ERAS for Gynecologic Surgery By Anna Strohl,MD; Jeffrey Huang, MD & Shireen Ahmad, MD Introduction E care.1 Several protocols and guidelines have been designed for the management of patients undergoing colorectal surgeries incorporating the ERAS principles. More recently, growing evidence supports the expansion of ERAS protocols to include women undergoing gynecologic surgery. Clinical Evidence Despite the significant number of randomized controlled trials (RCTs) in the colorectal literature, there is no evidence from randomized control trials (RCTs) to support or refute the use of ERAS in gynecologic surgery.2 Existing data examining clinical pathways aimed at improving postoperative recovery in gynecologic surgery include small cohort studies; however, these data report similar findings to those published in the colorectal literature, suggesting that ERAS protocols can be expanded to gynecologic subspecialty surgery. A recent review of ERAS programs in general gynecologic surgery demonstrated that ERAS-driven protocols reduce length of stay (LOS) without increasing complication or readmission rates.3 Dickson et al. demonstrated that an ERAS pathway in 400 women undergoing abdominal hysterectomy for benign disease decreased median LOS from 3 days to 1 day following implementation (p<0.001) without an increase in complications.4 A separate study compared 136 patients on an ERAS pathway with 211 historical controls using a conventional protocol and found that the median LOS decreased from 3 to 2 days (p=0.007) while also reducing complications rates from 40.2% to 21.3% (p=0.004).5 The benefits ERAS protocols are not limited to woman undergoing hysterectomy for benign disease. Carter et al. reviewed a 22-point ERAS program in 389 women undergoing laparotomy for suspected or confirmed gynecologic malignancy. This study found a median LOS of 3 days with a readmission rate of 4%.6 Kalogera et ASER ALERT • VOLUME 2, ISSUE 1 • aserhq.org al. included women with gynecologic malignancy in a retrospective study evaluating the implementation of an ERAS study in laparotomy for complex gynecologic surgery. This study found that median LOS was 4 days less in the ERAS group than in the conventional group (8.7 vs 11.9 days, p<0.001).7 While few data exist on ERAS programs specifically in women with gynecologic cancer, a systematic review of seven cohort studies found that enhanced recovery pathways in gynecologic cancer patients is safe and reduces length of stay, as well as cost.8 Due to the extensive data in support of ERAS programs from the colorectal literature, as well as the growing data from gynecologic surgery, the Society for Gynecologic Oncology (SGO) has endorsed the implementation of ERAS-driven programs in women undergoing gynecologic surgery in an effort to improve postoperative outcomes. , Future studies need to focus on the development of consistent, comprehensive ERAS programs in order to truly evaluate its impact on gynecologic surgery outcomes.9, 10 Recommended Preoperative Management: Patient education establishes expectations and promotes active participation of the patient in his/her own care and is strongly recommended.11 Preoperative cessation of smoking and alcohol consumption for at least 4 weeks and preoperative medical optimization reduces complications and is recommended. Routine preoperative mechanical bowel preparation lacks evidence of benefit in the gynecologic population and is not recommended. Patients without risks for delayed gastric emptying, should refrain from solids for 6 hours and liquids for 2 hours prior to surgery. The evidence supports preoperative carbohydrate loading to prevent postoperative insulin resistance and increased complications.12 In order to facilitate early ambulation and feeding routine administration of long acting sedatives is discouraged. Prophylactic anticoagulation and the use of pneumatic compression 11 nhanced Recovery After Surgery (ERAS) is a standardardized, highly coordinated interdisciplinary perioperative surgical care program that incorporates evidence-based interventions to minimize surgical stress, improve physiological and functional recovery, reduce complications, and facilitate earlier discharge from the hospital and reduced cost of
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