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