Enhanced recovery after surgery (ERAS®) in gynecologic oncology - Practical considerations for program development.

Abstract

•There is widespread interest in the ERAS® guidelines for gynecologic oncology.•Many clinical departments still struggle with how to initiate their ERAS® program.•These recommendations will help translate the ERAS® guidelines into practice. There has been widespread interest in the Enhanced Recovery After Surgery (ERAS®) guidelines in gynecologic oncology [1Nelson G. Altman A. Nick A. Meyer L. Ramirez P.T. Achtari C. Antrobus J. Huang J. Scott M. Wijk L. Acheson N. Ljungqvist O. Dowdy S.C. Guidelines for pre- and intraoperative care in gynecologic/oncology surgery: enhanced recovery after surgery (ERAS) society recommendations – part I.Gynecol. Oncol. 2016; 140: 313-322Abstract Full Text Full Text PDF PubMed Scopus (271) Google Scholar, 2Nelson G. Altman A. Nick A. Meyer L. Ramirez P.T. Achtari C. Antrobus J. Huang J. Scott M. Wijk L. Acheson N. Ljungqvist O. Dowdy S.C. guidelines for post-operative care in gynecologic/oncology surgery: enhanced recovery after surgery (eras) society recommendations – part ii.Gynecol. Oncol. 2016; 140: 323-332Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar] as evidenced by these articles being among the most downloaded from the Journal since February 2016 [[3]https://www.journals.elsevier.com/gynecologic-oncology/Google Scholar]. Despite this, many clinical departments still grapple with how to initiate their ERAS® program, particularly as it relates to translating the guidelines into an actual protocol. To date there have been few programs that have fully implemented a structured ERAS® program in gynecologic oncology – remembering that a formal program requires three elements: i) an ERAS® protocol, ii) an audit system (database) to review protocol compliance and clinical outcomes, and iii) an ERAS® team that iterates towards improved compliance and outcomes [4Kalogera E. Bakkum-Gamez J.N. Jankowski C.J. Trabuco E. Lovely J.K. Dhanorker S. Grubbs P.L. Weaver A.L. Haas L.R. Borah B.J. Bursiek A.A. Walsh M.T. Cliby W.A. Dowdy S.C. Enhanced recovery in gynecologic surgery.Obstet. Gynecol. 2013; 122: 319-328Crossref PubMed Google Scholar, 5Miralpeix E. Nick A.M. Meyer L.A. Cata J. Lasala J. Mena G.E. Gottumukkala V. Iniesta-Donate M. Salvo G. Ramirez P.T. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs.Gynecol. Oncol. 2016; 141: 371-378Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar, 6Nelson G. Altman A.D. Enhanced recovery after surgery interactive audit system for gynecologic/oncology surgery – importance of measuring protocol element compliance (you don't know what you don't measure!).Gynecol. Oncol. 2017; 145: 191Abstract Full Text Full Text PDF Google Scholar]. In order to address the growing demand for assistance in initiating an ERAS® program, we describe below a series of recommendations to serve as a primer for program development. While these recommendations are primarily aimed at patients undergoing laparotomy for gynecologic cancer, the majority of the recommendations are equally applicable to those undergoing minimally invasive surgery. Some protocol recommendations are quite prescriptive and include dosages and timing of administration, while others are more general and will require discussion among the ERAS® team prior to implementation. In rare instances, no standard of care exists and more than one option is provided. All patients should undergo extensive counseling by the surgeon, advanced practice provider, clinical nurse, and anesthesiologist regarding anticipated expectations of the patient and the healthcare team. An informational brochure that addresses patient expectations and provides education regarding the ERAS® protocol should be provided in each patient's preoperative information package. The use of preoperative bowel preparation continues to be an area of controversy in which no standard of care exists. A multitude of randomized trials have demonstrated that mechanical bowel preparation alone has no impact on rates of surgical site infection (SSI) or enteric leak, but may result in electrolyte imbalances and dehydration, and interfere with maintenance of euvolemia [[7]Guenaga K.F. Matos D. Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery.Cochrane Database Syst. Rev. 2011; : CD001544PubMed Google Scholar]. Retrospective data has shown that combining mechanical bowel preparation with oral antibiotics is associated with reduced rates of SSI and enteric leak [[8]Scarborough J.E. Mantyh C.R. Sun Z. Migaly J. Combined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection: an analysis of colectomy-targeted ACS NSQIP.Ann. Surg. 2015; 262: 331-337Crossref PubMed Scopus (197) Google Scholar]. However, some gynecologic oncology practices have published very low rates of SSI and enteric leak despite omission of mechanical bowel preparation and oral antibiotics [[9]Johnson M.P. Kim S.J. Langstraat C.L. Jain S. Habermann E.B. Wentink J.E. et al.Using bundled interventions to reduce surgical site infection after major gynecologic cancer surgery.Obstet. Gynecol. 2016 Jun; 127: 1135-1144Crossref PubMed Scopus (71) Google Scholar]. Thus, the decision for bowel preparation must be made according to the stance taken at each institution and, if included, should contain an oral antibiotic component. Eliminating prolonged fasting prior to surgery remains an obstacle at many institutions. Anesthesiologists should be aware that the recommendations below are taken directly from the American Society of Anesthesiologist's own guidelines [[10]Anesthesiology. 2011; 114: 495-511Crossref PubMed Scopus (624) Google Scholar]. □Bowel preparation-No mechanical bowel preparation [[7]Guenaga K.F. Matos D. Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery.Cochrane Database Syst. Rev. 2011; : CD001544PubMed Google Scholar]-If oral bowel preparation included, Neomycin 1 g PO + metronidazole 500 mg PO at 1:00 PM, 2:00 PM, and 10:00 PM day prior to surgery [[11]Ohman K.A. Wan L. Guthrie T. Johnston B. Leinicke J.A. Glasgow S.C. et al.Combination of oral antibiotics and mechanical bowel preparation reduces surgical site infection in colorectal surgery.J. Am. Coll. Surg. 2017 Jul 6; (pii: S1072-7515(17)30593-8)https://doi.org/10.1016/j.jamcollsurg.2017.06.011Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]-Rectal enema prn prior to procedure start if anticipating low anterior resection□Evening before surgery-If morning case: may eat solids until midnight-If afternoon case: light snack (dry toast and fruit) allowed up to 6–8 h prior to procedure [[10]Anesthesiology. 2011; 114: 495-511Crossref PubMed Scopus (624) Google Scholar]□Morning of surgery-May ingest clear fluids (excluding alcohol) up to 2–4 h before procedure-Carbohydrate loading drink (preferably composed of complex carbohydrates that empty readily from the stomach) 2 h prior to surgery [12Barazzoni R. Deutz N.E.P. Biolo G. Bischoff S. Boirie Y. Cederholm T. et al.Carbohydrates and insulin resistance in clinical nutrition: recommendations from the ESPEN expert group.Clin. Nutr. 2017 Apr; 36: 355-363Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 13Scott M.J. Fawcett W.J. Oral carbohydrate preload drink for major surgery - the first steps from famine to feast.Anaesthesia. 2014 Dec; 69: 1308-1313Crossref PubMed Scopus (15) Google Scholar, 14Smith M.D. McCall J. Plank L. Herbison G.P. Soop M. Nygren J. Preoperative carbohydrate treatment for enhancing recovery after elective surgery.Cochrane Database Syst. Rev. 2014; Google Scholar] (To be administered in the preoperative holding area; dose adjustment may be required based on age and/or co-morbid condition; see Fig. 1)□Acetaminophen 1000 mg PO/IV once□Celecoxib 400 mg PO once□Tramadol-ER 300 mg PO once□Gabapentin 300–600 mg PO once or Pregabalin 75 mg PO once For patients undergoing minimally invasive surgery, especially within the context of anticipated discharge on the day of surgery, omission of Tramadol ER and Gabapentin/Pregabalin as premedication is a reasonable consideration. □Heparin 5000 U SC given preoperatively or after induction of anesthesia [[15]Lyman G.H. Khorana A.A. Kuderer N.M. Lee A.Y. Arcelus J.I. Balaban E.P. 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: 2189-2204Crossref PubMed Scopus (671) Google Scholar]□Sequential compression devices placed prior to induction of anesthesia The specific anesthetic protocol utilized will vary between institutions, but we encourage standardization within each practice. To that aim, we have provided general guidelines focused towards recovery, rather than simply intraoperative status. Maintaining euvolemia during the entire perioperative period is particularly critical and requires excellent communication with the anesthesiology team. The use of local wound infiltration is accompanied by minimal side effects and may contribute to significant reductions in opioid requirements in the postoperative period. □Bathe or shower with soap or antiseptic agent the night before surgery [[16]Berríos-Torres S.I. Umscheid C.A. Bratzler D.W. Leas B. Stone E.C. Kelz R.R. et al.Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.JAMA Surg. 2017 May 3; https://doi.org/10.1001/jamasurg.2017.0904Crossref PubMed Scopus (1460) Google Scholar]□Chlorhexidine–alcohol for skin cleansing [[17]Darouiche R.O. Wall Jr., M.J. Itani K.M. Otterson M.F. Webb A.L. Carrick M.M. et al.Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis.N. Engl. J. Med. 2010 Jan 7; 362: 18-26Crossref PubMed Scopus (968) Google Scholar]□If no bowel resection anticipated: Cefazolin 2 g IV before incision (3 g if weight > 120 kg)□If bowel resection anticipated: Cefazolin 2 g IV before incision (3 g if weight > 120 kg) + Metronidazole 500 mg IV or Ertapenem 1 g IV [[18]Mahajan S.N. Ariza-Heredia E.J. Rolston K.V. Graviss L.S. Feig B.W. Aloia T.A. Chemaly R.F. Perioperative antimicrobial prophylaxis for intra-abdominal surgery in patients with cancer: a retrospective study comparing ertapenem and nonertapenem antibiotics.Ann. Surg. Oncol. 2014; 21: 513-519Crossref PubMed Scopus (12) Google Scholar] Administer postoperative nausea and vomiting (PONV) prophylaxis using ≥2 antiemetics (multimodal approach) given that patients undergoing gynecologic oncology surgery typically are at high risk for PONV [[19]Gan T.J. Diemunsch P. Habib A.S. Kovac A. Kranke P. Meyer T.A. et al.Consensus guidelines for the management of postoperative nausea and vomiting.Anesth. Analg. 2014 Jan; 118: 85-113Crossref PubMed Scopus (920) Google Scholar]. Antiemetics to choose from include:□Aprepitant 40 mg PO at induction□Dexamethasone 4–5 mg IV at induction□Droperidol 0.625–1.25 mg IV end of surgery□Ondansetron 4 mg IV end of surgery□Promethazine 6.25–12.5 mg IV at induction or end of surgery□Scopolamine transdermal patch prior evening or 2 h before surgery □Epidural or spinal where indications exist [20Oh T.K. Lim M.C. Lee Y. Yun J.Y. Yeon S. Park S.Y. Improved postoperative pain control for cytoreductive surgery in women with ovarian cancer using patient-controlled epidural analgesia.Int. J. Gynecol. Cancer. 2016 Mar; 26: 588-593Crossref PubMed Scopus (13) Google Scholar, 21Hughes M.J. Ventham N.T. McNally S. Harrison E. Wigmore S. Analgesia after open abdominal surgery in the setting of enhanced recovery surgery: a systematic review and meta-analysis.JAMA Surg. 2014 Dec; 149: 1224-1230Crossref PubMed Scopus (104) Google Scholar]□Opioid sparing techniques and multimodal analgesia.□Consideration of Total Intravenous Anesthesia (TIVA), suggestions include:-Propofol (main anesthetic agent) titrated to clinical effect and bispectral index (BIS) 40–60-Dexamethasone 10 mg IV-Acetaminophen 1000 mg IV q6 h-Dexmedetomidine 0.3 mcg/kg/h IV-Ketamine 10 mg/h IV-Lidocaine 2 mg/min IV□Short acting anesthetic agents (e.g. sevoflurane, desflurane, nitrous oxide) should be used if TIVA not performed.□Local wound infiltration (options):-Bupivicaine 0.25% with epinephrine at incision site-Liposomal bupivacaine 266 mg (20 mL) diluted to at least 180 mL of sterile saline injected at incision site [[22]Kalogera E. Bakkum-Gamez J.N. Weaver A.L. Moriarty J.P. Borah B.J. Langstraat C.L. et al.Abdominal incision injection of liposomal bupivacaine and opioid use after laparotomy for gynecologic malignancies.Obstet. Gynecol. 2016 Nov; 128: 1009-1017Crossref PubMed Scopus (38) Google Scholar]-Subcostal Transversus Abdominus Plane (sTAP) infiltration of Bupivicaine 0.25% with epinephrine and Transversus Abdominis Plane (TAP) infiltration to cover all 4 quadrants. □Avoidance of surgical drains [[23]Kalogera E. Dowdy S.C. Mariani A. Aletti G. Bakkum-Gamez J.N. Cliby W.A. Utility of closed suction pelvic drains at time of large bowel resection for ovarian cancer.Gynecol. Oncol. Sep 2012; 126: 391-396Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar] and nasogastric tubes [[24]Cheatham M.L. Chapman W.C. Key S.P. Sawyers J.L. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy.Ann. Surg. 1995; 221: 469-476Crossref PubMed Scopus (411) Google Scholar] □Use of active warming device (started in preoperative holding area if possible) [[16]Berríos-Torres S.I. Umscheid C.A. Bratzler D.W. Leas B. Stone E.C. Kelz R.R. et al.Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.JAMA Surg. 2017 May 3; https://doi.org/10.1001/jamasurg.2017.0904Crossref PubMed Scopus (1460) Google Scholar] □Use of lactated ringers to reduce salt load□Very restrictive or liberal fluid regimes should be avoided□Use of goal-directed fluid therapy (non-invasive cardiac output monitoring) where available. To a large extent, rapid recovery is a function of adherence to pre- and intra-operative optimization elements. Only the minimum amount of opioid should be used to achieve pain control in the postoperative period that allows for ambulation, while reducing nausea, constipation, and the potential for opioid dependence. □Solid diet (regular or low fat/fiber) started postoperative day (POD) 0 [[25]Charoenkwan K. Phillipson G. Vutyavanich T. Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery.Cochrane Database Syst. Rev. 2007; : CD004508PubMed Google Scholar]□Chewing gum orally for 30 min after meals three times per day (TID) as tolerated starting on POD 0 [[26]Ertas I.E. Gungorduk K. Ozdemir A. Solmaz U. Dogan A. Yildirim Y. Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial.Gynecol. Oncol. 2013 Oct; 131: 118-122Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar]□Oral Nutritional Supplement (e.g. Ensure Plus, Twocal HN) on POD 0 and continue until discharge□Glycemic control to maintain blood glucose levels <200 mg/dL [[16]Berríos-Torres S.I. Umscheid C.A. Bratzler D.W. Leas B. Stone E.C. Kelz R.R. et al.Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.JAMA Surg. 2017 May 3; https://doi.org/10.1001/jamasurg.2017.0904Crossref PubMed Scopus (1460) Google Scholar] □Acetaminophen 1000 mg PO q6h (should not exceed 4000 mg/24 h from all sources) (start POD 0)□Ibuprofen 400–800 mg PO q6h (start POD 1)□Pregabalin 75 mg PO BID × 48 h (start pm POD 1) If scheduled acetaminophen and ibuprofen ineffective (or if contraindications exist):□Oxycodone 5–10 mg PO q4 h prn□Tramadol 100 mg PO q4-6 h prn□Opioid IV (e.g. hydromorphone 0.5 mg IV q30 min prn) only if PO opioid medications ineffective within 30 min□PCA started only if patient requires two doses or more of IV opioids in a 24 h period □Ondansetron 4 mg PO q6 h prn nausea□Prochlorperazine 10 mg IV q6h breakthrough nausea after 30 min Ondansetron □Fluids at 40 mL/h postoperatively (typical duration 8–12 h)□Fluid bolus of 250–500 mL for urine output <20 mL/h□Peripheral lock IV when patient has 600 mL oral intake □Remove Foley catheter POD1 in am in the absence of contraindications (i.e. bladder reconstruction) [[27]Ahmed M.R. Sayed Ahmed W.A. Atwa K.A. Metwally L. Timing of urinary catheter removal after uncomplicated total abdominal hysterectomy.Eur. J. Obstet. Gynecol. Reprod. Biol. 2014; 176: 60-63Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar] □Ambulate 8×/day□All meals in chair□Out of bed 8 h/day □Senna 1–2 tabs PO qhs□Magnesium hydroxide 25 mL PO qhs□Lactulose 15–30 mL PO TID□Polyethylene glycol (PEG) 3350 17 g PO daily□Psyllium mucilloid powder 1–2 packets PO daily □Low molecular weight heparin (e.g. Dalteparin 5000 U SC daily or equivalent) starting POD 1 (regimen continued for 28 days for all patients undergoing laparotomy for cancer) [[15]Lyman G.H. Khorana A.A. Kuderer N.M. Lee A.Y. Arcelus J.I. Balaban E.P. 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: 2189-2204Crossref PubMed Scopus (671) Google Scholar]□Sequential compression devices while in bed in hospital Audit is a necessary component within an ERAS® program. Either use of the ERAS® Interactive Audit System (EIAS) or a tailored database allows measurement of compliance to the individual recommendations within the ERAS® Gynecologic/Oncology guidelines [1Nelson G. Altman A. Nick A. Meyer L. Ramirez P.T. Achtari C. Antrobus J. Huang J. Scott M. Wijk L. Acheson N. Ljungqvist O. Dowdy S.C. Guidelines for pre- and intraoperative care in gynecologic/oncology surgery: enhanced recovery after surgery (ERAS) society recommendations – part I.Gynecol. Oncol. 2016; 140: 313-322Abstract Full Text Full Text PDF PubMed Scopus (271) Google Scholar, 2Nelson G. Altman A. Nick A. Meyer L. Ramirez P.T. Achtari C. Antrobus J. Huang J. Scott M. Wijk L. Acheson N. Ljungqvist O. Dowdy S.C. guidelines for post-operative care in gynecologic/oncology surgery: enhanced recovery after surgery (eras) society recommendations – part ii.Gynecol. Oncol. 2016; 140: 323-332Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar]. At a minimum, the database should record each of the compliance elements and also importantly length of hospital stay (LOS), readmissions, and complications until 30 days post-discharge. It is well established that improved overall compliance is associated with reductions in both complications and hospital stay [[28]ERAS Compliance Group The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry.Ann. Surg. 2015; 261: 1153-1159Crossref PubMed Scopus (435) Google Scholar]. Audit allows the establishment of baseline compliance, LOS and complications pre-ERAS® implementation such that following formal implementation of the ERAS® program, efforts can be focused on areas where compliance is less than ideal and therefore iterate towards improved outcomes. A critical component for any successful ERAS® program is the development of a multi-disciplinary team that facilitates input from varying expertise and perspectives with the ultimate goal of reviewing ERAS® element compliance (obtained from audit) and iterating towards improved perioperative outcomes. In order to establish such a team, the following members should be considered:•Gynecologic oncology surgeons•Anesthesiologists and nurse anesthetists•Residents, fellows, advanced practice providers (NP/PAs)•Preoperative nursing team•Operating room nursing team•Recovery room nursing team•Outpatient and inpatient nursing team•Outpatient and inpatient pharmacist•Preoperative and postoperative dietitian•Research data coordinators•Data manager and statistician It is highly recommended that the team meet consistently (at minimum every two weeks) to ensure that there is continuity of flow in addressing critical issues regarding implementation, compliance, and growth of the ERAS® program. Team members should also be leaders in their respective disciplines in order to communicate practice changes back to each stakeholder group to facilitate implementation and troubleshooting. The initiation of an ERAS® program requires steadfast effort from the entire team along the surgical care continuum. The benefits of such efforts are well established with the majority of clinical units now consistently reporting reductions in LOS and complications [[29]Ljungqvist O. Scott M. Fearon K.C. Enhanced recovery after surgery: a review.JAMA Surg. 2017 Mar 1; 152: 292-298https://doi.org/10.1001/jamasurg.2016.4952Crossref PubMed Scopus (1563) Google Scholar], both of which are beneficial to the patient and healthcare system [[30]Nelson G. Kiyang L.N. Crumley E.T. Chuck A. Nguyen T. Faris P. et al.Implementation of Enhanced Recovery After Surgery (ERAS) across a provincial healthcare system: the ERAS Alberta colorectal surgery experience.World J. Surg. 2016; 40: 1092-1103Crossref PubMed Scopus (129) Google Scholar]. Recent economic analyses have shown that ERAS® resulted in cost-savings of US$4219-7642 per patient and highlight that ERAS® is an excellent example of value based surgery [31Visioni A. Shah R. Gabriel E. Attwood K. Kukar M. Nurkin S. Enhanced recovery after surgery for noncolorectal surgery?: a systematic review and meta-analysis ofmajor abdominal surgery.Ann. Surg. 2017; (Epub ahead of print)https://doi.org/10.1097/SLA.0000000000002267Crossref PubMed Scopus (124) Google Scholar, 32Ljungqvist O. Thanh N.X. Nelson G. ERAS - value based surgery.J. Surg. Oncol. 2017 Sep 5; (Epub ahead of print)https://doi.org/10.1002/jso.24820Crossref PubMed Scopus (47) Google Scholar]. Some studies have even suggested there is a survival benefit when patients are cared for with an ERAS® pathway [[33]Savaridas T. Serrano-Pedraza I. Khan S.K. Martin K. Malviya A. Reed M.R. Reduced medium-term mortality following primary total hip and knee arthroplasty with an enhanced recovery program: a study of 4,500 consecutive procedures.Acta Orthop. 2013; 84: 40-43Crossref PubMed Scopus (84) Google Scholar], although this observation requires further validation.