Advertisement

Enhanced recovery in gynecologic oncology – A sea change in perioperative management

      First referred to as fast-track, or more recently, Enhanced Recovery After Surgery (ERAS®), a growing number of disciplines, including gynecologic oncology, have begun to challenge long-held beliefs about pre-, intra-, and postoperative management in the pursuit of perioperative optimization [
      • Ljungqvist O.
      • Scott M.
      • Fearon K.C.
      Enhanced recovery after surgery: a review.
      ,
      • Nelson G.
      • et al.
      Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part II.
      ,
      • Nelson G.
      • et al.
      Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part I.
      ]. The most important tenets of enhanced recovery include nutritional optimization, maintenance of perioperative euvolemia, and opioid-sparing multimodal pain management. These measures have been shown in multiple surgical specialties to reduce length of hospital stay, improve patient satisfaction, reduce complications, reduce healthcare costs, and most importantly, hasten patient recovery [
      • Kalogera E.
      • et al.
      Enhanced recovery in gynecologic surgery.
      ,
      • Kehlet H.
      • Wilmore D.W.
      Evidence-based surgical care and the evolution of fast-track surgery.
      ]. These three concepts will be examined individually, concentrating on the most controversial elements in order to attempt to converge care pathways and focus future research.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gynecologic Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ljungqvist O.
        • Scott M.
        • Fearon K.C.
        Enhanced recovery after surgery: a review.
        JAMA Surg. 2017; 152: 292-298https://doi.org/10.1001/jamasurg.2016.4952
        • Nelson G.
        • et al.
        Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part II.
        Gynecol. Oncol. 2016; 140 (Epub 2016 Jan 3): 323-332https://doi.org/10.1016/j.ygyno.2015.12.019
        • Nelson G.
        • et al.
        Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—part I.
        Gynecol. Oncol. 2016; 140 (Epub 2015 Nov 18): 313-322https://doi.org/10.1016/j.ygyno.2015.11.015
        • Kalogera E.
        • et al.
        Enhanced recovery in gynecologic surgery.
        Obstet. Gynecol. 2013; 122: 319-328https://doi.org/10.1097/AOG.0b013e31829aa780
        • Kehlet H.
        • Wilmore D.W.
        Evidence-based surgical care and the evolution of fast-track surgery.
        Ann. Surg. 2008; 248: 189-198https://doi.org/10.1097/SLA.0b013e31817f2c1a
        • Kalogera E.
        • et al.
        A prospective algorithm to reduce anastomotic leaks after rectosigmoid resection for gynecologic malignancies.
        Gynecol. Oncol. 2017; 144 (Epub 2016 Dec 2): 343-347https://doi.org/10.1016/j.ygyno.2016.11.032
      1. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters.
        Anesthesiology. 2011; 114: 495-511https://doi.org/10.1097/ALN.0b013e3181fcbfd9
        • Brady M.
        • Kinn S.
        • Stuart P.
        Preoperative fasting for adults to prevent perioperative complications.
        Cochrane Database Syst. Rev. 2003; 4CD004423
        • Nygren J.
        • et al.
        Preoperative oral carbohydrate administration reduces postoperative insulin resistance.
        Clin. Nutr. 1998; 17: 65-71
        • Guenaga K.F.
        • Matos D.
        • Wille-Jorgensen P.
        Mechanical bowel preparation for elective colorectal surgery.
        Cochrane Database Syst. Rev. 2011; 9CD001544https://doi.org/10.1002/14651858.CD001544.pub4
        • Holte K.
        • et al.
        Physiologic effects of bowel preparation.
        Dis. Colon Rectum. 2004; 47: 1397-1402
        • Markowitz G.S.
        • et al.
        Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure.
        J. Am. Soc. Nephrol. 2005; 16 (Epub 2005 Sep 28): 3389-3396
        • Ji W.B.
        • et al.
        Mechanical bowel preparation does not affect clinical severity of anastomotic leakage in rectal cancer surgery.
        World J. Surg. 2017; 41: 1366-1374https://doi.org/10.1007/s00268-016-3839-9
        • W.H.
        Circular suture of the intestine: an experimental study.
        Am J Med Sci. 1887; 94: 436-461
        • Scarborough J.E.
        • et al.
        Combined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection: an analysis of colectomy-targeted ACS NSQIP.
        Ann. Surg. 2015; 262: 331-337https://doi.org/10.1097/SLA.0000000000001041
        • Chen M.
        • et al.
        Comparing mechanical bowel preparation with both oral and systemic antibiotics versus mechanical bowel preparation and systemic antibiotics alone for the prevention of surgical site infection after elective colorectal surgery: a meta-analysis of randomized controlled clinical trials.
        Dis. Colon Rectum. 2016; 59: 70-78
        • Johnson M.P.
        • et al.
        Using bundled interventions to reduce surgical site infection after major gynecologic cancer surgery.
        Obstet. Gynecol. 2016; 127: 1135-1144https://doi.org/10.1097/AOG.0000000000001449
        • Brandstrup B.
        • et al.
        Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.
        Ann. Surg. 2003; 238: 641-648
        • Rahbari N.N.
        • et al.
        Meta-analysis of standard, restrictive and supplemental fluid administration in colorectal surgery.
        Br J Surg. 2009; 96: 331-341https://doi.org/10.1002/bjs.6552
        • Phan T.D.
        • et al.
        A randomised controlled trial of fluid restriction compared to oesophageal Doppler-guided goal-directed fluid therapy in elective major colorectal surgery within an Enhanced Recovery After Surgery program.
        Anaesth. Intensive Care. 2014; 42: 752-760
        • Gomez-Izquierdo J.C.
        • et al.
        Goal-directed fluid therapy does not reduce primary postoperative ileus after elective laparoscopic colorectal surgery: a randomized controlled trial.
        Anesthesiology. 2017; 10000000000001663
        • McMahon S.B.
        • La Russa F.
        • Bennett D.L.
        Crosstalk between the nociceptive and immune systems in host defence and disease.
        Nat. Rev. Neurosci. 2015; 16: 389-402https://doi.org/10.1038/nrn3946
        • Zylla D.
        • Steele G.
        • Gupta P.
        A systematic review of the impact of pain on overall survival in patients with cancer.
        Support Care Cancer. 2017; 25 (Epub 2017 Feb 11): 1687-1698https://doi.org/10.1007/s00520-017-3614-y
        • Al-Hashimi M.
        • et al.
        Opioids and immune modulation: more questions than answers.
        Br. J. Anaesth. 2013; 111: 80-88https://doi.org/10.1093/bja/aet153
        • Boland J.W.
        • et al.
        Effects of opioids on immunologic parameters that are relevant to anti-tumour immune potential in patients with cancer: a systematic literature review.
        Br. J. Cancer. 2014; 111 (Epub 2014 Jul 15): 866-873https://doi.org/10.1038/bjc.2014.384
        • Juneja R.
        Opioids and cancer recurrence.
        Curr. Opin. Support. Palliat. Care. 2014; 8: 91-101https://doi.org/10.1097/SPC.0000000000000056
        • Wigmore T.
        • Farquhar-Smith P.
        Opioids and cancer: friend or foe?.
        Curr. Opin. Support. Palliat. Care. 2016; 10: 109-118https://doi.org/10.1097/SPC.0000000000000208
        • Grandhi R.K.
        • Lee S.
        • Abd-Elsayed A.
        Does opioid use cause angiogenesis and metastasis?.
        Pain Med. 2017; 18: 140-151https://doi.org/10.1093/pm/pnw132
        • Gasanova I.
        • et al.
        Transversus abdominis plane block versus surgical site infiltration for pain management after open total abdominal hysterectomy.
        Anesth. Analg. 2015; 121: 1383-1388https://doi.org/10.1213/ANE.0000000000000909
        • Kalogera E.
        • et al.
        Abdominal incision injection of liposomal bupivacaine and opioid use after laparotomy for gynecologic malignancies.
        Obstet. Gynecol. 2016; 128: 1009-1017
        • Hubner M.
        • et al.
        Randomized clinical trial on epidural versus patient-controlled analgesia for laparoscopic colorectal surgery within an enhanced recovery pathway.
        Ann. Surg. 2015; 261: 648-653https://doi.org/10.1097/SLA.0000000000000838
        • Wongyingsinn M.
        • et al.
        Spinal analgesia for laparoscopic colonic resection using an enhanced recovery after surgery programme: better analgesia, but no benefits on postoperative recovery: a randomized controlled trial.
        Br. J. Anaesth. 2012; 108 (Epub 2012 Mar 8): 850-856https://doi.org/10.1093/bja/aes028
        • Bardia A.
        • et al.
        Combined epidural-general anesthesia vs general anesthesia alone for elective abdominal aortic aneurysm repair.
        JAMA Surg. 2016; 151: 1116-1123https://doi.org/10.1001/jamasurg.2016.2733
        • Block B.M.
        • et al.
        Efficacy of postoperative epidural analgesia: a meta-analysis.
        JAMA. 2003; 290: 2455-2463
        • Rigg J.R.
        • et al.
        Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial.
        Lancet. 2002; 359: 1276-1282
        • Chen L.M.
        • et al.
        Perioperative outcomes comparing patient controlled epidural versus intravenous analgesia in gynecologic oncology surgery.
        Gynecol. Oncol. 2009; 115 (Epub 2009 Sep 23): 357-361https://doi.org/10.1016/j.ygyno.2009.08.015
        • Cummings III, K.C.
        • et al.
        A comparison of epidural analgesia and traditional pain management effects on survival and cancer recurrence after colectomy: a population-based study.
        Anesthesiology. 2012; 116: 797-806https://doi.org/10.1097/ALN.0b013e31824674f6
        • Myles P.S.
        • et al.
        Perioperative epidural analgesia for major abdominal surgery for cancer and recurrence-free survival: randomised trial.
        BMJ. 2011; 342: d1491https://doi.org/10.1136/bmj.d1491
        • Alazawi W.
        • et al.
        Inflammatory and immune responses to surgery and their clinical impact.
        Ann. Surg. 2016; 264: 73-80https://doi.org/10.1097/SLA.0000000000001691
        • Gaudilliere B.
        • et al.
        Clinical recovery from surgery correlates with single-cell immune signatures.
        Sci. Transl. Med. 2014; 6: 255ra131https://doi.org/10.1126/scitranslmed.3009701
        • Kranke P.
        • et al.
        Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery.
        Cochrane Database Syst. Rev. 2015; 7CD009642https://doi.org/10.1002/14651858.CD009642.pub2
        • Ajori L.
        • et al.
        Effects of gabapentin on postoperative pain, nausea and vomiting after abdominal hysterectomy: a double blind randomized clinical trial.
        Arch. Gynecol. Obstet. 2012; 285 (Epub 2011 Aug 5): 677-682https://doi.org/10.1007/s00404-011-2023-6
      2. Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial).
        BMJ. 2017; 357: j1455https://doi.org/10.1136/bmj.j1455
        • Albert-Vartanian A.
        • et al.
        Will peripherally restricted kappa-opioid receptor agonists (pKORAs) relieve pain with less opioid adverse effects and abuse potential?.
        J. Clin. Pharm. Ther. 2016; 41 (Epub 2016 Jun 1): 371-382https://doi.org/10.1111/jcpt.12404
        • Ji R.R.
        • Chamessian A.
        • Zhang Y.Q.
        Pain regulation by non-neuronal cells and inflammation.
        Science. 2016; 354: 572-577