Enhanced Recovery After Surgery Guidelines Research Articles

Impact of Early Mobilization on Recovery after Major Head and Neck Surgery with Free Flap Reconstruction.

Surgery with free flap reconstruction is a standard treatment for head and neck cancer (HNC). Because of the complexity of HNC surgery, recovery can be challenging, and complications are common. One of the foundations of enhanced recovery after surgery (ERAS) is early postoperative mobilization. The ERAS guidelines for HNC surgery with free flap reconstruction recommend mobilization within 24 h. This is based mainly on evidence from other surgical disciplines, and the extent to which mobilization within 24 h improves recovery after HNC surgery has not been explored. This retrospective analysis included 445 patients from the Calgary Head and Neck Enhanced Recovery Program. Mobilization after 24 h was associated with more complications of any type (OR = 1.73, 95% CI [confidence interval] = 1.16-2.57) and more major complications (OR = 1.76; 95% CI = 1.00-3.16). When accounting for patient and clinical factors, mobilization after 48 h was a significant predictor of major complications (OR = 2.61; 95% CI = 1.10-6.21) and prolonged length of stay (>10 days; OR = 2.85, 95% CI = 1.41-5.76). This comprehensive analysis of the impact of early mobilization on postoperative complications and length of stay in a large HNC cohort provides novel evidence supporting adherence to the ERAS early mobilization recommendations. Early mobilization should be a priority for patients undergoing HNC surgery with free flap reconstruction.

Canadian Enhanced Recovery After Surgery (ERAS) Cesarean Delivery Perioperative Management Survey

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative that has spread across numerous surgical disciplines. The uptake of ERAS in cesarean delivery in Canada is presently unknown. This study surveyed the current practices of Society of Obstetricians and Gynaecologists of Canada (SOGC) members with regards to ERAS guidelines for preoperative, intraoperative, and postoperative cesarean delivery care. Survey responses highlight perioperative practice variations across Canada. Active implementation of ERAS cesarean delivery guidelines could potentially lessen variations in perioperative care, improve patient outcomes, and minimize health care costs.

Impact of standardized clinical pathways on esophagectomy: a systematic review and meta-analysis.

Esophageal surgery is historically associated with adverse postoperative outcomes. Selected high-volume centers have previously reported the effect on clinical outcomes following the adoption of a standardized clinical pathway (SCP). This meta-analysis aims to evaluate the current literature to document the effect of SCP and enhanced recovery after surgery (ERAS) on esophagectomy outcomes. A literature search was conducted through the main search engines (PubMed, Embase, Medline, and Cochrane database) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. All eligible comparative studies (randomized control trial, prospective, retrospective, and combined) were identified and assessed based on Methodological Index for Non-Randomized Studies and Jadad quality criteria. Data concerning overall morbidity, early mortality, and length of stay (LOS) were primarily collected and compared. Secondary outcomes included anastomotic leaks, pulmonary complications, and readmission rate. Twenty-six articles (including five randomized controlled trials and six prospective trials) were included in the analysis. Overall study quality was moderate and the included studies utilized a variable approach to SCP. No statistically significant differences were found between groups in terms of overall morbidity, postoperative mortality, anastomotic leak, and readmission rates. Significant improvements included pulmonary complications (odds ratios [OR] 0.66, 95% confidence interval [CI] 0.49-0.94) and hospital LOS (OR -3.68, 95% CI -4.49 to -2.87). Previous reports of SCP within esophagectomy programs have demonstrated clinical improvements in postoperative pulmonary complications and LOS. Given the high heterogeneity historically demonstrated within SCPs, further improvement in outcomes should be expected following the adoption of standardized ERAS guidelines.

O83: COMPASS – MANAGEMENT OF COMPLICATED INTRA-ABDOMINAL COLLECTIONS AFTER COLORECTAL SURGERY, A EUROSURG COLLABORATIVE INTERNATIONAL STUDY

Abstract Presenting Author Email: ruthblancocolino@gmail.com Research question To explore current practices on the use of prophylactic postoperative drains in colorectal surgery and whether it influences 30-day postoperative outcomes. Background and aim Traditionally, postoperative drains have been used in colorectal surgery for the prevention or early detection of intraabdominal collections. However, current evidence suggests there is no clear clinical benefit to prophylactic drain placement following colorectal surgery, and Enhanced Recovery After Surgery (ERAS) guidelines recommend against their routine use. Nevertheless, a previous international audit by Eurosurg (Ileus Management International) found more than a third of participating centres routinely placed a drain in more than half of their patients. Therefore, this study aims to audit compliance to ERAS guidelines regarding the use of postoperative drains in colorectal surgery. Design Patients Adult patients undergoing elective and emergency colorectal surgery will be included. Procedures under any surgical approach including any formation of colostomy or ileostomy, resection of large bowel, or reversal of stoma will be eligible. Patients undergoing appendicectomy, transanal surgery, primarily urological, gynaecological or vascular procedure, surgery involving multivisceral resection, diagnostic laparotomy or laparoscopy or hernia surgery without colorectal resection, will be excluded. Comparator Group of patients receiving a prophylactic drain after surgery. Main explanatory variable will be intrabdominal collections rate including anastomotic leak. Outcomes The primary outcome measure will be the adherence to selected ERAS guidelines regarding rate of routine prophylactic drain insertion in colorectal surgery. As Secondary outcome measures we will assess: • Rate of intra-abdominal postoperative collections, defined as collections which alter the normal postoperative course (e.g. requiring either medical, radiological, endoscopic or surgical intervention). • Time-to-diagnosis (days) of intra-abdominal postoperative collections defined as collections which alter the normal postoperative course. • Rate of drain-related complications defined as: surgical site infection by Centers for Disease Control and Prevention definition; cutaneous irritation at the drain insertion site; small bowel evisceration and herniation of omentum, bowel injury (defined as intraoperative identification of or CT-proven drain-related iatrogenic bowel perforation); time (measured in whole days) until drain removal and drain output (quantity and contents) on day of removal; and overall 30-day adverse event rate as defined by the Clavien-Dindo scale of postoperative complications and length of stay (days). Study design This is a prospective, multicentre, audit that will be conducted through the student- and trainee-led EuroSurg collaborative network across Europe, South Africa and Australasia. Data will be collected on consecutive 14-day periods, from 3rd February to 26th April 2020, with 30-day follow-up on included patients. Data will be collected online on REDCap database based on Birmingham University. Team and infrastructure The study will be run by the European Student Research Collaborative. EuroSurg is a pan-European student- and trainee-led surgical which also counts with international collaboration from Australia, New Zealand and South Africa. The study will be coordinated by the International Study Management Group and at each participating country, there will be a core of national leads or national collaborative in charge of organising the study locally. Each hospital will count with a Local Lead who will coordinate the mini-teams based at their centre and will be in contact with its corresponding National Leads. A mini-team will be composed by three collaborators collecting data and a supervising consultant per centre. As infrastructure for leading the project, we will use social media for study diffusion including Twitter, Facebook, Instagram and LinkedIn, and emails through Gmail official account and Mailchimp. Management group communications will be held through WhatsApp, Slack and Skype.

V1 Enhanced Recovery After Surgery (ERAS) compliance in elective colorectal surgery: an international multicentre survey

IntroductionERAS protocols are widely endorsed after colorectal surgery. This study aims to describe compliance with the individual principles of ERAS across an international setting.MethodsA hospital-level survey was administered. This aimed to describe hospital-level compliance to 17 principles of ERAS after elective colorectal surgery. The questionnaire was mandatory for all hospitals participating in an international cohort study on colorectal surgery between October 2017 and July 2018.ResultsA total of 422 hospitals took part in the cohort study and submitted questionnaires. Most hospitals (90%) were located in Europe. The overall median compliance was 14 out of 17 items. Only 13.7% of centres were compliant with all 17 items. High compliance was noted for items: patient counseling (91%); antibiotic prophylaxis (91.5%); venous thromboembolism prophylaxis (98.8%); early mobilization (97.2%); and avoidance of hypothermia (92.5%). Lower compliance was noted for items: preoperative oral carbohydrates (55.4%), standardized anesthesia protocol, (68.6%), early oral tolerance (69.8%), avoidance of abdominal drain (64.4%), and avoidance of mechanical bowel preparation (59.3%).ConclusionOverall compliance with ERAS guidelines was high however there is still scope for improvement. New strategies should be considered to attain full adherence to ERAS guidelines in the management of patients undergoing elective colorectal surgery.

Enhanced Recovery after Surgery: Perspective in Elder Women.

Enhanced recovery after surgery (ERAS) is a multimodal convention first reported for colorectal and gynecologic procedures. The main benefits have been a shorter length of stay and reduced complications, leading to improved clinical outcomes and cost savings substantially. With increase in life expectancy, recent years has shown a significant rise in advanced age population, and similarly, a rise in age-related disorders requiring surgical management. Due to pathophysiological and metabolic changes in geriatric age group with increased incidence of medical comorbidities, there is higher risk of enhanced surgical stress response with undesirable postoperative morbidity, complications, prolonged immobility, and extended convalescence. The feasibility and effectiveness of ERAS protocols have been well researched and documented among all age groups, including the geriatric high-risk population.[1] Adhering to ERAS protocols after colorectal surgery showed no significant difference in postoperative complications, hospital stay, or readmission rate among various age groups.[2] A recent report mentions the safety and benefits following ERAS guidelines with reduced length of stay in elderly patients with short-level lumbar fusion surgery.[3] The concept of prehabilitation has evolved as an integral part of ERAS to build up physiological reserve, especially in geriatric high-risk group, and to adapt better to surgical stress.[4] High levels of compliance with ERAS interventions combined with prehabilitation can be achieved when a dedicated multidisciplinary team is involved in care of these high-risk patients.

Role for colorectal teams to support non-colorectal teams to improve clinical outcomes and adherence to ERAS guidelines for segmental colectomy: a cohort study

BackgroundTo identify whether compliance with Enhanced Recovery After Surgery (ERAS) Society recommendations is associated with length of stay (LOS) in a New Zealand hospital for patients undergoing segmental colectomy in mixed acute and elective general surgery wards.MethodsConsecutive elective colorectal surgeries (n = 770) between October 2012 and February 2019 were audited. Patients with non-segmental colectomies, multi-organ surgeries, LOS > 14 days, and those who died were excluded. Logistic regression was used to determine the relationship between patient demographics, compliance with ERAS guidelines, and suboptimal LOS (> 4 days).ResultsAnalysis included 376 patients. Age, surgery prior to 2014, surgical approach, non-colorectal surgical team, operation type, and complications were significantly associated with suboptimal LOS. Non-compliance with ERAS recommendations for laparoscopy [OR 8.9, 95% CI (4.52, 19.67)], removal of indwelling catheters (IDC) [OR 3.14, 95% CI (1.85, 5.51)], use of abdominal drains [OR 4.27, 95% CI (0.99, 18.35)], and removal of PCA [OR 8.71, 95% CI (1.78, 157.27)], were associated with suboptimal LOS (univariable analysis). Multivariable analysis showed that age, surgical team, late removal of IDC, and open approach were independent predictors of suboptimal LOS.ConclusionsNon-compliance with ERAS guidelines for laparoscopic approach and early removal of IDC was higher among procedures performed by non-colorectal surgery teams, and was also associated with adverse postoperative events and suboptimal LOS. This study demonstrates the importance of the surgical team’s expertise in affecting surgical outcomes, and did not find significant independent associations between most individual ERAS guidelines and suboptimal LOS once adjusting for other factors.

Impact of 2016 enhanced recovery after surgery (ERAS) recommendations on outcomes after hepatectomy in cirrhotic and non-cirrhotic patients

Introduction: The Enhanced Recovery After Surgery (ERAS) society published new recommendations for hepatectomy in 2016. Few studies have assessed their clinical impact. The aim of this monocentric study was to assess the impact of those guidelines on liver surgery with a special focus on cirrhotic patients. Method: Postoperative outcomes of patients undergoing hepatectomy 30 months before and after ERAS implementation according to the 2016 ERAS guidelines were compared after inverse probability of treatment weighting (IPTW). Primary endpoint was 90-day morbidity. Results: From 2015 to 2020, 430 patients underwent hepatectomy including 226 procedures performed before and 204 after ERAS implementation. After IPTW, overall morbidity (42.5% vs 64.7%, p<0.001), Comprehensive Complication Index (CCI) score (14.3 vs 20.8, p=0.004), length of stay (10.4 vs 13.7 days, p=0.001) and textbook outcome (40.2% vs 50%, p=0.022) were significantly improved in ERAS group, while mortality and severe complications were similar in both groups. In the non-cirrhosis subgroup these results were confirmed. However, in the cirrhosis subgroup, no difference appeared on outcomes after hepatectomy with an overall morbidity (47.5% vs 65.2%, p=0.069) and a length of stay (8 vs 9 days, p=0.310) which were not significantly different. Conclusion: Perioperative ERAS program for hepatectomy results in improved outcomes with decreased rate of non-severe morbidity. Although those guidelines are not deleterious in cirrhotic patients, they probably require revision to be more effective in this patient population.

Colorectal surgical outcomes following implementation of an enhanced recovery after surgery programme in Cape Town

ABSTRACT BACKGROUND: Colorectal surgery is commonly performed for benign and malignant colorectal disease. The aim of this study was to describe length of stay (LOS), complications and its associated factors in patients undergoing elective colorectal surgery following implementation of an enhanced recovery after surgery (ERAS) programme in South Africa (SA METHODS: Socio-demographic, pre- intra- and postoperative clinical details and compliance to the ERAS guidelines were recorded in all patients undergoing colorectal surgery in a private practice in Cape Town, SA. Means and standard deviations or medians and interquartile range (IQR), as appropriate, were used to describe continuous variables and frequencies and percentages for categorical variables. Bivariate and multivariate analyses using linear regression of log transformed LOS and logistic regression for development of complications were performed RESULTS: Between 2015 and 2019, 457 patients had elective colorectal surgical procedures. The median LOS was 5 days (IQR 3-7). Pre- and intraoperative compliance was 92% and 86% respectively. In total, 203 (44%) patients developed 346 complications, of which 61% were minor. On bivariate analysis, increased intraoperative compliance was associated with a significant decrease in LOS (coefficient [ß] = 0.987, 95% confidence interval [CI] 0.984-0.991) and complications (odds ratio [OR] 0.457, 95/5 CI 0.266-0.787). For every additional 30 minutes of theatre time, irrespective of type of procedure, LOS increased by 8% and complications by 12%. On multivariate analysis, laparoscopic compared to open surgery was also associated with a shorter LOS (exp [ß] = 0.667, 95% CI 0.580-0.767 p &lt; 0.001) and reduced complications (OR 0.457, 95% CI 0.266-0.787 CONCLUSION: Our results show that high compliance to the ERAS guidelines is possible in the private sector in SA and that a significant reduction in LOS can be achieved without placing the patient at a higher risk of complications Keywords: colorectal surgery, perioperative care, ERAS, LMIC, surgical checklist

Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada.

Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.

National survey of Korean hepatobiliary-pancreatic surgeons on attitudes about the enhanced recovery after surgery protocol.

Backgrounds/AimsThe purpose of this study was to investigate attitudes regarding the Enhanced Recovery After Surgery (ERAS) protocol of hepato-biliary-pancreatic (HBP) surgeons in Korea and the extent to which they use the protocol for perioperative management.MethodsAn online survey was conducted among members of the Korean Association of Hepato-Biliary-Pancreatic Surgery (KAHBPS) for eight weeks beginning on August 2019. The questionnaire, which was written in Korean, was based on the latest ERAS guidelines. Total responses were collected from 127 surgeons.ResultsOf the 127 total respondents, the largest proportion (44.9%) were working in Seoul. In terms of established in-hospital clinical pathways (CP), 19.7% of the participating surgeons had and followed a CP in pancreaticoduodenectomy (PD) and 21.3% in hepatectomy. Regarding the ERAS protocol for each surgery, four items (18.2%) regarding PD and seven items (35.0%) related to hepatectomy were followed by more than 50% of respondents.ConclusionsERAS guidelines are one of the consensuses for better recovery in perioperative management of patients undergoing major surgeries and encompass the overall process of patient recovery including patient education, pain control, physiologic balance, and perioperative nutrition. A novel project is needed to successfully implement an evidence-based enhanced recovery strategy.

FACTORS ASSOCIATED WITH EARLY EXTUBATION AFTER CARDIAC SURGERY: A RETROSPECTIVE STUDY

Enhanced Recovery After Surgery (ERAS) is a global initiative to deliver standardized peri-operative care aiming to promote recovery in patients undergoing surgery. Evidence-based ERAS protocols have been developed across multiple surgical specialities, but only recently for cardiac surgery (CS). As part of the CS ERAS guideline, early extubation, defined as extubation within 6 hours post-operation, was recommended. Early extubation was found to be safe and associated with decreased rates of reintubation, pneumonia and sepsis, as well as decreased intensive care unit (ICU) time, length of stay and costs.

Nutritional Implications in Preparing Patients for Total Gastrectomy

Prophylactic total gastrectomy is recommended to prolong life in individuals who carry the CDH1 variants associated with early diffuse gastric cancer. Loss of the stomach requires life-long changes in diet and poses a risk for select vitamin and mineral deficiencies that require supplementation and monitoring. This review covers the physiology of the stomach and the pathobiology and management of individuals post-gastrectomy with altered small bowel anatomy. Enhanced recovery after surgery guidelines (ERAS) for total gastrectomy reduces complication rates, enhances healing, and lessens hospital stay. Oral vitamin B12 in pharmacologic doses is equally effective to parenteral B12 supplementation post-gastrectomy. Glucagon-like peptide 1 (GLP-1) is an important hormone involved in the vasomotor symptoms of dumping syndrome that holds promise as a target for therapy. Although the stomach is not a vital organ, its motor and physiologic functions are important for nutrition and quality of life. Prevention of malnutrition and improving quality of life are accomplished by diet education, supplementation of vitamin B12 and other at risk vitamins and minerals, and monitoring throughout life.

Management of COMPlicAted intra-abdominal collectionS after colorectal Surgery (COMPASS): protocol for a multicentre, observational, prospective international study of drain placement practices in colorectal surgery.

Postoperative drains have historically been used for the prevention and early detection of intra-abdominal collections. However, current evidence suggests that prophylactic drain placement following colorectal surgery has no significant clinical benefit. This is reflected in the enhanced recovery after surgery (ERAS) guidelines, which recommend against their routine use. The Ileus Management International study found more than one-third of participating centres across the world routinely used drains in the majority of colorectal resections. The aim of the present study is to audit international compliance with ERAS guidelines regarding the use of postoperative drains in colorectal surgery. This prospective, multicentre audit will be conducted via the student- and trainee-led EuroSurg Collaborative network across Europe, South Africa and Australasia. Data will be collected on consecutive patients undergoing elective and emergency colorectal surgery with 30-day follow-up. This will include any colorectal resection, formation of colostomy/ileostomy and reversal of stoma. The primary end-point will be adherence to ERAS guidelines for intra-abdominal drain placement. Secondary outcomes will include the following: time to diagnosis of intra-abdominal postoperative collections; output and time to removal of drains; and 30-day postoperative complications defined by the Clavien-Dindo classification. This protocol describes the methodology for the first international audit of intra-abdominal drain placement after colorectal surgery. The study will be conducted across a large collaborative network with quality assurance and data validation strategies. This will provide a clear understanding of current practice and novel evidence regarding the efficacy and safety of intra-abdominal drain placement in colorectal surgical patients.

Management of postoperative nausea and vomiting in the context of an Enhanced Recovery after Surgery program.

The concept of Enhanced Recovery after Surgery (ERAS) emerged at the turn of the millennium and quickly gained footing worldwide leading to the establishment of institutional ERAS protocols and subspecialty guidelines. While the use of postoperative nausea and vomiting (PONV) prophylaxis predates ERAS by a significant extent, the emergence of ERAS amplified the importance of antiemetic prophylaxis in perioperative care and drew attention to the truly multifactorial nature of postoperative gastrointestinal dysfunction. The following discussion will review key paradigms behind PONV prophylaxis and ERAS, highlight the interrelationship between these two endeavors, and then explore subspecialty ERAS guidelines that uniquely influence PONV prophylaxis. Attention will center on the ERAS Society guidelines (ESGs) as the primary representative of current ERAS practice, though many deviations from the guidelines exist within the literature and institutional practices.

Implications of Practice Variability: Comment.

Implications of Practice Variability: Comment.

Continuous erector spinae plane block for pain management in laparoscopic liver resection: case report

Pain after liver resection can be difficult to manage. Epidural anesthesia (EA) isaneffective technique inpain control inthis surgery.&#x0D; However, postoperative coagulopathy and hypotension due to autonomic nervous system block in high-risk patients, may result that the EA is an inadequate analgesic technique in according to enhanced recovery after surgery (ERAS) recommendations for liver surgery.&#x0D; Regional block techniques have been recommended for liver surgery in ERAS guidelines.&#x0D; Erector spinae plane (ESP) block is a recent block described for thoracic and abdominal surgeries and provides both somatic and visceral analgesia.&#x0D; We describe a high-risk patient with cardiac dysfunction and Parkinson’s disease who underwent laparoscopic right liver resection for hepatocellular carcinoma.&#x0D; Satisfactory intra and postoperative analgesia was achieved by a combined continuous ESP block, transversus abdominis plane (TAP), and oblique subcostal TAP blocks.&#x0D; Surgery and postoperative period was uneventful. No opioids were administered during hospitalization.&#x0D; A combined of thoracic and abdominal wall blocks can be an effective approach for intra and postoperative analgesia in highrisk patients undergoing laparoscopic liver resection.&#x0D; Further clinical research is recommended to establish the effectiveness of the ESP block as an analgesic technique in this surgery.

Guidelines for Postoperative Care in Cesarean Delivery: Enhanced Recovery After Surgery (ERAS) Society Recommendations (Part 3)

(Am J Obstet Gynecol. 2019;221:247.e1–247.e9) Enhanced recovery after surgery (ERAS) is a perioperative care program that is standardized in various formats for disciplines including colorectal, urologic, gynecologic, and hepatobiliary surgery. ERAS has been shown to reduce hospital length of stay, complications, readmissions, and cost. Creating a standardized ERAS guideline for perioperative care in cesarean delivery will provide best practice recommendations for part 1 (antenatal/preoperative), part 2 (intraoperative), and part 3 (postoperative phases) with a maternal focus.

Agreements on perceived use of principles for Enhanced Recovery After Surgery between patients and nursing staff in a gynecological ward

ObjectivesThe aim of the study was to evaluate the agreements between patients and nursing staff in perceived use of the principles of Enhanced Recovery After Surgery (ERAS) in a gynecological ward, both prior to and following an educational session on ERAS guidelines for the nursing staff. Study designThis was a prospective observational study conducted in the in-patient gynecological section of the Department of Obstetrics and Gynecology at the University hospital of Linköping during spring 2017. The study groups comprised women scheduled for elective in-patient gynecological surgery due to benign or malignant diseases and the nursing staff at the gynecological ward. The study was performed in three parts with two structured questionnaire interviews of patients and nursing staff, and an intermediate educational session for the nursing staff regarding ERAS principles, conducted between the parts of the interview. Seventy-two patients were included in Interview part 1 and 68 patients in Interview part 2. The results are shown as the degree of inter-rater agreement and reliability of the responses between patients and nursing staff in numbers and percentages, along with the difference (Δ) in agreement between the interview parts, and its corresponding 95% confidence interval (CI). In addition, Cohen’s kappa was used to validate the findings. ResultsInter-rater agreement in answers to the interview questions was high even before the educational session. The observed agreement was ≥ 70% in 34 out of 42 questions in Interview part 1, and in 38 out of 42 questions in Interview part 2. Thirty of the 42 items (71%) had positive Δ agreement (%) whereas 12 of the 42 (29%) had negative Δ agreement (%). ConclusionsThis study showed high inter-rater agreement in perceived adherence to ERAS principles between patients and nursing staff in a gynecological ward. This was further improved by an educational session for the staff concerning ERAS guidelines. This might indicate the importance of repeated educational sessions to maintain high compliance with ERAS principles.

Decreased Narcotic Use After the Implementation of ERAS Guidelines in Gynecologic Oncology at an Academic Center [24H

INTRODUCTION: The Enhanced Recovery after Surgery (ERAS) program was made to provide a standard approach to pre- and post-operative care in order to decrease narcotics requirements for surgical pain. Also, improve peri-operative outcomes such as surgical complications, and readmission rates. Objective: To assess the impact on narcotic use before and after ERAS in gynecologic oncology patients. METHODS: IRB approved study. Retrospective cohort study in patients with newly diagnose endometrial cancer who underwent robotic assisted laparoscopic surgery from May 2016 to February 2019 at an Academic Center. Patient’s narcotic used, demographics, surgical outcomes, intra- and post-operative complications, blood loss, pain medication administered, length of stay, and hospital readmission was analyzed. RESULTS: One hundred thirty nine patients met study criteria. Forty-three and ninety-six patients were before and after the implementation of ERAS. Both groups were similar regarding demographics, age, body mass index, comorbidities, cancer histology, grade and stage. Narcotic use was significantly decreased in patients after ERAS introduction (26.73 vs 45.53 morphine equivalents, 95% CI 30.79 to 56.3; P=.008). The post-ERAS cohort also had increased use of multimodal drug therapy for pain (85% vs 63%, n=0.004) and increase gabapentin (12% vs 62%, P=.000) and NSAID use. (36% vs 16%, P=.017). ERAS introduction did not result in decreased length of stay, hospital readmissions, or surgical complications. CONCLUSION: ERAS incorporation decreased narcotics used and increased multimodal drug use for postoperative pain without compromising peri-operative outcomes.