Enhanced Recovery After Surgery (ERAS): New Concepts in the Perioperative Management of Gynecologic Surgery

Abstract Background To investigate the effects of enhanced recovery after surgery (ERAS) in patients undergoing gynecologic surgery on length of hospital stay, pain management, and complication rate. Results The length of hospital stay was reduced in ERAS groups when compared with the control groups (3.46 days vs 2.28 days; P < 0.0001; CI − 1.5767 to − 0.7833 for laparotomy groups and 2.18 vs 1.76 days; P = 0.0115; CI − 0.7439 to − 0.0961 for laparoscopy groups respectively). Intraoperative fluid use was reduced in both ERAS groups compared to the two control groups (934 ± 245 ml and 832 ± 197 ml vs 1747 ± 257 ml and 1459 ± 304 respectively; P < 0.0001) and postoperative fluid use was also less in the ERAS groups compared to the control groups (1606 ± 607 ml and 1210 ± 324 ml vs 2682 ± 396 ml and 1469 ± 315 ml respectively; P < 0.0001). Pain score using visual analog scale (VAS) on postoperative day 0 was 4.8 ± 1.4 and 4.1 ± 1.2 (P = 0.0066) for both laparotomy control and ERAS groups respectively, while in the laparoscopy groups, VAS was 3.8 ± 1.1 and 3.2 ± 0.9 (P = 0.0024) in control and ERAS groups respectively. Conclusion Implementation of ERAS protocols in gynecologic surgery was associated with significant reduction in length of hospital stay, associated with decrease intravenous fluids used and comparable pain control without increase in complication rates.

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PROPER—PRehabilitatiOn Plus Enhanced Recovery after surgery versus enhanced recovery after surgery in gynecologic oncology: a randomized clinical trial

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2021-003170 ◽

2021 ◽

pp. ijgc-2021-003170

Author(s):

Andre Lopes ◽

Alayne Magalhães Trindade Domingues Yamada ◽

Thais de Campos Cardenas ◽

Jaqueline Nunes de Carvalho ◽

Emília de Azevedo Oliveira ◽

...

Keyword(s):

Hospital Stay ◽

Functional Capacity ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Preoperative Care ◽

Gynecologic Surgery ◽

Calorie Intake ◽

Control Group ◽

Gynecological Surgery ◽

The Impact

BackgroundPrehabilitation is a process that occurs before surgery and aims to improve patient functional capacity and enhance surgical recovery. This process includes medical, nutritional, physical, and psychological interventions that may reduce the duration of hospital stay and provide postoperative physical benefits.Primary ObjectiveTo evaluate the impact of a prehabilitation program on postoperative recovery time for patients who will undergo gynecological surgery following the Enhanced Recovery After Surgery (ERAS) guidelines.Study HypothesisA multidisciplinary, preoperative prehabilitation program for patients who will undergo gynecological surgery leads to a reduction in the length of hospital stay and improves patient functional capacity.Trial DesignProspective, interventionist, and randomized controlled trial in a 1:1 ratio, open to multidisciplinary team and patients, blinded to surgeons and anesthesiologists. The control group will undergo ERAS standard preoperative care while the intervention group will have ERAS standard preoperative care plus prehabilitation.Major Inclusion CriteriaPatients scheduled to undergo gynecologic surgery performed by laparotomy with a preoperative schedule that allows prehabilitation intervention for 2 to 3 weeks.Primary EndpointTo compare time between surgery and the day the patient is ready for discharge in patients who underwent the prehabilitation process versus those who did not. Readiness for discharge is defined as the ability to take care of one’s-self, to walk alone, and to ingest at least 75% of daily recommended calorie intake.Sample Size194 participantsEstimated Dates for Completing Accrual and Presenting ResultsAt present, 30 patients have been recruited. Accrual should be completed by 2023–24.Trial RegistrationThe study is approved by the IBCC – São Camilo Oncologia ethics committee (reference number 4.256.553) and is registered at clinicaltrials.gov (NCT04596800).

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

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-000268 ◽

2019 ◽

Vol 29 (4) ◽

pp. 810-815 ◽

Cited By ~ 4

Author(s):

Basile Pache ◽

Jonas Jurt ◽

Fabian Grass ◽

Martin Hübner ◽

Nicolas Demartines ◽

...

Keyword(s):

Hospital Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Oncology ◽

Length Of Hospital Stay ◽

Gynecologic Surgery ◽

Complication Rates ◽

Prolonged Length ◽

Academic Center ◽

The Impact

IntroductionEnhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes.MethodsRetrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification.ResultsA total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I–V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001).ConclusionsCompliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

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Effect of anesthesia technique on intra-operative and post-operative morphine equivalent daily dose (MEDD) in open gynecologic surgery in an enhanced recovery after surgery (ERAS) pathway

Clinical Nutrition ESPEN ◽

10.1016/j.clnesp.2019.03.028 ◽

2019 ◽

Vol 31 ◽

pp. 106

Author(s):

J.D. Lasala ◽

M. Iniesta-Donate ◽

B. Pitcher ◽

K.E. Cain ◽

G.E. Mena ◽

...

Keyword(s):

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Surgery ◽

Daily Dose ◽

Anesthesia Technique ◽

Morphine Equivalent

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Role and impact of multimodal prehabilitation for gynecologic oncology patients in an Enhanced Recovery After Surgery (ERAS) program

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2019-000597 ◽

2019 ◽

Vol 29 (8) ◽

pp. 1235-1243 ◽

Cited By ~ 7

Author(s):

Ester Miralpeix ◽

Gemma Mancebo ◽

Sonia Gayete ◽

Marta Corcoy ◽

Josep-Maria Solé-Sedeño

Keyword(s):

Functional Capacity ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Oncology ◽

Psychological Support ◽

Gynecologic Surgery ◽

Nutritional Counseling ◽

Oncology Patients ◽

Operative Recovery ◽

Eras Protocol

Patients undergoing major surgery are predisposed to a decrease in functional capacity as a response to surgical stress that can delay post-operative recovery. A prehabilitation program consists of patient preparation strategies before surgery, and include pre-operative measures to improve functional capacity and enhance post-operative recovery. Multimodal prehabilitation may include exercise, nutritional counseling, psychological support, and optimization of underlying medical conditions, as well as cessation of unfavorable health behaviors such as smoking and drinking. Currently, there are no standardized guidelines for prehabilitation, and the existent studies are heterogeneous; however, multimodal approaches are likely to have a greater impact on functional outcomes than single management programs. We have reviewed the literature on prehabilitation in general, and in gynecologic surgery in particular, to identify tools to establish an optimal prehabilitation program within an Enhanced Recovery After Surgery (ERAS) protocol for gynecologic oncology patients. We suggest a safe, reproducible, functional, and easy-to-apply multimodal prehabilitation program for gynecologic oncology practice based on patient-tailored pre-operative medical optimization, physical training, nutritional counseling, and psychological support. The analysis of the prehabilitation program implementation in an ERAS protocol should undergo further research in order to test the efficacy on surgical outcome and recovery after surgery.

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Validation of an enhanced recovery after surgery protocol in gynecologic surgery: an Italian randomized study

American Journal of Obstetrics and Gynecology ◽

10.1016/j.ajog.2020.07.003 ◽

2020 ◽

Vol 223 (4) ◽

pp. 543.e1-543.e14 ◽

Cited By ~ 3

Author(s):

Federico Ferrari ◽

Sara Forte ◽

Nicola Sbalzer ◽

Valentina Zizioli ◽

Marta Mauri ◽

...

Keyword(s):

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Randomized Study ◽

Gynecologic Surgery

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Buprenorphine management: a conundrum for the anesthesiologist and beyond - a one-act play

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2020-101294 ◽

2020 ◽

Vol 45 (8) ◽

pp. 656-659

Author(s):

Shilen Thakrar ◽

Josh Lee ◽

Caitlin E Martin ◽

John Butterworth IV

Keyword(s):

Patient Outcomes ◽

Perioperative Management ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Local Level ◽

Evidence Based ◽

National Guidelines ◽

Evidence Based Guidelines ◽

One Act ◽

Patient Centric

We have witnessed a worldwide upsurge of streamlined enhanced recovery after surgery (ERAS) pathways advocating for consistency and compliance within their guidelines. At a recent national conference, two experts defended their institutional policies on perioperative management of buprenorphine, one defending its continuation, while the other suggesting its discontinuation. The moderator diplomatically proclaimed the need to have guidance at the institutional level and following it for favorable patient outcomes. Unfortunately, perioperative management of buprenorphine remains an understudied topic with a lack of national guidelines leading to variations at a local level despite its increased use nationally in the current opioid crisis. Although the moderator made a valid statement, we demonstrate via our one-act play the importance of recognizing a subset of the population within an ERAS pathway that necessitates multidisciplinary discussion, communication, and patient-centric care to formulate a perioperative plan coordinating a patient’s care. More robust research is needed to minimize variability in current practices and to further develop comprehensive evidence-based guidelines that encompass risk factors and anticipated postsurgical and peripartum pain for patients on buprenorphine.

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Compliance with an enhanced recovery after surgery (ERAS) program in gynecologic surgery: Impact on length of stay and complications

Clinical Nutrition ESPEN ◽

10.1016/j.clnesp.2017.04.033 ◽

2017 ◽

Vol 19 ◽

pp. 82

Author(s):

Andrea Rodriguez-Restrepo ◽

Maria D. Iniesta ◽

Gloria Salvo ◽

Nipa Sheth ◽

Camila Corzo ◽

...

Keyword(s):

Length Of Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Gynecologic Surgery

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Comparative Effectiveness of Enhanced Recovery After Surgery Program Combined With Single-Incision Laparoscopic Surgery in Colorectal Cancer Surgery: A Retrospective Analysis

Frontiers in Oncology ◽

10.3389/fonc.2021.768299 ◽

2022 ◽

Vol 11 ◽

Author(s):

Changgang Wang ◽

Haoran Feng ◽

Xiaoning Zhu ◽

Zijia Song ◽

You Li ◽

...

Keyword(s):

Colorectal Cancer ◽

Laparoscopic Surgery ◽

Retrospective Study ◽

Perioperative Management ◽

Single Incision ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Single Incision Laparoscopic Surgery ◽

Group A ◽

Group B

BackgroundRecently, enhanced recovery after surgery (ERAS) has been widely used in the perioperative management of colorectal cancer (CRC). This study aimed to evaluate the safety and feasibility of ERAS combined with single-incision laparoscopic surgery (SILS) in CRC surgery.MethodsThis was a retrospective study of patients with CRC who underwent surgery between April 2018 and April 2020 in Ruijin Hospital(North), Shanghai Jiaotong University School of Medicine. The patients were divided into three groups: group A (n=138), patients who underwent traditional multiport laparoscopic colectomy with conventional perioperative management; group B (n=63), patients who underwent SILS; and group C (n=51), patients who underwent SILS with ERAS.ResultsOverall, 252 participants were included in the retrospective study. The median operation time (min) in group B and group C was shorter than that in group A (group A 134.0 ± 42.5; group B 117 ± 38.9; group C 111.7 ± 35.4, p=0.004). The estimated surgical blood loss (ml) was lower in groups B and C than in group A (group A 165.1 ± 142.2; group B 122.0 ± 79.4; group C 105.2 ± 55.8, p=0.011). The length of surgical incision (cm) was shorter in groups B and C than in group A (group A 7.34 ± 1.05; group B 5.60 ± 0.80; group C 5.28 ± 0.52, p<0.001). The time before first flatus (hours) in group C was shorter than in groups A and B (group A 61.85 ± 21.14; group B 58.30 ± 20.08; group C 42.06 ± 23.72; p<0.001). The days prior to the administration of free oral fluids in group C was shorter than in groups A and B (group A 4.79 ± 1.28; group B 4.67 ± 1.11; group C 2.62 ± 0.64; p<0.001). The days of prior solid diet was less in group C than in groups A and B (group A 7.22 ± 3.87; group B 7.08 ± 3.18; group C 5.75 ± 1.70; p=0.027). The postoperative length of stay (LOS) was less in group C compared with that in groups A and B (group A 9.46 ± 4.84 days; group B 9.52 ± 7.45 days; group C 7.20 ± 2.37 days; p=0.023). The visual analog scale (VAS) scores on day 0, 1, and 2 in groups B and C were lower than those in group A (day 0, p<0.001; day 1, p<0.001; day 2, p=0.002), while the VAS score on day 3 showed no differences in the three groups (group A 1.29 ± 1.38; group B 0.98 ± 1.24; group C 0.75 ± 0.64, p=0.018).ConclusionThe findings suggest that SILS combined with ERAS may be a feasible and safe procedure for CRC surgery because it provides favorable cosmetic results, early dietary resumption, shorter hospital stays, and appropriate control of postoperative pain without increases in complications or readmission rates compared to conventional perioperative care with SILS or conventional laparoscopic surgery(CLS) of CRC. Further prospective randomized controlled studies are needed to enhance evidence-based medical evidence.

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Prevalence and Consequences of Preoperative Weight Loss in Gynecologic Surgery

Nutrients ◽

10.3390/nu11051094 ◽

2019 ◽

Vol 11 (5) ◽

pp. 1094 ◽

Cited By ~ 1

Author(s):

Basile Pache ◽

Fabian Grass ◽

Martin Hübner ◽

Amaniel Kefleyesus ◽

Patrice Mathevet ◽

...

Keyword(s):

Weight Loss ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Length Of Hospital Stay ◽

Gynecologic Surgery ◽

Preoperative Weight Loss ◽

Nutritional Screening ◽

Preoperative Weight ◽

Eras Protocol ◽

Extensive Surgery

Preoperative malnutrition and weight loss negatively impact postoperative outcomes in various surgical fields. However, for gynecologic surgery, evidence is still scarce, especially if surgery is performed within enhanced recovery after surgery (ERAS) pathways. This study aimed to assess the prevalence and impact of preoperative weight loss in patients undergoing major gynecologic procedures within a standardized ERAS pathway between October 2013 and January 2017. Out of 339 consecutive patients, 33 (10%) presented significant unintentional preoperative weight loss of more than 5% during the 6 months preceding surgery. These patients were less compliant to the ERAS protocol (>70% of all items: 70% vs. 94%, p < 0.001) presented more postoperative overall complications (15/33 (45%) vs. 69/306 (22.5%), p = 0.009), and had an increased length of hospital stay (5 ± 4 days vs. 3 ± 2 days, p = 0.011). While patients experiencing weight loss underwent more extensive surgical procedures, after multivariate analysis, weight loss ≥5% was retained as an independent risk factor for postoperative complications (OR 2.44; 95% CI 1.00–5.95), and after considering several surrogates for extensive surgery including significant blood loss (OR 2.23; 95% CI 1.15–4.31) as confounders. The results of this study suggest that systematic nutritional screening in ERAS pathways should be implemented.

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