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Clinical pathways of recovery after surgery for advanced ovarian/tubal/peritoneal cancer: an NSGO-MaNGO international survey in collaboration with AGO—a focus on surgical aspects
  1. Elisa Piovano1,
  2. Annamaria Ferrero2,
  3. Paolo Zola3,4,
  4. Christian Marth5,
  5. Mansoor Raza Mirza6 and
  6. Kristina Lindemann7,8
  1. 1Obstetrics and Gynecology Unit, Regina Montis Regalis Hospital, Mondovì (CN), Italy
  2. 2Academic Department of Gynaecology and Obstetrics, University of Torino, Mauriziano Hospital, Torino, Italy
  3. 3Department Surgical Sciences, University of Torino, Torino, Italy
  4. 4Città della Salute e della Scienza di Torino, S. Anna University Hospital, Torino, Italy
  5. 5Department of Obstetrics and Gynecology, Innsbruck Medical University, Innsbruck, Austria
  6. 6Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
  7. 7Department of Gynaecological Cancer, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
  8. 8Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, NSGO, Oslo, Norway
  1. Correspondence to Elisa Piovano, Obstetrics and Gynecology Unit, Regina Montis Regalis Hospital, Mondovì 12084, Italy; piovano.elisa{at}


Objectives This survey assessed the implementation of enhanced recovery after surgery (ERAS) for patients undergoing surgery for advanced ovarian cancer in three European cooperative study groups in Scandinavia, Italy, and Austria. The aim was to evaluate the landscape for future trials on ERAS pathways in ovarian cancer, because high-level evidence for such interventions is lacking.

Methods In July 2017, a web-based questionnaire (SurveyMonkey Inc, Palo Alto, CA, USA) was sent to centers conducting surgery for advanced ovarian cancer within the Nordic Society of Gynecologic Oncology (NSGO), Mario Negri Gynecologic Oncology Group (MaNGO) and other Italian institutions, and the Association for Gynecologic Oncology Austria (AGO Austria) (n = 100). The survey covered all aspects of an ERAS pathway including surgery, nursing, and anesthesia. We herein report on the survey findings relating to surgery, including nursing care issues; however, anesthesiologic issues will be discussed in a separate report.

Results The overall response rate was 62%. Only a third of the centers in Italy and Austria follow a written ERAS protocol compared with 60% of the Scandinavian centers. Only a minority of centers have completely abandoned bowel preparation, with the highest proportion in Scandinavia (36%). Two hours of fasting for fluids before surgery is routinely practiced in Scandinavia and Austria (67–57%, respectively), but not in Italy (5%). Carbohydrate loading is routinely administered only in Scandinavia (67%). Peritoneal drainage is used by 22% routinely and by 61% in cases of bowel resection/lymphadenectomy/peritonectomy. Early feeding with a light diet on day 0 or 1 is the standard of care in Scandinavia and Austria, but not in Italy.

Conclusions The degree of implementation of ERAS protocols varies across and within cooperative groups. The centralization of ovarian cancer care seems to facilitate standardization of peri-operative protocols. Currently, the high heterogeneity in patterns of care may challenge an international approach to a clinical trial.

  • enhanced recovery
  • fast­track
  • ovarian cancer
  • perioperative care
  • survey

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  • Collaborators Survey participants. From Scandinavia (NSGO): Maarit Anttila - Kuopio University Hospital; Charlotte H. Søgaard - Aarhus University Hospital; Sami Saarelainen - Tampere University Hospital; Berit Jul Mosgaard - Rigshospitalet Copenhagen; Elisabeth Berge Nilsen - Stavanger University Hospital; Johanna Hynninen - Turku University Hospital; Pernille Jensen - Odense University Hospital; Pernilla Dahm Kahler - Sahlgrensksa University Hospital Goteborg; Karin Stalberg - Uppsala University Hospital; Brynhildur Eyjolfsdottir - The Norwegian Radiumhospital, Oslo University Hospital; Paivi Pakarinen - Helsinki University Hospital; Elisabeth Araya - St Olavs Hospital HF Trondheim; Martin M Lindblad - Universitetssykehuset Nord-Norge Tromsø; Line Bjørge - Haukeland University Hospital Bergen; Preben Kjolhede - Linkoping University Hospital. From Austria (AGO Austria): Karl Tamussino - Medical University of Graz; Gerhard Bogner - PMU Salzburg; Manfred Mortl - Clinical Center Klagenfurt; Christian Marth - University Hospital Innsbruck; Alexander Reinthaller - Medical University of Vienna; Lukas Hefler - Ordensklinikum Linz; Paul Sevelda - General Hospital Hietzing Vienna. From Italy (MaNGO and other Italian institutions): Alessandro Buda - San Gerardo Hospital Monza; Giorgio Giorda - CRO Aviano (PN); Tiziano Maggino - Ospedale dell' Angelo Mestre (VE); Pierandrea De Iaco - Policlinico S.Orsola Bologna; Vincenzo Dario Mandato - IRCCS-ASMN Reggio Emilia; Annamaria Ferrero and Guido Menato - Mauriziano Hospital Torino; Comerci Giuseppe - S. Maria delle Croci Hospital Ravenna; Antonino Ditto - Fondazione IRCCS Istituto Tumori Milano; Enrico Breda - San Giovanni Calibita Hospital Roma; Stefano Prigione - Ospedale Civile Santi Antonio e Biagio Alessandria; Stella Capriglione and Roberto Angioli - University Campus Biomedico of Rome; Francesco Plotti - University Campus Biomedico of Rome; Gianluca Gregori - Città della Salute e della Scienza di Torino, S.Anna Hospital Torino; Francesca Falcone - National Cancer Instituite G. Pascale Foundation Napoli; Graziana Ronzino - Vito Fazzi Hospial Lecce; Chiara Cassani - Fondazione IRCCS Policlinico San Matteo Pavia; Dionyssios Katsaros - Città della Salute e della Scienza di Torino, S.Anna University Hospital Torino; Silvia Corso - Alessandro Manzoni Hosptal, Lecco; Giuseppe Vizzielli and Giovanni Scambia - Policlinico Gemelli Roma; Marco Camanni and Elena Delpiano - Gradenigo Humanitas Hospital Torino; Andrea Puppo - Regina Montis Regalis Hospital Mondovì (CN); Angiolo Gadducci - Azienda Ospedaliera Universitaria Pisana Pisa; Alberto Daniele and Eugenio Volpi - Ospedale Santa Croce e Carle Cuneo; Marocco Francesco and Riccardo Ponzone – Istituto di Candiolo IRCCS Candiolo (TO); Michele Peiretti - University Hosptal of Cagliari; Flavia Sorbi e Massimiliano Fambrini - Careggi University Hospital Firenze; Ilaria Pezzani - Treviso Hospital; Daniela Gatti - Manerbio Hospital (BS); Paolo Sala - Policlinico San Martino Genova; Paolo Zola - Città della Salute e della Scienza di Torino, S.Anna University Hospital Torino; Giuseppe Scibilia and Paolo Scollo - Cannizzaro Hospital Catania; Simona Frezzini - Istituto Oncologico Veneto Padova; Gennaro Cormio - Bari University Hospital; Manuel Maria Ianieri and Marcello Ceccaroni - Ospedale Sacro Cuore Don Calabria Negrar (VR); Gerardo Rosati - S. Carlo Hospital Potenza; Stefano Greggi - Istituto Nazionale Tumori di Napoli; Roberto Berretta - Parma University Hospital; Giovanni Aletti - European Institute of Oncology Milano; Ilaria Spagnoletti - Fatebenefratelli Hospital Benevento; Martina Ratti and Enrico Sartori - ASST Spedali Civili Di Brescia.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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