Effect of an Enhanced Recovery After Surgery Program on Opioid Use and Patient-Reported Outcomes

Meyer, Larissa A.; Lasala, Javier; Iniesta, Maria D.; Nick, Alpa M.; Munsell, Mark F.; Shi, Qiuling; Wang, Xin Shelley; Cain, Katherine; Lu, Karen H.; Ramírez, Pedro T.

doi:10.1097/aog.0000000000002735

Cited by 130 publications

(95 citation statements)

References 36 publications

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“…For example, economic recovery and return to work may lag behind emotional or physical dimensions of recovery. In one study, patients on an ERAS pathway reported return to mild or no fatigue in 10 days compared with 30 days for the pre-ERAS cohort, while returning to mild or no interference with walking after laparotomy was reported at a median of 5 days for ERAS patients compared with 13 days in the pre-ERAS group 177. Patients undergoing minimally invasive surgery on an ERAS pathway reported a return to mild or no interference with walking at a median of 2 days 152…”

Section: Resultsmentioning

confidence: 99%

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

Nelson¹,

Bakkum-Gamez

Kalogera

et al. 2019

Int J Gynecol Cancer

Self Cite

533

364

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BackgroundThis is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.MethodsA database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.ResultsAll recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.ConclusionsThe updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.

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Section: Resultsmentioning

confidence: 99%

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

Nelson¹,

Bakkum-Gamez

Kalogera

et al. 2019

Int J Gynecol Cancer

Self Cite

533

364

View full text Add to dashboard Cite

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“…Furthermore, comprehensive prospective screening by a dedicated ERAS nurse includes all complications according to the principle of Clavien classification,13 meaning that even complications usually tagged as 'irrelevant' were included here. This might contribute to a comparatively rather high complication rate in the present study.…”

Section: Discussionmentioning

confidence: 99%

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

Pache

Jurt

Grass

et al. 2019

Int J Gynecol Cancer

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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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“…23 In our study, the use of epidurals was negatively associated with complications for the group of complex surgery. Meyer et al 24 and Wijk et al 11 both showed a clear reduction in opioid consumption after introducing an ERAS protocol with multimodal pain treatment without epidurals, whereas Bergstrom et al 25 found a reduction in opioids in the ERAS population with an increased use of epidural. Approaches with multimodal oral pain management, often combined with alternative locoregional analgesia such as continuous lidocaine infusions, spinal analgesia or transversus abdominis plane blocks, or incisional injection also have been used successfully in gynecological ERAS protocols.…”

Section: Gynecology Original Researchmentioning

confidence: 99%

International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery

Wijk

Udumyan

Pache

et al. 2019

American Journal of Obstetrics and Gynecology

108

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BACKGROUND: Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively. OBJECTIVE: To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort. STUDY DESIGN: The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates. RESULTS: Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score 3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4e11). Median length of stay was 2 days in the low-and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90e0.95; P<.001) decrease in days in hospital among lowcomplexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82e0.93; P<.001) decrease among patients with medium/highcomplexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P<.05) among low-complexity patients. CONCLUSION: Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation.

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Effect of an Enhanced Recovery After Surgery Program on Opioid Use and Patient-Reported Outcomes

Abstract: Implementation of an ERAS program was associated with significantly decreased opioid use after surgery and improvement in key patient-reported outcomes associated with functional recovery after surgery without compromising pain scores.

Cited by 130 publications

References 36 publications

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

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

International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery

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