A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs

Abstract

Enhanced recovery after surgery (ERAS) programs aim to hasten functional recovery and improve postoperative outcomes. However, there is a paucity of data on ERAS programs in gynecologic surgery. We reviewed the published literature on ERAS programs in colorectal surgery, general gynecologic surgery, and gynecologic oncology surgery to evaluate the impact of such programs on outcomes, and to identify key elements in establishing a successful ERAS program. ERAS programs are associated with shorter length of hospital stay, a reduction in overall health care costs, and improvements in patient satisfaction. We suggest an ERAS program for gynecologic oncology practice involving preoperative, intraoperative, and postoperative strategies including; preadmission counseling, avoidance of preoperative bowel preparation, use of opioid-sparing multimodal perioperative analgesia (including loco-regional analgesia), intraoperative goal-directed fluid therapy (GDT), and use of minimally invasive surgical techniques with avoidance of routine use of nasogastric tube, drains and/or catheters. Postoperatively, it is important to encourage early feeding, early mobilization, timely removal of tubes and drains, if present, and function oriented multimodal analgesia regimens. Successful implementation of an ERAS program requires a multidisciplinary team effort and active participation of the patient in their goal-oriented functional recovery program. However, future outcome studies should evaluate the efficacy of an intervention within the pathway, include objective measures of symptom burden and control, study measures of functional recovery, and quantify outcomes of the program in relation to the rates of adherence to the key elements of care in gynecologic oncology such as oncologic outcomes and return to intended oncologic therapy (RIOT).

Safety and efficacy of enhanced recovery after surgery (ERAS) programs in patients undergoing hepatectomy: A prospective randomized controlled trial

“…Pulmonary exercise can accelerate the recovery of lung function after surgery . No bowel preparation as usual can prevent dehydration and disturbance of electrolyte . Oral carbohydrates 400 milliliters two hours before operation can relieve thirst, reduce anxiety, lower insulin resistance, and promote postoperative intestinal function recovery …”

“…27 No bowel preparation as usual can prevent dehydration and disturbance of electrolyte. 28 Oral carbohydrates 400 milliliters two hours before operation can relieve thirst, reduce anxiety, lower insulin resistance, and promote postoperative intestinal function recovery. 29,30 The advanced concept of surgery, anesthesia, infusion, heat preservation, and analgesia during the operation reflect the superiority of ERAS programs.…”

The Impact of an Enhanced Recovery After Surgery Program on Patients Treated for Gynecologic Cancer in the Community Hospital Setting

“…2,4,11 Specifically, ERAS pathways in gynecologic surgery have reportedly been successful 4,14,15 at addressing the issues thereof, but the results have been limited by relatively small patient populations and the inclusion of study participants with benign disease and data that have primarily reflected observations from academic medical centers. 12,16 In the current investigation, we report our experience in implementing an ERAS protocol with a gynecologic oncology population that was treated in the community hospital setting.…”

ERAS—Anticipated outcomes and realistic goals

“…Being a dynamic clinical care pathway, the ERAS program has to be evaluated for effectiveness and continuous improvement . The interactive audit system developed by the ERAS Group is a central element supporting practice change .…”

“…Enhanced recovery programs have been demonstrated to be safe, cost effective, and capable of improving recovery of patients through diminished complications and length of stay (LOS) in different surgical areas. [48][49][50] Currently, the ERAS Group guidelines comprise 24 core elements with different grades of recommendation. 5 One important gap in these programs is the lack of clarity regarding the relative weight of each particular component in relationship to its impact on improved outcomes.…”