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Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part II

Open AccessPublished:January 03, 2016DOI:https://doi.org/10.1016/j.ygyno.2015.12.019

      Highlights

      • We provide evidence supporting postoperative management of patients undergoing gynecologic/oncology surgery.
      • This guideline will help integrate knowledge into practice, align perioperative care, and encourage future investigations.

      Keywords

      1. Introduction

      The “Guidelines for Pre- and Intra-operative Care in Gynecologic/Oncology Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations — Part I,” [
      • Nelson G.
      • Altman A.
      • Nick A.
      • Meyer L.
      • Ramirez P.T.
      • Achtari C.
      • et al.
      Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
      ] examined the evidence surrounding care elements including preoperative medical optimization, bowel preparation, carbohydrate loading, thromboembolism prophylaxis, skin preparation, standard anesthetic protocol and intraoperative fluid management. The goal of this article is to critically review existing evidence and make recommendations for elements of postoperative care. This effort forms the basis of the ERAS® Guideline for postoperative care in gynecologic/oncology surgery.

      2. Methods

      2.1 Literature search

      The authors convened in July 2014 to discuss topics for inclusion — the topic list was based on the ERAS® Colonic Surgery [
      • Gustafsson U.O.
      • Scott M.J.
      • Schwenk W.
      • Demartines N.
      • Roulin D.
      • Francis N.
      • et al.
      Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.
      ] and Rectal/Pelvic [
      • Nygren J.
      • Thacker J.
      • Carli F.
      • Fearon K.C.
      • Norderval S.
      • Lobo D.N.
      • et al.
      Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.
      ] Guidelines which were used as templates. After the topics were agreed upon they were then allocated amongst the group according to expertise. The literature search (1966–2014) used Embase and PubMed to search medical subject headings including “gynecology”, “gynecologic oncology” and all postoperative ERAS® items (see Table 1). Reference lists of all eligible articles were crosschecked for other relevant studies.
      Table 1Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
      ItemRecommendationEvidence levelRecommendation grade
      Prophylaxis against thromboembolismPatients should wear well-fitting compression stockings and have intermittent pneumatic compressionHighStrong
      Extended prophylaxis (28 days) should be given to patients after laparotomy for abdominal or pelvic malignanciesHighStrong
      Postoperative fluid therapyIntravenous fluids should be terminated within 24 h after surgery; balanced crystalloid solutions are preferred to 0.9% normal salineModerateStrong
      Perioperative nutritional careA regular diet within the first 24 h after gynecologic/oncology surgery is recommendedHighStrong
      Prevention of postoperative ileusThe use of postoperative laxatives should be consideredLowWeak
      The use of chewing gum should be consideredModerateWeak
      Postoperative glucose controlERAS elements that reduce metabolic stress should be employed to reduce insulin resistance and the development of hyperglycemiaHighStrong
      Perioperative maintenance of blood glucose levels (<180–200 mg/dL) results in improved perioperative outcomes; glucose levels above this range should be treated with insulin infusions and regular blood glucose monitoring to avoid the risk of hypoglycemiaHighStrong
      Postoperative analgesiaA multimodal approach to analgesia should be adopted including use of NSAIDS/acetaminophen, gabapentin and dexamethasone (unless contraindications exist)Multimodal: high

      NSAIDS/aceta: high

      Gabapentin: moderate

      Dexamethasone: low
      Strong
      Vaginal hysterectomy
       Paracervical nerve block or intrathecal morphine can be used to reduce pain and opioid consumptionLowWeak
      Open general gynecologic surgery
       Spinal anesthesia with intrathecal morphine is recommendedModerateStrong
       Alternatively, thoracic epidural analgesia (TEA) with low concentration local anesthetic solutions with the addition of opiates for 24-48 h can be consideredHighStrong
       Truncal nerve blocks (TAP or ilioinguinal) can be recommended where patients have undergone general anesthesia without neuraxial blockadeModerateStrong
       Continuous wound infiltration (CWI) of local anesthetic can be consideredModerateStrong
      Major oncologic surgery
       TEA may be considered but patients frequently require additional IV opioids in addition to TEA to achieve adequate analgesiaLowWeak
      Laparoscopic gynecologic/oncology surgery
       Lack of evidence makes it difficult to recommend one analgesic intervention over another, however a multimodal approach should be employedLowWeak
      Peritoneal drainagePeritoneal drainage is not recommended routinely in gynecologic/oncology surgery including for patients undergoing lymphadenectomy or bowel surgeryModerateStrong
      Urinary drainageUrinary catheters should be used for postoperative bladder drainage for a short period preferably <24 h postopLowStrong
      Early mobilizationPatients should be encouraged to mobilize within 24 h of surgeryLowStrong

      2.2 Study selection

      Titles and abstracts were screened by individual reviewers to identify potentially relevant articles. Discrepancies in judgment were resolved by the lead (GN) and senior authors (OL, SD). Meta-analyses, systematic reviews, randomized controlled studies, non-randomized controlled studies, reviews, and case series were considered for each individual topic.

      2.3 Quality assessment and data analyses

      The quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system (see Tables 2a and 2b) [
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • Kunz R.
      • Falck-Ytter Y.
      • Alonso-Coello P.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      ] whereby recommendations are given as follows: Strong recommendations indicate that the panel is confident that the desirable effects of adherence to a recommendation outweigh the undesirable effects. Weak recommendations indicate that the desirable effects of adherence to a recommendation probably outweigh the undesirable effects, but the panel is less confident. Recommendations are based on quality of evidence: high, moderate, low and very low but also on the balance between desirable and undesirable effects; and on values and preferences. As such, consistent with other ERAS® Guideline Working groups [
      • Gustafsson U.O.
      • Scott M.J.
      • Schwenk W.
      • Demartines N.
      • Roulin D.
      • Francis N.
      • et al.
      Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.
      ,
      • Cerantola Y.
      • Valerio M.
      • Persson B.
      • Jichlinski P.
      • Ljungqvist O.
      • Hubner M.
      • et al.
      Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
      ], in some cases strong recommendations may be reached from low-quality data and vice versa. Of note, this would be considered a modified GRADE evaluation since we did not consider resource utilization when making our recommendations [
      • Brunetti M.
      • Shemilt I.
      • Pregno S.
      • Vale L.
      • Oxman A.D.
      • Lord J.
      • et al.
      GRADE guidelines: 10. Considering resource use and rating the quality of economic evidence.
      ].
      Table 2aGRADE system for rating quality of evidence.
      Evidence levelDefinition
      High qualityFurther research unlikely to change confidence in estimate of effect
      Moderate qualityFurther research likely to have important impact on confidence in estimate of effect and may change the estimate
      Low qualityFurther research very likely to have important impact on confidence in estimate of effect and likely to change the estimate
      Very low qualityAny estimate of effect is very uncertain
      Reference
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • Kunz R.
      • Falck-Ytter Y.
      • Alonso-Coello P.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      .
      Table 2bGRADE system for rating strength of recommendations.
      Recommendation strengthDefinition
      StrongWhen desirable effects of intervention clearly outweigh the undesirable effects, or clearly do not
      WeakWhen trade-offs are less certain — either because of low quality evidence or because evidence suggests desirable and undesirable effects are closely balanced
      Reference
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • Kunz R.
      • Falck-Ytter Y.
      • Alonso-Coello P.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      .

      3. Results

      The evidence base, recommendations, evidence level, and recommendation grade are provided for each individual ERAS® item below.

      4. Postoperative thromboembolism prophylaxis

      4.1 Immediate postoperative prophylaxis

      Pneumatic compression stockings reduce the rate of VTE (venous thromboembolism) when compared to observation [
      • Clarke-Pearson D.L.
      • Synan I.S.
      • Dodge R.
      • Soper J.T.
      • Berchuck A.
      • Coleman R.E.
      A randomized trial of low-dose heparin and intermittent pneumatic calf compression for the prevention of deep venous thrombosis after gynecologic oncology surgery.
      ]. The risk reduction is equivalent when compared to heparin [
      • Maxwell G.L.
      • Synan I.
      • Dodge R.
      • Carroll B.
      • Clarke-Pearson D.L.
      Pneumatic compression versus low molecular weight heparin in gynecologic oncology surgery: a randomized trial.
      ] and improved when combined with heparin [
      • Einstein M.H.
      • Kushner D.M.
      • Connor J.P.
      • Bohl A.A.
      • Best T.J.
      • Evans M.D.
      • et al.
      A protocol of dual prophylaxis for venous thromboembolism prevention in gynecologic cancer patients.
      ] in gynecologic oncology patients. Graduated compression stockings decrease the rate of DVT in hospitalized patients, especially when combined with another method [
      • Sachdeva A.
      • Dalton M.
      • Amaragiri S.V.
      • Lees T.
      Graduated compression stockings for prevention of deep vein thrombosis.
      ].

      4.2 Extended postoperative prophylaxis

      A large prospective cohort trial showed an increased rate of VTE within 30 days of surgery in cancer patients [
      • Agnelli G.
      • Bolis G.
      • Capussotti L.
      • Scarpa R.M.
      • Tonelli F.
      • Bonizzoni E.
      • et al.
      A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the @RISTOS project.
      ], and extended prophylaxis (28 days) is now considered a common practice within major gynecologic oncology surgery [
      • Gould M.K.
      • Garcia D.A.
      • Wren S.M.
      • Karanicolas P.J.
      • Arcelus J.I.
      • Heit J.A.
      • et al.
      Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
      ]. A Cochrane review of 4 randomized controlled trials examining extended prophylaxis has shown a decrease in VTE (14.3% vs. 6.1%; p < 0.0005) and a decrease in symptomatic VTE (1.7% vs. 0.2%; p = 0.02) [
      • Rasmussen M.S.
      • Jorgensen L.N.
      • Wille-Jorgensen P.
      Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery.
      ]. The role of extended prophylaxis in minimally invasive surgery is likely not necessary without other high-risk features (elevated BMI, previous VTE, coagulopathy, decreased mobility) [
      • Ramirez P.T.
      • Nick A.M.
      • Frumovitz M.
      • Schmeler K.M.
      Venous thromboembolic events in minimally invasive gynecologic surgery.
      ].

      4.2.1 Summary and recommendations

      Patients should wear well-fitting compression stockings and have intermittent pneumatic compression. Extended prophylaxis (28 days) should be given to patients after laparotomy for abdominal or pelvic malignancies.

      4.2.2 Evidence level

      High.

      4.2.3 Recommendation grade

      Strong.

      5. Postoperative fluid therapy

      Oral intake of fluid and food should be started the day of surgery whenever possible. With the commencement of oral diet and oral analgesia as soon as tolerated after surgery the need for postoperative intravenous fluids beyond 12–24 h is rarely needed in an uncomplicated recovery. Patients can drink immediately after surgery. Flavored high energy protein drinks prescribed three times a day are safe and can bridge the postoperative period of building back up to a normal diet to ensure some protein and calorie intake early in the recovery process. They are usually 200–250 ml in volume with around 150 kJ/100 ml of carbohydrate and 3–6 g/100 mL of protein with the addition of vitamins, mineral and trace elements. If intravenous fluids must be maintained then a total hourly volume of no more than 1.2 mL/kg (including drugs, approximately 90 mL/h for a 75 kg female) should be given [
      • National Clinical Guideline Centre (UK)
      Intravenous Fluid Therapy: Intravenous Fluid Therapy in Adults in Hospital.
      ]. Balanced crystalloid solutions are preferred to 0.9% normal saline due to the cumulative risk of hyper-chloremic acidosis. The use of starch solutions during the perioperative period should be limited by dose and duration to avoid the adverse effects seen in studies on intensive care patients such as bleeding and renal dysfunction [
      • Perner A.
      • Haase N.
      • Guttormsen A.B.
      • Tenhunen J.
      • Klemenzson G.
      • Åneman A.
      • et al.
      Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis.
      ]. Oliguria as low as 20cm3/h is a normal response to surgery, and the need for further intravenous fluid boluses should be assessed within clinical context. A small proportion of patients undergoing major surgery will develop SIRS (Systemic Inflammatory Response Syndrome) causing marked vasodilation and hypotension without sepsis. These patients will require vasopressor therapy such as a noradrenaline infusion during surgery and postoperatively until resolution.

      5.1 Summary and recommendations

      Intravenous fluids should be terminated within 24 h after surgery. Balanced crystalloid solutions are preferred to 0.9% normal saline.

      5.2 Evidence level

      Moderate.

      5.3 Recommendation grade

      Strong.

      6. Perioperative nutritional care

      A number of randomized trials on the subject of early feeding (defined as having oral intake of fluids or food within the first 24 h after surgery) have been performed in gynecologic oncology [
      • Charoenkwan K.
      • Phillipson G.
      • Vutyavanich T.
      Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery.
      ,
      • Minig L.
      • Biffi R.
      • Zanagnolo V.
      • Attanasio A.
      • Beltrami C.
      • Bocciolone L.
      • et al.
      Early oral versus “traditional” postoperative feeding in gynecologic oncology patients undergoing intestinal resection: a randomized controlled trial.
      ,
      • Minig L.
      • Biffi R.
      • Zanagnolo V.
      • Attanasio A.
      • Beltrami C.
      • Bocciolone L.
      • et al.
      Reduction of postoperative complication rate with the use of early oral feeding in gynecologic oncologic patients undergoing a major surgery: a randomized controlled trial.
      ,
      • Schilder J.M.
      • Hurteau J.A.
      • Look K.Y.
      • Moore D.H.
      • Raff G.
      • Stehman F.B.
      • et al.
      A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery.
      ]. Effects include accelerated return of bowel activity, reduced length of stay, with no evidence of higher complication rates related to wound healing, anastomotic leaks, or pulmonary complications. A randomized study in patients with ovarian cancer showed a significantly lower rate of complications for patients receiving early feeding. However, complication rates were not different between groups when the analysis was limited to a smaller cohort of patients undergoing intestinal resections [
      • Minig L.
      • Biffi R.
      • Zanagnolo V.
      • Attanasio A.
      • Beltrami C.
      • Bocciolone L.
      • et al.
      Early oral versus “traditional” postoperative feeding in gynecologic oncology patients undergoing intestinal resection: a randomized controlled trial.
      ,
      • Minig L.
      • Biffi R.
      • Zanagnolo V.
      • Attanasio A.
      • Beltrami C.
      • Bocciolone L.
      • et al.
      Reduction of postoperative complication rate with the use of early oral feeding in gynecologic oncologic patients undergoing a major surgery: a randomized controlled trial.
      ]. It is important to note that early feeding is associated with a higher rate of nausea, but not vomiting, abdominal distension, or nasogastric tube use. Patient satisfaction with control of vomiting in one series was over 90% with early feeding despite a higher incidence of nausea in the enhanced recovery group [
      • Kalogera E.
      • Bakkum-Gamez J.N.
      • Jankowski C.J.
      • Trabuco E.
      • Lovely J.K.
      • Dhanorker S.
      • et al.
      Enhanced recovery in gynecologic surgery.
      ].

      6.1 Summary and recommendation

      A regular diet within the first 24 h after gynecologic/oncology surgery is recommended.

      6.2 Evidence level

      High.

      6.3 Recommendation grade

      Strong.

      7. Prevention of postoperative ileus

      Laxatives are commonly used within enhanced recovery protocols to hasten the return of bowel function, but no high quality data is available in gynecologic oncology. In one prospective, but nonrandomized trial of 20 patients undergoing open radical hysterectomy, milk of magnesia and biscolic suppositories were well tolerated and associated with a reduction in hospital stay compared with historical controls [
      • Fanning J.
      • Yu-Brekke S.
      Prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy.
      ]. In 68 patients undergoing hepatic resection via laparotomy, patients randomized to magnesium hydroxide experienced a median one-day reduction in time to passage of stool [
      • Hendry P.O.
      • van Dam R.M.
      • Bukkems S.F.
      • McKeown D.W.
      • Parks R.W.
      • Preston T.
      • et al.
      Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery protocol following liver resection.
      ]. Although data are limited and effects appear modest, continued use of laxatives is reasonable given the low cost and side effect profile.
      In patients undergoing hysterectomy and colonic resection, randomized trials have shown improved recovery when a peripheral mu antagonist was administered [
      • Traut U.
      • Brugger L.
      • Kunz R.
      • Pauli-Magnus C.
      • Haug K.
      • Bucher H.C.
      • et al.
      Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults.
      ]. Its use in patients undergoing planned enteric resections is reasonable, but we cannot provide a recommendation for its use at the present time as cost-effectiveness and efficacy data in patients with gynecologic malignancies continues to be collected. Perioperative use of chewing gum had a positive effect on the incidence of postoperative ileus (36% vs. 15%) and length of stay (1 day reduction) in a randomized trial of patients undergoing staging for gynecologic malignancies [
      • Ertas I.E.
      • Gungorduk K.
      • Ozdemir A.
      • Solmaz U.
      • Dogan A.
      • Yildirim Y.
      Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial.
      ]. A meta-analysis of randomized trials investigating prokinetics such as erythromycin, the cholecystokinin-like drugs, cisapride, dopamine-antagonists, propranolol, vasopressin, and intravenous lidocaine [
      • Kranke P.
      • Jokinen J.
      • Pace N.L.
      • Schnabel A.
      • Hollmann M.W.
      • Hahnenkamp K.
      • et al.
      Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.
      ] or neostigmine [
      • Karanicolas P.J.
      • Smith S.E.
      • Kanbur B.
      • Davies E.
      • Guyatt G.H.
      The impact of prophylactic dexamethasone on nausea and vomiting after laparoscopic cholecystectomy: a systematic review and meta-analysis.
      ] failed to demonstrate benefit.

      7.1 Summary and recommendations

      The use of postoperative laxatives and chewing gum should be considered.

      7.2 Evidence level

      Laxatives: Low.
      Chewing gum: Moderate.

      7.3 Recommendation grade

      Weak.

      8. Postoperative control of glucose

      Perioperative hyperglycemia, classically defined as blood glucose levels greater than 180 to 200 mg/dL is associated with poor clinical outcomes including increased perioperative mortality, hospital length of stay, ICU length of stay and postoperative infection [
      • Kiran R.P.
      • Turina M.
      • Hammel J.
      • Fazio V.
      The clinical significance of an elevated postoperative glucose value in nondiabetic patients after colorectal surgery: evidence for the need for tight glucose control?.
      ,
      • Ramos M.
      • Khalpey Z.
      • Lipsitz S.
      • Steinberg J.
      • Panizales M.T.
      • Zinner M.
      • et al.
      Relationship of perioperative hyperglycemia and postoperative infections in patients who undergo general and vascular surgery.
      ]. Most clinicians would agree that prevention of perioperative hyperglycemia is a desirable intervention, the optimal blood glucose range remains controversial due to the potential adverse events related to iatrogenic hypoglycaemia [
      • Qaseem A.
      • Humphrey L.L.
      • Chou R.
      • Snow V.
      • P S.
      Clinical Guidelines Committee of the American College of Physicians. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians.
      ]. Clinical trials in adult surgical patients illustrate this paradigm of outcomes with intensive insulin therapy (IIT) defined as 140 to 200 mg/dL by the American College of Physicians. The Leuven surgical trial randomly assigned patients to IIT or conventional glucose management with a decrease in mean blood glucose levels and ICU mortality in the IIT group [
      • van den Berghe G.
      • Wouters P.
      • Weekers F.
      • Verwaest C.
      • Bruyninckx F.
      • Schetz M.
      • et al.
      Intensive insulin therapy in critically ill patients.
      ]. However, hypoglycemia was more frequent in the IIT group. These findings were supported by meta-analytical data from 5 randomized trials, which compared IIT to less stringent glycemic control and demonstrated significantly lower mortality [
      • Griesdale D.E.
      • de Souza R.J.
      • van Dam R.M.
      • Heyland D.K.
      • Cook D.J.
      • Malhotra A.
      • et al.
      Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data.
      ]. In contrast, the Normoglycemic in Intensive Care Evaluation Survival Glucose Algorithm Regulation (NICE-SUGAR) trial demonstrated a higher rate of severe hypoglycemia and higher 90-day mortality in those patients who received IIT compared to conventional glucose management [
      • NICE-SUGAR Study Investigators
      • Finfer S.
      • Chittock D.R.
      • Su S.Y.
      • Blair D.
      • Foster D.
      • Dhingra V.
      • et al.
      Intensive versus conventional glucose control in critically ill patients.
      ]. Hypoglycemia is the most common adverse effect of IIT and can lead to unwanted morbidity such as seizures, brain damage, and cardiac arrhythmias. As a result, more liberal blood glucose targets of 180 to 200 mg/dL are typically recommended in effort to prevent significant hyperglycemia whilst avoiding iatrogenic hypoglycemia [
      • Preiser J.C.
      • Devos P.
      • Ruiz-Santana S.
      • Mélot C.
      • Annane D.
      • Groeneveld J.
      • et al.
      A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study.
      ,
      • Vanhorebeek I.
      • Langouche L.
      • Van den Berghe G.
      Tight blood glucose control with insulin in the ICU: facts and controversies.
      ,
      • Krinsley J.S.
      • Grover A.
      Severe hypoglycemia in critically ill patients: risk factors and outcomes.
      ].
      The surgical stress response triggers a cascade of sympathetic nervous system and endocrine responses that include activation of the HPA axis and increased cortisol secretion, which leads to a net increase in peripheral insulin resistance [
      • Desborough J.P.
      The stress response to trauma and surgery.
      ]. Traditional perioperative interventions such as mechanical bowel preparation, pre-operative fasting, and slow resumption of normal diet all contribute to the relative insulin resistant state noted perioperatively and have been shown to correlate with perioperative complications and increased length of hospital stay [
      • Nygren J.
      The metabolic effects of fasting and surgery.
      ]. Several elements of enhanced recovery protocols abrogate postoperative insulin resistance and thereby result in lower perioperative glucose levels without resulting hypoglycemia. Examples of key elements include avoidance of oral mechanical preoperative bowel preparation and avoidance of preoperative fasting until 2 h prior to surgery, pre-operative carbohydrate loading along with stimulation of gut function by early resumption of postoperative oral intake and optimal fluid balance [
      • Nelson G.
      • Altman A.
      • Nick A.
      • Meyer L.
      • Ramirez P.T.
      • Achtari C.
      • et al.
      Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
      ].

      8.1 Summary and recommendation

      ERAS elements that reduce metabolic stress should be employed to reduce insulin resistance and the development of hyperglycemia. Perioperative maintenance of blood glucose levels (<180–200 mg/dL) results in improved perioperative outcomes. Glucose levels above this range should be treated with insulin infusions and regular blood glucose monitoring to avoid the risk of hypoglycemia.

      8.2 Evidence level

      Use of stress reducing elements: High.
      Treating hyperglycemia above 180–200 mg/dL: High.

      8.3 Recommendation grade

      Strong.

      9. Postoperative analgesia

      Pain following gynecological abdominal surgery can be severe [
      • Massicotte L.
      • Chalaoui K.D.
      • Beaulieu D.
      • Roy J.D.
      • Bissonnette F.
      Comparison of spinal anesthesia with general anesthesia on morphine requirement after abdominal hysterectomy.
      ]. Uncontrolled acute post-operative pain is associated with dissatisfaction [
      • Myles P.S.
      • Weitkamp B.
      • Jones K.
      • Melick J.
      • Hensen S.
      Validity and reliability of a postoperative quality of recovery score: the QoR-40.
      ], post-operative complications, and is a strong risk factor for development of chronic pain [
      • Macrae W.A.
      Chronic post-surgical pain: 10 years on.
      ]. Morphine is commonly used to control post-operative pain but is associated with nausea, sedation [
      • Woodhouse A.
      • Mather L.E.
      The effect of duration of dose delivery with patient-controlled analgesia on the incidence of nausea and vomiting after hysterectomy.
      ], fatigue [
      • Dolin S.J.
      • Cashman J.N.
      Tolerability of acute postoperative pain management: nausea, vomiting, sedation, pruritis, and urinary retention. Evidence from published data.
      ] and poorer quality of recovery [
      • Catro-Alves L.J.
      • De Azevedo V.L.
      • De Freitas Braga T.F.
      • Goncalves A.C.
      • De Oliveira Jr., G.S.
      The effect of neuraxial versus general anesthesia techniques on postoperative quality of recovery and analgesia after abdominal hysterectomy.
      ] and may prolong time to mobilization. Opioid analgesics also contribute to the development of ileus. Therefore an enhanced recovery pathway for gynecological surgery must employ a strategy to effectively control post-operative pain and allow attainment of other ERAS targets such as early mobilization and return to oral diet whilst reducing the need for opiates. Many RCTs in the last 20 years in open surgery have focused on epidural analgesia, which can offer excellent analgesia, reduction in the surgical stress response, and earlier return of gut function. However the role of epidural analgesia is now a matter of debate. With the increasing uptake of laparoscopic and robotic assisted surgery the magnitude and duration of visceral and wound pain have been markedly reduced such that good post-operative pain control is achievable by many different analgesic techniques, often used in combination to tackle both the visceral and wound elements. The literature base is developing rapidly and may well impact on future recommendations.

      9.1 Multimodal analgesia

      The concept of achieving analgesia through the additive or synergistic effects of different types of analgesics is not new [
      • Buvanendran A.
      • Kroin J.S.
      Multimodal analgesia for controlling acute postoperative pain.
      ]. Non-steroidal anti-inflammatory drugs (NSAIDs) have been extensively investigated, both as part of a multi-modal analgesic regime as well as for gynecologic surgery, and are effective at reducing pain and opioid consumption and improving patient satisfaction [
      • Niruthisard S.
      • Werawataganon T.
      • Bunburaphong P.
      • Ussawanophakiat M.
      • Wongsakornchaikul C.
      • Toleb K.
      Improving the analgesic efficacy of intrathecal morphine with parecoxib after total abdominal hysterectomy.
      ,
      • Blackburn A.
      • Stevens J.D.
      • Wheatley R.G.
      • Madej T.H.
      • Hunter D.
      Balanced analgesia with intravenous ketorolac and patient-controlled morphine following lower abdominal surgery.
      ], and a combination of NSAID and acetaminophen is more effective than either drug alone [
      • Ong C.K.
      • Seymour R.A.
      • Lirk P.
      • Merry A.F.
      Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain.
      ]. Both should be administered regularly unless contraindication exists. Gabapentin has recently become popular for treatment of post-operative pain. A recent systematic review found that pre-emptive administration of gabapentin for abdominal hysterectomy was effective in reducing post-operative pain, opioid consumption and side effects [
      • Alayed N.
      • Alghanaim N.
      • Tan X.
      • Tulandi T.
      Preemptive use of gabapentin in abdominal hysterectomy: a systematic review and meta-analysis.
      ] and has been used in one gynecologic enhanced recovery program [
      • Kalogera E.
      • Bakkum-Gamez J.N.
      • Jankowski C.J.
      • Trabuco E.
      • Lovely J.K.
      • Dhanorker S.
      • et al.
      Enhanced recovery in gynecologic surgery.
      ]. However, studies have not yet identified the optimal dose, or timing of administration. Dexamethasone appears to have analgesic effects [
      • Lunn T.H.
      • Kristensen B.B.
      • Andersen L.Ø.
      • Husted H.
      • Otte K.S.
      • Gaarn-Larsen L.
      • et al.
      Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial.
      ,
      • De Oliveira Jr., G.S.
      • Ahmad S.
      • Fitzgerald P.C.
      • Marcus R.J.
      • Altman C.S.
      • Panjwani A.S.
      • et al.
      Dose ranging study on the effect of preoperative dexamethasone on postoperative quality of recovery and opioid consumption after ambulatory gynaecological surgery.
      ], as well as preventing post-operative nausea and vomiting, so may be useful as part of an ERP for gynecologic surgery. However its analgesic effects are yet to be fully investigated and it may cause transient post-operative hyperglycemia. Chronic administration of steroids are known to impair wound healing, although this has not been demonstrated following administration of a course <10 days duration [
      • Wang A.S.
      • Armstrong E.J.
      • Armstrong A.W.
      Corticosteroids and wound healing: clinical considerations in the perioperative period.
      ]. Intravenous lidocaine is gaining popularity as an analgesic adjunct in abdominal surgery. A Cochrane analysis concluded that there was low quality evidence of an early reduction in pain, and opioid consumption and time to bowel recovery were reduced, though the effect on these outcomes was small [
      • Kranke P.
      • Jokinen J.
      • Pace N.L.
      • Schnabel A.
      • Hollmann M.W.
      • Hahnenkamp K.
      • et al.
      Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.
      ].

      9.1.1 Summary and recommendations

      A multimodal analgesia strategy should be employed with the aim of reducing post-operative opioid requirement. Post-operatively, opioids should be given orally to patients who can tolerate diet. For patients unable to tolerate diet following surgery, then an opioid IV PCA can be used until resumption of GI function, but the oral route should be used as soon as possible.
      Acetaminophen and NSAIDs in combination should be administered regularly to all patients unless contraindication exists.
      Dexamethasone may be administered to prevent PONV and reduce pain, but should be used with caution in diabetic patients.
      Gabapentin may reduce pain and side effects and may be considered, although the optimal dose is not known.

      9.1.2 Level of evidence

      Use of multimodal analgesia: High.
      Combination of acetaminophen and NSAIDs: High.
      Gabapentin: Moderate.
      Dexamethasone as an analgesic: Low.

      9.1.3 Recommendation grade

      Strong.

      9.2 Analgesia for vaginal hysterectomy

      Few rigorous studies have been performed investigating analgesia in patients undergoing vaginal hysterectomy. In one study, intra-operative paracervical nerve block appeared to reduce post-operative pain and morphine consumption, and although the analgesic benefit appears to be limited to the first few hours after surgery, patients mobilized more quickly [
      • Hristovska A.M.
      • Kristensen B.B.
      • Rasmussen M.A.
      • Rasmussen Y.H.
      • Elving L.B.
      • Nielsen C.V.
      • et al.
      Effect of systematic local infiltration analgesia on postoperative pain in vaginal hysterectomy: a randomized, placebo-controlled trial.
      ]. However a Cochrane review concluded that paracervical nerve block was ineffective for cervical dilatation [
      • Tangsiriwatthana T.
      • Sangkomkamhang U.S.
      • Lumbiganon P.
      • Laopaiboon M.
      Paracervical local anaesthesia for cervical dilatation and uterine intervention.
      ]. One study investigated high-volume local anesthetic infiltration of the surrounding tissues and found that although the analgesic benefit was limited to the first four hours post-operatively, patients used less opioid analgesics and mobilized earlier [
      • Kristensen B.B.
      • Rasmussen Y.H.
      • Agerlin M.
      • Topp M.W.
      • Weincke M.O.
      • Kehlet H.
      Local infiltration analgesia in urogenital prolapse surgery: a prospective randomized, double-blind, placebo-controlled study.
      ]. In another study, spinal anesthesia with intrathecal morphine and clonidine also reduced early post-operative pain and morphine consumption, though the effect was modest [
      • Sprung J.
      • Sanders M.S.
      • Warner M.E.
      • Gebhart J.B.
      • Stanhope C.R.
      • Jankowski C.J.
      • et al.
      Pain relief and functional status after vaginal hysterectomy: intrathecal versus general anesthesia.
      ]. Both spinal morphine and paracervical nerve block have been used to facilitate early discharge in enhanced recovery vaginal hysterectomy pathways [
      • Penketh R.
      • Griffiths A.
      • Chawathe S.
      A prospective observational study of the safety and acceptability of vaginal hysterectomy performed in a 24-hour day case surgery setting.
      ,
      • Ottesen M.
      • Sørensen M.
      • Rasmussen Y.
      • Smidt-Jensen S.
      • Kehlet H.
      • Ottesen B.
      Fast track vaginal surgery.
      ].

      9.2.1 Summary and recommendations

      Local anesthetic infiltration may be effective at reducing early post-operative pain and opioid consumption, and facilitating early mobilization. Either paracervical nerve block or intrathecal morphine may reduce pain and opioid consumption after vaginal hysterectomy. However, the effect is small.

      9.2.2 Evidence level

      Low.

      9.2.3 Recommendation grade

      Weak.

      9.3 Analgesia for open general gynecologic surgery

      The optimal analgesic regimen for open gynecologic surgery is currently a subject of debate. Thoracic epidural analgesia (TEA) has gained widespread acceptance in providing post-operative analgesia for major abdominal surgery [
      • Gustafsson U.O.
      • Scott M.J.
      • Schwenk W.
      • Demartines N.
      • Roulin D.
      • Francis N.
      • et al.
      Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations.
      ], and has been shown to be superior to intravenous PCA [
      • Wu C.L.
      • Cohen S.R.
      • Richman J.M.
      • Rowlingson A.J.
      • Courpas G.E.
      • Cheung K.
      • et al.
      Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis.
      ]. TEA is effective in attenuating the surgical stress response and reducing pain and opioid consumption for up to 72 h [
      • Wu C.L.
      • Cohen S.R.
      • Richman J.M.
      • Rowlingson A.J.
      • Courpas G.E.
      • Cheung K.
      • et al.
      Efficacy of postoperative patient-controlled and continuous infusion epidural analgesia versus intravenous patient-controlled analgesia with opioids: a meta-analysis.
      ,
      • Carli F.
      • Mayo N.
      • Klubien K.
      • Schricker T.
      • Trudel J.
      • Belliveau P.
      Epidural analgesia enhances functional exercise capacity and health-related quality of life after colonic surgery: results of a randomized trial.
      ] following abdominal incisions, and also has an impact on complications following abdominal surgery, reducing the time to bowel recovery by up to 36 h and may reduce cardiac and respiratory complications in high risk patients. TEA has been shown to effectively reduce pain following abdominal hysterectomy [
      • Jørgensen H.
      • Fomsgaard J.S.
      • Dirks J.
      • Wetterslev J.
      • Andreasson B.
      • Dahl J.B.
      Effect of peri- and postoperative epidural anaesthesia on pain and gastrointestinal function after abdominal hysterectomy.
      ] and gynecologic cancer surgery [
      • Ferguson S.E1.
      • Malhotra T.
      • Seshan V.E.
      • Levine D.A.
      • Sonoda Y.
      • DS C.
      • et al.
      A prospective randomized trial comparing patient-controlled epidural analgesia to patient-controlled intravenous analgesia on postoperative pain control and recovery after major open gynecologic cancer surgery.
      ], and reduces time to return of gut function. However the role of TEA in enhanced recovery surgery is now less clear: whilst analgesia and recovery seem to be better with TEA than IV PCA, epidural failure rates may be as high as 30% [
      • Ready L.B.
      Acute pain: lessons learned from 25,000 patients.
      ], and many of these patients will require supplemental opiates. Even if patients are normovolemic the sympathetic block that results from TEA may result in hypotension that may require treatment with vasopressors [
      • Hübner M.
      • Blanc C.
      • Roulin D.
      • Winiker M.
      • Gander S.
      • Demartines N.
      Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway.
      ]. Patients who undergo abdominal hysterectomy in ERAS protocols can target a length of hospital stay of 1–2 days, in which case TEA may hinder achievement of other ERAS goals such as mobilization [
      • Chen L.M.
      • Weinberg V.K.
      • Chen C.
      • Powell C.B.
      • Chen L.L.
      • Chan J.K.
      • et al.
      Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery.
      ] and removal of urinary catheter, and TEA has been shown to increase hospital stay and complication rates in gynaecologic cancer surgery [
      • Belavy D.
      • Janda M.
      • Baker J.
      • Obermair A.
      Epidural analgesia is associated with an increased incidence of postoperative complications in patients requiring an abdominal hysterectomy for early stage endometrial cancer.
      ].
      Where TEA is to be used local anesthetic should be of low concentration, and should be combined with an opioid such as fentanyl. Post-operative hypotension may require treatment with vasopressors. Some consideration must be made to the impact on early ERAS goals and how they will be achieved, and expert post-operative input may be required to ensure reliable analgesia. Although epidurals sited in the lumbar spine have an evidence base for analgesic benefit in gynecologic surgery, thoracic epidurals are preferred: epidurals should be sited at the level appropriate for innervation of the surgical area, and thoracic epidurals are likely to cause less hypotension [
      • Sagiroglu G.
      • Meydan B.
      • Copuroglu E.
      • Baysal A.
      • Yoruk Y.
      • Altemur Karamustafaoglu Y.
      • et al.
      A comparison of thoracic or lumbar patient-controlled epidural analgesia methods after thoracic surgery.
      ] and motor block [
      • Visser W.A.
      • Lee R.A.
      • Gielen M.J.
      Factors affecting the distribution of neural blockade by local anesthetics in epidural anesthesia and a comparison of lumbar versus thoracic epidural anesthesia.
      ] than those in the lumbar segments.
      An alternative to TEA is spinal anesthesia with low-dose intrathecal morphine (ITM). As a single injection, this has benefits over TEA in allowing early mobilization and removal of urinary catheter as well as facilitating early discharge from hospital [
      • Levy B.F.
      • Scott M.J.
      • Fawcett W.
      • Fry C.
      • Rockall T.A.
      Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery.
      ]. When compared to a general anesthetic without neuraxial block, spinal anesthesia with ITM significantly reduces pain and morphine consumption both for hysterectomy [
      • Massicotte L.
      • Chalaoui K.D.
      • Beaulieu D.
      • Roy J.D.
      • Bissonnette F.
      Comparison of spinal anesthesia with general anesthesia on morphine requirement after abdominal hysterectomy.
      ,
      • Catro-Alves L.J.
      • De Azevedo V.L.
      • De Freitas Braga T.F.
      • Goncalves A.C.
      • De Oliveira Jr., G.S.
      The effect of neuraxial versus general anesthesia techniques on postoperative quality of recovery and analgesia after abdominal hysterectomy.
      ,
      • Borendal Wodlin N.
      • Nilsson L.
      • Kjølhede P.
      • for the ‘GASPI’ Study Group
      The impact of mode of anaesthesia on postoperative recovery from fast-track abdominal hysterectomy: a randomised clinical trial.
      ] and this analgesic benefit may persist for up to 48 h post-operatively [
      • Massicotte L.
      • Chalaoui K.D.
      • Beaulieu D.
      • Roy J.D.
      • Bissonnette F.
      Comparison of spinal anesthesia with general anesthesia on morphine requirement after abdominal hysterectomy.
      ,
      • Catro-Alves L.J.
      • De Azevedo V.L.
      • De Freitas Braga T.F.
      • Goncalves A.C.
      • De Oliveira Jr., G.S.
      The effect of neuraxial versus general anesthesia techniques on postoperative quality of recovery and analgesia after abdominal hysterectomy.
      ]. The added benefit of reduced morphine consumption is the reduced risk of post-operative ileus. Additionally ITM appears to reduce peri-operative stress hormone release [
      • Karaman S.
      • Kocabas S.
      • Uyar M.
      • Zincircioglu C.
      • Firat V.
      Intrathecal morphine: effects on perioperative hemodynamics, postoperative analgesia, and stress response for total abdominal hysterectomy.
      ], improve post-operative recovery [
      • Catro-Alves L.J.
      • De Azevedo V.L.
      • De Freitas Braga T.F.
      • Goncalves A.C.
      • De Oliveira Jr., G.S.
      The effect of neuraxial versus general anesthesia techniques on postoperative quality of recovery and analgesia after abdominal hysterectomy.
      ,
      • Wodlin N.B.
      • Nilsson L.
      • Kjolhede P.
      Health-related quality of life and postoperative recovery in fast-track hysterectomy.
      ] and reduce post-operative drowsiness and fatigue, though at the expense of increased pruritus [
      • Wodlin N.B.
      • Nilsson L.
      • Årestedt K.
      • Kjolhede P.
      • for the ‘GASPI’ Study Group
      Mode of anesthesia and postoperative symptoms following abdominal hysterectomy in a fast-track setting.
      ]. Most studies do not indicate an increase in vomiting with low-dose ITM when compared with IV PCA [
      • Massicotte L.
      • Chalaoui K.D.
      • Beaulieu D.
      • Roy J.D.
      • Bissonnette F.
      Comparison of spinal anesthesia with general anesthesia on morphine requirement after abdominal hysterectomy.
      ,
      • Hein A.
      • Rösblad P.
      • Gillis-Haegerstrand C.
      • Schedvins K.
      • Jakobsson J.
      • Dahlgren G.
      Low dose intrathecal morphine effects on post-hysterectomy pain: a randomized placebo-controlled study.
      ]. Dose-finding studies appear to show a ceiling of effect at 200 mcg [
      • Hein A.
      • Rösblad P.
      • Gillis-Haegerstrand C.
      • Schedvins K.
      • Jakobsson J.
      • Dahlgren G.
      Low dose intrathecal morphine effects on post-hysterectomy pain: a randomized placebo-controlled study.
      ] and doses of ITM within this range do not appear to increase the risk of respiratory depression [
      • Gehling M.
      • Tryba M.
      Risks and side-effects of intrathecal morphine combined with spinal anaesthesia: a meta-analysis.
      ]. Spinal anesthesia without long-acting opioids does not improve post-operative pain when compared to general anesthesia [
      • Dakin M.J.
      • Osinubi O.Y.
      • Carli F.
      Preoperative spinal bupivacaine does not reduce postoperative morphine requirement in women undergoing total abdominal hysterectomy.
      ].
      Experience dictates that to improve patient acceptability of spinal anesthesia with ITM, general anesthesia may need to be offered in addition, in which case the dose of intrathecal local anesthetic should be reduced to avoid intra-operative hypotension and intraoperative narcotics should be minimized to reduce side effects.
      Where patients have undergone general anesthesia without neuraxial blockade, truncal nerve blocks may serve to reduce pain and reduce post-operative morphine requirement. Transversus abdominis plane (TAP) blocks involve the injection of a large volume of local anesthetic in between the muscle layers of the trunk, and may now be performed under ultrasound guidance to ensure accurate delivery of local anesthetic. This technique has been shown to be efficacious for abdominal incisions [
      • Petersen P.L.
      • Mathiesen O.
      • Torup H.
      • Dahl J.B.
      The transversus abdominis plane block: a valuable option for postoperative analgesia? A topical review.
      ], including abdominal hysterectomy [
      • Carney J.
      • McDonnell J.G.
      • Ochana A.
      • Bhinder R.
      • Laffey J.G.
      The transversus abdominis plane block provides effective postoperative analgesia in patients undergoing total abdominal hysterectomy.
      ], and a meta-analysis concluded that TAP blocks reduce pain and morphine requirement up to 24 h after open gynecologic surgery [
      • Champaneria R.
      • Shah L.
      • Geoghegan J.
      • Gupta J.K.
      • Daniels J.P.
      Analgesic effectiveness of transversus abdominis plane blocks after hysterectomy: a meta-analysis.
      ]. In patients undergoing Cesarean section, TAP blocks appear to be less effective than intrathecal morphine at controlling post-operative pain, although side effects were fewer than ITM [
      • Mishriky B.M.
      • George R.B.
      • AS H.
      Transversus abdominis plane block for analgesia after Cesarean delivery: a systematic review and meta-analysis.
      ] and TAP blocks do not appear to add any analgesic benefit when used in combination with ITM [
      • Abdallah F.W.
      • Halpern S.H.
      • Margarido C.B.
      Transversus abdominis plane block for postoperative analgesia after Caesarean delivery performed under spinal anaesthesia? A systematic review and meta-analysis.
      ]. Bilateral ilioinguinal nerve blocks also appear to reduce post-operative morphine requirement, however may not reduce morphine-related side effects [
      • Oriola F.
      • Toque Y.
      • Mary A.
      • Gagneur O.
      • Beloucif S.
      • Dupont H.
      Bilateral ilioinguinal nerve block decreases morphine consumption in female patients undergoing nonlaparoscopic gynecologic surgery.
      ].
      Wound infiltration with local anesthetic is safe and easy to perform, though any effect on post-operative pain and opioid consumption is modest and short-lived [
      • Lowenstein L.
      • Zimmer E.Z.
      • Deutsch M.
      • Paz Y.
      • Yaniv D.
      • Jakobi P.
      Preoperative analgesia with local lidocaine infiltration for abdominal hysterectomy pain management.
      ]. Prolongation of this analgesic effect may be achieved through insertion of sub-cutaneous wound catheters [
      • Zohar E.
      • Fredman B.
      • Phillipov A.
      • Jedeikin R.
      • Shapiro A.
      The analgesic efficacy of patient-controlled bupivacaine wound instillation after total abdominal hysterectomy with bilateral salpingo-oophorectomy.
      ]. A meta-analysis concluded that continuous wound infiltration (CWI) reduced pain and opioid consumption and improved recovery after major abdominal surgery [
      • Liu S.S.
      • Richman J.M.
      • Thirlby R.C.
      • Wu C.L.
      Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials.
      ], and may provide analgesia equivalent to TEA for abdominal surgery [
      • Ventham N.T.
      • Hughes M.
      • O'Neill S.
      • Johns N.
      • Brady R.R.
      • Wigmore S.J.
      Systematic review and meta-analysis of continuous local anaesthetic wound infiltration versus epidural analgesia for postoperative pain following abdominal surgery.
      ]. Another study found that, when compared to TEA for open colorectal surgery, CWI reduced opioid usage, vomiting and time to bowel recovery, and improved patient satisfaction [
      • Bertoglio S.
      • Fabiani F.
      • Negri P.D.
      • Corcione A.
      • Merlo D.F.
      • Cafiero F.
      • et al.
      The postoperative analgesic efficacy of preperitoneal continuous wound infusion compared to epidural continuous infusion with local anesthetics after colorectal cancer surgery: a randomized controlled multicenter study.
      ]. However for gynecologic surgery the data is less clear, and although CWI has been shown to improve analgesia, reduce opioid requirements and reduce time to return of gut function [
      • Maric S.
      • Banovic M.
      • Zdravcevic K.S.
      Continuous wound infusion of levobupivacaine after total abdominal hysterectomy with bilateral salpingo-oophorectomy.
      ] a number of studies have either only demonstrated benefit in the first few hours after surgery [
      • Zohar E.
      • Fredman B.
      • Phillipov A.
      • Jedeikin R.
      • Shapiro A.
      The analgesic efficacy of patient-controlled bupivacaine wound instillation after total abdominal hysterectomy with bilateral salpingo-oophorectomy.
      ], or failed to demonstrate benefit at all [
      • Kristensen B.B.
      • Christensen D.S.
      • Ostergaard M.
      • Skjelsager K.
      • Nielsen D.
      • Mogensen T.S.
      Lack of postoperative pain relief after hysterectomy using preperitoneally administered bupivacaine.
      ,
      • Leong W.M.
      • Lo W.K.
      • Chiu J.W.
      Analgesic efficacy of continuous delivery of bupivacaine by an elastomeric balloon infusor after abdominal hysterectomy: a prospective randomised controlled trial.
      ,
      • Kushner D.M.
      • LaGalbo R.
      • Connor J.P.
      • Chappell R.
      • Stewart S.L.
      • Hartenbach E.M.
      Use of a bupivacaine continuous wound infusion system in gynecologic oncology: a randomized trial.
      ]. There is lack of agreement concerning ideal catheter placement [
      • Rackelboom T.
      • Le Strat S.
      • Silvera S.
      • Schmitz T.
      • Bassot A.
      • Goffinet F.
      • et al.
      Improving continuous wound infusion effectiveness for postoperative analgesia after cesarean delivery: a randomized controlled trial.
      ,
      • Hafizoglu M.C.
      • Katircioglu K.
      • Ozkalkanli M.Y.
      • Savaci S.
      Bupivacaine infusion above or below the fascia for postoperative pain treatment after abdominal hysterectomy.
      ], though in most studies the infusion catheter was placed below the abdominal fascia. The impact of continuous wound infiltration on wound healing has not been fully studied, though existing data has not shown an increase in wound complication rates. More research with this technique is required in this patient group before any conclusions may be drawn.
      Intraperitoneal local anesthetic (IPLA) has been utilized to reduce post-operative pain, and one trial demonstrated reduced opioid consumption and improved surgical recovery score when used alongside TEA following colorectal surgery [
      • Kahokehr A.
      • Sammour T.
      • Zargar Shoshtari K.
      • Taylor M.
      • Hill A.G.
      Intraperitoneal local anesthetic improves recovery after colon resection: a double-blinded randomized controlled trial.
      ]. A systematic review of other trials concluded that IPLA reduces post-operative pain but not opioid consumption, and recovery parameters were unchanged [
      • Kahokehr A.
      • Sammour T.
      • Soop M.
      • Hill A.G.
      Intraperitoneal local anaesthetic in abdominal surgery — a systematic review.
      ]. IPLA has also been tested for open hysterectomy and has been found to reduce post-operative pain [
      • Gupta A.
      • Perniola A.
      • Axelsson K.
      • Thörn S.E.
      • Crafoord K.
      • Rawal N.
      Postoperative pain after abdominal hysterectomy: a double-blind comparison between placebo and local anesthetic infused intraperitoneally.
      ] and morphine consumption [
      • Ng A.
      • Swami A.
      • Smith G.
      • Davidson A.C.
      • Emembolu J.
      The analgesic effects of intraperitoneal and incisional bupivacaine with epinephrine after total abdominal hysterectomy.
      ], however the benefit was limited to the first few hours after surgery, and analgesia from IPLA does not seem to be dose-responsive [
      • Perniola A.
      • Gupta A.
      • Crafoord K.
      • Darvish B.
      • Magnuson A.
      • Axelsson K.
      Intraabdominal local anaesthetics for postoperative pain relief following abdominal hysterectomy: a randomized, double-blind, dose-finding study.
      ].

      9.3.1 Summary and recommendations

      For open surgery a multimodal, opiate sparing analgesic strategy should be utilized. TEA or spinal anesthesia with intrathecal morphine may improve recovery parameters and are recommended. However TEA may increase time to mobilization and removal of urinary catheter, and may potentially impact on hospital stay.
      Where patients have undergone general anesthesia without neuraxial blockade, a truncal block, such as TAP blocks, may reduce pain and opioid consumption for up to 24 h and should be employed. Continuous wound infiltration or intraperitoneal instillation of local anesthetic may improve recovery for colorectal surgery and may be considered as an alternative to TAP blocks or TEA, however the evidence of benefit in gynecologic surgery is lacking.
      Post-operatively, multimodal analgesia should be used. Systemic opioids may be given either orally or by intravenous PCA. The IV PCA should be discontinued when normal gut function resumes.

      9.3.2 Evidence level

      Intrathecal morphine: Moderate.
      Thoracic epidural analgesia: High.
      TAP blocks: Moderate.
      CWI: Moderate.

      9.3.3 Recommendation grade

      Strong.

      9.4 Analgesia for major oncologic surgery

      In patients undergoing cytoreductive surgery, the large surgical area and complex patient pain history means that post-operative pain is often severe. TEA is widely used, and was associated with superior pain control at rest and on movement for the first 3 post-operative days in one observational study [
      • Courtney-Brooks M.
      • Tanner Kurtz K.C.
      • Pelkofski E.B.
      • Nakayama J.
      • Duska L.R.
      Continuous epidural infusion anesthesia and analgesia in gynecologic oncology patients: less pain, more gain?.
      ], and a randomized controlled study [
      • Ferguson S.E.
      • Malhotra T.
      • Seshan V.E.
      • Levine D.A.
      • Sonoda Y.
      • Chi D.S.
      • et al.
      A prospective randomized trial comparing patient-controlled epidural analgesia to patient-controlled intravenous analgesia on postoperative pain control and recovery after major open gynecologic cancer surgery.
      ] found improved pain control on coughing for the first 3 post-operative days. However other investigators found no benefit in pain, bowel recovery or length of stay in patients with peri-operative TEA, and an increase in vasopressor requirement [
      • Chen L.M.
      • Weinberg V.K.
      • Chen C.
      • Powell C.B.
      • Chen L.L.
      • Chan J.K.
      • et al.
      Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery.
      ]. In patients undergoing heated intraperitoneal chemotherapy (HIPEC), the use of TEA is controversial. TEA may reduce opioid consumption and reduce time to extubation [
      • Schmidt C.
      • Steinke T.
      • Moritz S.
      • Bucher M.
      Thoracic epidural anesthesia in patients with cytoreductive surgery and HIPEC.
      ] although an IV PCA is often required in addition to TEA to achieve adequate analgesia [
      • Bell J.C.
      • Rylah B.G.
      • Chambers R.W.
      • Peet H.
      • Mohamed F.
      • Moran B.J.
      Perioperative management of patients undergoing cytoreductive surgery combined with heated intraperitoneal chemotherapy for peritoneal surface malignancy: a multi-institutional experience.
      ]. HIPEC may be associated with a post-operative coagulopathy that may complicate removal of the epidural catheter, however in one study removal of epidural catheter was delayed in only 0.5% of cases [
      • Owusu-Agyemang P.
      • Soliz J.
      • Hayes-Jordan A.
      • Harun N.
      • Gottumukkala V.
      Safety of epidural analgesia in the perioperative care of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.
      ]. Some centers use intravenous PCA in preference to TEA, citing adequate analgesia with fewer hemodynamic effects [
      • Nelson G.
      • Kalogera E.
      • Dowdy S.C.
      Enhanced recovery pathways in gynecologic oncology.
      ]. TAP blocks were examined in one retrospective study and appeared to reduced opioid consumption on post-operative day 1 only [
      • Rivard C.
      • Dickson E.L.
      • Vogel R.I.
      • Argenta P.A.
      • Teoh D.
      The effect of anesthesia choice on post-operative outcomes in women undergoing exploratory laparotomy for a suspected gynecologic malignancy.
      ].

      9.4.1 Summary and recommendations

      TEA is effective in reducing post-operative pain after gynecologic laparotomy. However TEA may not improve other post-operative outcomes and patients may require additional IV opioids in addition to TEA to achieve adequate analgesia. TEA may compound hypotension that requires vasopressor support. Intravenous PCA appears to be a suitable alternative.

      9.4.2 Evidence level

      Low.

      9.4.3 Recommendation grade

      Weak.

      9.5 Analgesia for laparoscopic gynecologic/oncology surgery

      A meta-analysis examining TAP blocks for laparoscopic surgery across a range of abdominal procedures [
      • De Oliveira Jr., G.S.
      • Castro-Alves L.J.
      • Nader A.
      • Kendall M.C.
      • McCarthy R.J.
      Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: a meta-analysis of randomized controlled trials.
      ] found only pain at rest, and not dynamic pain, was reduced. For laparoscopic hysterectomy, one trial showed that TAP blocks improved post-operative quality of recovery (QoR40) score [
      • De Oliveira Jr., G.S.
      • Milad M.P.
      • Fitzgerald P.
      • Rahmani R.
      • McCarthy R.J.
      Transversus abdominis plane infiltration and quality of recovery after laparoscopic hysterectomy: a randomized controlled trial.
      ] however 3 further trials did not show benefit [
      • Calle G.A.
      • López C.C.
      • Sánchez E.
      • De Los Ríos J.F.
      • Vásquez E.M.
      • Serna E.
      • et al.
      Transversus abdominis plane block after ambulatory total laparoscopic hysterectomy: randomized controlled trial.
      ,
      • Kane S.M.
      • Garcia-Tomas V.
      • Alejandro-Rodriguez M.
      • Astley B.
      • Pollard R.R.
      Randomized trial of transversus abdominis plane block at total laparoscopic hysterectomy: effect of regional analgesia on quality of recovery.
      ,
      • El Hachem L.
      • Small E.
      • Chung P.
      • Moshier E.L.
      • Friedman K.
      • Fenske S.S.
      • et al.
      Randomized controlled double-blind trial of transversus abdominis plane block versus trocar site infiltration in gynecologic laparoscopy.
      ]. Intra-peritoneally administered local anesthetic has been used successfully for minor gynecologic laparoscopic procedures but this technique does not seem to be effective for major gynecologic laparoscopic surgery, either by single instillation or continuous infusion [
      • Andrews V.
      • Wright J.T.
      • Zakaria F.
      • Banerjee S.
      • Ballard K.
      Continuous infusion of local anaesthetic following laparoscopic hysterectomy — a randomised controlled trial.
      ,
      • Keita H.
      • Benifla J.L.
      • Le Bouar V.
      • Porcher R.
      • Wachowska B.
      • Bedairia K.
      • et al.
      Prophylactic ip injection of bupivacaine and/or morphine does not improve postoperative analgesia after laparoscopic gynecologic surgery.
      ,
      • Shaw I.C.
      • Stevens J.
      • Krishnamurthy S.
      The influence of intraperitoneal bupivacaine on pain following major laparoscopic gynaecological procedures.
      ,
      • Kaufman Y.
      • Hirsch I.
      • Ostrovsky L.
      • Klein O.
      • Shnaider I.
      • Khoury E.
      • et al.
      Pain relief by continuous intraperitoneal nebulization of ropivacaine during gynecologic laparoscopic surgery — a randomized study and review of the literature.
      ,
      • Arden D.
      • Seifert E.
      • Donnellan N.
      • Guido R.
      • Lee T.
      • Mansuria S.
      Intraperitoneal instillation of bupivacaine for reduction of postoperative pain after laparoscopic hysterectomy: a double-blind randomized controlled trial.
      ]. Additionally, a Cochrane analysis of intraperitoneal local anesthetic for laparoscopic cholecystectomy found low quality evidence of benefit, though the effect was likely to be clinically insignificant [
      • Gurusamy K.S.
      • Nagendran M.
      • Guerrini G.P.
      • Toon C.D.
      • Zinnuroglu M.
      • Davidson B.R.
      Intraperitoneal local anaesthetic instillation versus no intraperitoneal local anaesthetic instillation for laparoscopic cholecystectomy.
      ]. ITM showed a small benefit in robotic surgery [
      • Segal D.
      • Awad N.
      • Nasir H.
      • Mustafa S.
      • Lowenstein L.
      Combined spinal and general anesthesia vs general anesthesia for robotic sacrocervicopexy: a randomized controlled trial.
      ]. TEA has been investigated for laparoscopic colorectal surgery and appeared to prolong hospital stay without improving patient outcomes [
      • Levy B.F.
      • Scott M.J.
      • Fawcett W.
      • Fry C.
      • Rockall T.A.
      Randomized clinical trial of epidural, spinal or patient-controlled analgesia for patients undergoing laparoscopic colorectal surgery.
      ].

      9.5.1 Summary and recommendations

      For laparoscopic gynecologic/oncology surgery, neither TAP blocks nor intraperitoneal instillation of local anesthetic are recommended on the current level of evidence. For laparoscopic abdominal surgery, TEA may prolong hospital stay without improving outcomes. Multimodal analgesia should be employed, and post-operative opioids may be given either orally or by IV PCA depending on magnitude of surgery and predicted post-operative gut function.

      9.5.2 Level of evidence

      Low.

      9.5.3 Recommendation grade

      Weak.

      10. Peritoneal drainage

      Peritoneal drainage has traditionally been used to prevent accumulation of fluid in the bed of dissection, to evacuate blood, serous collections, or infection, and in colorectal surgery it has been thought to prevent anastomotic leakage. However, peritoneal drainage has not been shown to prevent anastomotic leaks or improve overall outcome, and is not recommended routinely after either colonic or rectal surgery [
      • Karliczek A.
      • Jesus E.C.
      • Matos D.
      • Castro A.A.
      • Atallah A.N.
      • Wiggers T.
      Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis.
      ,
      • Jesus E.C.
      • Karliczek A.
      • Matos D.
      • Castro A.A.
      • Atallah A.N.
      Prophylactic anastomotic drainage for colorectal surgery.
      ,
      • Petrowsky H.
      • Demartines N.
      • Rousson V.
      • Clavien P.A.
      Evidence-based value of prophylactic drainage in gastrointestinal surgery: a systematic review and meta-analyses.
      ]. There is little research regarding drains after colonic or rectal anastomosis in gynecologic oncology surgery [
      • Kalogera E.
      • Dowdy S.C.
      • Mariani A.
      • Aletti G.
      • Bakkum-Gamez J.N.
      • Cliby W.A.
      Utility of closed suction pelvic drains at time of large bowel resection for ovarian cancer.
      ]. It is difficult to extrapolate the results from the colorectal literature directly to all gynecological surgery. For patients with metastatic ovarian cancer, the scope of surgery is larger, encompassing other organ resections, most of the peritoneal surfaces, and the risk factor profile for postoperative morbidity is elevated with poor nutritional status, ascites, peritoneal carcinomatosis, extended operative times, and cytotoxic therapy. Regardless, the rate of anastomotic leakage in ovarian cancer surgery in the literature ranges from 1 to 7%, in the range found in colorectal surgery [
      • Kalogera E.
      • Dowdy S.C.
      • Mariani A.
      • Aletti G.
      • Bakkum-Gamez J.N.
      • Cliby W.A.
      Utility of closed suction pelvic drains at time of large bowel resection for ovarian cancer.
      ,
      • Kalogera E.
      • Dowdy S.C.
      • Mariani A.
      • Weaver A.L.
      • Aletti G.
      • Bakkum-Gamez J.N.
      • et al.
      Multiple large bowel resections: potential risk factor for anastomotic leak.
      ,
      • Jurado M.
      • Alcazar J.L.
      • Baixauli J.
      • Hernandez-Lizoain J.L.
      Low colorectal anastomosis after pelvic exenteration for gynecologic malignancies: risk factors analysis for leakage.
      ]. In summary, we did not find evidence that drainage gives better outcomes after gynecological surgery. Furthermore, a Cochrane systematic review including 4 studies with 571 participants [
      • Charoenkwan K.
      • Kietpeerakool C.
      Retroperitoneal drainage versus no drainage after pelvic lymphadenectomy for the prevention of lymphocyst formation in patients with gynaecological malignancies.
      ] concluded that drains did not prevent lymphocysts, but were rather associated with a higher risk of cyst formation after pelvic lymphadenectomy. Fewer studies have investigated para-aortic lymphadenectomy, but no evidence exists to recommend drainage [
      • Morice P.
      • Lassau N.
      • Pautier P.
      • Haie-Meder C.
      • Lhomme C.
      • Castaigne D.
      Retroperitoneal drainage after complete para-aortic lymphadenectomy for gynecologic cancer: a randomized trial.
      ]. Urological surgical techniques are frequently employed during major gynecologic oncology cases. Historically drains have been placed at the site of bladder resection/reconstruction, ureteral reimplantation, and urinary diversion (ileal conduit, continent reservoir) with the aim of identifying early urine leaks. Nevertheless, there are no specific studies that have evaluated the use of drains in such surgeries in our patient population. Looking to the urological literature, it should be noted that the ERAS Radical Cystectomy guideline found no evidence to support or refute the use of drains in this setting and as such further research is required in this area [
      • Cerantola Y.
      • Valerio M.
      • Persson B.
      • Jichlinski P.
      • Ljungqvist O.
      • Hubner M.
      • et al.
      Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
      ].

      10.1.1 Summary and recommendation

      Peritoneal drainage is not recommended routinely in gynecologic/oncology surgery including for patients undergoing lymphadenectomy or bowel surgery.

      10.1.2 Evidence level

      Moderate.

      10.1.3 Recommendation grade

      Strong.

      11. Urinary drainage

      The primary indications for postoperative bladder drainage are to monitor urine output and prevent urinary retention. However, there is considerable variation in the method and duration of bladder drainage following surgery for gynecological cancers. In addition, there is a high incidence of bladder related morbidity to the lower genital tract following such surgery, which may include effects on urinary voiding and bladder capacity [
      • Brooks R.A.
      • Wright J.D.
      • Powell M.A.
      • Rader J.S.
      • Gao F.
      • Mutch D.G.
      • et al.
      Long-term assessment of bladder and bowel dysfunction after radical hysterectomy.
      ].
      A review of policies for removal of short-term urinary catheters identified only a small number of studies including patients undergoing gynecologic surgery [
      • Griffiths R.
      • Fernandez R.
      Policies for the removal of short-term indwelling urethral catheters.
      ]. When comparing the timing of removal of the catheter, time to first voiding was longer, but larger volumes of urine were passed following midnight removal compared to early morning. In one study, midnight removal of catheters was also associated with significantly shorter length of stay [
      • Ind T.E.J.
      • Brown R.
      • Pyneeandee V.M.
      • Swanne M.
      • Taylor G.
      Midnight removal of urinary catheters — improved outcome following gynaecological surgery.
      ]. A recent single center study following uncomplicated total abdominal hysterectomy compared removal of urethral catheters immediately after surgery, 6 h, or 24 h postoperatively. The intermediate group had fewer re-catheterizations compared to the immediate removal group, and lower rates of urinary tract infection than the prolonged users [
      • Ahmed M.R.
      • Sayed Ahmed W.A.
      • Atwa K.A.
      • Metwally L.
      Timing of urinary catheter removal after uncomplicated total abdominal hysterectomy.
      ]. These findings are supported by a recent review [
      • Phipps S.
      • Lim Y.N.
      • McClinton S.
      • Barry C.
      • Rane A.
      • N'Dow J.
      Short term urinary catheter policies following urogenital surgery in adults.
      ]. In the same review, a greater number of patients required re-catheterization following a urethral compared to a suprapubic catheter. Two small studies focusing on patients undergoing radical hysterectomy for cervical cancer showed the suprapubic route to be associated with fewer bladder infections [
      • Wells T.H.
      • Steed H.
      • Capstick V.
      • Schepanksy A.
      • Hiltz M.
      • Faught W.
      What is the optimal method of bladder drainage after radical hysterectomy?.
      ,
      • Naik R.
      • Maughan K.
      • Nordin A.
      • Lopes A.
      • Godfrey K.A.
      • Hatem M.H.
      A prospective randomised controlled trial of intermittent self catheterisation vs suprapubic catheterisation for postoperative bladder care following radical hysterectomy.
      ]. In one of these studies intermittent self- catheterization was associated with a higher infection rate but patients found the technique to be catheterization [
      • Naik R.
      • Maughan K.
      • Nordin A.
      • Lopes A.
      • Godfrey K.A.
      • Hatem M.H.
      A prospective randomised controlled trial of intermittent self catheterisation vs suprapubic catheterisation for postoperative bladder care following radical hysterectomy.
      ].

      11.1.1 Summary and recommendation

      Urinary catheters should be used for postoperative bladder drainage for a short period preferably <24 h postoperatively.

      11.1.2 Evidence level

      Low.

      11.1.3 Recommendation grade

      Strong.

      12. Early mobilization

      There are multiple hypothesized benefits to early mobilization, including a reduction in pulmonary complications, decreased insulin resistance, less muscle atrophy, and reduced length of hospital stay [
      • Kehlet H.
      • Wilmore D.W.
      Multimodal strategies to improve surgical outcome.
      ,
      • Van der Leeden M.
      • Huijsmans R.
      • Geleijn E.
      • ES d.L.-d.K.
      • Dekker J.
      • Bonjer H.J.
      • et al.
      Early enforced mobilisation following surgery for gastrointestinal cancer: feasibility and outcomes.
      ]. Early mobilization has been shown to be an integral part of systematic efforts to reduce venous thromboembolic complications in the surgical patient [
      • Cassidy M.R.
      • Rosenkranz P.
      • McAneny D.
      Reducing postoperative venous thromboembolism complications with a standardized risk-stratified prophylaxis protocol and mobilization program.
      ]. Foley catheters, poor pain control, and IV poles, have been identified by gynecologic surgical patients as barriers to ambulation [
      • Liebermann M.
      • Awad M.
      • Dejong M.
      • Rivard C.
      • Sinacore J.
      • Brubaker L.
      Ambulation of hospitalized gynecologic surgical patients: a randomized controlled trial.
      ]. Therefore, compliance with other aspects of enhanced recovery protocols may improve early mobilization by limiting these barriers [
      • Ahmed M.R.
      • Sayed Ahmed W.A.
      • Atwa K.A.
      • Metwally L.
      Timing of urinary catheter removal after uncomplicated total abdominal hysterectomy: a prospective randomized trial.
      ]. A care plan listing daily mobilization goals and patient engagement with an activity diary may be helpful [
      • Van der Leeden M.
      • Huijsmans R.
      • Geleijn E.
      • ES d.L.-d.K.
      • Dekker J.
      • Bonjer H.J.
      • et al.
      Early enforced mobilisation following surgery for gastrointestinal cancer: feasibility and outcomes.
      ,
      • Lassen K.
      • Soop M.
      • Nygren J.
      • Cox P.B.
      • Hendry P.O.
      • Spies C.
      • et al.
      Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) group recommendations.
      ].

      12.1.1 Summary and recommendation

      Patients should be encouraged to mobilize within 24 h of surgery.

      12.1.2 Evidence level

      Low.

      12.1.3 Recommendation grade

      Strong.

      13. Discussion

      This guideline outlines the recommendations of the ERAS® Group for the postoperative management of patients undergoing gynecologic/oncology surgery, and is based on the best available evidence. As was the case in Part I [
      • Nelson G.
      • Altman A.
      • Nick A.
      • Meyer L.
      • Ramirez P.T.
      • Achtari C.
      • et al.
      Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
      ], in some instances good quality data was not available. This was particularly true for the evidence surrounding urinary drainage, early mobilization and postoperative analgesia in which the optimal analgesic regimen for vaginal surgery/MIS and open gynecologic surgery is currently a subject of debate. In some instances recommendations were made based on findings from other surgical disciplines in which major abdominal surgery is routinely utilized.
      We are hopeful that these gynecologic/oncology ERAS® guidelines will help integrate existing knowledge into practice, align perioperative care, and encourage future investigations to address existing knowledge gaps. Measuring compliance has proven to be a key factor required for success and sustainability of ERAS® protocols [
      • Gustafsson U.O.
      • Hausel J.
      • Thorell A.
      • Ljungqvist O.
      • Soop M.
      • Nygren J.
      Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery.
      ]. A process is currently underway whereby the gynecologic/oncology guidelines are being translated into their corresponding audit system (ERAS Interactive Audit System, EIAS) which will help to ensure compliance [] and allow surgeons/clinicians to improve the care delivered to our patient population.

      Conflict of interest statement

      Dr. Acheson reports personal fees from Baxter UK Ltd., outside the submitted work. In addition, Dr. Acheson has a commercial (future royalties on a medical device in development) relationship with Mediplus Ltd. He has also held the following appointments: Joint National Clinical Advisor (Gynaecology) to the Enhanced Recovery Partnership Programme, Department of Health (2010–2011), and continued under NHS Improvement (2011–2013); Member of Steering Board, Enhanced Recovery ERAS (UK) (2011–2013).
      Dr. Scott received honoraria for lecturing and travel expenses from Baxter Healthcare, Merck, and Deltex. He is an Executive Committee member of the ERAS Society.
      Dr. Ljungqvist has an appointment with Nutricia Advisory Board, has received speakers honoraria from Nutricia, MSD, BBraun and Fresenius-Kabi. He is the current Chairman of the ERAS Society (www.erassociety.org). He founded, serves on the Board and owns stock in Encare AB that runs the ERAS Society Interactive Audit System (EIAS).

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