecological surgeries.
Collapse
Affiliation(s)
- Rooma Sinha
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Neeru Verma
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Rupa Bana
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Nivya Kalidindi
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Sowmya Sampurna
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | | |
Collapse
|
16
|
O'Neill AM, Calpin GG, Norris L, Beirne JP. The impact of enhanced recovery after gynaecological surgery: A systematic review and meta-analysis. Gynecol Oncol 2023; 168:8-16. [PMID: 36356373 DOI: 10.1016/j.ygyno.2022.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery programs have become the gold standard of care in many surgical specialities. OBJECTIVES This updated systematic review and meta-analysis aims to evaluate how an ERAS program can impact outcomes across both benign and oncological gynaecological surgery to inform standard surgical practice. SEARCH STRATEGY An electronic search of the SCOPUS, Embase and PubMed Medline databases was performed for relevant studies assessing the use of ERAS in patients undergoing gynaecological surgery compared with those without ERAS. SELECTION CRITERIA The studies included were all trials using ERAS programs in gynaecological surgery with a clearly outlined protocol which included at least four items from the most recent guidelines and recorded one primary outcome. DATA COLLECTION AND ANALYSIS Meta-analysis was performed on two primary endpoints; post-operative length of stay and readmission rate and one secondary endpoint; rates of ileus. Further subgroup analyses was performed to compare benign and oncological surgeries. MAIN RESULTS Forty studies (7885 patients) were included in the meta-analysis; 15 randomised controlled trials and 25 cohort studies. 21 studies (4333 patients) were included in meta-analyses of length of stay. Patients in the ERAS group (2351 patients) had a shortened length of stay by 1.22 days (95% CI: -1.59 - -0.86, P < 0.00001) compared to those in the control group (1982 patients). Evaluation of 27 studies (6051 patients) in meta-analysis of readmission rate demonstrated a 20% reduction in readmission rate (OR: 0.80, 95% CI: 0.65-0.97). Analysis of our secondary outcome, demonstrated a 47% reduction in rate of ileus compared to the control group. CONCLUSIONS ERAS pathways significantly reduce length of stay without increasing readmission rates or rates of ileus across benign and oncological gynaecological surgery.
Collapse
Affiliation(s)
- Alice M O'Neill
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Gavin G Calpin
- Department of Surgery, University Hospital Galway, Newcastle Road, Galway, Ireland
| | - Lucy Norris
- Department of Obstetrics and Gynaecology, Trinity St. James' Cancer Institute, Trinity Centre for Health Sciences, St. James' Hospital, Dublin 8, Ireland
| | - James P Beirne
- Department of Gynaecological Oncology, Trinity St. James' Cancer Institute, St. James' Hospital, Dublin 8, Ireland
| |
Collapse
|
17
|
Van Christ Manirakiza A, Pfaendler KS. Breast, Ovarian, Uterine, Vaginal, and Vulvar Cancer Care in Low- and Middle-Income Countries. Obstet Gynecol Clin North Am 2022; 49:783-793. [DOI: 10.1016/j.ogc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
18
|
Altman AD, Rozenholc A, Saciragic L, Liu XQ, Nelson G. The Canadian Gynecologic Oncology Peri-operative Management Survey: re-examining Enhanced Recovery After Surgery (ERAS) recommendations. Int J Gynecol Cancer 2022; 32:ijgc-2022-003562. [PMID: 35750353 DOI: 10.1136/ijgc-2022-003562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Enhanced Recovery After Surgery (ERAS) is a global surgery quality improvement program associated with improved clinical outcomes across the spectrum of disciplines, including gynecologic oncology. The objective of this study was to re-survey the practice of ERAS Gynecologic Oncology guidelines across Canada, after the initial guidelines publication (2016), subsequent guidelines update (2019), and Society of Gynecologic Oncology of Canada (GOC) education events. METHODS A survey was created and developed through the GOC Communities of Practice ERAS section and distributed to all members between March and November 2021. The results of this survey were compared with the survey performed in 2015 RESULTS: The initial GOC survey in 2015 included 77/92 active gynecologic oncologists (84%) representing all provinces in Canada. The current updated survey had responses from 59/118 active gynecologic oncologists (51%) also from every province. Compared with the original survey there was a statistically significant improvement in uptake of 10 ERAS recommendations: smoking/alcohol cessation, modern fasting guidelines (allowance of clear fluids and solid food pre-operatively), carbohydrate loading, pre-operative warming, early feeding, post-operative laxative use, avoidance of nasogastric tubes and abdominal drains, foley catheter removal at 6 hours, and active mobilization (all p<0.003). Only two fields (stopping oral contraceptive medications pre-operatively and foley catheter removal post-operative day 1) showed worsening uptake across the two surveys (p<0.01). The ERAS recommendations that did not change in the examined time frame included routine use of mechanical bowel preparation, venous thromboembolism prophylaxis, pre-operative antibiotics, and additional antibiotic dosing for prolonged surgery. CONCLUSIONS This survey demonstrates increased uptake of 10 of the ERAS guideline recommendations among Canadian gynecologic oncology providers. These findings may translate to improvements in clinical outcomes and healthcare system-level benefits including increased hospital capacity and cost savings.
Collapse
Affiliation(s)
- Alon D Altman
- Gynecologic Oncology, University of Manitoba College of Medicine, Winnipeg, Manitoba, Canada
- CancerCareManitoba, Research Institute in Oncology and Hematology, Winnipeg, Manitoba, Canada
| | - Alexandre Rozenholc
- Gynecologic Oncology Service; Obstetrics and Gynecology Service, Hopital de Gatineau, Gatineau, Quebec, Canada
| | - Lana Saciragic
- Gynecologic Oncology, Dalhousie University Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Xiao-Qing Liu
- Biochemistry and Medical Genetics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gregg Nelson
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
19
|
Greggi S, Falcone F, Aletti GD, Cascella M, Bifulco F, Colombo N, Pignata S. Evaluation of perioperative management of advanced ovarian (tubal/peritoneal) cancer patients: a survey from MITO-MaNGO Groups. J Gynecol Oncol 2022; 33:e60. [PMID: 35712972 PMCID: PMC9428297 DOI: 10.3802/jgo.2022.33.e60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/05/2022] [Accepted: 05/21/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The European Society of Gynaecological Oncology (ESGO)-quality indicators (QIs) for advanced ovarian cancer (AOC) have been assessed only by few Italian centers, and data are not available on the proportion of centers reaching the score considered for a satisfactory surgical management. There is great consensus that the Enhanced Recovery After Surgery (ERAS) approach is beneficial, but there is paucity of data concerning its application in AOC. This survey was aimed at gathering detailed information on perioperative management of AOC patients within MITO-MaNGO Groups. METHODS A 66-item questionnaire, covering ESGO-QIs for AOC and ERAS items, was sent to MITO/MaNGO centers reporting to operate >20 AOC/year. RESULTS Thirty/34 questionnaires were analyzed. The median ESGO-QIs score was 31.5, with 50% of centers resulting with a score ≥32 which provides satisfactory surgical management. The rates of concordance with ERAS guidelines were 46.6%, 74.1%, and 60.7%, respectively, for pre-operative, intra-operative, and post-operative items. The proportion of overall agreement was 61.3%, and with strong recommendations was 63.1%. Pre-operative diet, fasting/bowel preparation, correction of anaemia, post-operative feeding and early mobilization were the most controversial. A significant positive correlation was found between ESGO-QIs score and adherence to ERAS recommendations. CONCLUSION This survey reveals a satisfactory surgical management in only half of the centers, and an at least sufficient adherence to ERAS recommendations. Higher the ESGO-QIs score stronger the adherence to ERAS recommendations, underlining the correlations between case volume, appropriate peri-operative management and quality of surgery. The present study is a first step to build a structured platform for harmonization within MITO-MaNGO networks.
Collapse
Affiliation(s)
- Stefano Greggi
- Department of Gynecologic Oncology, Istituto Nazionale Tumori, IRCSS, "Fondazione G. Pascale", Naples, Italy.
| | - Francesca Falcone
- Department of Gynecologic Oncology, Istituto Nazionale Tumori, IRCSS, "Fondazione G. Pascale", Naples, Italy
| | - Giovanni D Aletti
- Department of Gynecologic Surgery, European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Marco Cascella
- Division of Anesthesia and Pain Management, Istituto Nazionale Tumori, IRCSS, "Fondazione G. Pascale", Naples, Italy
| | - Francesca Bifulco
- Division of Anesthesia and Pain Management, Istituto Nazionale Tumori, IRCSS, "Fondazione G. Pascale", Naples, Italy
| | - Nicoletta Colombo
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, Milan, Italy.,University of Milan-Bicocca, Italy
| | - Sandro Pignata
- Department of Urology and Gynecology, Istituto Nazionale Tumori, IRCSS, "Fondazione G. Pascale", Naples, Italy
| |
Collapse
|
20
|
ERAS: An Audit of Existing Practices. J Obstet Gynaecol India 2022; 72:243-249. [DOI: 10.1007/s13224-021-01517-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/09/2021] [Indexed: 11/26/2022] Open
|
21
|
Mechanical and oral antibiotic bowel preparation in ovarian cancer debulking: Are we lowering or just trading surgical complications? Gynecol Oncol 2022; 166:76-84. [PMID: 35589434 DOI: 10.1016/j.ygyno.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/03/2022] [Accepted: 05/08/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To examine postoperative complications associated with preoperative mechanical and oral antibiotic bowel preparation (MOABP) for patients with ovarian cancer who underwent bowel resection at cytoreductive surgery (CRS). METHODS This was a single-institution retrospective study of patients with ovarian cancer undergoing CRS from 01/2011-12/2020 using ICD-10 diagnoses and procedure codes. Patients were stratified by those who underwent bowel resection versus no resection. Bowel resection patients were further stratified by those who underwent MOABP versus no bowel preparation. Patient demographics, tumor data, and perioperative metrics were collected. Unadjusted and adjusted logistic regression evaluated odds of 30-day postoperative complications in patients with bowel resection versus no resection and those with MOABP versus no bowel preparation. RESULTS Of 919 patients identified, 215 (23.3%) required bowel resection, which included 81 (37.7%) who received MOABP. Patient characteristics, co-morbidities, and cancer data were similar between MOABP versus no bowel preparation patients. MOABP patients underwent more interval CRS (34.6% versus 9.0%), more optimal surgical resections (96.3% versus 83.8%), fewer diverting ostomies (13.5% versus 33.5%), and shorter hospital stays (7.1 versus 9.4 days) than no bowel preparation patients. On adjusted analyses, MOABP patients experienced significantly lower odds of deep/organ-space surgical infections and 30-day readmissions but higher odds of unplanned intensive care unit (ICU) admissions and grade 3 or higher cardiac and gastrointestinal complications. CONCLUSIONS Patients who underwent preoperative MOABP prior to ovarian cancer CRS with bowel resection had lower odds or deep/organ-space infections and readmissions, shorter hospital stays, fewer diverting ostomies, and more optimal resections. However, these patients also experienced higher odds of ICU admissions and grade 3 or higher cardiac and gastrointestinal complications. The positive and negative postoperative outcomes in this population should be considered in clinical practice.
Collapse
|
22
|
Piedimonte S, Pond GR, Plante M, Nelson G, Kwon J, Altman A, Feigenberg T, Elit L, Lau S, Sabourin J, Willows K, Aubrey C, Jang JH, Teo-Fortin LA, Cockburn N, Saunders NB, Shamiya S, Helpman L, Vicus D. Comparison of outcomes between abdominal, minimally invasive and combined vaginal-laparoscopic hysterectomy in patients with stage IAI/IA2 cervical cancer: 4C (Canadian Cervical Cancer Collaborative) study. Gynecol Oncol 2022; 166:230-235. [DOI: 10.1016/j.ygyno.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/06/2022] [Accepted: 05/10/2022] [Indexed: 12/01/2022]
|
23
|
Chiewhatpong P, Charoenkwan K, Smithiseth K, Lapisatepun W, Lapisatepun P, Phimphilai M, Muangmool T, Cheewakriangkrai C, Suprasert P, Srisomboon J. Effectiveness of enhanced recovery after surgery protocol in open gynecologic oncology surgery: A randomized controlled trial. Int J Gynaecol Obstet 2022; 159:568-576. [PMID: 35396709 DOI: 10.1002/ijgo.14211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/22/2022] [Accepted: 04/04/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the effectiveness of applying the recommended enhanced recovery after surgery (ERAS) protocol compared with our usual care in women with gynecologic malignancy undergoing elective laparotomy. METHODS From June 2020 to May 2021, 93 women with gynecologic cancers (cervix, endometrium, and ovary) undergoing elective laparotomy at our institution were randomly assigned into an intervention group (ERAS protocol, 46 women) or control group (usual care, 47 women). For the intervention group, each woman was brought through the pre-specified ERAS protocol starting from preoperative counseling to postoperative management. For the control group, participants underwent routine standard care. The primary outcomes were length of hospital stay and postoperative pain. RESULTS The intervention group demonstrated shorter hospital stay by 20 h (47.48 h vs 67.17 h, P = 0.02) with lower postoperative pain score at postoperative day 0 (1.58 vs 4.00, P < 0.01) and day 1 (1.00 vs 2.67, P < 0.01) while having decreased opioid consumption (P < 0.01). The intervention group also had faster recovery of gastrointestinal function. Overall, good compliance to most of the ERAS pathway domains was obtained. CONCLUSION The ERAS protocol demonstrates benefits on shortening hospital stay, reducing pain, and bowel function recovery without increasing complications in our population. CLINICAL TRIAL REGISTRATION The present study was registered at clinicaltrials.gov (NCT04201626) on December 3, 2019. Initial participant enrollment began on June 1, 2020. Access through URL of the registration site: https://clinicaltrials.gov/ct2/show/NCT04201626?cond=ERAS&cntry=TH&draw=2&rank=3.
Collapse
Affiliation(s)
- Phasawee Chiewhatpong
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kittipat Charoenkwan
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kannika Smithiseth
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Warangkana Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Panuwat Lapisatepun
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Mattabhorn Phimphilai
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tanarat Muangmool
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chalong Cheewakriangkrai
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Prapaporn Suprasert
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Jatupol Srisomboon
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
24
|
Chau JPC, Liu X, Lo SHS, Chien WT, Hui SK, Choi KC, Zhao J. Perioperative enhanced recovery programmes for women with gynaecological cancers. Cochrane Database Syst Rev 2022; 3:CD008239. [PMID: 35289396 PMCID: PMC8922407 DOI: 10.1002/14651858.cd008239.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015. OBJECTIVES To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes. SEARCH METHODS We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty. MAIN RESULTS We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.
Collapse
Affiliation(s)
- Janita Pak Chun Chau
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Xu Liu
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai Tong Chien
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Sze Ki Hui
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong, China
| | - Kai Chow Choi
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Jie Zhao
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| |
Collapse
|
25
|
Gebbia V, Piazza D, Valerio MR, Firenze A. WhatsApp Messenger use in oncology: a narrative review on pros and contras of a flexible and practical, non-specific communication tool. Ecancermedicalscience 2022; 15:1334. [PMID: 35211203 PMCID: PMC8816506 DOI: 10.3332/ecancer.2021.1334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Indexed: 01/06/2023] Open
Abstract
The spread of instant messenger systems provides an excellent opportunity and a helpful tool to healthcare professionals. WhatsApp instant messenger use is widely prevalent among health professionals, cancer patients, caregivers and the general population. It is a quick and easy communication tool that may also be used on personal computers and business purposes. WhatsApp instant messenger and other similar tools may be a very useful complement for e-medicine. Instant messaging systems may be helpful, especially in rural areas, in medium- or low-income countries, or to avoid unnecessary travels, improve knowledge and awareness of cancer, monitor home care and support the delivery of home care. The unregulated use of WhatsApp instant messenger requires sound and shared guidelines to assure impeccable professional service. Although a significant number of papers have investigated the roles of social networks in connecting patients to health professionals, there is still a lack of information and scientific data about their uses, benefits and limitations in connecting health providers only for professional communication. The role of instant messenger systems in cancer practice and research needs to be clarified. In this paper, we report a focus on available data, pros and contras of the unregulated use of WhatsApp instant messaging, in the context of e-medicine, as an interprofessional and doctor/patient communication tool in oncology.
Collapse
Affiliation(s)
- Vittorio Gebbia
- Medical Oncology Unit, La Maddalena Clinic for Cancer, Palermo, Italy.,Department of Internal Medicine 'Promise', University of Palermo, Palermo, Italy
| | - Dario Piazza
- GSTU Foundation for Cancer Research, Palermo, Italy
| | - Maria Rosaria Valerio
- Medical Oncology Unit, Policlinic 'P. Giaccone', University of Palermo, Palermo, Italy
| | - Alberto Firenze
- Department of Internal Medicine 'Promise', University of Palermo, Palermo, Italy.,Risk Management Unit, Policlinic 'P. Giaccone', University of Palermo, Palermo, Italy
| |
Collapse
|
26
|
Preoperative low-residue diet in gynecological surgery. Eur J Obstet Gynecol Reprod Biol 2022; 271:172-176. [DOI: 10.1016/j.ejogrb.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/21/2022]
|
27
|
Perioperative Care in Colorectal Cancer Surgery before a Structured Implementation Program of the ERAS Protocol in a Regional Network. The Piemonte EASY-NET Project. Healthcare (Basel) 2021; 10:healthcare10010072. [PMID: 35052236 PMCID: PMC8775376 DOI: 10.3390/healthcare10010072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/22/2021] [Accepted: 12/28/2021] [Indexed: 01/02/2023] Open
Abstract
Background: In 2019, the Enhanced Recovery After Surgery (ERAS) protocol for colorectal cancer surgery was adopted by a minority of hospitals in Piemonte (4.3 million inhabitants, north-west Italy). The present analysis aims to compare the level of application of the ERAS protocol between hospitals already adopting it (ERAS, N = 3) with the rest of the regional hospitals (non-ERAS, N = 28) and to identify possible obstacles to its application. Methods: All patients surgically treated for a newly diagnosed colorectal cancer during September–November 2019, representing the baseline period of a randomized controlled trial with a cluster stepped-wedge design, were included. Indicators of compliance to the ERAS items were calculated overall and for groups of items (preoperative, intraoperative and postoperative) and analyzed with a multilevel linear model adjusting for patients’ characteristics, considering centers as random effects. Results: Overall, the average level of compliance to the ERAS protocol was 56% among non-ERAS centers (N = 364 patients) and 80% among ERAS ones (N = 79), with a difference of 24% (95% CI: −41.4; −7.3, p = 0.0053). For both groups of centers, the lowest level of compliance was recorded for postoperative items (42% and 66%). Sex, age, presence of comorbidities and American Society of Anesthesiologists (ASA) score were not associated with a different probability of compliance to the ERAS protocol. Conclusions: Several items of the ERAS protocol were poorly adopted in colorectal surgery units in the Piemonte region in the baseline period of the ERAS Colon-Rectum Piemonte study and in the ERAS group. No relevant obstacles to the ERAS protocol implementation were identified at patient level.
Collapse
|
28
|
Deckers P, Yamada AMTD, Lopes A. Correspondence on 'Enhanced recovery after surgery in gynecologic oncology: time to address barriers to implementation in low- and middle-income countries' by Nelson et al. Int J Gynecol Cancer 2021; 31:1497. [PMID: 34551894 DOI: 10.1136/ijgc-2021-003055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Paula Deckers
- Department of Gynecology, Sao Camilo Oncologia, Sao Paulo, Brazil
| | | | - Andre Lopes
- Department of Gynecology, Sao Camilo Oncologia, Sao Paulo, Brazil .,Discipline of Gynecology, Department of Obstetrics and Gynecology, Instituto do Cancer do Estado de Sao Paulo ICESP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| |
Collapse
|
29
|
Bajwa SJS, Jain D, Anand S, Palta S. Neural blocks at the helm of a paradigm shift in enhanced recovery after surgery (ERAS). Indian J Anaesth 2021; 65:S99-S103. [PMID: 34703053 PMCID: PMC8500195 DOI: 10.4103/ija.ija_807_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 08/30/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
| | - Divya Jain
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Smriti Anand
- Department of Anaesthesia, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
| | - Sanjeev Palta
- Department of Anaesthesiology and Intensive Care, Govenment Medical College and Hospital, Chandigarh, India
| |
Collapse
|
30
|
de Boer HD, Fawcett WJ, Scott MJ. Enhanced recovery after surgery: The road to improve peri-operative care globally. Eur J Anaesthesiol 2021; 38:905-907. [PMID: 34397525 DOI: 10.1097/eja.0000000000001509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Hans D de Boer
- From the Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, The Netherlands (HDdeB), the Department of Anaesthesia and Pain Medicine, Royal Surrey NHS Foundation Trust, Guildford, UK (WJF), the Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA (MJS)
| | | | | |
Collapse
|
31
|
Bhandoria G, Solanki SL, Bhavsar M, Balakrishnan K, Bapuji C, Bhorkar N, Bhandarkar P, Bhosale S, Divatia JV, Ghosh A, Mahajan V, Peedicayil A, Nath P, Sinukumar S, Thambudorai R, Seshadri RA, Bhatt A. Enhanced recovery after surgery (ERAS) in cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC): a cross-sectional survey. Pleura Peritoneum 2021; 6:99-111. [PMID: 34676283 PMCID: PMC8482448 DOI: 10.1515/pp-2021-0117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/12/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Enhanced recovery after surgery (ERAS) protocols have been questioned in patients undergoing cytoreductive surgery (CRS) with/without hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies. This survey was performed to study clinicians' practice about ERAS in patients undergoing CRS-HIPEC. METHODS An online survey, comprising 76 questions on elements of prehabilitation (n=11), preoperative (n=8), intraoperative (n=16) and postoperative (n=32) management, was conducted. The respondents included surgeons, anesthesiologists, and critical care specialists. RESULTS The response rate was 66% (136/206 clinicians contacted). Ninety-one percent of respondents reported implementing ERAS practices. There was encouraging adherence to implement the prehabilitation (76-95%), preoperative (50-94%), and intraoperative (55-90%) ERAS practices. Mechanical bowel preparation was being used by 84.5%. Intra-abdominal drains usage was 94.7%, intercostal drains by 77.9% respondents. Nasogastric drainage was used by 84% of practitioners. The average hospital stay was 10 days as reported by 50% of respondents. A working protocol and ERAS checklist have been designed, based on the results of our study, following recent ERAS-CRS-HIPEC guidelines. This protocol will be prospectively validated. CONCLUSIONS Most respondents were implementing ERAS practices for patients undergoing CRS-HIPEC, though as an extrapolation of colorectal and gynecological guidelines. The adoption of postoperative practices was relatively low compared to other perioperative practices.
Collapse
Affiliation(s)
- Geetu Bhandoria
- Department of Obstetrics & Gynecology, Command Hospital, Pune, India
| | - Sohan Lal Solanki
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Mrugank Bhavsar
- Department of Critical Care Medicine, Zydus Hospital, Ahmedabad, India
| | | | | | - Nitin Bhorkar
- Department of Anaesthesiology, Saifee Hospital, Mumbai, India
| | | | - Sameer Bhosale
- Department of Anaesthesiology, Jehangir Hospital, Pune, India
| | - Jigeeshu V. Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Anik Ghosh
- Department of Gynecologic Oncology, Tata Medical Centre, Kolkata, India
| | - Vikas Mahajan
- Department of Surgical Oncology, Apollo Hospital, Chennai, India
| | - Abraham Peedicayil
- Department of Gynecologic Oncology, Christian Medical College, Vellore, India
| | - Praveen Nath
- Department of Anaesthesiology, Kumaran Hospital, Chennai, India
| | - Snita Sinukumar
- Department of Surgical Oncology, Jehangir Hospital, Pune, India
| | - Robin Thambudorai
- Department of Surgical Oncology, Tata Medical Centre, Kolkata, India
| | | | - Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Ahmedabad, India
| |
Collapse
|
32
|
Nelson G, Wang X, Nelson A, Faris P, Lagendyk L, Wasylak T, Bathe OF, Bigam D, Bruce E, Buie WD, Chong M, Fairey A, Hyndman ME, MacLean A, McCall M, Pin S, Wang H, Gramlich L. Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada. JAMA Netw Open 2021; 4:e2119769. [PMID: 34357394 PMCID: PMC8346943 DOI: 10.1001/jamanetworkopen.2021.19769] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. OBJECTIVE To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. INTERVENTIONS Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. MAIN OUTCOMES AND MEASURES Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. RESULTS A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). CONCLUSIONS AND RELEVANCE The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.
Collapse
Affiliation(s)
- Gregg Nelson
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Xiaoming Wang
- Analytics, Data Integration, Measurement, and Reporting, Alberta Health Services, Calgary, Alberta, Canada
| | - Alison Nelson
- Surgery Strategic Clinical Network, Alberta Health Services, Calgary, Alberta, Canada
| | - Peter Faris
- Analytics, Data Integration, Measurement, and Reporting, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Tracy Wasylak
- Strategic Clinical Networks, Alberta Health Services, Calgary, Alberta, Canada
| | - Oliver F. Bathe
- Department of Oncology, University of Calgary, Calgary, Alberta, Canada
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - David Bigam
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Erin Bruce
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - W. Donald Buie
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael Chong
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Fairey
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - M. Eric Hyndman
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anthony MacLean
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Michael McCall
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Sophia Pin
- Department of Obstetrics & Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Haili Wang
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Leah Gramlich
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
33
|
Ljungqvist O, de Boer HD, Balfour A, Fawcett WJ, Lobo DN, Nelson G, Scott MJ, Wainwright TW, Demartines N. Opportunities and Challenges for the Next Phase of Enhanced Recovery After Surgery: A Review. JAMA Surg 2021; 156:775-784. [PMID: 33881466 DOI: 10.1001/jamasurg.2021.0586] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative now firmly entrenched within the field of perioperative care. Although ERAS is associated with significant clinical outcome improvements and cost savings in numerous surgical specialties, several opportunities and challenges deserve further discussion. Observations Uptake and implementation of ERAS Society guidelines, together with ERAS-related research, have increased exponentially since the inception of the ERAS movement. Opportunities to further improve patient outcomes include addressing frailty, optimizing nutrition, prehabilitation, correcting preoperative anemia, and improving uptake of ERAS worldwide, including in low- and middle-income countries. Challenges facing enhanced recovery today include implementation, carbohydrate loading, reversal of neuromuscular blockade, and bowel preparation. The COVID-19 pandemic poses both a challenge and an opportunity for ERAS. Conclusions and Relevance To date, ERAS has achieved significant benefit for patients and health systems; however, improvements are still needed, particularly in the areas of patient optimization and systematic implementation. During this time of global crisis, the ERAS method of delivering care is required to take surgery and anesthesia to the next level and bring improvements in outcomes to both patients and health systems.
Collapse
Affiliation(s)
- Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, Örebro University School of Health and Medical Sciences, Örebro, Sweden
| | - Hans D de Boer
- Department of Anaesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
| | - Angie Balfour
- Surgical Services, NHS [National Health Service] Lothian, Edinburgh, United Kingdom
| | - William J Fawcett
- Department of Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
- MRC (Medical Research Council) Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham School of Life Sciences, Queen's Medical Centre, Nottingham, United Kingdom
| | - Gregg Nelson
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Scott
- Anesthesiology and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas W Wainwright
- Orthopaedic Research Institute, Bournemouth University, Bournemouth, United Kingdom
- Physiotherapy Department, University Hospitals Dorset NHS Foundation Trust, Bournemouth, United Kingdom
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
34
|
Ranganathan P, Chinnaswamy G, Sengar M, Gadgil D, Thiagarajan S, Bhargava B, Booth CM, Buyse M, Chopra S, Frampton C, Gopal S, Grant N, Krailo M, Langley R, Mathur P, Paoletti X, Parmar M, Purushotham A, Pyle D, Rajaraman P, Stockler MR, Sullivan R, Swaminathan S, Tannock I, Trimble E, Badwe RA, Pramesh CS. The International Collaboration for Research methods Development in Oncology (CReDO) workshops: shaping the future of global oncology research. Lancet Oncol 2021; 22:e369-e376. [PMID: 34216541 PMCID: PMC8328959 DOI: 10.1016/s1470-2045(21)00077-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/27/2021] [Accepted: 02/04/2021] [Indexed: 02/07/2023]
Abstract
Low-income and middle-income countries (LMICs) have a disproportionately high burden of cancer and cancer mortality. The unique barriers to optimum cancer care in these regions necessitate context-specific research. The conduct of research in LMICs has several challenges, not least of which is a paucity of formal training in research methods. Building capacity by training early career researchers is essential to improve research output and cancer outcomes in LMICs. The International Collaboration for Research methods Development in Oncology (CReDO) workshop is an initiative by the Tata Memorial Centre and the National Cancer Grid of India to address gaps in research training and increase capacity in oncology research. Since 2015, there have been five CReDO workshops, which have trained more than 250 oncologists from India and other countries in clinical research methods and protocol development. Participants from all oncology and allied fields were represented at these workshops. Protocols developed included clinical trials, comparative effectiveness studies, health services research, and observational studies, and many of these protocols were particularly relevant to cancer management in LMICs. A follow-up of these participants in 2020 elicited an 88% response rate and showed that 42% of participants had made progress with their CReDO protocols, and 73% had initiated other research protocols and published papers. In this Policy Review, we describe the challenges to research in LMICs, as well as the evolution, structure, and impact of CReDO and other similar workshops on global oncology research.
Collapse
Affiliation(s)
- Priya Ranganathan
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Girish Chinnaswamy
- Division of Paediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Manju Sengar
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Durga Gadgil
- Research Administration Council, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shivakumar Thiagarajan
- Department of Head and Neck Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | | | - Christopher M Booth
- Departments of Oncology and Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Marc Buyse
- International Drug Development Institute, Louvain-la-Neuve, Belgium; Data Science Institute, Hasselt University, Diepenbeek, Belgium
| | | | - Chris Frampton
- Departments of Medicine and Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, Rockville, MD, USA
| | | | - Mark Krailo
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ruth Langley
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Prashant Mathur
- National Centre for Disease Informatics and Research, Bengaluru, India
| | - Xavier Paoletti
- University of Versailles Saint-Quentin-en-Yvelines, Versailles, France; Department of Biostatistics, Institut Curie, Saint-Cloud, France; Department of Statistics for Precision Medicine, INSERM U900, Paris, France
| | - Mahesh Parmar
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - Arnie Purushotham
- School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
| | - Douglas Pyle
- American Society of Clinical Oncology, Alexandria, VA, USA
| | - Preetha Rajaraman
- US Department of Health and Human Services, Washington, DC, USA; US Embassy, New Delhi, India
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | | | | | - Ian Tannock
- Division of Medical Oncology, Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Edward Trimble
- Office of the Director, National Cancer Institute, NIH, US Department of Health and Human Services, Washington, DC, USA
| | - Rajendra A Badwe
- Departments of Administration and Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - C S Pramesh
- Departments of Administration and Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| |
Collapse
|
35
|
Nelson G, Alvarez A, Ramirez PT. Enhanced recovery after surgery in gynecologic oncology: time to address barriers to implementation in low- and middle-income countries. Int J Gynecol Cancer 2021; 31:1195-1196. [PMID: 34226244 DOI: 10.1136/ijgc-2021-002841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/22/2021] [Indexed: 12/28/2022] Open
Affiliation(s)
- Gregg Nelson
- Department of Obstetrics & Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
36
|
Sánchez-Iglesias JL, Gómez-Hidalgo NR, Pérez-Benavente A, Carbonell-Socias M, Manrique-Muñoz S, Serrano MP, Gutiérrez-Barceló P, Bradbury M, Nelson G, Gil-Moreno A. Importance of Enhanced Recovery After Surgery (ERAS) Protocol Compliance for Length of Stay in Ovarian Cancer Surgery. Ann Surg Oncol 2021; 28:8979-8986. [PMID: 34091804 DOI: 10.1245/s10434-021-10228-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/10/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Enhanced Recovery After Surgery (ERAS) programs include multiple perioperative care elements, which when implemented together are designed to improve recovery after surgery with subsequent reduction in hospital length of stay (LOS). The aim of this study is to examine the impact of ERAS protocol compliance on LOS in patients undergoing advanced ovarian cancer surgery within the context of a randomized clinical trial. METHODS Patients were enrolled in a prospective, consecutive, interventional randomized clinical trial between June 2014 and March 2018. Women with either suspected or confirmed advanced ovarian cancer with International Federation of Gynecology and Obstetrics (FIGO) stages IIB-IVA and recurrent ovarian cancer, who underwent cytoreduction surgery, were randomly assigned to either a conventional management (CM) protocol or an ERAS protocol. Demographic items, preoperative clinical data, and surgical characteristics of patients were recorded, as were LOS and ERAS protocol compliance. Negative binomial regression was used to model the relation between length of stay and ERAS protocol compliance. RESULTS We included 49 patients in the CM group and 50 patients in the ERAS group. The overall rate of ERAS compliance was 92%. We observed that increasing ERAS protocol compliance was associated with shorter median LOS, and in patients who underwent higher complex surgeries, the length of stay reduction was greater. CONCLUSION This study identifies a correlation between increasing ERAS protocol compliance and decreasing LOS in ovarian cancer surgery. This finding underlines the necessity to implement as many ERAS protocol elements as possible to achieve optimal clinical outcome improvements.
Collapse
Affiliation(s)
- Jose Luis Sánchez-Iglesias
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain.
| | - Natalia R Gómez-Hidalgo
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain.
| | - Asunción Pérez-Benavente
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain
| | - Melchor Carbonell-Socias
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain
| | | | | | - Pilar Gutiérrez-Barceló
- Nursing Unit for Gynecologic Oncology and Breast Diseases, Vall d'Hebron Hospital, Barcelona, Spain
| | - Melissa Bradbury
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Antonio Gil-Moreno
- Unit of Gynecologic Oncology, Service of Gynecology, Gynecological Oncology Department, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Madrid, Spain
| |
Collapse
|
37
|
Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - A systematic review and meta-analysis. Gynecol Oncol 2020; 161:46-55. [PMID: 33388155 DOI: 10.1016/j.ygyno.2020.12.035] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/22/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the benefit of Enhanced Recovery After Surgery (ERAS) on length of stay (LOS), postoperative complications, 30-day readmission, and cost in gynecologic oncology. METHODS A systematic literature search was performed in MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and Web of Science for all peer-reviewed cohort studies and controlled trials on ERAS involving gynecologic oncology patients. Abstracts, commentaries, non-controlled studies, and studies without specific data on gynecologic oncology patients were excluded. Meta-analysis was performed on the primary endpoint of LOS. Subgroup analyses were performed based on risk of bias of the studies included, number of ERAS elements, and ERAS compliance. Secondary endpoints were readmission rate, complications, and cost. RESULTS A total of 31 studies (6703 patients) were included: 5 randomized controlled trials, and 26 cohort studies. Meta-analysis of 27 studies (6345 patients) demonstrated a decrease in LOS of 1.6 days (95% confidence interval, CI 1.2-2.1) with ERAS implementation. Meta-analysis of 21 studies (4974 patients) demonstrated a 32% reduction in complications (OR 0.68, 95% CI 0.55-0.83) and a 20% reduction in readmission (OR 0.80, 95% CI 0.64-0.99) for ERAS patients. There was no difference in 30-day postoperative mortality (OR 0.61, 95% CI 0.23-1.6) for ERAS patients compared to controls. No difference in the odds of complications or reduction in LOS was observed based on number of included ERAS elements or reported compliance with ERAS interventions. The mean cost savings for ERAS patients was $2129 USD (95% CI $712 - $3544). CONCLUSIONS ERAS protocols decrease LOS, complications, and cost without increasing rates of readmission or mortality in gynecologic oncology surgery. This evidence supports implementation of ERAS as standard of care in gynecologic oncology.
Collapse
|
38
|
Elias K. Knowing but not doing: the state of global enhanced recovery after surgery in gynecologic oncology. Int J Gynecol Cancer 2020; 30:1479. [PMID: 32817082 DOI: 10.1136/ijgc-2020-001938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/10/2020] [Indexed: 11/03/2022] Open
Affiliation(s)
- Kevin Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|