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

https://doi.org/10.1016/j.ygyno.2020.12.035Get rights and content

Highlights

  • Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative.

  • ERAS protocols decrease length of stay, complications, and cost without increasing readmission in gynecologic oncology.

  • Meta-analysis of evidence supports implementation of ERAS as standard of care in gynecologic oncology.

Abstract

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.

Introduction

The aim of Enhanced Recovery After Surgery (ERAS) pathways is to reduce length of stay (LOS) and complications following surgery [1]. Meta-analyses have consistently shown that ERAS is efficacious in colorectal, pancreatic, thoracic, liver and urologic surgery, as well as benign gynecology [[2], [3], [4]]. Following the release of ERAS Society guidelines specific to gynecologic oncology [[5], [6], [7]], several studies have demonstrated substantial benefit of ERAS in our discipline [[8], [9], [10]]. These results support practice recommendations for ERAS implementation from organizations such as the American College of Obstetricians and Gynecologists [11]. Despite these efforts, the adoption of ERAS in gynecologic oncology on a global level has been disappointingly low [12] and some centers have shown minimal improvement in clinical outcomes after adopting ERAS [13]. Given these findings, an updated quantitative review of the published literature on ERAS is needed to address the safety and efficacy of ERAS in gynecologic oncology.

The aim of this meta-analysis was to evaluate the impact of ERAS protocols on LOS, complications, and cost compared to the previously established standard of care in patients undergoing gynecologic oncology surgery. In addition, this study aimed to look at specific complications by affected organ system, rare complications (e.g. 30-day postoperative mortality, and anastomotic leak), and postoperative hospital readmissions. Finally, this study aimed to explore how the number of ERAS elements and compliance with these ERAS elements influenced LOS and complications.

Section snippets

Protocol and registration

This study was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines [14]. The PROSPERO database of systematic reviews was screened and the protocol for this review was registered in the PROSPERO Database prior to abstract screening (Study ID CRD42020195966). Details of the protocol can be found online [15].

Eligibility criteria

Inclusion criteria: Peer-reviewed prospective and retrospective cohort studies, randomized, and non-randomized controlled

Study characteristics and risk of bias

After removing duplicates, 2519 abstracts were screened and, 179 full-text articles were assessed for eligibility. One hundred and forty-eight studies were excluded (Fig. 1). Thirty-one studies involving 6703 patients were included in the final analysis. Details of the data abstraction process can be found in Fig. 1. The majority of the studies (16/31) were at centres in the United States [9,10,13,[25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36]], with the remaining

Discussion

This meta-analysis demonstrated a mean reduction of LOS of approximately 2 days and a mean cost reduction of over $2000 USD per patient following the implementation of ERAS in gynecologic oncology. Despite the reduction in LOS, ERAS implementation was associated with a decreased risk of readmission and resulted in a 32% reduction in complications following gynecologic oncology surgery. Taking into consideration that the complication rate in gynecologic oncology surgery can be as high as 50%

Conclusions

This meta-analysis provides evidence to support the safety and efficacy of ERAS pathways in gynecologic oncology. ERAS pathway implementation was associated with a significant decrease in LOS, readmission, postoperative complications, and costs. This study adds to the mounting body of evidence in the literature creating a pressing need for widespread standardized adoption of ERAS pathways as an evidence-based scientific approach towards a safer and more cost-effective perioperative care

Declaration of Competing Interest

Dr. Nelson reports advisory fees from Abbott, outside the submitted work; and Secretary of the ERAS® Society. Dr. Meyer reports research support from AstraZeneca and consulting for GlaxoSmithKline outside the submitted work. The remaining authors declare no conflict of interest.

Acknowledgments

The authors would like to recognize the following individuals who provided supplementary data (mean length of stay +/- standard deviation) which was required for the analysis: Laurence Belanger, Marie-Claude Renaud (University of Laval); Gloria Broadwater, Laura Havrilesky (Duke University Medical Center); Rebecca Stone (Johns Hopkins School of Medicine); Basile Pache, Chahin Achtari (Lausanne University Hospital); and Maria Iniesta (The University of Texas MD Anderson Cancer Center).

References (57)

  • K. Ghosh et al.

    The implementation of critical pathways in gynecologic oncology in a managed care setting: a cost analysis

    Gynecol. Oncol.

    (2001)
  • M.C. Renaud et al.

    Effectiveness of an enhanced recovery after surgery program in Gynaecology oncologic surgery: a single-Centre prospective cohort study

    J. Obstet. Gynaecol. Canada.

    (2019)
  • J.J.A. de Groot et al.

    Diffusion of enhanced recovery principles in gynecologic oncology surgery: is active implementation still necessary?

    Gynecol. Oncol.

    (2014)
  • J.L. Sánchez-Iglesias et al.

    PROFAST: A randomised trial implementing enhanced recovery after surgery for highcomplexity advanced ovarian cancer surgery

    Eur. J. Cancer.

    (2020)
  • B. Pache et al.

    Cost-analysis of enhanced recovery after surgery (ERAS) program in gynecologic surgery

    Gynecol. Oncol.

    (2019)
  • J.E. Bergstrom et al.

    Narcotics reduction, quality and safety in gynecologic oncology surgery in the first year of enhanced recovery after surgery protocol implementation

    Gynecol. Oncol.

    (2018)
  • O. Ljungqvist et al.

    Enhanced recovery after surgery: a review

    JAMA Surg.

    (2017)
  • A. Visioni et al.

    Enhanced recovery after surgery for noncolorectal surgery? A systematic review and meta-analysis of major abdominal surgery

    Ann. Surg.

    (2018)
  • E.L. Barber et al.

    Enhanced recovery pathways in gynecology and gynecologic oncology

    Obstet. Gynecol. Surv.

    (2015)
  • G. Nelson et al.

    Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations—2019 update

    Int. J. Gynecol. Cancer

    (2019)
  • L.A. Meyer et al.

    Effect of an enhanced recovery after surgery program on opioid use and patient-reported outcomes

    Obstet. Gynecol.

    (2018)
  • E. Kalogera et al.

    Enhanced recovery in gynecologic surgery

    Obstet. Gynecol.

    (2013)
  • ACOG Committee Opinion No. 750 Summary: Perioperative Pathways: Enhanced Recovery After Surgery

    Obstet. Gynecol.

    (2018)
  • G.P. Bhandoria, P. Bhandarkar, V. Ahuja, A. Maheshwari, R.K. Sekhon, M. Gultekin, A. Ayhan, F. Demirkiran, I....
  • E.L. Dickson et al.

    Enhanced recovery program and length of stay after laparotomy on a gynecologic oncology service: a randomized controlled trial

    Obstet. Gynecol.

    (2017)
  • S.P. Bisch et al.

    Outcomes of ERAS in Gynecologic Cancer Surgery – A Systematic Review and Meta-Analysis, PROSPERO

  • D. Dindo et al.

    Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey

    Ann. Surg.

    (2004)
  • G. Wells et al.

    The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses

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