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Lindemann K, Kleppe A, Eyjólfsdóttir B, Heimisdottir Danbolt S, Wang YY, Heli-Haugestøl AG, Walcott SL, Mjåland O, Navestad GA, Hermanrud S, Juul-Hansen KE, Kongsgaard U. Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer. Int J Gynecol Cancer 2023; 33:1279-1286. [PMID: 37451690 PMCID: PMC10423533 DOI: 10.1136/ijgc-2023-004355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/18/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts. METHODS Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed. RESULTS Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS. CONCLUSIONS ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.
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Affiliation(s)
- Kristina Lindemann
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Andreas Kleppe
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | | | | | - Yun Yong Wang
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Sara L Walcott
- Department of Clinical Service, Oslo University Hospital, Oslo, Norway
| | - Odd Mjåland
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
| | - Gerd-Anita Navestad
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Silje Hermanrud
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Knut Erling Juul-Hansen
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
| | - Ulf Kongsgaard
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
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Robella M, Tonello M, Berchialla P, Sciannameo V, Ilari Civit AM, Sommariva A, Sassaroli C, Di Giorgio A, Gelmini R, Ghirardi V, Roviello F, Carboni F, Lippolis PV, Kusamura S, Vaira M. Enhanced Recovery after Surgery (ERAS) Program for Patients with Peritoneal Surface Malignancies Undergoing Cytoreductive Surgery with or without HIPEC: A Systematic Review and a Meta-Analysis. Cancers (Basel) 2023; 15:cancers15030570. [PMID: 36765534 PMCID: PMC9913706 DOI: 10.3390/cancers15030570] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/02/2023] [Accepted: 01/09/2023] [Indexed: 01/20/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) program refers to a multimodal intervention to reduce the length of stay and postoperative complications; it has been effective in different kinds of major surgery including colorectal, gynaecologic and gastric cancer surgery. Its impact in terms of safety and efficacy in the treatment of peritoneal surface malignancies is still unclear. A systematic review and a meta-analysis were conducted to evaluate the effect of ERAS after cytoreductive surgery with or without HIPEC for peritoneal metastases. MEDLINE, PubMed, EMBASE, Google Scholar and Cochrane Database were searched from January 2010 and December 2021. Single and double-cohort studies about ERAS application in the treatment of peritoneal cancer were considered. Outcomes included the postoperative length of stay (LOS), postoperative morbidity and mortality rates and the early readmission rate. Twenty-four studies involving 5131 patients were considered, 7 about ERAS in cytoreductive surgery (CRS) + HIPEC and 17 about cytoreductive alone; the case histories of two Italian referral centers in the management of peritoneal cancer were included. ERAS adoption reduced the LOS (-3.17, 95% CrI -4.68 to -1.69 in CRS + HIPEC and -1.65, 95% CrI -2.32 to -1.06 in CRS alone in the meta-analysis including 6 and 17 studies respectively. Non negligible lower postoperative morbidity was also in the meta-analysis including the case histories of two Italian referral centers. Implementation of an ERAS protocol may reduce LOS, postoperative complications after CRS with or without HIPEC compared to conventional recovery.
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Affiliation(s)
- Manuela Robella
- Unit of Surgical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Torino, Italy
- Correspondence: ; Tel.: +39-338-382-4104
| | - Marco Tonello
- Advanced Surgical Oncology Unit, Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Paola Berchialla
- Center for Biostatistics, Epidemiology and Public Health (C-BEPH), Deptartment of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
| | - Veronica Sciannameo
- Center for Biostatistics, Epidemiology and Public Health (C-BEPH), Deptartment of Clinical and Biological Sciences, University of Torino, 10124 Torino, Italy
| | | | - Antonio Sommariva
- Advanced Surgical Oncology Unit, Surgical Oncology of the Esophagus and Digestive Tract, Veneto Institute of Oncology IOV-IRCCS, 35128 Padova, Italy
| | - Cinzia Sassaroli
- Abdominal Oncology Department, Fondazione Giovanni Pascale, IRCCS, 80131 Naples, Italy
| | - Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Roberta Gelmini
- SC Chirurgia Generale d’Urgenza ed Oncologica, AOU Policlinico di Modena, 41125 Modena, Italy
| | - Valentina Ghirardi
- UOC Ovarian Carcinoma Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Franco Roviello
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery, and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Fabio Carboni
- Peritoneal Tumours Unit, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | | | - Shigeki Kusamura
- Peritoneal Surface Malignancies Unit, Fondazione Istituto Nazionale Tumori IRCCS Milano, 20133 Milano, Italy
| | - Marco Vaira
- Unit of Surgical Oncology, Candiolo Cancer Institute, FPO-IRCCS, 10060 Torino, Italy
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Transnasal Endoscopic Orbital Decompression Combined with an Enhanced Recovery after Surgery Protocol in Graves Ophthalmopathy. J Ophthalmol 2022; 2022:6382429. [PMID: 36157679 PMCID: PMC9507727 DOI: 10.1155/2022/6382429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Objective. Although enhanced recovery after surgery (ERAS) was shown to improve patients’ recovery after surgery and transnasal endoscopic orbital decompression has been associated with lesser risks of postoperative complications compared to other surgical techniques in treating Graves ophthalmopathy (GO), there are currently no clinical studies on the application of ERAS in transnasal endoscopic orbital decompression. This study aimed to investigate the potential effects of combining transnasal endoscopic orbital decompression with ERAS in the treatment of GO. Methods. A retrospective analysis was performed for 5 GO patients (10 eyes) treated with transnasal endoscopic orbital decompression from January 2021 to December 2021 at the Third Affiliated Hospital of Sun Yat-Sen University. All patients underwent ERAS, and the effects of ERAS on the postoperative complications and recovery of patients were evaluated. Results. Ophthalmological examination showed that GO patients had good correction of exophthalmos after surgery combined with ERAS. Specifically, the exophthalmos reduction in subjects was 0.9–2.1 mm, with a mean reduction of 1.23 mm. In addition, a visual acuity improvement of 0.15–0.4, with an average improvement of 0.23, was also observed. Further, the Scale of Quality of Life for Diseases with Visual Impairment (SQOL-DVI) showed that, compared with before surgery, the patients’ QOL was significantly improved 2 weeks after surgery. Before surgery, there were 2 patients with diplopia and blurred vision, and after postoperative adaptive exercise, the symptoms of these 2 patients disappeared after 6 months of follow-up. As for the other 3 patients, they had no diplopia or blurred vision after surgery. Conclusion. This observational study found that transnasal endoscopic orbital decompression might be effective in treating GO, and ERAS might be considered an important adjunct to improving perioperative care and postoperative recovery.
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Egger EK, Merker F, Ralser DJ, Marinova M, Vilz TO, Matthaei H, Hilbert T, Mustea A. Postoperative paralytic ileus following debulking surgery in ovarian cancer patients. Front Surg 2022; 9:976497. [PMID: 36090332 PMCID: PMC9448895 DOI: 10.3389/fsurg.2022.976497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022] Open
Abstract
Aim This study aims to evaluate the incidence of postoperative ileus (POI) following cytoreductive surgery in epithelial ovarian cancer (EOC) patients and its impact on anastomotic leakage occurrence and postoperative complications. Methods A total of 357 surgeries were performed on 346 ovarian cancer patients between 1/2010 and 12/2020 at our institution. The postoperative course regarding paralytic ileus, anastomotic leakage, and postoperative complications was analyzed by Fisher's exact test and through ordinal logistic regression. Results A total of 233 patients (65.3%) returned to normal gastrointestinal functions within 3 days after surgery. A total of 123 patients (34.5%) developed POI. There were 199 anastomoses in 165 patients and 24 leakages (12.1%). Postoperative antibiotics (p 0.001), stoma creation (p 0.0001), and early start of laxatives (p 0.0048) significantly decreased POI, while anastomoses in general (p 0.0465) and especially low anastomoses (p 0.0143) showed increased POI rates. Intraoperative positive fluid excess >5,000 cc was associated with a higher risk for POI (p 0.0063), anastomotic leakage (p 0.0254), and severe complications (p 0.0012). Conclusion Postoperative antibiotics, an early start with laxatives, and stoma creation were associated with reduced POI rates. Patients with anastomoses showed an increased risk for POI. Severe complications, anastomotic leakages, and POI were more common in the case of intraoperative fluid balance exceeding 5,000 cc.
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Affiliation(s)
- Eva K. Egger
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
- Correspondence: Eva K. Egger
| | - Freya Merker
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Damian J. Ralser
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Milka Marinova
- Department of Interventional and Diagnostic Radiology, University Hospital Bonn, Bonn, Germany
| | - Tim O. Vilz
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - Hanno Matthaei
- Department of Surgery, University Hospital Bonn, Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Mustea
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
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