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Lindemann K, Heimisdottir Danbolt S, Ramberg L, Eyjólfsdóttir B, Wang YY, Heli-Haugestøl AG, Walcott SL, Mjåland O, Navestad GA, Hermanrud S, Juul-Hansen KE, Bragstad LK, Opheim R, Kleppe A, Kongsgaard U. Patient-reported nausea after implementation of an enhanced recovery after surgery protocol for gynae-oncology patients. Int J Gynecol Cancer 2023; 33:1287-1294. [PMID: 37451689 PMCID: PMC10423539 DOI: 10.1136/ijgc-2023-004356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES This study aimed to analyze the adherence to strategies to prevent post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) protocol for gynae-oncology patients. Patient-reported nausea before and after ERAS was also studied. METHODS This prospective observational study included all patients undergoing laparotomy for a suspicious pelvic mass or confirmed advanced ovarian cancer before (pre-ERAS) and after the implementation of ERAS (post-ERAS) at Oslo University Hospital, Norway. Patients were a priori stratified according to the planned extent of surgery into two cohorts (Cohort 1: Surgery of advanced disease; Cohort 2: Surgery for a suspicious pelvic tumor). Clinical data including baseline characteristics and outcome data were prospectively collected. RESULTS A total of 439 patients were included, 243 pre-ERAS and 196 post-ERAS. At baseline, 27% of the patients reported any grade of nausea. In the post-ERAS cohort, statistically significantly more patients received double post-operative nausea and vomiting prophylaxis (64% pre-ERAS vs 84% post-ERAS, p<0.0001). There was no difference in the need for rescue medication (82% pre-ERAS vs 79% post-ERAS; p=0.17) and no statistically significant difference between pre- and post-ERAS or between the surgical cohorts in patient-reported nausea of any grade on day 2. Patients who reported none/mild nausea on day 2 had significantly less peri-operative fluid administered during surgery than those who reported moderate or severe nausea (median 12.5 mL/kg/hour vs 16.5 mL/kg/hour, p=0.045) but, in multivariable analysis, fluid management did not remain significantly associated with nausea. CONCLUSION Implementation of an ERAS protocol increased the adherence to post-operative nausea and vomiting prevention guidelines. Nausea, both before and after laparotomy, remains an unmet clinical need of gynae-oncology patients also in an ERAS program. Patient-reported outcome measures warrant further investigation in the evaluation of ERAS.
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Affiliation(s)
- Kristina Lindemann
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Svana Heimisdottir Danbolt
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Lene Ramberg
- Department of Gynecology and Obstetrics, Akershus University Hospital, Lørenskog, Norway
| | - Brynhildur Eyjólfsdóttir
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Yun Yong Wang
- Department of Gynecological Oncology, Division of Cancer Medicine, 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, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Silje Hermanrud
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut Erling Juul-Hansen
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
| | - Line K Bragstad
- Department of Public Health Science and CHARM Research Centre for Habilitation and Rehabilitation models & services, University of Oslo, Oslo, Norway
| | - Randi Opheim
- Department of Public Health, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Andreas Kleppe
- Institute of Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Ulf Kongsgaard
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
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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] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/18/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts. METHODS Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed. RESULTS Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS. CONCLUSIONS ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.
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Affiliation(s)
- Kristina Lindemann
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Andreas Kleppe
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | | | | | - Yun Yong Wang
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Sara L Walcott
- Department of Clinical Service, Oslo University Hospital, Oslo, Norway
| | - Odd Mjåland
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
| | - Gerd-Anita Navestad
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Silje Hermanrud
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Knut Erling Juul-Hansen
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
| | - Ulf Kongsgaard
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
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