ERAS and Gynecologic Surgery – New Findings from Study Support Continued Expansion Across Surgical Indications

Enhanced recovery after surgery (ERAS) has rapidly advanced across surgical indications and specialties as its efficacious effects on patient perioperative outcomes, financial costs, reductions in the administration of narcotic pain medications, and other metrics are borne out in multitudes of research studies and clinical trials.

What began in the world of gastrointestinal surgery, ERAS, and its various protocols, have steadily marched across the surgical landscape. The Department of Obstetrics, Gynecology, and Reproductive Sciences at UPMC Magee-Womens Hospital was an early adopter of ERAS for various gynecologic surgical indications – hysterectomy, urogynecology, and gynecologic oncology. The implementation of ERAS for these procedures and patients, among others, have provided clear evidence for its use and expansion. However, there is still much work to be done to provide clear indications of efficacy for the vast majority of surgical procedures for which ERAS has yet to be rigorously studied.

This evidence base was again expanded in August by researchers from the Department who published new findings in the American Journal of Obstetrics & Gynecology on the use of ERAS in minimally invasive nonhysterectomy gynecologic procedures. The research team included first author Ann Peters, MD, and senior author Nicole M. Donnellan, MD, from the minimally invasive gynecology surgery program at UPMC Magee. This is the first study of its kind to examine perioperative outcomes related to ERAS protocols for these procedures.

Study Overview and Aims

This retrospective study sought to understand the effects that ERAS protocols have on various outcomes for some of the more common minimally invasive gynecologic surgical (MIGS) procedures compared to more traditional methods of perioperative care. A variety of indications for which MIGS is performed were included in the study, indications such as endometriosis, uterine fibroids, tubal or adnexal pathology, and others.

The two cohorts of patients compared in the study – ERAS and conventional perioperative care (CPC) – were both derived from a 24-month period of surgical procedures from July 2015 through the end of 2018. ERAS protocols were implemented in February 2017, and the ERAS cases examined in this study all occurred from that point to the cutoff for the study. CPC cases examined in the study all occurred between July 2015 through the end of 2016 (prior to the start of ERAS).

A total of 412 surgical cases were examined – 196 in the ERAS cohort and 214 in the CPC cohort. Nearly 50% of all cases examined in the study were for endometriosis.

The primary outcome examined in the study were the rates of same-day discharges after surgery, and perioperative outcomes for such things as postoperative pain, sedation, postoperative nausea and vomiting, and unplanned admissions were explored in both the immediate postoperative period and at 30 days postprocedure.

Primary Findings and Implications for Clinical Practice

Outcomes from the study showed a clear benefit for ERAS versus the conventional approach to perioperative care. The primary outcome – same-day discharge rates – were markedly increased in the ERAS cohort – higher by 9.4% versus the CPC group.

Other postoperative metrics were also significantly improved in the ERAS group by comparison. Total unplanned admissions were low in both cohorts (CPC n=17; ERAS n=6), with pain accounting for the majority of the unplanned admissions. 

The total use of antiemetics was not significantly different between the two groups. However, antiemetic use while in the PACU was lower by 57% for the ERAS cohort. This is likely attributable to the preoperative use and higher dose level of antiemetics in this group versus their CPC counterparts. It should also be noted that the ERAS group spent less time in the PACU, with stays decreased by 19 minutes versus the CPC patients.

Postoperative pain scores and the use of narcotic pain medications showed significant differences between the two surgical groups. The use of narcotics for pain control was lower by 64% in the ERAS group. In the aggregate for the pre-, intra-, and perioperative phases, the CPC group was found to have used a total of 152.2 oral morphine equivalents (OME), while the ERAS group used just 55.3 OME. Furthermore, it should be noted that while opioid use was significantly lower in the ERAS group, pain scores did not increase, nor did admissions for pain from this group.

"Opioid use continues to be of significant concern across the country, and it is even more of a concern for our pelvic pain patients, which accounted for the majority of the surgical cases examined in our study. Showing that pain control is more than adequate within our multimodal ERAS protocols for this patient cohort is a significant finding," says Dr. Donnellan.

Also significant is that taken as a whole, ERAS protocols were shown to have no detrimental effects on 30-day morbidities. In fact, on virtually every measure analyzed in the study, the ERAS cohort outperformed the CPC cohort or was shown to be equivalent.

"We are confident, based on the findings from our study and the significant amount of work related to ERAS that has progressed across our Department in recent years, that ERAS protocols ought to become a part of the standard of care for these types of minimally invasive gynecologic surgeries. Our patients benefit tremendously in their outcomes and operative experience, and health care costs can be lowered. I think the work now becomes how do we continue to refine and improve our ERAS protocols to realize even greater benefits," says Dr. Donnellan.

Reference

Peters A, Siripong N, Wang L, Donnellan NM. Enhanced Recovery After Surgery Outcomes in Minimally Invasive Nonhysterectomy Gynecologic Procedures. Am J Obstet Gynecol. 2020; 223: 234 e1-8. Epub ahead of print.