Impact of compliance with an enhanced recovery after surgery pathway on patient outcomes in open gynecologic surgery

ObjectiveThe aim of this study was to evaluate if varying levels of compliance with an enhanced recovery after surgery (ERAS) protocol impacted post-operative outcomes (length of stay, complications, readmissions, and re-operations) in gynecologic surgery at a tertiary center.MethodsWe included 584 patients who had open gynecologic surgery between November 1, 2014 and December 31, 2016. Patients were categorized into subgroups according to their date of surgery from the time of the ERAS protocol implementation. Patients were categorized by their per cent compliance into two groups:<80% versus ≥80%. We analyzed compliance with the elements of the protocol over time and its relation with post-operative outcomes, length of stay, post-operative complications, readmission, and re-operations rates. We modeled the probability of having a post-operative complication within 30 days of surgery as a function of overall compliance.ResultsOverall compliance was 72.3%. Patients with compliance ≥80% had significantly less complications (P<0.001) and shorter length of stay (P<0.001). Readmission and re-operation rates were not impacted by compliance (P=0.182, P=0.078, respectively). Avoidance of salt water overload, early mobilization, early oral nutrition, and early removal of Foley catheter were significantly associated with less post-operative complications within 30 days.ConclusionsCompliance with an ERAS pathway exceeding 80% was associated with lower complication rates and shorter length of stay without impacting on re-operations or readmissions.

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Reduction in opioid use and postoperative pain scores after elective laparotomy with implementation of enhanced recovery after surgery protocol on a gynecologic oncology service

International Journal of Gynecological Cancer ◽

10.1136/ijgc-2018-000131 ◽

2019 ◽

Vol 29 (5) ◽

pp. 935-943 ◽

Cited By ~ 7

Author(s):

Amanda Rae Schwartz ◽

Stephanie Lim ◽

Gloria Broadwater ◽

Lauren Cobb ◽

Fidel Valea ◽

...

Keyword(s):

Length Of Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Oral Morphine ◽

Gynecologic Surgery ◽

Complication Rates ◽

Opioid Use ◽

Pain Scores ◽

Significant Difference ◽

Eras Protocol

ObjectiveEnhanced Recovery After Surgery (ERAS) protocols are designed to mitigate the physiologic stress response created by surgery, to decrease the time to resumption of daily activities, and to improve overall recovery. This study aims to investigate postoperative recovery outcomes following gynecologic surgery before and after implementation of an ERAS protocol.MethodsA retrospective chart review was performed of patients undergoing elective laparotomy at a major academic center following implementation of an ERAS protocol (11/4/2014–7/27/2016) with comparison to a historical cohort (6/23/2013–9/30/2014). The primary outcome was length of hospital stay. Secondary outcomes included surgical variables, time to recovery of baseline function, opioid usage, pain scores, and complication rates. Statistical analyses were performed using Wilcoxon rank sum, Fisher’s exact, and chi squared tests.ResultsOne hundred and thirty-three women on the ERAS protocol who underwent elective laparotomy were compared with 121 historical controls. There was no difference in length of stay between cohorts (median 4 days; P = 0.71). ERAS participants had lower intraoperative (45 vs 75 oral morphine equivalents; P < 0.0001) and postoperative (45 vs 154 oral morphine equivalents; P < 0.0001) opioid use. ERAS patients reported lower maximum pain scores in the post-anesthesia care unit (three vs six; P < 0.0001) and on postoperative day 1 (four vs six; P = 0.002). There was no statistically significant difference in complication or readmission rates.ConclusionsERAS protocol implementation was associated with decreased intraoperative and postoperative opioid use and improved pain scores without significant changes in length of stay or complication rates.

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Implementation of enhanced recovery after surgery in gynecological operations: a randomized controlled trial

Ain-Shams Journal of Anesthesiology ◽

10.1186/s42077-020-00116-4 ◽

2020 ◽

Vol 12 (1) ◽

Author(s):

Amr Nady Abdelrazik ◽

Ahmad Sameer Sanad

Keyword(s):

Hospital Stay ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Controlled Trial ◽

Length Of Hospital Stay ◽

Gynecologic Surgery ◽

Complication Rates ◽

Control Groups ◽

Analog Scale ◽

Randomized Controlled

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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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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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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Implementation of an ERAS Pathway in Colorectal Surgery

Clinics in Colon and Rectal Surgery ◽

10.1055/s-0038-1676474 ◽

2019 ◽

Vol 32 (02) ◽

pp. 102-108 ◽

Cited By ~ 9

Author(s):

Liliana Bordeianou ◽

Paul Cavallaro

Keyword(s):

Colorectal Surgery ◽

Length Of Stay ◽

Postoperative Care ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Standardized Protocol ◽

Improve Hospital ◽

Eras Protocol

AbstractEnhanced Recovery after Surgery (ERAS) protocols have been demonstrated to improve hospital length of stay and outcomes in patients undergoing colorectal surgery. This article presents the specific components of an ERAS protocol implemented at the authors' institution. In particular, details of both surgical and anesthetic ERAS pathways are provided with explanation of all aspects of preoperative, perioperative, and postoperative care. Evidence supporting inclusion of various aspects within the ERAS protocol is briefly reviewed. The ERAS protocol described has significantly benefitted postoperative outcomes in colorectal patients and can be employed at other institutions wishing to develop an ERAS pathway for colorectal patients. A checklist is provided for clinicians to easily reference and facilitate implementation of a standardized protocol.

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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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Impact of enhanced recovery after surgery protocol compliance on patients’ outcome in benign hysterectomy and establishment of a predictive nomogram model

BMC Anesthesiology ◽

10.1186/s12871-021-01509-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Yiwei Shen ◽

Feng Lv ◽

Su Min ◽

Gangming Wu ◽

Juying Jin ◽

...

Keyword(s):

Patient Satisfaction ◽

Postoperative Complications ◽

Length Of Stay ◽

Postoperative Complication ◽

Patient Experience ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Early Mobilization ◽

Urinary Drainage ◽

Eras Protocol

Abstract Background Enhanced recovery after surgery (ERAS) pathways have been shown to improve clinical outcomes after surgery. Considering the importance of patient experience for patients with benign surgery, this study evaluated whether improved compliance with ERAS protocol modified for gynecological surgery which recommended by the ERAS Society is associated with better clinical outcomes and patient experience, and to determine the influence of compliance with each ERAS element on patients’ outcome after benign hysterectomy. Methods A prospective observational study was performed on the women who underwent hysterectomy between 2019 and 2020. A total of 475 women greater 18 years old were classified into three groups according to their per cent compliance with ERAS protocols: Group I: < 60% (148 cases); Group II:≥60 and < 80% (160 cases); Group III: ≥80% (167 cases). Primary outcome was the 30-day postoperative complications. Second outcomes included QoR-15 questionnaire scores, patient satisfaction on a scale from 1 to 7, and length of stay after operation. After multivariable binary logistic regression analyse, a nomogram model was established to predict the incidence of having a postoperative complication with individual ERAS element compliance. Results The study enrolled 585 patients, and 475 completed the follow-up assessment. Patients with compliance over 80% had a significant reduction in postoperative complications (20.4% vs 41.2% vs 38.1%, P < 0.001) and length of stay after surgery (4 vs 5 vs 4, P < 0.001). Increased compliance was also associated with higher patient satisfaction and QoR-15 scores (P < 0.001),. Among the five dimensions of the QoR-15, physical comfort (P < 0.05), physical independence (P < 0.05), and pain dimension (P < 0.05) were better in the higher compliance groups. Minimally invasive surgery (MIS) (P < 0.001), postoperative nausea and vomiting (PONV) prophylaxis (P < 0.001), early mobilization (P = 0.031), early oral nutrition (P = 0.012), and early removal of urinary drainage (P < 0.001) were significantly associated with less complications. Having a postoperative complication was better predicted by the proposed nomogram model with high AUC value (0.906) and sensitivity (0.948) in the cohort. Conclusions Improved compliance with the ERAS protocol was associated with improved recovery and better patient experience undergoing hysterectomy. MIS, PONV prophylaxis, early mobilization, early oral intake, and early removal of urinary drainage were of concern in reducing postoperative complications. Trial registration Chinese Clinical Trial Registry, ChiCTR1800019178. Registered on 30/10/2018.

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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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Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

Journal of Neurosurgery Spine ◽

10.3171/2020.6.spine20795 ◽

2020 ◽

pp. 1-23

Author(s):

Zach Pennington ◽

Ethan Cottrill ◽

Daniel Lubelski ◽

Jeff Ehresman ◽

Nicholas Theodore ◽

...

Keyword(s):

Lumbar Spine ◽

Spine Surgery ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Meta Analysis ◽

Lumbar Spine Surgery ◽

Complication Rates ◽

Protocol Implementation ◽

Eras Protocol ◽

Adult Spine

OBJECTIVESpine surgery has been identified as a significant source of healthcare expenditures in the United States. Prolonged hospitalization has been cited as one source of increased spending, and there has been drive from providers and payors alike to decrease inpatient stays. One strategy currently being explored is the use of Enhanced Recovery After Surgery (ERAS) protocols. Here, the authors review the literature on adult spine ERAS protocols, focusing on clinical benefits and cost reductions. They also conducted a quantitative meta-analysis examining the following: 1) length of stay (LOS), 2) complication rate, 3) wound infection rate, 4) 30-day readmission rate, and 5) 30-day reoperation rate.METHODSUsing the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, CINAHL, and OVID Medline databases was conducted to identify all full-text articles in the English-language literature describing ERAS protocol implementation for adult spine surgery. A quantitative meta-analysis using random-effects modeling was performed for the identified clinical outcomes using studies that directly compared ERAS protocols with conventional care.RESULTSOf 950 articles reviewed, 34 were included in the qualitative analysis and 20 were included in the quantitative analysis. The most common protocol types were general spine surgery protocols and protocols for lumbar spine surgery patients. The most frequently cited benefits of ERAS protocols were shorter LOS (n = 12), lower postoperative pain scores (n = 6), and decreased complication rates (n = 4). The meta-analysis demonstrated shorter LOS for the general spine surgery (mean difference −1.22 days [95% CI −1.98 to −0.47]) and lumbar spine ERAS protocols (−1.53 days [95% CI −2.89 to −0.16]). Neither general nor lumbar spine protocols led to a significant difference in complication rates. Insufficient data existed to perform a meta-analysis of the differences in costs or postoperative narcotic use.CONCLUSIONSPresent data suggest that ERAS protocol implementation may reduce hospitalization time among adult spine surgery patients and may lead to reductions in complication rates when applied to specific populations. To generate high-quality evidence capable of supporting practice guidelines, though, additional controlled trials are necessary to validate these early findings in larger populations.

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Safety and efficacy of a novel neurosurgical enhanced recovery after surgery protocol for elective craniotomy: a prospective randomized controlled trial

Journal of Neurosurgery ◽

10.3171/2018.1.jns171552 ◽

2019 ◽

Vol 130 (5) ◽

pp. 1680-1691 ◽

Cited By ~ 10

Author(s):

Yuan Wang ◽

Bolin Liu ◽

Tianzhi Zhao ◽

Binfang Zhao ◽

Daihua Yu ◽

...

Keyword(s):

Clinical Trial ◽

Perioperative Management ◽

Enhanced Recovery ◽

Enhanced Recovery After Surgery ◽

Tertiary Care ◽

Hospital Length Of Stay ◽

Control Group ◽

Complication Rates ◽

Safety And Efficacy ◽

Eras Protocol

OBJECTIVEAlthough enhanced recovery after surgery (ERAS) programs have gained acceptance in various surgical specialties, no established neurosurgical ERAS protocol for patients undergoing elective craniotomy has been reported in the literature. Here, the authors describe the design, implementation, safety, and efficacy of a novel neurosurgical ERAS protocol for elective craniotomy in a tertiary care medical center located in China.METHODSA multidisciplinary neurosurgical ERAS protocol for elective craniotomy was developed based on the best available evidence. A total of 140 patients undergoing elective craniotomy between October 2016 and May 2017 were enrolled in a randomized clinical trial comparing this novel protocol to conventional neurosurgical perioperative management. The primary endpoint of this study was the postoperative hospital length of stay (LOS). Postoperative morbidity, perioperative complications, postoperative pain scores, postoperative nausea and vomiting, duration of urinary catheterization, time to first solid meal, and patient satisfaction were secondary endpoints.RESULTSThe median postoperative hospital LOS (4 days) was significantly shorter with the incorporation of the ERAS protocol than that with conventional perioperative management (7 days, p < 0.0001). No 30-day readmission or reoperation occurred in either group. More patients in the ERAS group reported mild pain (visual analog scale score 1–3) on postoperative day 1 than those in the control group (79% vs. 33%, OR 7.49, 95% CI 3.51–15.99, p < 0.0001). Similarly, more patients in the ERAS group had a shortened duration of pain (1–2 days; 53% vs. 17%, OR 0.64, 95% CI 0.29–1.37, p = 0.0001). The urinary catheter was removed within 6 hours after surgery in 74% patients in the ERAS group (OR 400.1, 95% CI 23.56–6796, p < 0.0001). The time to first oral liquid intake was a median of 8 hours in the ERAS group compared to 11 hours in the control group (p < 0.0001), and solid food intake occurred at a median of 24 hours in the ERAS group compared to 72 hours in the control group (p < 0.0001).CONCLUSIONSThis multidisciplinary, evidence-based, neurosurgical ERAS protocol for elective craniotomy appears to have significant benefits over conventional perioperative management. Implementation of ERAS is associated with a significant reduction in the postoperative hospital stay and an acceleration in recovery, without increasing complication rates related to elective craniotomy. Further evaluation of this protocol in large multicenter studies is warranted.Clinical trial registration no.: ChiCTR-INR-16009662 (chictr.org.cn)

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