ERAS Gynecologic Oncology (2019).pptx

Shaukat Khanum Memorial Cancer Hospital and Research Centre
Perioperative Care in Gynecologic Oncology:
Enhanced Recovery After Surgery (ERAS)
Society Recommendations – 2019 Update
Iqra Yasin
Fellow Gynecologic Oncology (Department of Surgical Oncology)

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Outline
 Introduction
 Literature Search
 ERAS items
 Summary

Introduction
 ERAS
 Global surgical quality improvement initiative
 Clinical improvement [1] + cost benefits to the healthcare system [2]
 Highest quality evidence + regular updates [3]
 ERAS – Gynecologic Oncology
 1st Published – February 2016 [4,5]
 Update version – 2019
 ERAS society + International ERAS Gynecologic Chapters
1. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg 2017;152:292–8.
2. Ljungqvist O, Thanh NX, Nelson G. ERAS-Value based surgery. J Surg Oncol 2017;116:608–12.
3. Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations: 2018. World J Surg 2019;43:659–95.
4. Nelson G, Altman AD, Nick A, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations--Part I. Gynecol Oncol 2016;140:313–22.
5. Nelson G, Altman AD, Nick A, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) society recommendations--part II. Gynecol Oncol 2016;140:323–32.

Literature Search
 1966 – 2018 (Embase, PubMed)
 Meta-analysis,
 Systemic reviews,
 RCT,
 Non-RCT, and
 Case Series.

ERAS Items
1. Pre-admission Information, Education, and Counseling
2. Prehabilitation
3. Pre-operative Bowel Preparation
4. Pre-operative Fasting and Carbohydrate Treatment
5. Venous Thromboembolism Prophylaxis
6. Surgical Site Infection (SSI) Reduction Bundles
7. Minimally Invasive Surgery
8. Standard Anesthetic Protocol

ERAS Items
9. Perioperative Fluid Management/Goal-Directed Fluid Therapy
10. Opioid Sparing Multimodal Post-operative Analgesia
11. Perioperative Nutrition
12. Prevention of Post-operative Ileus
13. Patients Reported Outcomes, Including Functional Recovery
14. Role of ERAS in Pelvic Exenteration and HIPEC
15. ERAS Audit and Reporting

1. Pre-admission Information, Education,
and Counseling
 Reduce fatigue, stress, and anxiety [1,2]
 Improve patient satisfaction and early discharge [3]
 Reduced pain, nausea and improve well-being [4,5]
 RCT: Written > Verbal [6]
 All members of the surgery team, anesthetist, dietician, and nurse [7,8]
1. Waller A, Forshaw K, Bryant J, et al. Preparatory education for cancer patients undergoing surgery: a systematic review of volume and quality of research output over time. Patient Educ Couns 2015. doi:10.1016/j.pec.2015.05.008. [Epub ahead of print: 23 May 2015].
2. Powell R, Scott NW, Manyande A, et al. Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database Syst Rev 2016;5.
3. Wang F, Li C-B, Li S, et al. Integrated interventions for improving negative emotions and stress reactions of young women receiving total hysterectomy. Int J Clin Exp Med 2014;7:331–6.
4. de Aguilar-Nascimento JE, Leal FS, Dantas DCS, et al. Preoperative education in cholecystectomy in the context of a multimodal protocol of perioperative care: a randomized, controlled trial. World J Surg 2014;38:357–62.
5. Cavallaro PM, Milch H, Savitt L, et al. Addition of a scripted preoperative patient education module to an existing ERAS pathway further reduces length of stay. Am J Surg 2018;216:652–7.
6. Angioli R, Plotti F, Capriglione S, et al. The effects of giving patients verbal or written pre-operative information in gynecologic oncology surgery: a randomized study and the medical-legal point of view. Eur J Obstet Gynecol Reprod Biol 2014;177:67–71.
7. Booth K, Beaver K, Kitchener H, et al. Women's experiences of information, psychological distress and worry after treatment for gynaecological cancer. Patient Educ Couns 2005;56:225–32.
8. Stewart DE, Wong F, Cheung AM, et al. Information needs and decisional preferences among women with ovarian cancer. Gynecol Oncol 2000;77:357–61.

 Summary and recommendation
 Counseling provides beneficial effects with no evidence of harm
 Patients should receive dedicated pre-operative counseling
Recommendation grade: Strong
1. Pre-admission Information, Education,
and Counseling

 Process on the continuum of care
 Time of cancer diagnosis  start of acute treatment
 Physical and psychological assessments
 Establishes baseline functional level,
 Identification of impairment, and
 Provide targeted interventions that reduce the incidence and severity of current
and future impairment. [1]
2. Cancer Prehabilitation
1. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil 2013;92:715–27.

 Principles of Multimodal Approach [1]
 Aerobic and resistance exercises – cardiorespiratory fitness
 Targeted functional exercises – minimize/prevent impairments
 Dietary interventions - support
 Exercise-induced anabolism
 Disease/treatment–related malnutrition
 Psychological interventions – reduce stress/support behavior change/overall
well-being
1. Carli F, Silver JK, Feldman LS, et al. Surgical prehabilitation in patients with cancer: state-of-the-science and recommendations for future research from a panel of subject matter experts. Phys Med Rehabil Clin N Am 2017;28:49–64.

 No high-quality direct evidence in gynecologic oncology patients [1,2]
 Extrapolated work in colorectal surgery [3-5]
 Certain patients benefit clinically from Prehabilitation but further work in
gynecologic oncology is needed.
Recommendation grade: Weak
1. Bolshinsky V, Li MH-G, Ismail H, et al. Multimodal Prehabilitation programs as a bundle of care in gastrointestinal cancer surgery: a systematic review. Dis Colon Rectum 2018;61:124–38.
2. Ebner F, Schulz SVW, de Gregorio A, et al. Prehabilitation in gynecological surgery? What do gynecologists know and need to know. Arch Gynecol Obstet 2018;297:27–31.
3. Gillis C, Buhler K, Bresee L, et al. Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and metaanalysis. Gastroenterology 2018;155:391–410.
4. Moran J, Guinan E, McCormick P, et al. The ability of Prehabilitation to influence postoperative outcome after intra-abdominal operation: a systematic review and meta-analysis. Surgery 2016;160:1189–201.
5. Minnella EM, Bousquet-Dion G, Awasthi R, et al. Multimodal prehabilitation improves functional capacity before and after colorectal surgery for cancer: a five-year research experience. Acta Oncol 2017;56:295–300

 Minimally invasive gynecologic surgery
 Limited data from RCT
 Conclusively showed no improved intraoperative visualization, ease of bowel
handling, or procedure performance. [1-5]
 Open gynecologic surgery
 Lack of data – extrapolated from colorectal surgery [6-9]
1. Arnold A, Aitchison LP, Abbott J. Preoperative mechanical bowel preparation for abdominal, laparoscopic, and vaginal surgery: a systematic review. J Minim Invasive Gynecol 2015;22:737–52.
2. Huang H, Wang H, He M. Is mechanical bowel preparation still necessary for gynecologic laparoscopic surgery? A meta-analysis. Asian J Endosc Surg 2015;8:171–9.
3. Mulayim B, Karadag B. Do we need mechanical bowel preparation before benign gynecologic laparoscopic surgeries a randomized, single-blind, controlled trial. Gynecol Obstet Invest 2018;83:203–8.
4. Ryan NA, Ng VS-M, Sangi-Haghpeykar H, et al. Evaluating mechanical bowel preparation prior to total laparoscopic hysterectomy. JSLS 2015;19.
5. Zhang J, Xu L, Shi G. Is mechanical bowel preparation necessary for gynecologic surgery? A systematic review and meta-analysis. Gynecol Obstet Invest 2016;81:155–61.
6. Cao F, Li J, Li F. Mechanical bowel preparation for elective colorectal surgery: updated systematic review and meta-analysis. Int J Colorectal Dis 2012;27:803–10.
7. Dahabreh IJ, Steele DW, Shah N, et al. Oral mechanical bowel preparation for colorectal surgery: systematic review and metaanalysis. Dis Colon Rectum 2015;58:698–707.
8. Pineda CE, Shelton AA, Hernandez-Boussard T, et al. Mechanical bowel preparation in intestinal surgery: a meta-analysis and review of the literature. J Gastrointest Surg 2008;12:2037–44.
9. Slim K, Vicaut E, Launay-Savary M-V, et al. Updated systematic review and meta-analysis of randomized clinical trials on the role of mechanical bowel preparation before colorectal surgery. Ann Surg 2009;249:203–9.

 Routine pre-operative bowel preparation should not be used before
minimally invasive gynecologic surgery.
 Similarly discouraged before open laparotomy in gynecologic
surgery/gynecologic oncology
 Surgeon Preference - limited to planned colonic resection
 Oral antibiotics ± mechanical bowel preparation
 High-quality data from colorectal surgery
 Mechanical bowel preparation alone doesn’t reduce postoperative
morbidity and should be abandoned.

 Surgical stress + Prolonged fasting – Post-operative catabolic response
 RCTs [1,2] – elective surgery under G/A
 Clear fluids – 2 hours / Light meal – 6 hours
 Preoperative carbohydrate treatment - Oral 50 g 2-3 hours before induction of
anesthesia
 Attenuate catabolic response [3]
 Less post-operative nausea/vomiting, metoclopramide consumption, and
improved patient satisfaction [4]
4. Pre-operative Fasting and Carbohydrate
Treatment
2. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003;4.
3. Nygren J, Thorell A, Ljungqvist O. Preoperative oral carbohydrate therapy. Curr Opin Anaesthesiol 2015;28:364–9.
4. Ajuzieogu OV, Amucheazi AO, Nwagha UI, et al. Effect of routine preoperative fasting on residual gastric volume and acid in patients undergoing myomectomy. Niger J Clin Pract 2016;19:816–20.

 Cochrane review [1] - Preoperative carbohydrate treatment
 Reduced post-operative insulin resistance, improve well-being
 Enhanced return of bowel function, and shorter hospital stay
 With no effect on postoperative complication rates
 Limitations
 Delayed gastric emptying (overnight or 8 hours) or GI motility disorders
 Emergency surgery
 Obese [2] / Diabetic [3] (no issue with safety but insufficient data for general
recommendation)
4. Pre-operative Fasting and Carbohydrate
Treatment
1. Smith MD, McCall J, Plank L, et al. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 2014;8.
2. Azagury DE, Ris F, Pichard C, et al. Does perioperative nutrition and oral carbohydrate load sustainably preserve muscle mass after bariatric surgery? A randomized control trial. Surg Obes Relat Dis 2015;11:920–6.
3. Laffin MR, Li S, Brisebois R, et al. The use of a pre-operative carbohydrate drink in patients with diabetes mellitus: a prospective, non-inferiority, cohort study. World J Surg 2018;42:1965–70.

 Risk of VTE in Gynecologic Oncology Surgery [1-6]
 Ovarian cancer: 17-38 %
 Endometrial cancer: 4-9 %
 Cervical cancer: 3-4 %
 All Gynecologic Oncology patients – major surgery (> 30 mins) [7-9]
 Dual VTE mechanical prophylaxis and chemoprophylaxis (LMWH or
unfractionated heparin) throughout the hospital stay
1. Matsuo K, Yessaian AA, Lin YG, et al. Predictive model of venous thromboembolism in endometrial cancer. Gynecol Oncol 2013;128:544–51.
2. Levitan N, Dowlati A, Remick SC, et al. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. risk analysis using Medicare claims data. Medicine 1999;78:285–91.
3. Mokri B, Mariani A, Heit JA, et al. Incidence and predictors of venous thromboembolism after debulking surgery for epithelial ovarian cancer. Int J Gynecol Cancer 2013;23:1684–91.
4. Jacobson BF, Louw S, Büller H, et al. Venous thromboembolism: prophylactic and therapeutic practice guideline. S Afr Med J 2013;103:260–7.
5. Satoh T, Matsumoto K, Uno K, et al. Silent venous thromboembolism before treatment in endometrial cancer and the risk factors. Br J Cancer 2008;99:1034–9.
6. Greco PS, Bazzi AA, McLean K, et al. Incidence and timing of thromboembolic events in patients with ovarian cancer undergoing neoadjuvant chemotherapy. Obstet Gynecol 2017;129:979–85.
7. Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013;31:2189–204.
8. Baykal C, Al A, Demirtaş E, et al. Comparison of enoxaparin and standard heparin in gynaecologic oncologic surgery: a randomized prospective double-blind clinical study. Eur J Gynaecol Oncol 2001;22:127–30.
9. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTe in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ED: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141(2 Suppl):e227S–77.

 Should be initiated preoperatively [1, 2] and continued postoperatively
 Extended Chemoprophylaxis [3-6] (28 days post-op)
 High-risk - Caprini Risk Assessment Model
 ACCP [7], ASCO [8], NCCN [9]
1. Whitworth JM, Schneider KE, Frederick PJ, et al. Double prophylaxis for deep venous thrombosis in patients with gynecologic oncology who are undergoing laparotomy: does preoperative anticoagulation matter? Int J Gynecol Cancer
2011;21:1131–4.
2. Selby LV, Sovel M, Sjoberg DD, et al. Preoperative chemoprophylaxis is safe in major oncology operations and effective at preventing venous thromboembolism. J Am Coll Surg 2016;222:129–37.
3. Bergqvist D, Agnelli G, Cohen AT, et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med 2002;346:975–80.
4. Felder S, Rasmussen MS, King R, et al. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database Syst Rev 2018;11.
5. Fagarasanu A, Alotaibi GS, Hrimiuc R, et al. Role of extended thromboprophylaxis after abdominal and pelvic surgery in cancer patients: a systematic review and meta-analysis. Ann Surg Oncol 2016;23:1422–30.
6. Carrier M, Altman AD, Blais N, et al. Extended thromboprophylaxis with low-molecular weight heparin (LMWH) following abdominopelvic cancer surgery. Am J Surg 2018. doi:10.1016/j.amjsurg.2018.11.046. [Epub ahead of print: 16 Dec 2018].
7. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTe in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ED: American College of Chest Physicians evidence-based clinical practice guidelines. Chest
2012;141(2 Suppl):e227S–77.
8. Lyman GH, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2013;31:2189–204.
9. Streiff MB, National Comprehensive Cancer Center Network. The National Comprehensive Cancer Center Network (NCCN) guidelines on the management of venous thromboembolism in cancer patients. Thromb Res 2010;125 Suppl 2:S128–S133.

 Further studies needed
 ?Extended post-op prophylaxis – minimally invasive gynecologic surgery [1-4]
 ?Direct-acting oral anticoagulation [5]
 ?Ambulatory chemotherapy patients [6-8]
1. Ramirez PT, Nick AM, Frumovitz M, et al. Venous thromboembolic events in minimally invasive gynecologic surgery. J Minim Invasive Gynecol 2013;20:766–9.
2. Nick AM, Schmeler KM, Frumovitz MM, et al. Risk of thromboembolic disease in patients undergoing laparoscopic gynecologic surgery. Obstet Gynecol 2010;116:956–61.
3. Freeman AH, Barrie A, Lyon L, et al. Venous thromboembolism following minimally invasive surgery among women with endometrial cancer. Gynecol Oncol 2016;142:267–72.
4. Bouchard-Fortier G, Geerts WH, Covens A, et al. Is venous thromboprophylaxis necessary in patients undergoing minimally invasive surgery for a gynecologic malignancy? Gynecol Oncol 2014;134:228–32.
5. Forster R, Stewart M. Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair. Cochrane Database Syst Rev 2016;3.
6. Greco PS, Bazzi AA, McLean K, et al. Incidence and timing of thromboembolic events in patients with ovarian cancer undergoing neoadjuvant chemotherapy. Obstet Gynecol 2017;129:979–85.
7. Wagner BE, Langstraat CL, McGree ME, et al. Beyond prophylaxis: extended risk of venous thromboembolism following primary debulking surgery for ovarian cancer. Gynecol Oncol 2019;152.
8. Schmeler KM, Wilson GL, Cain K, et al. Venous thromboembolism (VTe) rates following the implementation of extended duration prophylaxis for patients undergoing surgery for gynecologic malignancies. Gynecol Oncol 2013;128:204–8.

 20–30% of open Gynecologic Oncology surgery [1-5]
 Bundle Elements
i. Antimicrobial Prophylaxis
ii. Skin Preparation
iii. Prevention of Hypothermia
iv. Avoidance of Drains/Tubes
v. Control of Perioperative Hyperglycemia
6. Surgical Site Infection Reduction
Bundles
1. de Lissovoy G, Fraeman K, Hutchins V, et al. Surgical site infection: incidence and impact on hospital utilization and treatment costs. Am J Infect Control 2009;37:387–97.
2. Nugent EK, Hoff JT, Gao F, et al. Wound complications after gynecologic cancer surgery. Gynecol Oncol 2011;121:347–52.
3. Taylor JS, Marten CA, Munsell MF, et al. The DISINFECT Initiative: decreasing the incidence of surgical infections in gynecologic oncology. Ann Surg Oncol 2017;24:362–8.
4. Tran CW, McGree ME, Weaver AL, et al. Surgical site infection after primary surgery for epithelial ovarian cancer: predictors and impact on survival. Gynecol Oncol 2015;136:278–84.
5. Bakkum-Gamez JN, Dowdy SC, Borah BJ, et al. Predictors and costs of surgical site infections in patients with endometrial cancer. Gynecol Oncol 2013;130:100–6.

 1st Generation cephalosporin – 1st line antibiotic for hysterectomy [1,2]
 Addition of anaerobe coverage in pelvic cancer or bowel surgery [2,3]
 Dosage according to body weight [1,2]
 Within 1 hour of skin incision [1,2]
 Redosing:
 > 2 half-lives of drug i.e. 3-4 hours or
 blood loss > 1500 ml
 CDC (1B recommendation)
6.1 Antimicrobial Prophylaxis
1. ACOG practice Bulletin No. 195: prevention of infection after gynecologic procedures. Obstet Gynecol 2018;131:e172–89.
2. Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Surg Infect 2013;14:73–156.
3. Alexander JW, Solomkin JS, Edwards MJ. Updated recommendations for control of surgical site infections. Ann Surg 2011;253:1082–93.
4. Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg 2017;152:784–91.

 Shower before surgery with a chlorhexidine-based antimicrobial soap
 Chlorhexidine-alcohol skin preparation in OR
 CDC 1A recommendation [6]
 40 % lower SSI compared to povidone-iodine [7] (Level I evidence)
6.2 Skin Preparation [1-5]
1. Johnson MP, Kim SJ, Langstraat CL, et al. Using bundled interventions to reduce surgical site infection after major gynecologic cancer surgery. Obstet Gynecol 2016;127:1135–44.
2. Lippitt MH, Fairbairn MG, Matsuno R, et al. Outcomes associated with a five-point surgical site infection prevention bundle in women undergoing surgery for ovarian cancer. Obstet Gynecol 2017;130:756–64.
3. Taylor JS, Marten CA, Munsell MF, et al. The DISINFECT Initiative: decreasing the incidence of surgical infections in gynecologic oncology. Ann Surg Oncol 2017;24:362–8.
4. Schiavone MB, Moukarzel L, Leong K, et al. Surgical site infection reduction bundle in patients with gynecologic cancer undergoing colon surgery. Gynecol Oncol 2017;147:115–9.
5. ACOG practice Bulletin No. 195: prevention of infection after gynecologic procedures. Obstet Gynecol 2018;131:e172–89.
7. Darouiche RO, Wall MJ, Itani KMF, et al. Chlorhexidine–alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18–26.

 Hypothermia – Cardiac events, SSI
 Maintenance of perioperative normothermia should be incorporated in all
ERAS programs
 CDC: Category 1 recommendation [2]
6.3 Prevention of Hypothermia [1]
1. Wong PF, Kumar S, Bohra A, et al. Randomized clinical trial of perioperative systemic warming in major elective abdominal surgery. Br J Surg 2007;94:421–6.

 Lack of high-quality data- role in the reduction of SSI
 Drain biofilm colonization – as early as 2 hours after placement [1]
 NGT – increased post-op pneumonia, no effect on wound dehiscence or intestinal
leaks. [2,3]
 Tailored according to surgical procedure and rationale for individual drain
placement
 Peritoneal drains, subcutaneous drains, and NGT should be avoided after
abdominal surgery.
6.4 Avoidance of Drains/Tubes
1. Dower R, Turner ML. Pilot study of timing of biofilm formation on closed suction wound drains. Plast Reconstr Surg 2012;130:1141–6.
2. Cheatham ML, Chapman WC, Key SP, et al. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995;221:469–78.
3. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007;8:CD004929.

 Associated with SSI in both diabetic and non-diabetic patients [1-8]
 CDC (Category 1A) [9]
 Perioperative glucose levels - maintained at < 200 mg/dL in diabetics and
non-diabetics.
 All surgical patients should be screened for diabetes
 Reduced Insulin resistance: Oral carbohydrate loading, MIS, early feeding [10]
6.5 Control of Perioperative Hyperglycemia
1. Bakkum-Gamez JN, Dowdy SC, Borah BJ, et al. Predictors and costs of surgical site infections in patients with endometrial cancer. Gynecol Oncol 2013;130:100–6.
2. Hopkins L, Brown-Broderick J, Hearn J, et al. Implementation of a referral to discharge glycemic control initiative for reduction of surgical site infections in gynecologic oncology patients. Gynecol Oncol 2017;146:228–33.
3. Steiner HL, Strand EA. Surgical-site infection in gynecologic surgery: pathophysiology and prevention. Am J Obstet Gynecol 2017;217:121–8.
4. Mahdi H, Goodrich S, Lockhart D, et al. Predictors of surgical site infection in women undergoing hysterectomy for benign gynecologic disease: a multicenter analysis using the National surgical quality improvement program data. J Minim Invasive Gynecol
2014;21:901–9.
5. Martin ET, Kaye KS, Knott C, et al. Diabetes and risk of surgical site infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2016;37:88–99.
6. Al-Niaimi AN, Ahmed M, Burish N, et al. Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients. Gynecol Oncol 2015;136:71–6.
7. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med Overseas Ed 2001;345:1359–67.
8. van den Boom W, Schroeder RA, Manning MW, et al. Effect of A1C and glucose on postoperative mortality in noncardiac and cardiac surgeries. Diabetes Care 2018;41:782–8.

 Laparoscopic surgery (vs open /moderate-highly invasive surgery)
 Decreased inflammatory and immunomodulatory response [1-3]
 MIS (including vaginal surgery) recommended/preferred
 Appropriate patients (long-term oncologic outcomes-similar), and
 Expertise and resources are available (feasible)
7. Minimally Invasive Surgery
1. Kehlet H, Nielsen HJ. Impact of laparoscopic surgery on stress responses, immunofunction, and risk of infectious complications. New Horiz 1998;6(2 Suppl):CD009642):S80–8.
2. Holub Z. Impact of laparoscopic surgery on immune function. Clin Exp Obstet Gynecol 2002;29:77–81.
3. Prete A, Yan Q, Al-Tarrah K, et al. The cortisol stress response induced by surgery: a systematic review and meta-analysis. Clin Endocrinol 2018;89:554–67.

 Goal
 To provide hypnosis and analgesia
 To optimize surgical condition and cardiovascular system
 With minimal residual anesthesia effect for rapid neurocognitive recovery and
minimize nausea/vomiting.
 Use of short-acting anesthetics
 Complete reversal of NM blockage
 Protected ventilation strategy (Tidal Volume 6-8 ml/Kg, PEEP 6-8 cm H2O)
8. Standard Anesthetic Protocol

 Hypervolemia – paralytic ileus, nausea/vomiting, increased length of stay [1-3]
 Hypovolemia – AKI, SSI, Sepsis, Delirium, increased hospital stay [4-6]
 Goal-directed fluid therapy - physiological measurements of blood flow, fluid
responsiveness, and organ perfusion [7-10]
 High-risk (high blood loss and high comorbid)
 Fluids /inotropes; Improve end –organ tissue perfusion and oxygenation [11-12]
 Improved short and long term outcomes [13-14]
 Reduces length of stay and complications undergoing abdominal surgery.
9. Perioperative Fluid Management/Goal-
Directed Fluid Therapy
1. Miller TE, Thacker JK, White WD, et al. Reduced length of hospital stay in colorectal surgery after implementation of an enhanced recovery protocol. Anesth Analg 2014;118:1052–61.
2. Brandstrup B, Tønnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003;238:641–8.
3. Adesanya A, Rosero E, Timaran C, et al. Intraoperative fluid restriction predicts improved outcomes in major vascular surgery. Vasc Endovascular Surg 2009;42:531–6.
4. Thom O, Taylor DM, Wolfe RE, et al. Pilot study of the prevalence, outcomes and detection of occult hypoperfusion in trauma patients. Emerg Med J 2010;27:470–2.
5. Davies SJ, Wilson RJT. Preoperative optimization of the high-risk surgical patient. Br J Anaesth 2004;93:121–8.
6. Bennett-Guerrero E, Welsby I, Dunn TJ, et al. The use of a postoperative morbidity survey to evaluate patients with prolonged hospitalization after routine, moderate-risk, elective surgery. Anesth Analg 1999;89:514–9.
7. Doherty M, Buggy DJ. Intraoperative fluids: how much is too much? Br J Anaesth 2012;109:69–79.
8. Holte K, Foss NB, Andersen J, et al. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, doubleblind study. Br J Anaesth 2007;99:500–8.
9. Chong PC, Greco EF, Stothart D, et al. Substantial variation of both opinions and practice regarding perioperative fluid resuscitation. Can J Surg 2009;52:207–14.
10. Lilot M, Ehrenfeld JM, Lee C, et al. Variability in practice and factors predictive of total crystalloid administration during abdominal surgery: retrospective two-centre analysis. Br J Anaesth 2015;114:767–76.
11. Miralpeix E, Nick AM, Meyer LA, et al. A call for new standard of care in perioperative gynecologic oncology practice: impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016;141:371–8.
12. Thiele RH, Raghunathan K, Brudney CS, et al. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery. Perioper Med
2016;5.
13. Michard F. The burden of high-risk surgery and the potential benefit of goal-directed strategies. Crit Care 2011;15.
14. Pearse R, Dawson D, Fawcett J, et al. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomized, controlled trial. Crit Care 2005;9:R687–R693.

 Post-operative pain
 Quality of life, high complications, increased hospital stay, readmission/cost [1,2]
 Opioids alone for post-op pain [3-5]
 Nausea, sedation, fatigue, addiction –financial / Social cost
 Non-opioids [6-7]
 NSAIDs, paracetamol, gabapentin; Combined analgesia  Synergetic effects [8]
 Multimodal post-operative analgesic protocol successfully reduces opioid
administration both in the hospital and at discharge.
10. Opioid Sparing Multimodal Post-
operative Analgesia
1. Wells N, Pasero C, McCaffery M. Improving the quality of care through pain assessment and management. In: Patient safety and quality: an evidence-based Handbook for nurses. Rockville (MD), 2008.
2. Massicotte L, Chalaoui KD, Beaulieu D, et al. Comparison of spinal anesthesia with general anesthesia on morphine requirement after abdominal hysterectomy. Acta Anaesthesiol Scand 2009;53:641–7.
3. Florence CS, Zhou C, Luo F, et al. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care 2016;54:901–6.
4. Woodhouse A, Mather LE. The effect of duration of dose delivery with patient-controlled analgesia on the incidence of nausea and vomiting after hysterectomy. Br J Clin Pharmacol 1998;45:57–62.
5. Dolin SJ, Cashman JN. Tolerability of acute postoperative pain management: nausea, vomiting, sedation, pruritus, and urinary retention. Evidence from published data. Br J Anaesth 2005;95:584–91.
6. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol 2013;122:319–28.
7. Meyer LA, Lasala J, Iniesta MD, et al. Effect of an enhanced recovery after surgery program on opioid use and patient-reported outcomes. Obstet Gynecol 2018;132:281–90.
8. Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol 2009;22:588–93.

 Preoperative: ORAL paracetamol/celecoxib/gabapentin [1]
 Intraoperative: Incisional bupivacaine [2,3]
 Postoperative: non-opioid ORAL analgesia (tolerate oral diet)
 IV analgesia: Limited to breakthrough pain
 PCA: < 5 % laparotomy
operative Analgesia
1. Ong CKS, Seymour RA, Lirk P, et al. Combining Paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010;110:1170–9
2. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol 2013;122:319–28.
3. Kalogera E, Bakkum-Gamez JN, Weaver AL, et al. Abdominal incision injection of liposomal bupivacaine and opioid use after laparotomy for gynecologic malignancies. Obstet Gynecol 2016;128:1009–17.

 Transverse Abdominis Plane (TAP) block [1-5] (Low*)
 Thoracic epidural [6] (Moderate*)
 Incisional Bupivacaine injection (High*)
 No direct comparison
 Current literature [7-12] : failed to show improvement over local injection
Recommendation grade: Strong (* Level of Evidence)
operative Analgesia
1. Wu CL, Cohen SR, Richman JM, et al. Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis. Anesthesiology 2005;103:1079–88.
2. Carli F, Mayo N, Klubien K, et al. Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 2002;97:540–9.
3. Ready LB. Acute pain: lessons learned from 25,000 patients. Reg Anesth Pain Med 1999;24:499–505.
4. Hübner M, Blanc C, Roulin D, et al. Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway. Ann Surg 2015;261:648–53.
5. Chen L-M, Weinberg VK, Chen C, et al. Perioperative outcomes comparing patient-controlled epidural versus intravenous analgesia in gynecologic oncology surgery. Gynecol Oncol 2009;115:357–61.
6. Champaneria R, Shah L, Geoghegan J, et al. Analgesic effectiveness of transversus abdominis plane blocks after hysterectomy: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2013;166:1–9.
7. Gasanova I, Alexander J, Ogunnaike B, et al. Transversus abdominis plane block versus surgical site infiltration for pain management after open total abdominal hysterectomy. Anesth Analg 2015;121:1383–8.
8. Levy BF, Scott MJ, Fawcett W, et al. Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery. Br J Surg 2011;98:1068–78.
9. Calle GA, López CC, Sánchez E, et al. Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial. Acta Obstet Gynecol Scand 2014;93:345–50.
10. Kane SM, Garcia-Tomas V, Alejandro-Rodriguez M, et al. Randomized trial of transversus abdominis plane block at total laparoscopic hysterectomy: effect of regional analgesia on quality of recovery. Am J Obstet Gynecol 2012;207:419.e1–419.e5.
11. El Hachem L, Small E, Chung P, et al. Randomized controlled double-blind trial of transversus abdominis plane block versus trocar site infiltration in gynecologic laparoscopy. Am J Obstet Gynecol 2015;212:182.e1–182.e9.
12. Torgeson M, Kileny J, Pfeifer C, et al. Conventional epidural vs transversus abdominis plane block with liposomal bupivacaine: a randomized trial in colorectal surgery. J Am Coll Surg 2018;227:78–83

 Maintenance of Appropriate post-op nutrition
 Early return of bowel activity, short hospital stay
 Equivalent complication rate [7]: Pulmonary, wound healing, anastomosis leaks
 Immune Nutrition and High Protein diet
 Low risk of infection and hospital stay
 A Regular diet within the first 24 hours after Gynecologic/oncology surgery
is recommended.
 High protein diet may be considered in post-operative surgical patients
11. Perioperative Nutrition [1-6]
1. Cutillo G, Maneschi F, Franchi M, et al. Early feeding compared with nasogastric decompression after major oncologic gynecologic surgery: a randomized study. Obstet Gynecol 1999;93:41–5.
2. Charoenkwan K, Matovinovic E. Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev 2014;12.
3. Minig L, Biffi R, Zanagnolo V, et al. Early oral versus "traditional“ postoperative feeding in gynecologic oncology patients undergoing intestinal resection: a randomized controlled trial. Ann Surg Oncol 2009;16:1660–8.
4. Minig L, Biffi R, Zanagnolo V, et al. Reduction of postoperative complication rate with the use of early oral feeding in gynecologic oncologic patients undergoing a major surgery: a randomized controlled trial. Ann Surg Oncol 2009;16:3101–10.
5. Pearl ML, Valea FA, Fischer M, et al. A randomized controlled trial of early postoperative feeding in gynecologic oncology patients undergoing intra-abdominal surgery. Obstet Gynecol 1998;92:94–7.
6. Schilder JM, Hurteau JA, Look KY, et al. A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecol Oncol 1997;67:235–40.
7. Wischmeyer PE, Carli F, Evans DC, et al. American Society for enhanced recovery and perioperative quality initiative joint consensus statement on nutrition screening and therapy within a surgical enhanced recovery pathway. Anesth Analg 2018;126:1883–95.

 30 % - 40 % in gynecologic oncology surgery [1,2]
 Preventive Measures [3-7] (2-5 x low)
 MIS, Euvolemia,
 Opioids sparing analgesia,
 Early mobilization, Early feeding,
 Coffee Consumption,
 Gum Chewing ?[8], and
 Alvimopan [9-11]
12. Prevention of Post-operative Ileus
1. Güngördük K, Özdemir İsa Aykut, Güngördük Özgü, et al. Effects of coffee consumption on gut recovery after surgery of gynecological cancer patients: a randomized controlled trial. Am J Obstet Gynecol 2017;216:145.e1–145.e7.
2. Bakkum-Gamez JN, Langstraat CL, Martin JR, et al. Incidence of and risk factors for postoperative ileus in women undergoing primary staging and debulking for epithelial ovarian carcinoma. Gynecol Oncol 2012;125:614–20.
3. Müller SA, Rahbari NN, Schneider F, et al. Randomized clinical trial on the effect of coffee on postoperative ileus following elective colectomy. Br J Surg 2012;99:1530–8.
4. Bisch SP, Wells T, Gramlich L, et al. Enhanced recovery after surgery (ERAS) in gynecologic oncology: system-wide implementation and audit leads to improved value and patient outcomes. Gynecol Oncol 2018;151:117–23.
5. Boitano TKL, Smith HJ, Rushton T, et al. Impact of enhanced recovery after surgery (ERAS) protocol on gastrointestinal function in gynecologic oncology patients undergoing laparotomy. Gynecol Oncol 2018;151:282–6.
6. Jernigan AM, Chen CCG, Sewell C. A randomized trial of chewing gum to prevent postoperative ileus after laparotomy for benign gynecologic surgery. Int J Gynaecol Obstet 2014;127:279–82.
7. Vergara-Fernandez O, Gonzalez-Vargas AP, Castellanos-Juarez JC, et al. Usefulness of gum chewing to decrease postoperative ileus in colorectal surgery with primary anastomosis: a randomized controlled trial. Rev Invest Clin 2016;68:314–8.
8. de Leede EM, van Leersum NJ, Kroon HM, et al. Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery. Br J Surg 2018;105:820–8.
9. Wolff BG, Weese JL, Ludwig KA, et al. Postoperative ileus-related morbidity profile in patients treated with Alvimopan after bowel resection. J Am Coll Surg 2007;204:609–16.
10. Lee CT, Chang SS, Kamat AM, et al. Alvimopan accelerates gastrointestinal recovery after radical cystectomy: a multicenter randomized placebo-controlled trial. Eur Urol 2014;66:265–72.
11. Bakkum-Gamez JN, Langstraat CL, Lemens MA, et al. Accelerating gastrointestinal recovery in women undergoing ovarian cancer debulking: a randomized, double-blind, placebo-controlled trial. Gynecol Oncol 2016;141.

 Consistent collection and documentation of patient reported outcomes within
ERAS programs allow institutions to monitor, understand, and compare
functional recovery in a patient-centered fashion.
 Patient reported outcomes, including symptom burden assessment, can also be
utilized to guide individual post-operative care.
13. Patient Reported Outcomes, Including
Functional Recovery

14. Role of ERAS in Pelvic Exenteration
and HIPEC
 Currently, a paucity of data on the impact of an ERAS program specifically
targeting patients undergoing high complexity procedures, such as pelvic
exenteration and HIPEC surgery.
 Further research is needed from high-volume referral centers in order to
document outcomes of ERAS programs in this patient population.
Recommendation grade: Weak

15. ERAS Audit and Reporting
 Auditing is an essential component of an ERAS program.
 Reports on ERAS pathways should include detailed information on the
relationship between outcomes and compliance with individual ERAS
elements.

ERAS Items
(Unchanged from 1st Version)
 Pre-operative optimization
 4 weeks – smoking/alcohol cessation, anemia correction
 Pre-anesthetic medication
 Avoid sedative for anxiety
 Nausea and Vomiting Prophylaxis
 Multimodal approach, > 2 anti-emetic in postoperative time
 Urinary Drainage / Catheter (< 24 hours)
 Early mobilization (< 24 hours)

Summary
Continued Quality Improvement Team Activities
Analyze and share quality measures, patient survey, an staff input to celebrate successes and identify opportunities for improvement
Post-discharge Phase
Monitor for symptoms or changes in health
to seek assistance
Follow-up with surgeon, primary care and/or
specialty care
Continue therapy and other interprofessional
activities as planned
Postoperative Phase
Early nutrition Early mobilization
Multimodal
analgesia
Nausea/Vomiting
management
No or judicious IV
fluid management
Patient & family
education
Intraoperative Phase
Opioid Sparing
multimodal
analgesia
Normothermia
Nausea/Vomiting
prophylaxis
Normovolemia Normoglycemia
Avoid tubes and
drains
Preoperative Phase
Limit fasting (light meal up to 6
hrs. preop)
Carbohydrate beverage up to 2
hrs. preop
Initial multimodal medications
and/or regional block placement
Discharge planning, education,
and home medication plan
Pre-hospital Phase
Patient/family education Pain management plan Patient optimization Prehabilitation of select patients

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ERAS Gynecologic Oncology (2019).pptx

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