Enhanced recovery after surgery program in Gynaecologic Oncological surgery in a minimally invasive techniques expert center

Enhanced recovery after surgery versus conventional postoperative care in patients undergoing hysterectomy: a systematic review and meta-analysis

PURPOSE

Hysterectomy is a common gynecological surgery associated with significant postoperative discomfort and extended hospital stays. Enhanced recovery after surgery (ERAS), a multidisciplinary approach, has emerged as a strategy aimed at improving perioperative outcomes and promoting faster patient recovery and satisfaction. This meta-analysis aimed to evaluate the impact of ERAS protocols on clinical outcomes, such as hospital stay length, readmission rates, and postoperative complications, in patients undergoing gynecological hysterectomy.

METHODS

Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, a systematic review and meta-analysis were conducted. Databases including PubMed, Embase, and Cochrane library were searched for relevant studies published up to January 31, 2023. A total of seventeen studies were selected based on predefined eligibility and exclusion criteria. Meta-analysis was carried out using a random-effects model with the STATA SE 14.0 software, focusing on outcomes like length of hospital stay, postoperative complications, and readmission rates.

RESULTS

ERAS protocols significantly reduced the length of hospital stays and incidence of postoperative complications such as ileus, without increasing readmission rates or the level of patient-reported pain. Notable heterogeneity was observed among included studies, attributed to the variation in patient populations and the specificity of the documented study protocols.

CONCLUSION

The findings underscore the effectiveness of ERAS protocols in enhancing recovery trajectories in gynecological hysterectomy patients. This reinforces the imperative for broader, standardized adoption of ERAS pathways as an evidence-based approach, fostering a safer and more efficient perioperative care paradigm.

Is minimally invasive surgical approach a reasonable option in apparent early stage epithelial ovarian cancer restaging? Results from a multicentric retrospective study

INTRODUCTION

To perform surgical staging of early stage ovarian cancer (EOC), conventional laparoscopy (LS) and robot-assisted laparoscopy (RLS) appear to be reliable procedures compared to open surgery. But oncologicals results with long-term follow up are limited in the literature. The objective of this study is to evaluate the surgical and long-term survival for patients managed by minimally invasive surgery (MIS).

MATERIALS AND METHODS

We conducted a multicentric retrospective study in 6 institutions. All patients referred for epithelial EOC (apparent stage I-IIa) managed with LS and RLS were involved.

RESULTS

From December 2008 to December 2017, 140 patients were included (109 in LS group and 31 in RLS group). A total of 27 (19.2 %) patients were upstaged to an advanced ovarian cancer (FIGO stage > IIA), and 73 % of patients received chemotherapy. Mean operative time was 265,8 ± 88,4 min and significantly longer in RLS group (LS = 254,5 ± 86,8; RLS = 305,6 ± 85,5; p = 0,008). Rate of severe post-operative complications (grade 3) was 5,7 %. Thirteen conversion to laparotomy occurred, including one per-operative hemorrhaege. After a mean follow-up of 60,7 months, 29 (20.7 %) patients recurred, with a time to recurrence was >24 months in 51,7 % of cases. Overall survival (OS) was 88.6 % and disease-free survival (DFS) was 79.3 %. Oncologic outcomes were similar between LS and RLS group (OS: p = 0,504 and DFS: p = 0,213).

CONCLUSION

Surgical staging of EOC by LS or RLS approach has long-term equivalent surgical and oncological approach. These results seem to be equivalent to open surgery according to literature review.

Ultrasound-guided paravertebral nerve block anesthesia for percutaneous endoscopic laser unroofing treatment of symptomatic simple renal cysts-An innovative ambulatory surgery mode

Objective

This study was designed to evaluate the feasibility, efficacy, and safety of percutaneous ureteroscopy laser unroofing as an ambulatory surgery for symptomatic simple renal cysts under multilevel paravertebral nerve block anesthesia.

Methods

From December 2015 to September 2017, 33 simple renal cyst patients who had surgical indications were enrolled. Under ultrasound guidance, the T10/T11, T11/T12, and T12/L1 paravertebral spaces were identified, and 7-10 mL 0.5% ropivacaine was injected at each segment. Then a puncture needle was placed inside the cyst cavity under ultrasonic monitoring. A guidewire was introduced followed by sequential dilation up to 28/30 Fr. The extra parenchymal portion of the cyst wall was dissociated and incised using a thulium laser, and a pathological examination was performed.

Results

Sensory loss to pinprick from T8 to L1 and sensory loss to ice from T6 to L2 were observed in all patients. None of the patients complained of pain during surgery. No serious complications occurred perioperatively. After the surgery, all patients recovered their lower limb muscle strength quickly, got out of bed, resumed oral feeding, and left the hospital within 24 h of admission. The pathologic diagnosis of all cyst walls was a simple renal cyst. The mean follow-up was 35.8 months. At the end of follow-up, the cyst units were reduced in size by more than 50% compared to the preoperative size, and no patient experienced a recurrence.

Conclusion

Multi-level paravertebral nerve block for percutaneous ureteroscopy laser unroofing as an ambulatory surgery mode is feasible, safe, and effective for the treatment of simple renal cysts in selected patients.

Factors Associated with 1-Year Mortality in Elderly Patients (Age ≥ 80 Years) with Cancer Undergoing Major Abdominal Surgery: A Retrospective Cohort Study

BACKGROUND

The number of elderly patients undergoing major abdominal surgery is increasing, but the factors affecting their postoperative outcomes remain unclear. This study aimed to identify the factors associated with 1-year mortality among elderly patients (age ≥ 80 years) with cancer undergoing major abdominal surgery.

METHODS

This retrospective cohort study was conducted from March 2009 to December 2020. The study enrolled 378 patients 80 years old or older who underwent major abdominal surgery. The main outcome was 1-year mortality, and the factors associated with mortality were analyzed.

RESULTS

Of the 378 patients, 92 died at 1 year (24.3%), whereas the 30-day mortality rate was 4% (n = 15). In the multivariate analysis, the factors independently associated with 1-year mortality were preoperative Eastern Cooperative Oncology Group (ECOG) performance status (PS) score higher than 1 (odds ratio [OR], 3.189; 95% confidence interval [CI], 1.595-6.377; p = 0.001), preoperative weight loss greater than 3 kg (OR, 2.145; 95% CI, 1.044-4.404; p = 0.038), use of an intraoperative vasopressor (OR, 3.090; 95% CI, 1.188-8.042; p = 0.021), and postoperative red blood cell units (OR, 1.212; 95% CI, 1.045-1.405; p = 0.011). Survival was associated with perioperative management according to an enhanced recovery after surgery (ERAS) protocol (OR, 0.370; 95% CI, 0.160-0.854; p = 0.006) and supramesocolic surgery (OR, 0.371; 95% CI, 0.158-0.871; p = 0.023).

CONCLUSION

The study identified several factors associated with an encouraging 1-year mortality rate in this setting. These results highlight the need for identification of suitable targets to optimize pre-, intra-, and postoperative management in order to improve outcomes for this vulnerable population.

Impact of ERAS in breast reconstruction with a latissimus dorsi flap, compared to conventional management

BACKGROUND

Enhanced recovery after surgery (ERAS) programs are associated with improved management, reduced hospital stays, and lower complication rates.

OBJECTIVE

To evaluate the impact of ERAS on mean length of stay (LOS) and postoperative morbidity in breast reconstruction with latissimus dorsi flap (LDF) compared with conventional recovery program.

PATIENTS AND METHOD

All patients operated by LDF between December 2014 and October 2020: those managed before April 2018, when the ERAS protocol was introduced, were included in the "no ERAS" group, and beyond in the "ERAS" group.

RESULTS

Out of 193 patients, 129 were included in the "ERAS" group and 64 in the "no ERAS" group. There was a significant difference between the two groups in LOS (4.2 ± 1.5 days in the "ERAS" group vs. 5.4 ± 1.9 days in the "no ERAS" group; p < 0.001), high-grade complications at 30 days (9.3% in the "ERAS" group vs. 25% in the "no ERAS" group; p = 0.01), reintervention rate (13.9% vs. 26.6%, respectively; p = 0.02), and 30-day rehospitalization rate (6.2% in the "ERAS" group vs. 15.6% in the "no ERAS" group; p = 0.03).

CONCLUSION

The ERAS protocol has a positive impact on breast reconstruction with LDF without generating additional adverse effects. These results support the democratization of these programs for breast reconstruction surgery.

Can robotic-assisted surgery support enhanced recovery programs?

Enhanced recovery after surgery (ERAS) protocols comprise a multimodal approach to optimize patient outcome and recovery. ERAS guidelines recommend minimally invasive surgery (MIS) when possible. Key components in MIS include preoperative patient education and optimization; multimodal and narcotic-sparing analgesia; prophylactic measures regarding nausea, infection, and venous thrombosis; maintenance of euvolemia; and promotion of the early activity. ERAS protocols in MIS improve outcome mainly in terms of reduced length of stay and subsequently reduced cost. In addition, ERAS protocols in MIS reduce postoperative pain and nausea, increase patient satisfaction, and might reduce the rate of postoperative complications. Robotic surgery supports ERAS through facilitating MIS in complex procedures where laparotomy is an alternative approach.

Enhanced Recovery after Surgery and Endometrial Cancers: Results from an Initial Experience Focused on Elderly Patients

Endometrial cancer is the fifth most common cancer among French women and occurs most frequently in the over-70-year-old population. Recent years have seen a significant shift towards minimally invasive surgery and Enhanced Recovery After Surgery (ERAS) protocols in endometrial cancer management. However, the impact of ERAS on endometrial cancer has not been well-established. We conducted a prospective observational study in a comprehensive cancer center, comparing the outcomes between endometrial cancer patients who received care in an ERAS pathway (261) and those who did not (166) between 2006 and 2020. We performed univariate and multivariate analysis. Our primary objective was to evaluate the impact of ERAS on length of hospital stay (LOS), with the secondary objectives being the determination of the rates of early discharge, post-operative morbidity, and rehospitalization. We found that patients in the ERAS group had a significantly shorter length of stay, with an average of 3.18 days compared to 4.87 days for the non-ERAS group (estimated decrease -1.69, p < 0.0001). This effect was particularly pronounced among patients over 70 years old (estimated decrease -2.06, p < 0.0001). The patients in the ERAS group also had a higher chance of early discharge (47.5% vs. 14.5% in the non-ERAS group, p < 0.0001), for which there was not a significant increase in post-operative complications. Our study suggests that ERAS protocols are beneficial for the management of endometrial cancer, particularly for older patients, and could lead to the development of ambulatory pathways.

RACCE Study: Impact of an enhanced recovery after surgery program (ERAS) in the management of endometrial cancer: A single-center retrospective study

OBJECTIVE

This study evaluates the implementation of an ERAS program in the gynecological surgery department of Caen University Hospital and its impact on the management of endometrial cancer. The objective was to show its impact on the length of hospitalization of patients before and after its implementation.

PATIENTS AND METHOD

We conducted a retrospective study including all women treated surgically for endometrial cancer at Caen University Hospital between January 1, 2015 and December 31, 2021. The ERAS program started in September 2017. We compared the pre-, intra- and postoperative characteristics of two groups: the first one concerning the period before the implementation of ERAS called « prior ERAS group » and the second one after implementation called « post ERAS group ».

RESULTS

A total of 198 patients were included in our study. 139 patients were included after ERAS implementation. Our study shows that there is a significant reduction in median length of stay between the post ERAS and prior ERAS groups respectively 3 and 4 days (p = 0.004). There was also a reduction of time to resume ambulation (p < 0.001) and re-feeding (p < 0.001) for the post ERAS group compared to the prior ERAS group. Complication rates (p = 0.87) and readmission rates (p = 0.28) were not significant. Overall survival was not significant (p = 0.28).

CONCLUSION

ERAS is a safe and effective method in the overall management of patients allowing an improvement in the quality of patient care and accelerating recovery to a previous physiological state. Finally, this results in a reduction in the patient's length of stay, without impacting morbidity and readmission rate.

The impact of enhanced recovery after gynaecological surgery: A systematic review and meta-analysis

BACKGROUND

Enhanced Recovery After Surgery programs have become the gold standard of care in many surgical specialities.

OBJECTIVES

This updated systematic review and meta-analysis aims to evaluate how an ERAS program can impact outcomes across both benign and oncological gynaecological surgery to inform standard surgical practice.

SEARCH STRATEGY

An electronic search of the SCOPUS, Embase and PubMed Medline databases was performed for relevant studies assessing the use of ERAS in patients undergoing gynaecological surgery compared with those without ERAS.

SELECTION CRITERIA

The studies included were all trials using ERAS programs in gynaecological surgery with a clearly outlined protocol which included at least four items from the most recent guidelines and recorded one primary outcome.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed on two primary endpoints; post-operative length of stay and readmission rate and one secondary endpoint; rates of ileus. Further subgroup analyses was performed to compare benign and oncological surgeries.

MAIN RESULTS

Forty studies (7885 patients) were included in the meta-analysis; 15 randomised controlled trials and 25 cohort studies. 21 studies (4333 patients) were included in meta-analyses of length of stay. Patients in the ERAS group (2351 patients) had a shortened length of stay by 1.22 days (95% CI: -1.59 - -0.86, P < 0.00001) compared to those in the control group (1982 patients). Evaluation of 27 studies (6051 patients) in meta-analysis of readmission rate demonstrated a 20% reduction in readmission rate (OR: 0.80, 95% CI: 0.65-0.97). Analysis of our secondary outcome, demonstrated a 47% reduction in rate of ileus compared to the control group.

CONCLUSIONS

ERAS pathways significantly reduce length of stay without increasing readmission rates or rates of ileus across benign and oncological gynaecological surgery.

Evaluation of the impact of an enhanced recovery after surgery (ERAS) programme on the quality of recovery in patients undergoing a scheduled hysterectomy: a prospective single-centre before-after study protocol (RAACHYS study)

INTRODUCTION

The enhanced recovery after surgery (ERAS) programmes following hysterectomies have been studied since 2010, and their positive effects on clinical or economic criteria are now well established. However, the benefits on health outcomes, especially rapid recovery after surgery from patients' perspective is lacking in literature, leading to develop scores supporting person-centred and value-based care such as patient-reported outcome measures. The aim of this study is to assess the impact of an ERAS programme on patients' well-being after undergoing hysterectomy.

METHODS AND ANALYSIS

This is an observational, prospective single-centre before-after clinical trial. 148 patients are recruited and allocated into two groups, before and after ERAS programme implementation, respectively. The ERAS programme consists in optimising factors dealing with early rehabilitation, such as preoperative patient education, multimodal pain management, early postoperative fluid taken and mobilisation. A self-questionnaire quality of recovery-15 (QoR-15) on the preoperative day 1 (D-1), postoperative day 0 evening (D0) and the postoperative day 1 (D+1) is completed by patients. Patients scheduled to undergo hysterectomy, aged 18 years and above, whose physical status are classified as American Society of Anesthesiologists score 1-3 and who are able to return home after being discharged from hospital and contact their physician or the medical department if necessary are recruited for this study. The total duration of inclusion is 36 months. The primary outcome is the difference in QoR-15 scores measured on D+1 which will be compared between the 'before' and the 'after' group, using multiple linear regression model.

ETHICS AND DISSEMINATION

Approval was obtained from the Ethical Committee (Paris, France). Subjects are actually being recruited after giving their oral agreement or non-objection to participate in this clinical trial and following the oral and written information given by the anaesthesiologist practitioner.Trial registration number: ClinicalTrials.gov: NCT04268576 (Pre-result).

Perioperative enhanced recovery programmes for women with gynaecological cancers

BACKGROUND

Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015.

OBJECTIVES

To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes.

SEARCH METHODS

We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty.

MAIN RESULTS

We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants).

AUTHORS' CONCLUSIONS

Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.

Outcomes of Enhanced Recovery after Surgery (ERAS) in Gynecologic Oncology: A Review

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement program that started in colorectal surgery and has now expanded to numerous specialties, including gynecologic oncology. ERAS guidelines comprise multidisciplinary, evidence-based recommendations in the preoperative, intraoperative, and postoperative period; these interventions broadly encompass patient education, anesthetic choice, multimodal pain control, avoidance of unnecessary drains, maintenance of nutrition, and prevention of emesis. Implementation of ERAS has been shown to be associated with improved clinical outcomes (length of hospital stay, complications, readmissions) and cost. Marx and colleagues first demonstrated the feasibility of ERAS in gynecologic oncology in 2003; since then, over 30 comparative studies and 4 guidelines have been published encompassing major gynecologic surgery, cytoreductive surgery, and vulvar/vaginal surgery. Implementation of ERAS in gynecologic oncology has been demonstrated to provide improvements in length of stay, complications, cost, opioid use, and patient satisfaction. Increased compliance with ERAS guidelines has been associated with greater improvement in outcomes.

New surgical realities: implementation of an enhanced recovery after surgery protocol for gynecological laparoscopy-a prospective study

Background

Multimodal rehabilitation allows optimization of functional recovery in surgery patients by reducing the postoperative stress and hospital stay duration, without increasing the morbidity and mortality. It is reportedly successful in other surgical disciplines, and guidelines for its application to gynecological surgery are available; however, most evidence for these guidelines is derived from observational and/or retrospective studies. Therefore, this study aimed to investigate the applicability of an enhanced recovery after surgery (ERAS) protocol in laparoscopic gynecological surgery and its influence on the postoperative stay, morbidity, mortality, and readmission, through a prospective approach.

Methods

This prospective cohort study was performed on 90 patients who underwent laparoscopic hysterectomy for benign causes from October 2017 to October 2019. Patients in whom the ERAS (ERAS group, n = 30) and traditional (control group, n = 60) protocols were implemented were compared. All patients were followed for 6 months.

Results

The groups were homogeneous and did not differ significantly with respect to the demographic characteristics (age, ASA score, body mass index), surgical indications, and surgery types. Adherence to the ERAS protocol was over 99%. The postoperative hospital-stay durations were 1.73 days (r = 1–3) and 2.97 days (r = 2–6) in the ERAS and control groups, respectively (p = 0.000). No significant intergroup differences were observed in the rates of complications and readmissions.

Conclusions

The ERAS protocol is applicable in laparoscopic gynecological surgery and can be implemented with good adherence. This can allow optimization of patient recovery by reducing the hospital stay duration, without increasing the rates of morbidity, mortality, or readmission.

Systematic review of the effect of implementing enhanced recovery after surgery on selected attributes of surgical recovery in gynecology

This study aimed to systematically review the available literature on enhanced recovery after surgery (ERAS) following gynecologic procedures performed either as an open surgery or as a minimally invasive gynecological surgery (MIGS) in terms of outcomes. This review revealed the results of published literature and assessed the benefits and diverse outcomes of ERAS implementation in patients undergoing MIGS or other gynecologic surgeries. In this review, we sought to examine the efficacy of entire ERAS protocols, faithfully performed, to determine whether they were successful in improving individual attributes of surgical recovery. Electronic databases of PubMed, Cochrane, Web of Science, Scopus, MEDLINE, and ClinicalTrials.gov were systematically searched in January 2021 for relevant studies. Data were extracted from eligible studies including LOS, change in the quality-of-life and recovery over time, postoperative complications including nausea and vomiting, opioid or anesthesia use, hospital cost, patient satisfaction, postoperative pain, and readmission rate as outcomes. Many of the included studies reported a significant reduction in the LOS as well as in readmission rates, hospital cost, and occurrence of nausea and vomiting postoperatively. Moreover, a clinically significant increase was noted in patient satisfaction in studies that have used tools that measure patient satisfaction. No studies have reported a significant increase in the overall quality of recovery using appropriately validated tools. Following ERAS implementation, patients’ postoperative rehabilitation, including postoperative discomfort, readmission rates, and satisfaction, showed a clinically significant improvement.

Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway

STUDY OBJECTIVE

Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m² undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP.

DESIGN

A retrospective cohort study.

SETTING

An academic teaching hospital.

PATIENTS

A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m²) undergoing robotic hysterectomy.

INTERVENTIONS

The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls.

MEASUREMENTS AND MAIN RESULTS

Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room).

CONCLUSION

The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.

Care as Usual: An Acceptable Strategy to Apply During the COVID-19 Pandemic in a French Tertiary Gynecologic Oncology Department

We describe and analyze a “care as usual” strategy of a French Comprehensive Cancer Center during the COVID-19 pandemic to manage surgical patients with gynecological cancer. We conducted a retrospective analysis evaluating the surgical activity in our gynecologic oncology department between January 21 and May 12, 2020. We compared the surgical activity and surgical and oncologic outcomes during the pre-lockdown period and the pandemic period. The main objective was to evaluate the impact of the COVID-19 pandemic on surgical activity. The secondary objectives were to analyze the surgical and the oncologic outcomes. We compared the surgical activity during the 8 weeks after the national lockdown (85 procedures) to the surgical activity in the 8 weeks preceding the lockdown (127 procedures). We observed a 33% decrease in activity between the two periods. The clinical and epidemiologic characteristics were similar between the two periods. There were no differences between the surgical approaches (p = 0.592), the surgical complexity (p = 0.323), the length of stay (p = 0.85), and even for the complex procedure (p = 0.96) and the perioperative (p = 0.791) and postoperative complication rates (p = 0.102). We observed a significant decrease in the time of return to intended oncological treatment (RIOT) during the lockdown period with an average of 31.9 days compared to 46.9 days in the pre-lockdown period (p = 0.003). During the COVID-19 pandemic, “care as usual” represents an acceptable strategy without impairing the oncologic outcome in a Comprehensive Cancer Center with a patient-centered clinical pathway for gynecologic oncologic surgical patients.

Women's experiences of an enhanced recovery after surgery program: A qualitative study

The Enhanced Recovery After Surgery Program aims to transfer much of the responsibility for postoperative recovery to the patient and their next of kin. The aim of the study was to identify and describe women's experiences of care within this program in relation to gynecological abdominal surgery. A qualitative approach was used where 16 women were interviewed within 1 to 2 weeks of their surgery. A thematic analysis focusing on interpretation of latent content was performed. Three themes were identified: Empowerment, Self-care, and Participation. Empowerment represents aspects of the recovery program that strengthen self-efficacy, such as being seen, being given information, and continuity of care. Self-care identifies the practical implications of empowerment, namely internal resources, knowledge, and external resources. These two themes were identified as separate but interlinked through the theme Participation. Preoperative information, postoperative encouragement, and follow-up empowered the women in their recovery. Early discharge from hospital was beneficial for recovery if accompanied by social support and sufficient self-care ability. A desire for a person-centered approach in the preoperative meeting and in postoperative care was identified.

Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - A systematic review and meta-analysis

OBJECTIVE

To assess the benefit of Enhanced Recovery After Surgery (ERAS) on length of stay (LOS), postoperative complications, 30-day readmission, and cost in gynecologic oncology.

METHODS

A systematic literature search was performed in MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and Web of Science for all peer-reviewed cohort studies and controlled trials on ERAS involving gynecologic oncology patients. Abstracts, commentaries, non-controlled studies, and studies without specific data on gynecologic oncology patients were excluded. Meta-analysis was performed on the primary endpoint of LOS. Subgroup analyses were performed based on risk of bias of the studies included, number of ERAS elements, and ERAS compliance. Secondary endpoints were readmission rate, complications, and cost.

RESULTS

A total of 31 studies (6703 patients) were included: 5 randomized controlled trials, and 26 cohort studies. Meta-analysis of 27 studies (6345 patients) demonstrated a decrease in LOS of 1.6 days (95% confidence interval, CI 1.2-2.1) with ERAS implementation. Meta-analysis of 21 studies (4974 patients) demonstrated a 32% reduction in complications (OR 0.68, 95% CI 0.55-0.83) and a 20% reduction in readmission (OR 0.80, 95% CI 0.64-0.99) for ERAS patients. There was no difference in 30-day postoperative mortality (OR 0.61, 95% CI 0.23-1.6) for ERAS patients compared to controls. No difference in the odds of complications or reduction in LOS was observed based on number of included ERAS elements or reported compliance with ERAS interventions. The mean cost savings for ERAS patients was $2129 USD (95% CI $712 - $3544).

CONCLUSIONS

ERAS protocols decrease LOS, complications, and cost without increasing rates of readmission or mortality in gynecologic oncology surgery. This evidence supports implementation of ERAS as standard of care in gynecologic oncology.

EVAN-G score in patients undergoing minimally invasive gynecology oncologic surgery in an Enhanced Recovery After Surgery (ERAS) program

INTRODUCTION

Enhanced Recovery After Surgery (ERAS) has been proven to decrease the length of hospital stay without increasing re-admission rates or complications. There are limited data on the satisfaction of patients undergoing minimally invasive surgery for gynecologic malignancy within ERAS programs. The aim of this study was to evaluate patient satisfaction after minimally invasive surgery for gynecologic malignancy within the ERAS program using the 'Evaluation du Vécu de l'Anésthésie Génerale (EVAN-G)' questionnaire.

METHODS

This observational retrospective study was conducted at the Paoli-Calmettes Institute between June 2016 and December 2018. All the included patients underwent minimally invasive surgery for a gynecologic malignancy. EVAN-G, a validated questionnaire, was used to measure peri-operative patient satisfaction. This questionnaire consists of 26 items assessing six elements: attention, privacy, information, pain, discomfort, and waiting time. Each element is assessed via a 5-step numerical scale and then transformed to a 0-100 scale according to the degree of satisfaction. The EVAN-G questionnaire was given to patients before surgery and collected during the post-operative consultation (2-3 weeks after surgery).

RESULTS

A total of 175 patients underwent minimally invasive surgery for gynecologic malignancy within the ERAS program. Of these, 92 patients were included in the study and 83 patients were excluded. The overall patient compliance rate with our ERAS program was 90%. The analysis of the EVAN-G score of all participants showed an overall high level of satisfaction with a mean score of 81.9 (range 41.6-100). Patients with peri-operative complications or having prolonged hospitalization also showed high levels of satisfaction with a mean score of 80.5 (41.6-100) and 83.2(55-100), respectively.

CONCLUSION

In this study we showed a high patient satisfaction with the ERAS program. When comparing length of stay and complications, neither extended length of stay nor development of complications after minimally invasive surgery impacted patient satisfaction.

Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center

Objective

The aim of the study was to compare the characteristics of procedures for gynecologic cancers conducted with conventional laparoscopy (CL) or robotically assisted laparoscopy (RAL) in the context of an enhanced recovery program (ERP).

Methods

This is a secondary analysis of prospectively collected data from a cohort study conducted between 2016 (when the ERP was first implemented at the Institut Paoli-Calmettes, a comprehensive cancer center in France) and 2018. We included patients who had undergone minimally invasive surgery for gynecological cancers and followed our ERP. The endpoints were the analysis of postoperative complications, the length of postoperative hospitalization (LPO), and the proportion of combined procedures depending on the approach (RAL or CL). Combined procedures were defined by the association of at least two of the following operative items: hysterectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy.

Results

A total of 362 women underwent either CL (n = 187) or RAL (n = 175) for gynecologic cancers and followed our ERP. The proportion of combined procedures performed by RAL was significantly higher (85/175 [48.6%]) than that performed by CL (23/187 [12.3%]; p < 0.001). The proportions of postoperative complications were similar between the two groups (19.4% versus 17.1%; p = 0.59). Logistic regression analysis revealed a statistically insignificant trend in the association of RAL with a reduced likelihood of an LPO > 3 days after adjusting for predictors of prolonged hospitalization (adjusted OR = 0.573 [0.236–1.388]; p = 0.217).

Conclusion

Experts from our cancer center preferentially choose RAL to perform gynecologic oncological procedures that present elements of complexity. More studies are needed to determine whether this strategy is efficient in managing complex procedures in the framework of an ERP.

Impact of time to radiation therapy in adjuvant settings in endometrial carcinoma: A multicentric retrospective study

OBJECTIVE

Time to adjuvant treatment could have an impact on cancer prognosis. It is possible that robotic surgery lengthens the healing time of vaginal cuff after minimally invasive hysterectomy. The objective of this study was to state the impact of time to RT (TTR) on prognosis in endometrial carcinoma (EC) patients and to assess variables associated with TTR.

STUDY DESIGN

We conducted a multicentric retrospective study in two cancer centers. We included EC patients, between January 1996 and January 2016. We searched variables associated with TTR and impact of TTR on end-points: local recurrence-free survival, metastatic-free survival, event-free survival and overall survival.

RESULTS

329 patients were included and 279 were analyzed for TTR impact. Robotic surgery was associated with shorter TTR (8 weeks, 8.9 w for laparotomy, 9.2 w for laparoscopy). Pelvic lymphadenectomy, para-aortic lymphadenectomy, discussion in multidisciplinary meeting and treatment center was independently associated with TTR. No impact of TTR was shown on metastatic-free survival, event-free survival and overall survival but there was a trend of a decreased local recurrence rate in case of prolonged TTR (HR_{continuous variable} = 1.08; CI95 %: 0.97-1.2).

CONCLUSION

Our study did not show any impact of treatment delay on survival end-points although prolonged TTR could moderate the benefit of radiotherapy on local control rate. Surgical route was not associated with TTR, particularly robot-associated laparoscopy did not lengthen treatment delay. TTR seems dependent of health-care organization and could represent a quality criterion of EC care for institutions.

Prediction of early discharge after gynaecological oncology surgery within ERAS

OBJECTIVES

Enhanced recovery after surgery programs (ERAS) have been proven to decrease the length of hospital stay without increasing readmission rates or complications. However, the patient and operative characteristics that improve the chance of a successful early hospital discharge are not well established. The aim of this study was to design a nomogram which could be used before surgery, using the characteristics of patients, to establish who could benefit from early discharge (POD ≤ 2 days).

METHODS

This observational study has been prospectively conducted. All the included patients were referred for surgical treatment of gynecologic cancer. We defined two sub-groups of patients on surgical procedure characteristics: isolated procedures (hysterectomy or lymphadenectomy) and combined procedures (at least the association of two procedures).

RESULTS

230 patients were enrolled during the study protocol. 83.9% of patients were treated with a minimally invasive surgery (MIS). 159 patients (69.1%) were discharged on or before POD 2. On multivariate analysis, the surgical approach (open surgery vs. laparoscopy, OR  0.02 (95% CI [0-0.07]), p < 0.001) and the type of surgery (combined procedure versus isolated procedure, OR  0.41 (95% CI [0.18-0.91]), p = 0.028) were found to be significant predictors of increased hospital stay. A nomogram has been built for the purpose of predicting eligible patients for early post-operative discharge based on the multivariate analysis results (AUC = 0.86, 95% CI [0.81-0.92]).

CONCLUSION

The use of MIS for isolated procedures in oncologic indications constitutes an independent factor of early discharge in a setting of ERAS. These promising preliminary results still require to be validated on a prospective cohort.

Enhanced recovery after surgery program in older patients undergoing gynaecologic oncological surgery is feasible and safe

BACKGROUND

Enhanced Recovery After Surgery Programs (ERP) include multimodal approaches of perioperative patient's clinical pathways designed to achieve early recovery after surgery and a decreased length of hospital stay (LOS). By allowing patients to return rapidly to their everyday surroundings, older patients are those who could take the greatest benefit from ERP. This is the first study to date to assess feasibility and safety of ERP on older patients undergoing gynaecologic oncological surgery.

METHODS

Data were prospectively collected between December 2015 and September 2017 at the Institut Paoli-Calmettes, a French comprehensive cancer centre. All the patients included in the study were referred for hysterectomy and/or pelvic or para-aortic lymphadenectomy for gynaecological cancer. The primary objective was to achieve similar LOS in patients ≥70 years old compared to younger patients without increasing the proportion of complications and readmission rates. A binary (LOS < or ≥ 2 days) logistic regression was built, including age, Charlson score, BMI, ASA score, oncological indication, surgical procedures and surgical approaches. G8 score was estimated for all the ≥70 years old patients.

RESULTS

Of a total of 329 patients, 75 were ≥70 years old and 254 were <70. Except a disparity in oncological indications with a higher proportion of endometrial cancer in the ≥70 years old group (56% vs. 27%; p < 0.01), there were no differences in patient's characteristics and surgical procedures. Age ≥ 70 years was associated with a longer LOS (means, 3.88 vs. 3.11 days; p = 0.024) only in univariate analysis. Considering the logistic regression, age was no longer associated with LOS. Total hysterectomy with pelvic lymphadenectomy and ASA score ≥ 3 were independently associated with longer LOS while mini-invasive techniques were associated with a shorter LOS. Morbidities and readmissions occurred respectively in 23% and 8% of the total population without any difference between the two groups. In the ≥70 years old population, G8 score was not predictive of LOS, morbidities or readmissions.

CONCLUSION

Although it is already widely accepted that ERP improves early recovery, our study shows that ERP for patients over 70 years of age undergoing gynaecologic oncological surgery is as safe and feasible as on younger patients.