Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: System-wide implementation and audit leads to improved value and patient outcomes

Bisch, Steven; Wells, Tiffany; Gramlich, Leah; Faris, Peter; Wang, X.; Tran, Dinh Thien-An; Thanh, Nguyen Xuan; Glaze, Sarah; Chu, Pamela; Ghatage, Prafull; Nation, Jill; Capstick, Valerie; Steed, Helen; Sabourin, Jean‐Christophe; Nelson, Gregg

doi:10.1016/j.ygyno.2018.08.007

Cited by 123 publications

(104 citation statements)

References 27 publications

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“…Observational studies from colorectal surgery including more than 10 000 patients have described a strong correlation between increasing compliance with ERAS guidelines and decreased rates of complications and shorter lengths of stay 47 243. While there are no randomized studies in gynecologic oncology comparing auditing of compliance with ERAS elements to no auditing, a non-randomized Canadian prospective study of more than 500 gynecologic oncology patients using an ERAS compliance audit tool found that an increase in ERAS compliance from 56% to 77% was associated with a 31.4% reduction in adjusted length of stay and net cost savings of $952 per patient 220. Active auditing appears to be more effective at achieving compliance than passive implementation alone 244 245…”

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

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

533

364

View full text Add to dashboard Cite

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“…Our findings highlight the need for further protocol education among care teams and continual auditing of the protocol at our institution. An investigation of an ERAS audit system in gynecologic oncology demonstrated improved patient outcomes with a modest increase in protocol compliance 31. Studies of ERAS in the gynecologic literature are limited by heterogeneity with regard to protocol implementation as well as lack of compliance reporting, with a recent meta-analysis noting compliance rates published in only two of 16 studies 27 32.…”

Section: Discussionmentioning

confidence: 99%

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

Schwartz

Lim

Broadwater

et al. 2019

Int J Gynecol Cancer

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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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“…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. 12,26,27 It is clear that introduction of an ERAS protocols influences opioid consumption using many different approaches. Even more important than the impact of ERAS on short-term clinical outcomes are the effects in oncological surgery, specifically the potential effect on progression-free survival and overall survival.…”

Section: Gynecology Original Researchmentioning

confidence: 99%

“…8e10 This also has been shown for gynecologic surgery in single institutions. 11,12 The aim of this study was to evaluate the association between compliance with pre-and intraoperative ERAS Society gynecologic/oncologic guideline elements and postoperative outcomes following elective gynecologic surgery in an international cohort.…”

mentioning

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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Enhanced Recovery After Surgery (ERAS) in gynecologic oncology: System-wide implementation and audit leads to improved value and patient outcomes

Cited by 123 publications

References 27 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

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

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