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Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review
Accepted Manuscript
Enhanced Recovery Following Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review Eleftheria Kalogera MD, MSc , Gretchen E. Glaser MD , Amanika Kumar MD , Sean C. Dowdy MD , Carrie L. Langstraat MD PII: DOI: Reference:
S1553-4650(18)31321-9 https://doi.org/10.1016/j.jmig.2018.10.016 JMIG 3668
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
3 August 2018 16 October 2018 17 October 2018
Please cite this article as: Eleftheria Kalogera MD, MSc , Gretchen E. Glaser MD , Amanika Kumar MD , Sean C. Dowdy MD , Carrie L. Langstraat MD , Enhanced Recovery Following Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review, The Journal of Minimally Invasive Gynecology (2018), doi: https://doi.org/10.1016/j.jmig.2018.10.016
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Kalogera 1
Enhanced Recovery Following Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review Eleftheria Kalogera MD MSc, Gretchen E. Glaser MD, Amanika Kumar MD, Sean C. Dowdy MD, Carrie L. Langstraat MD Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
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Corresponding author: Carrie L. Langstraat, MD, Division of Gynecologic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905. E-mail: [email protected] Phone: (507) 266-9323. Fax: (507) 266-9300. Disclosure statement: There are no conflicts of interest for this manuscript. Word Count: 3,341
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Précis
Limited data suggests that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity and readmission
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rates. Abstract
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Enhanced Recovery After Surgery (ERAS) is an evidence-based approach to perioperative care of the surgical patient. A mounting body of literature in gynecologic surgery has demonstrated that ERAS improves postoperative outcomes, shortens hospital length of stay and reduces cost without increasing complications or readmissions. Most of the existing literature has concentrated on open surgery, questioning if patients
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undergoing minimally invasive surgery (MIS) also derive benefit. Our aim was to systematically review the literature on ERAS following minimally invasive gynecologic surgery (MIGS) with and without bowel surgery. Given the paucity of studies on ERAS in MIGS with bowel surgery (one
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study), we expanded our search to include studies of ERAS in patients undergoing minimally invasive colorectal resections alone. Twelve studies were identified through an electronic database search of PubMed, MEDLINE, and Ovid EMBASE. These studies included patients undergoing
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Kalogera 2 ` MIGS for benign and/or malignant indications and showed that ERAS pathways decreased length of stay and/or increased the proportion of sameday discharge surgeries, improved patient satisfaction, and reduced hospital costs while maintaining low postoperative complication and readmission rates. Although limited, data from a single study suggests that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity and readmissions. While the variation between the published protocols underscores the need for standardization,
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existing literature supports the adoption of ERAS as safe and effective when planning MIGS. (Word count: 226)
Keywords: bowel surgery; enhanced recovery; enhanced recovery pathway; gynecologic surgery; minimally invasive gynecologic surgery; minimally invasive Introduction
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Both the American College of Obstetricians and Gynecologists [1] and the American Association of Gynecologic Laparoscopists recommend minimally invasive hysterectomy as the preferred approach for benign indications to improve outcomes while reducing hospital stay [2].
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Approximately 100,000-200,000 hysterectomies are performed in the outpatient ambulatory setting per year [3]. Enhanced Recovery After Surgery (ERAS) is a bundled pathway based on evidence-based practices with the goal of hastening recovery [4, 5]. While ERAS was studied in colorectal surgery in the 1990s [4], important progress has been achieved over the past few years in introducing ERAS in gynecologic surgery for both benign
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[6-10] and malignant indications [11-13], including publication of pre-, intra-, and post-operative guidelines for gynecologic surgery and gynecologic oncology by the ERAS Society [14, 15]. ERAS pathways have been shown in multiple investigations to accelerate return of bowel function, reduce
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opioid use, decrease hospital length of stay, and reduce costs with high patient satisfaction following gynecologic surgery [6-13]. However, the focus in the literature has been placed on reporting outcomes of ERAS following open gynecologic surgery possibly due to the higher associated
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morbidity and mortality and the greater opportunity for improvement. This paucity of data regarding ERAS in MIGS in conjunction with the seeming overlap of benefits between minimally invasive surgery (MIS) and ERAS pathways has brought to question whether there is a benefit to be gained in
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Kalogera 3 ` adopting the ERAS approach for MIGS. The goal of the current study was thus to review the published literature on ERAS in MIGS with a special focus on bowel surgery within MIGS. Methods
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A literature search was performed in PubMed, MEDLINE, Ovid EMBASE for articles published before May 2018 using the following keywords for ERAS: ERAS, enhanced recovery after surgery, enhanced recovery, enhanced recovery pathway, ERP, fast-track, fast-tract surgery, and the following keywords for MIGS: MIGS, minimally invasive gynecologic surgery, laparoscopy, laparoscopic surgery, robotic surgery, robotic, minimally invasive, minimally invasive surgery, and MIS. The search was limited to Gynecology by combining these search terms with the keywords Gynecology, Gynecologic, Gynecologic Surgery, and Gynecologic Oncology. In order to identify the literature focused on ERAS outcomes following
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MIGS with bowel surgery, a second search was performed and refined by adding the keywords bowel surgery, bowel resection, colon resection, colectomy, sigmoid resection, sigmoidectomy, rectosigmoidectomy, rectal resection, and ileocolic resection. Results from both search strategies were then combined and screened as one group. We anticipated that the literature on ERAS in MIGS with bowel surgery would be limited, thus the
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same search strategy was used in order to identify relevant literature in CRS. Select studies from the CRS literature are presented in this review. We included randomized controlled trials, cohort studies, case-control studies, and case series either focused on minimally invasive (laparoscopic
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or robotic) gynecologic surgery (or CRS as applicable) or including a separate minimally invasive subset. All studies were published in English with a study size >10 patients. In order to include a paper, we required a description of the ERAS pathway (unless published as an abstract for a
Results
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scientific meeting), with evaluation of the following outcomes: length of stay, perioperative complications, and readmissions.
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The electronic database search resulted in 96 citations. After abstract review, 26 were eligible for full-text analysis and 12 studies met the predefined selection criteria. The detailed study selection process is presented in Figure 1. Of the 12 studies, 2 included patients undergoing
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Kalogera 4 ` laparoscopic or robotic-assisted hysterectomy for benign indications [16, 17], 3 studies reported on patients undergoing MIGS including radical hysterectomy with or without pelvic and/or para-aortic lymphadenectomy for malignant indications [18-20], and 6 included a mixed population of patients undergoing MIGS for benign or malignant indications [21-26]. Only one study was identified for patients undergoing MIGS with bowel surgery for definitive treatment of intestinal deep infiltrating endometriosis [27]. Table 1 summarizes the characteristics of the studies included from
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the gynecologic surgical literature. An additional 14 studies evaluating ERAS following MIS CRS were identified as relevant from the electronic database search. ERAS pathway components
Although there is not a standardized ERAS pathway, basic principles include maintaining euvolemia, optimizing nutrition, and achieving excellent
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pain control while minimizing opioid use. A detailed summary of the components included in the ERAS pathways among the included studies is presented in Table 2. The components that were included in more than half of the pathways were patient education, limiting preoperative fasting, preoperative use of carbohydrate-rich drinks, use of multimodal postoperative nausea and vomiting prophylaxis regimens, discontinuation of naso-
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or oro-gastric tubes at the end of the case or at the PACU, euvolemic intra- and post-operative fluid management, preemptive analgesia, use of a non-opioid-centric multimodal analgesic regimen postoperatively, early mobilization, accelerated resumption of general diet, and use of strict
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discharge criteria. Variation existed regarding the timing of urinary catheter discontinuation: urinary catheters were expected to be removed at the end of the case in 4 of 8 studies, within 6 hours of surgery in 1 study, and on postoperative day 1 in 2 studies. Opioid-free total intravenous
Length of hospital stay
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anesthesia and postoperative laxative use were the least frequently included components.
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Most of the ERAS programs in MIGS reduced length of stay or increased the proportion of patients being discharged within 24 hours of surgery (Table 1.). Clemente et al. reported that among 254 patients undergoing laparoscopic hysterectomy for benign indications, 90% were discharged in
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Kalogera 5 ` less than 1 day [16]. Similarly, when Keil et al. compared 165 patients undergoing laparoscopic or robot-assisted hysterectomy for benign indications under an ERAS pathway to 90 patients undergoing similar procedures under their previous practice, they found that 56% of the ERAS group was able to be discharged on the day of surgery compared to only 9% in historic controls (P<0.001) [17]. Improvements in the length of stay have similarly been observed in MIGS for malignant indications (Table 1.). Lambaudie et al. observed a 1 day reduction in the median length of stay
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after implementation of an ERAS pathway in both the laparoscopic and robot-assisted hysterectomy groups (with or without pelvic and/or paraaortic lymphadenectomy)(P=0.022 and P=0.028, respectively) [19]. In the study by Chapman et al., 93% of patients undergoing laparoscopic and robotic surgeries under an ERAS pathway were discharged on postoperative day 1 compared to 60% under traditional perioperative care (P<0.001) [18]. In contrast, Myriokefalitaki et al. did not find a statistically significant difference in median length of stay following ERAS implementation among women undergoing laparoscopic surgery for malignant indications (Table 1.) [20]. The additional 6 studies that we identified investigating ERAS in
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mixed cohorts of patients undergoing MIGS for benign or malignant indications corroborate that most patients are discharged within 1 day of surgery, although these studies did not include a direct comparison control group (Table 2.). Importantly, these results appear to be comparable
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between US and non-US studies. Postoperative complications and Readmissions
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Among the studies of ERAS in MIGS for benign indications (Table 1.), Keil et al. did not observe any difference between the ERAS and historic referent groups in postoperative outcomes including urgent clinic or emergency room visits and reoperations [17]. The 30-day readmission rate
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remained low at 3.6%, which was not significantly different from the pre-ERAS rate of 5.6%. In addition, no difference in complication rates was demonstrated in malignant cohorts at a higher risk for morbidity and mortality (Table 1.). None of the 3 studies observed any difference in the rate of postoperative morbidity and readmission rates between ERAS and pre-ERAS practices with the rate of grade 3 or higher complications ranging
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from 0 to 5.7% [18-20]; readmission rates varied from 5.5 to 9.1% in the ERAS groups. The study by Modesitt et al. included a population of patients undergoing MIGS for either benign or malignant indications, and was the only investigation that found an increase in overall postoperative
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Kalogera 6 ` complication rate post-ERAS (18.1% vs. 10.8%, P=0.01), which was attributed to an increase in the frequency of postoperative urinary tract infections (5.2% vs. 1.9%, P=0.03) [26]. Of note, in this paper, there were no details about the exact protocol for urinary catheter removal or any explanation for this increase.
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Opioid Use
With regards to intraoperative opioid use, only two studies implemented in the ERAS protocol opioid-sparing total intravenous anesthesia (TIV) [17, 26] but only one reported on intraoperative opioid consumption [26]. Modesitt et al. found that use of opioid-sparing TIV was associated with a statistically significant reduction in the intraoperative mean oral morphine equivalents compared to the historic cohort (0.3 vs. 12.7mg, P<0.001) [26]. Of the 6 studies that implemented a non-opioid centric multimodal postoperative analgesia protocol [17-19, 22, 25, 26], only two studies
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reported results on opioid use [18, 26]. While Modesitt et al. did not find a difference in postoperative opioid use between the ERAS and historic cohorts [26], Champan et al. reported a statistically significant decrease in postoperative oral morphine equivalents after ERAS implementation
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compared to the historic referent cohort (30.7 vs. 44.3mg, P<0.01). Hospital costs
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We found two studies that reported hospital costs [18, 26]. Both showed significant cost reductions associated with ERAS implementation. Chapman et al. found a 12% decrease in mean total hospital costs for gynecologic oncology patients undergoing MIGS in the ERAS group compared to the historic referent group ($13,771 vs. $15,649, P=0.01) [18]. In the second study, Modesitt et al. estimated a median 30-day total
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hospital cost per patient rate of $7,606 after ERAS compared to $8,277 before ERAS among patients undergoing MIGS for benign or malignant indications (P=0.014) [26]; of note, vaginal surgery was performed in approximately 20%.
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Patient satisfaction
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Kalogera 7 ` Although limited data exists regarding patient satisfaction and ERAS pathways, two studies demonstrated that ERAS maintained or improved patients’ postoperative experience [21, 26]. Ali et al. reported that 94% (47/50) of patients undergoing laparoscopic hysterectomy for benign or malignant indications were “exactly happy with the experience” [21]. Modesitt et al. observed that patient satisfaction scores specifically on the pain control question showed a significant improvement from the 34th to the 99th percentile (P<0.001) [26].
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ERAS in MIGS with bowel surgery
We identified one study that investigated the implementation of ERAS in MIGS with bowel surgery. Kondo et al. evaluated the outcomes of 161 patients undergoing laparoscopic surgery for treatment of intestinal deep infiltrating endometriosis under an ERAS pathway (Table 1.) [27]. The cohort was divided into those who underwent segmental bowel resection (n=59) and those undergoing less radical bowel surgery, which included
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rectal shaving, mucosal skinning or anterior disk resection (n=102). Among patients who received a bowel resection, median length of stay was 1 day, identical to both the cohort with the less radical bowel surgery, and to patients undergoing MIGS without bowel surgery as discussed above. Importantly, 91.5% of patients who underwent bowel resection were discharged within 2 days after surgery. Although the readmission rate was
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significantly higher in the group undergoing bowel resection compared to the less radical group [6.8% (4/59) vs. 1% (1/102), P=0.04], this readmission rate was within the range observed among the ERAS studies in MIGS without bowel surgery (0-9.1%). Rates of return to the operating
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room did not differ between groups [3.4% (2/59) vs. 1% (1/102), P=0.28]. The authors concluded that implementation of an ERAS protocol resulted in a short length of stay and readmission rate after laparoscopic surgery for treatment of intestinal deep infiltrating endometriosis including bowel
ERAS in MIS CRS
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resection.
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Given the paucity of data reporting on ERAS in MIGS that included bowel surgery, we expanded our review to the colorectal surgery literature. In 2017, Wang et al. published a meta-analysis of 10 clinical trials comparing outcomes between fast-track surgery and conventional care following
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Kalogera 8 ` laparoscopic CRS for cancer [28]. The authors found that fast-track surgery was associated with significantly shorter LOS [weighted mean difference (WMD) -0.64 days, 95% confidence interval (CI) -0.76, -0.53], significantly shorter time to first flatus (WMD -1.91, 95% CI -3.31, -0.50) and first bowel movement (WMD -0.70, 95% CI -0.85, -0.55), lower complication rates [relative risk (RR) 0.73, 95% CI 0.60, 0.88) with no difference in the readmission rate (RR 0.66, 95% CI 0.42, 1.05) or mortality rate (RR 1.53, 95% CI 0.42, 5.66). These findings are corroborated by other
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studies on ERAS in MIS CRS for both malignant [29, 30] and benign indications [31-35]. Importantly, the type of bowel surgery performed does not impact safety. Patients in these studies underwent a wide range of procedures including ileocecal resection [35], large bowel resection including subtotal colectomy/ileal pouch-anal anastomosis [31], high anterior resection [32], abdominoperineal resection and proctocolectomy [29]. Similarly, Kisialeuski et al. found that implementation of ERAS in the setting of MIS CRS is feasible irrespective of the patients’ age; LOS was lower among elderly patients (defined as > 65 years) without an increase in postoperative complications or readmissions compared to patients 65 years or
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younger [36].
ERAS pathways were also found to be cost-effective in MIS CRS. Lovely et al. observed a statistically significant decrease of $1,039 in the mean
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patient care cost (P=0.021) but a mean increase of $409 in anesthesia costs (P<0.001) in a case-matched series of patients following MIS CRS for benign and malignant indications. The increase in anesthesia costs was attributed to the preemptive use of intrathecal analgesia [31]. In the LAFA trial (LAparoscopy and/or FAst track multimodal management versus standard care), Vlug et al. sought to investigate which form of perioperative
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treatment, laparoscopic or open surgery with fast-track or standard care is the optimal approach (4 treatment groups) [37]. Although they did not directly compare MIS with fast-track vs. MIS with standard of care, they found that median in-hospital costs among University hospitals were
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$10,594 vs. $11,967 and among teaching hospitals $5,768 vs. $6,228, respectively, suggesting cost reductions favoring fast-track surgery. These early findings have been confirmed with recent studies showing statistically significant cost reductions with implementation of ERAS in MIS CRS
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[34, 38, 39].
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Kalogera 9 ` The use of oral mechanical and antibiotic bowel preparations varied between studies. In a recent meta-analysis of patients undergoing MIS CRS, 7 out of the 10 studies omitted its use within an ERAS pathway with no adverse postoperative outcomes [28]. The majority of the above-mentioned studies similarly either did not use oral bowel preparation [30, 34, 35, 37, 40] or used it only for specific indications such as low anterior resection [36], total mesorectal excision [39], planned diverting ileostomy, or intraoperative colonoscopy [38]. Bowel preparation was used routinely as part of
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the ERAS pathway in only one study [33] whereas two studies did not comment on its use [29, 31]. Importantly, no differences were observed in overall postoperative complications, anastomotic leak rate, or postoperative infectious morbidity in those studies where bowel preparation was omitted with ERAS compared to conventional care. Discussion
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Since the introduction of the concept of fast-track surgery and subsequently the development of ERAS pathways in CRS, a growing body of high quality literature continues to support adoption of ERAS in gynecologic surgery. The vast majority of the literature investigating ERAS has focused on open gynecologic surgery, which offers a greater opportunity for measureable benefit compared to MIS given the greater physiologic insult. In
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our systematic review, we identified 12 studies reporting outcomes specific to ERAS in MIGS and only 1 study on ERAS in MIGS with bowel surgery confirming this imbalance in the literature. Interestingly, we did not identify any studies assessing ERAS in minimally invasive non-hysterectomy
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procedures which demonstrates a need for additional research. In keeping with findings for ERAS in open gynecologic surgery, ERAS pathways shortened hospital length of stay and/or increased the proportion of same-day discharges, improved patient satisfaction, and significantly reduce
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hospital costs without increasing postoperative complications or readmission rates. Although previous studies have shown that ERAS following open gynecologic surgeries is associated with significant reduction in opioid requirements while maintaining adequate pain management, most studies on ERAS following MIGS did not report on opioid use. The difference in outcomes in opioid use between the two studies which looked at
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oral morphine equivalents consumption postoperatively likely represents the different threshold of opioid use for pain management before
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Kalogera 10 ` attempting other non-opioid medication. Of the 12 studies, only one included a cohort of patients undergoing MIGS with bowel surgery, which mirrored the findings of ERAS in both MIGS without bowel surgery and MIS CRS supporting the safety and efficacy of ERAS in this subset. Given the paucity of data for patients with MIGS and bowel surgery, we reviewed results from studies in the colorectal literature that investigated patients undergoing MIS without gynecologic surgery. While the value of applying findings from CRS may be questioned, it is important to consider
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that one of the sentinel premises of ERAS is to support evidence-based interventions (or lack thereof) that decrease surgical stress (omission of preoperative fasting) or enhance the body’s ability to mitigate the negative consequences of surgery (euvolemia, normothermia). Interestingly, laparoscopy combined with a fast-track pathway has been shown to support the highest level of immune function postoperatively [41]. Thus, extrapolating results across similar surgical disciplines appears to be justified from a physiologic perspective. Although the magnitude of improvement with ERAS is certainly lower in MIS than open surgery compared to traditional management, the evidence supports a synergistic effect
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of combining MIS with ERAS [42]. While length of stay and cost are seminal endpoints in perioperative recovery, other endpoints such as PACU stay, time to return to work, and patient reported outcomes will take on larger importance in future studies of perioperative optimization for patients
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undergoing MIS.
One of the difficulties with successful widespread dissemination of the ERAS approach stems from the lack of standardization. As noted in the
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current review, there was considerable variation in the number and type of ERAS elements included in the published ERAS protocols in MIGS, which may also explain variations in improvement. Over the past few years, there have been increasing efforts towards ERAS standardization.
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Though not specific to MIGS, the ERAS Society published guidelines for ERAS pathways in gynecologic surgery [14, 15], which was followed by an article on practical considerations specific to the development of ERAS in gynecologic oncology [43]. The American College of Surgeons in collaboration with the Armstrong Institute developed the Safety Program for Improving Surgical Care and Recovery sponsored by the Agency for
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Healthcare Research and Quality with the goal of supporting hospitals nationwide in implementing ERAS pathways across 5 surgical specialties including gynecologic surgery [44-47]. Finally, a protocol customized for MIGS has been proposed which includes the components we identified as
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Kalogera 11 ` most frequent in the investigations included in our systematic review including patient education, preoperative oral hydration and carbohydrate loading, SSI bundle interventions, limiting use of drains and catheters, opioid-limiting multimodal analgesia, early alimentation and early mobilization [48]. Importantly, dissemination of a standardized ERAS protocol will help eliminate or at least reduce the considerable variation in perioperative care models including length of stay across practices and geographic locations.
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One point of contention in need of further study and objective assessment of risk and benefit is the use of bowel preparation. While the use of mechanical bowel preparation alone has been shown in many randomized trials to not offer benefit, the efficacy of combined mechanical and oral antibiotic prep, or oral antibiotic alone is unclear [49, 50]. In the single study we identified investigating ERAS in MIGS with bowel surgery, use of bowel preparation was not included in the list of ERAS components, and the authors referenced the ERAS group guidelines in CRS which advise against their routine use [27, 51]. In a recent systematic review of the gynecologic surgical literature conducted for the Agency for Healthcare
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Research and Quality Safety Program for Improving Surgical Care and Recovery, we identified 1 systematic review, 2 meta-analyses and 2 randomized controlled trials that provided strong evidence that oral mechanical bowel preparation before MIGS without bowel surgery does not offer
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benefit, including no benefit in intraoperative visualization and bowel handling [47]. However, no data specifically focused on the use of preoperative bowel preparation before MIGS with bowel surgery. Even when reviewing the CRS literature, controversy still exists over the use of bowel preparation in MIS, particularly when an ERAS pathway is utilized. In the systematic review focused on CRS conducted within the same initiative by
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the Agency for Healthcare Research and Quality Safety, the authors concluded that combined oral antibiotics and mechanical bowel preparations is recommended within an ERAS protocol for CRS, as evidence supports that this practice decreases surgical site infection rates despite the
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possibility that they may cause physiologic derangements [44]. This recommendation is in agreement with guidelines published by the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons [52, 53]. However, the authors note that this is a weak recommendation based on moderate quality evidence, and sub-analysis of laparoscopic cases was not performed. Importantly,
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bowel preparation is frequently used before MIS CRS to facilitate intraoperative colonoscopy [53, 54], which is not a common consideration in MIGS. In agreement with the ERAS society recommendations for CRS [55, 56], many groups omitted preoperative bowel preparations in ERAS
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Kalogera 12 ` protocols in MIS CRS without an increase in infectious morbidity [39, 57-60]. Given the lack of high quality data to guide the decision to include or omit bowel preparations before MIGS and the ongoing controversy in the CRS literature, it is important for clinicians to weigh the risks associated with their use against the theoretical benefit of decreasing infectious morbidity in a group of patients with extremely low rates of surgical site infection.
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In conclusion, ERAS represents best clinical practice and should be adopted across gynecologic surgical specialties irrespective of operative approach. Although the data is limited on ERAS following MIGS with bowel surgery, the one relevant study demonstrated that the length of stay remained low with stable postoperative morbidity and readmission rates. This is consistent with data derived from the ERAS literature for patients undergoing MIS CRS as well as open gynecologic oncology surgery with bowel resection. Systematic efforts are needed to standardize
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perioperative pathways and encourage widespread dissemination in order to maximize patient outcomes. References
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[27] Kondo W, Ribeiro R, Zomer MT. Fast-track surgery in intestinal deep infiltrating endometriosis. Journal of minimally invasive gynecology.
[28] Wang Y, Zhao GH, Zhao J, Yang H, Lin J. A pooled analysis of fast track procedure vs. Conventional care in laparoscopic colorectal cancer
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surgery. International Journal of Clinical and Experimental Medicine. 2017;10:5778-87.
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Kalogera 15 ` [29] Khreiss W, Huebner M, Cima RR, Dozois ER, Chua HK, Pemberton JH, et al. Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer. Diseases of the colon and rectum. 2014;57:557-63.
[30] Taupyk Y, Cao X, Zhao Y, Wang C, Wang Q. Fast-track laparoscopic surgery: A better option for treating colorectal cancer than conventional laparoscopic surgery. Oncology Letters. 2015;10:443-8.
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[31] Lovely JK, Maxson PM, Jacob AK, Cima RR, Horlocker TT, Hebl JR, et al. Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. The British journal of surgery. 2012;99:120-6.
[32] Mari GM, Costanzi A, Maggioni D, Origi M, Ferrari GC, De Martini P, et al. Fast-track versus standard care in laparoscopic high anterior resection: a prospective randomized-controlled trial. Surgical laparoscopy, endoscopy & percutaneous techniques. 2014;24:118-21. [33] Martin TD, Lorenz T, Ferraro J, Chagin K, Lampman RM, Emery KL, et al. Newly implemented enhanced recovery pathway positively impacts
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hospital length of stay. Surgical endoscopy. 2016;30:4019-28.
[34] Scioscia M, Ceccaroni M, Gentile I, Rossini R, Clarizia R, Brunelli D, et al. Randomized Trial on Fast Track Care in Colorectal Surgery for Deep
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Infiltrating Endometriosis. Journal of minimally invasive gynecology. 2017;24:815-21. [35] Spinelli A, Bazzi P, Sacchi M, Danese S, Fiorino G, Malesci A, et al. Short-term outcomes of laparoscopy combined with enhanced recovery pathway after ileocecal resection for Crohn's disease: a case-matched analysis. Journal of gastrointestinal surgery : official journal of the Society for
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Surgery of the Alimentary Tract. 2013;17:126-32; discussion p.32. [36] Kisialeuski M, Pedziwiatr M, Matlok M, Major P, Migaczewski M, Kolodziej D, et al. Enhanced recovery after colorectal surgery in elderly
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patients. Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques. 2015;10:30-6. [37] Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Annals of surgery. 2011;254:868-75.
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[38] Baker C, Tomlinson F, Berry J, Tsepov D. Should all suitable women be offered laparoscopic hysterectomy over abdominal hysterectomy? Gynecological Surgery. 2015;12:S383.
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Kalogera 16 ` [39] Pedziwiatr M, Wierdak M, Nowakowski M, Pisarska M, Stanek M, Kisielewski M, et al. Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study. Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques. 2016;11:14-21.
[40] Baldini A, Golfier F, Mouloud K, Bruge Ansel MH, Navarro R, Ruffion A, et al. Day case laparoscopic nephrectomy with vaginal extraction: initial
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experience. Urology. 2014;84:1525-8.
[41] Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES, et al. Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial. Ann Surg. 2012;255:216-21. [42] Pache B, Hubner M, Jurt J, Demartines N, Grass F. Minimally invasive surgery and enhanced recovery after surgery: The ideal combination? Journal of surgical oncology. 2017;116:613-6.
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[43] Nelson G, Dowdy SC, Lasala J, Mena G, Bakkum-Gamez J, Meyer LA, et al. Enhanced recovery after surgery (ERAS(R)) in gynecologic oncology - Practical considerations for program development. Gynecol Oncol. 2017;147:617-20.
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[44] Ban KA, Gibbons MM, Ko CY, Wick EC. Surgical Technical Evidence Review for Colorectal Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg. 2017;225:548-57 e3. [45] Siletz A, Childers CP, Faltermeier C, Singer ES, Hu QL, Ko CY, et al. Surgical Technical Evidence Review of Hip Fracture Surgery Conducted
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for the AHRQ Safety Program for Improving Surgical Care and Recovery. Geriatr Orthop Surg Rehabil. 2018;9:2151459318769215. [46] AHRQ website.
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[47] Kalogera E, Nelson G, Liu J, Hu QL, Ko CY, Wick E, et al. Surgical Technical Evidence Review for Gynecologic Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. American journal of obstetrics and gynecology. 2018. [48] Stone R. Enhanced Recovery After Minimally Invasive Surgery (ERAmiS) for Gynecology. Current Obstetrics and Gynecology Reports.
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2018;7:39-50.
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Kalogera 17 ` [49] Pirro N, Ouaissi M, Sielezneff I, Fakhro A, Pieyre A, Consentino B, et al. [Feasibility of colorectal surgery without colonic preparation. A prospective study]. Ann Chir. 2006;131:442-6.
[50] Zmora O, Lebedyev A, Hoffman A, Khaikin M, Munz Y, Shabtai M, et al. Laparoscopic colectomy without mechanical bowel preparation. Int J Colorectal Dis. 2006;21:683-7.
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[51] Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009;144:961-9.
[52] Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, et al. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Diseases of the colon and rectum. 2017;60:761-84.
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[53] Zerey M, Hawver LM, Awad Z, Stefanidis D, Richardson W, Fanelli RD, et al. SAGES evidence-based guidelines for the laparoscopic resection of curable colon and rectal cancer. Surg Endosc. 2013;27:1-10.
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[54] Yost MT, Jolissaint JS, Fields AC, Whang EE. Mechanical and Oral Antibiotic Bowel Preparation in the Era of Minimally Invasive Surgery and Enhanced Recovery. Journal of laparoendoscopic & advanced surgical techniques Part A. 2018;28:491-5. [55] Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, et al. Guidelines for perioperative care in elective colonic surgery:
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Enhanced Recovery After Surgery (ERAS((R))) Society recommendations. World J Surg. 2013;37:259-84. [56] Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, et al. Guidelines for perioperative care in elective rectal/pelvic surgery:
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Enhanced Recovery After Surgery (ERAS(R)) Society recommendations. Clin Nutr. 2012;31:801-16. [57] Braga M, Borghi F, Scatizzi M, Missana G, Guicciardi MA, Bona S, et al. Impact of laparoscopy on adherence to an enhanced recovery pathway and readiness for discharge in elective colorectal surgery: Results from the PeriOperative Italian Society registry. Surg Endosc.
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2017;31:4393-9.
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Kalogera 18 ` [58] Keller DS, Tantchou I, Flores-Gonzalez JR, Geisler DP. Predicting delayed discharge in a multimodal Enhanced Recovery Pathway. American journal of surgery. 2017;214:604-9.
[59] Larson DW, Lovely JK, Cima RR, Dozois EJ, Chua H, Wolff BG, et al. Outcomes after implementation of a multimodal standard care pathway for laparoscopic colorectal surgery. Br J Surg. 2014;101:1023-30.
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[60] Pirrera B, Alagna V, Lucchi A, Berti P, Gabbianelli C, Martorelli G, et al. Transversus abdominis plane (TAP) block versus thoracic epidural
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analgesia (TEA) in laparoscopic colon surgery in the ERAS program. Surgical endoscopy. 2018;32:376-82.
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Figure 1. Study Selection Flow Diagram
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Clemente† [16]
2016
Prospective cohort
LH
Malignant Lambaudie [19]
2017
Prospective cohort
LH/RAH +/- PELND +/- PALND
Chapman [18]
2016
Comparator
Complication rate*
Readmission rate*
ERAS 165 Historic 90
Mean LOS: 20 vs. 34 hours (P<0.001) Same-day discharge: 56 vs. 9% (P<0.001)
30-day: 3.6 vs. 5.6% (NS) 90-day: 5.4 vs. 5.6% (NS)
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<1 day stay 90%
30-day urgent clinic visit: 12 vs. 9% (NS) 30-day ER visits: 13 vs. 14% (NS) 90-day reoperation: 4 vs. 3% (NS) Reoperation 2.4%
Traditional care Historic cohort matched on age, ASA score, type of procedure (LH/RAH)
LH: ERAS 53 Historic 53 RAH: ERAS 34 Historic 35
Median LOS LH: 2 vs. 3 days (P=0.022) RAH: 3 vs. 4 days (P=0.028)
30-day overall 6 vs. 4% (NS)
Traditional care Historic cohort matched 2:1 on age, type of surgery to ERAS
ERAS 55 Historic 110
Median LOS 30 vs. 34 hours (P<0.01) Discharge on POD1 93 vs. 60% (P<0.01)
30-day overall LH: 17 vs. 13.2% (NS) RAH: 14.7 vs. 14.3% (NS) Grade 3/4 (Clavien Dindo classification) LH: 5.7 vs. 1.9% (NS) RAH: 0 vs. 2.9% (NS) Reoperation 0% Morbidity 0% (in both groups)
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Retrospective cohort
LH/RAH +/- LND; L/R LND +/- SO
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Length of stay*
Traditional care Historic cohort
Number of patients
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Table 1. Main Characteristics of included studies First author Year Study design Type of surgery Benign Keil [17] 2018 Prospective LH/RAH +/cohort SO
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7.9%
30-day: 5.5 vs. 8.2% (NS)
` 2016
Prospective cohort
Mixed (benign and malignant) Modesitt [26] 2016 Retrospective cohort
Traditional care Historic cohort
ERAS 33 Historic 24
Mean LOS 2.7 vs. 2.7 days (NS)
30-day overall 21.2 vs. 8.3% (NS) Grade 3/4 (ClavienDindo classification) 0 vs. 3% (NS)
9.1 vs. 4.2% (NS)
LH +/- BSO +/-LND; TVH +/- BSO; L colpopexy
Traditional care Historic cohort
ERAS 249 Historic 324
Median LOS 1 vs. 1 day (NS)
30-day: 6.8 vs. 3.4% (NS)
Initial ERAS
Updated ERAS 70 Initial ERAS 57
<24 hours 49 vs. 27% Discharge on POD1 74 vs. 56% (no P reported) Same-day discharge 6% <48 hours 100% Median LOS 22.7 hours Same-day discharge 27% Discharge on POD1 58% (90% due to patient preference) ≥36 hours discharge 15% (45% due to patient preference) Same-day discharge 90.9% (2/22 overnight stay due to patient
30-day overall 18.1 vs. 10.8% (P=0.01); attributed to UTI rate 5.2 vs. 1.9% (P=0.03) Updated ERAS: reoperation 1.4%
12% (all “minor”; no grading system mentioned)
0%
Grade 2: 6.8% Grade 3: 10.2% (Accordion classification)
3%
Grade 2: 4.5% (Accordion classification)
0%
2015
Retrospective cohort
LH
Ali† [21]
2015
Retrospective cohort
LH
Minig [25]
2015
Prospective cohort
LH +/- BSO
Dinesen [22]
2015
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50
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88
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Johnston† [23]
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Prospective cohort
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L (included radical H/ trachelectomy)
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Myriokefalitaki [20]
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Updated ERAS: 30-day 5.7%
` Kent† [24]
Bowel surgery Kondo [27]
2012
Prospective cohort
LH
-
376
2013
Retrospective cohort
L for complete treatment of intestinal deep infiltrative endometriosis
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161 Segmental bowel resection 59 Conservative bowel surgery 102
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preference) Mean LOS 1.2 days <23 hours 90%
Reoperation 2.3%
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7.8%
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Median LOS/ Segmental Segmental Discharge on resection: resection: 6.8% POD1 Grade 1/2 3.4% Conservative Segmental surgery: 1% Grade 3 3.4% resection: 1 day/ Conservative 64.4% surgery: Conservative Grade 3 1% surgery 1 day/ 90.2% Abbreviations: LH laparoscopic hysterectomy; RAH robot-assisted hysterectomy; (B)SO (bilateral) salpingo-oophorectomy; ERAS enhanced recovery after surgery; LOS length of stay; NS non-significant; (PE)/(PA)LND (pelvic)/(para-aortic) lymphadenectomy; POD postoperative day; L laparoscopy; H hysterectomy. *For all comparisons: ERAS vs. respective comparator † Meeting abstract
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Table 2. ERAS pathway elements across included studies* Benign Malignant Keil Clemente† Lambaudie Chapman Myriokefalitaki
Mixed (benign and malignant) Modesitt Johnston† Ali† Minig Dinesen Kent†
+
+
+
+
+
+ +
+ + No
+ No
+ + No
+ + Yes <5% +
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Preoperative Patient education mmediate preoperative Limiting fasting Carbohydrate loading Bowel preparation
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+
+
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Bowel surgery Kondo + +
No
Preemptive analgesia + + PONV prophylaxis + + + + + ntraoperative Fluid management + + + + + Normothermia + + Pain management + + + + + + + PONV prophylaxis + + + + + Opioid-sparing TIV + + Remove NG/OGT‡ + + + + Remove Foley‡ + +1 +2 +1 + + Limit peritoneal drains + + Postoperative Early mobilization + + + + + + Early alimentation + + + + + + Multimodal analgesia + + + + + + + Non-opioid centric + + + + + + Fluid management + + + + Laxative use + + Strict discharge criteria + + + + + + Abbreviations: PONV postoperative nausea and vomiting; TIV total intravenous anesthesia; NG/OGT nasogastric/orogastric tube. *If entry is empty, there was no mention of the respective element in the manuscript † Abstract - detailed protocol not available; ‡At the end of the case unless differently indicated
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3
Enhanced Recovery Following Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review Eleftheria Kalogera MD, MSc , Gretchen E. Glaser MD , Amanika Kumar MD , Sean C. Dowdy MD , Carrie L. Langstraat MD PII: DOI: Reference:
S1553-4650(18)31321-9 https://doi.org/10.1016/j.jmig.2018.10.016 JMIG 3668
To appear in:
The Journal of Minimally Invasive Gynecology
Received date: Revised date: Accepted date:
3 August 2018 16 October 2018 17 October 2018
Please cite this article as: Eleftheria Kalogera MD, MSc , Gretchen E. Glaser MD , Amanika Kumar MD , Sean C. Dowdy MD , Carrie L. Langstraat MD , Enhanced Recovery Following Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review, The Journal of Minimally Invasive Gynecology (2018), doi: https://doi.org/10.1016/j.jmig.2018.10.016
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Kalogera 1
Enhanced Recovery Following Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review Eleftheria Kalogera MD MSc, Gretchen E. Glaser MD, Amanika Kumar MD, Sean C. Dowdy MD, Carrie L. Langstraat MD Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
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Corresponding author: Carrie L. Langstraat, MD, Division of Gynecologic Surgery, Mayo Clinic, 200 1st St. SW, Rochester, MN 55905. E-mail: [email protected] Phone: (507) 266-9323. Fax: (507) 266-9300. Disclosure statement: There are no conflicts of interest for this manuscript. Word Count: 3,341
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Précis
Limited data suggests that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity and readmission
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rates. Abstract
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Enhanced Recovery After Surgery (ERAS) is an evidence-based approach to perioperative care of the surgical patient. A mounting body of literature in gynecologic surgery has demonstrated that ERAS improves postoperative outcomes, shortens hospital length of stay and reduces cost without increasing complications or readmissions. Most of the existing literature has concentrated on open surgery, questioning if patients
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undergoing minimally invasive surgery (MIS) also derive benefit. Our aim was to systematically review the literature on ERAS following minimally invasive gynecologic surgery (MIGS) with and without bowel surgery. Given the paucity of studies on ERAS in MIGS with bowel surgery (one
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study), we expanded our search to include studies of ERAS in patients undergoing minimally invasive colorectal resections alone. Twelve studies were identified through an electronic database search of PubMed, MEDLINE, and Ovid EMBASE. These studies included patients undergoing
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Kalogera 2 ` MIGS for benign and/or malignant indications and showed that ERAS pathways decreased length of stay and/or increased the proportion of sameday discharge surgeries, improved patient satisfaction, and reduced hospital costs while maintaining low postoperative complication and readmission rates. Although limited, data from a single study suggests that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity and readmissions. While the variation between the published protocols underscores the need for standardization,
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existing literature supports the adoption of ERAS as safe and effective when planning MIGS. (Word count: 226)
Keywords: bowel surgery; enhanced recovery; enhanced recovery pathway; gynecologic surgery; minimally invasive gynecologic surgery; minimally invasive Introduction
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Both the American College of Obstetricians and Gynecologists [1] and the American Association of Gynecologic Laparoscopists recommend minimally invasive hysterectomy as the preferred approach for benign indications to improve outcomes while reducing hospital stay [2].
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Approximately 100,000-200,000 hysterectomies are performed in the outpatient ambulatory setting per year [3]. Enhanced Recovery After Surgery (ERAS) is a bundled pathway based on evidence-based practices with the goal of hastening recovery [4, 5]. While ERAS was studied in colorectal surgery in the 1990s [4], important progress has been achieved over the past few years in introducing ERAS in gynecologic surgery for both benign
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[6-10] and malignant indications [11-13], including publication of pre-, intra-, and post-operative guidelines for gynecologic surgery and gynecologic oncology by the ERAS Society [14, 15]. ERAS pathways have been shown in multiple investigations to accelerate return of bowel function, reduce
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opioid use, decrease hospital length of stay, and reduce costs with high patient satisfaction following gynecologic surgery [6-13]. However, the focus in the literature has been placed on reporting outcomes of ERAS following open gynecologic surgery possibly due to the higher associated
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morbidity and mortality and the greater opportunity for improvement. This paucity of data regarding ERAS in MIGS in conjunction with the seeming overlap of benefits between minimally invasive surgery (MIS) and ERAS pathways has brought to question whether there is a benefit to be gained in
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Kalogera 3 ` adopting the ERAS approach for MIGS. The goal of the current study was thus to review the published literature on ERAS in MIGS with a special focus on bowel surgery within MIGS. Methods
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A literature search was performed in PubMed, MEDLINE, Ovid EMBASE for articles published before May 2018 using the following keywords for ERAS: ERAS, enhanced recovery after surgery, enhanced recovery, enhanced recovery pathway, ERP, fast-track, fast-tract surgery, and the following keywords for MIGS: MIGS, minimally invasive gynecologic surgery, laparoscopy, laparoscopic surgery, robotic surgery, robotic, minimally invasive, minimally invasive surgery, and MIS. The search was limited to Gynecology by combining these search terms with the keywords Gynecology, Gynecologic, Gynecologic Surgery, and Gynecologic Oncology. In order to identify the literature focused on ERAS outcomes following
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MIGS with bowel surgery, a second search was performed and refined by adding the keywords bowel surgery, bowel resection, colon resection, colectomy, sigmoid resection, sigmoidectomy, rectosigmoidectomy, rectal resection, and ileocolic resection. Results from both search strategies were then combined and screened as one group. We anticipated that the literature on ERAS in MIGS with bowel surgery would be limited, thus the
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same search strategy was used in order to identify relevant literature in CRS. Select studies from the CRS literature are presented in this review. We included randomized controlled trials, cohort studies, case-control studies, and case series either focused on minimally invasive (laparoscopic
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or robotic) gynecologic surgery (or CRS as applicable) or including a separate minimally invasive subset. All studies were published in English with a study size >10 patients. In order to include a paper, we required a description of the ERAS pathway (unless published as an abstract for a
Results
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scientific meeting), with evaluation of the following outcomes: length of stay, perioperative complications, and readmissions.
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The electronic database search resulted in 96 citations. After abstract review, 26 were eligible for full-text analysis and 12 studies met the predefined selection criteria. The detailed study selection process is presented in Figure 1. Of the 12 studies, 2 included patients undergoing
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Kalogera 4 ` laparoscopic or robotic-assisted hysterectomy for benign indications [16, 17], 3 studies reported on patients undergoing MIGS including radical hysterectomy with or without pelvic and/or para-aortic lymphadenectomy for malignant indications [18-20], and 6 included a mixed population of patients undergoing MIGS for benign or malignant indications [21-26]. Only one study was identified for patients undergoing MIGS with bowel surgery for definitive treatment of intestinal deep infiltrating endometriosis [27]. Table 1 summarizes the characteristics of the studies included from
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the gynecologic surgical literature. An additional 14 studies evaluating ERAS following MIS CRS were identified as relevant from the electronic database search. ERAS pathway components
Although there is not a standardized ERAS pathway, basic principles include maintaining euvolemia, optimizing nutrition, and achieving excellent
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pain control while minimizing opioid use. A detailed summary of the components included in the ERAS pathways among the included studies is presented in Table 2. The components that were included in more than half of the pathways were patient education, limiting preoperative fasting, preoperative use of carbohydrate-rich drinks, use of multimodal postoperative nausea and vomiting prophylaxis regimens, discontinuation of naso-
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or oro-gastric tubes at the end of the case or at the PACU, euvolemic intra- and post-operative fluid management, preemptive analgesia, use of a non-opioid-centric multimodal analgesic regimen postoperatively, early mobilization, accelerated resumption of general diet, and use of strict
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discharge criteria. Variation existed regarding the timing of urinary catheter discontinuation: urinary catheters were expected to be removed at the end of the case in 4 of 8 studies, within 6 hours of surgery in 1 study, and on postoperative day 1 in 2 studies. Opioid-free total intravenous
Length of hospital stay
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anesthesia and postoperative laxative use were the least frequently included components.
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Most of the ERAS programs in MIGS reduced length of stay or increased the proportion of patients being discharged within 24 hours of surgery (Table 1.). Clemente et al. reported that among 254 patients undergoing laparoscopic hysterectomy for benign indications, 90% were discharged in
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Kalogera 5 ` less than 1 day [16]. Similarly, when Keil et al. compared 165 patients undergoing laparoscopic or robot-assisted hysterectomy for benign indications under an ERAS pathway to 90 patients undergoing similar procedures under their previous practice, they found that 56% of the ERAS group was able to be discharged on the day of surgery compared to only 9% in historic controls (P<0.001) [17]. Improvements in the length of stay have similarly been observed in MIGS for malignant indications (Table 1.). Lambaudie et al. observed a 1 day reduction in the median length of stay
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after implementation of an ERAS pathway in both the laparoscopic and robot-assisted hysterectomy groups (with or without pelvic and/or paraaortic lymphadenectomy)(P=0.022 and P=0.028, respectively) [19]. In the study by Chapman et al., 93% of patients undergoing laparoscopic and robotic surgeries under an ERAS pathway were discharged on postoperative day 1 compared to 60% under traditional perioperative care (P<0.001) [18]. In contrast, Myriokefalitaki et al. did not find a statistically significant difference in median length of stay following ERAS implementation among women undergoing laparoscopic surgery for malignant indications (Table 1.) [20]. The additional 6 studies that we identified investigating ERAS in
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mixed cohorts of patients undergoing MIGS for benign or malignant indications corroborate that most patients are discharged within 1 day of surgery, although these studies did not include a direct comparison control group (Table 2.). Importantly, these results appear to be comparable
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between US and non-US studies. Postoperative complications and Readmissions
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Among the studies of ERAS in MIGS for benign indications (Table 1.), Keil et al. did not observe any difference between the ERAS and historic referent groups in postoperative outcomes including urgent clinic or emergency room visits and reoperations [17]. The 30-day readmission rate
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remained low at 3.6%, which was not significantly different from the pre-ERAS rate of 5.6%. In addition, no difference in complication rates was demonstrated in malignant cohorts at a higher risk for morbidity and mortality (Table 1.). None of the 3 studies observed any difference in the rate of postoperative morbidity and readmission rates between ERAS and pre-ERAS practices with the rate of grade 3 or higher complications ranging
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from 0 to 5.7% [18-20]; readmission rates varied from 5.5 to 9.1% in the ERAS groups. The study by Modesitt et al. included a population of patients undergoing MIGS for either benign or malignant indications, and was the only investigation that found an increase in overall postoperative
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Kalogera 6 ` complication rate post-ERAS (18.1% vs. 10.8%, P=0.01), which was attributed to an increase in the frequency of postoperative urinary tract infections (5.2% vs. 1.9%, P=0.03) [26]. Of note, in this paper, there were no details about the exact protocol for urinary catheter removal or any explanation for this increase.
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Opioid Use
With regards to intraoperative opioid use, only two studies implemented in the ERAS protocol opioid-sparing total intravenous anesthesia (TIV) [17, 26] but only one reported on intraoperative opioid consumption [26]. Modesitt et al. found that use of opioid-sparing TIV was associated with a statistically significant reduction in the intraoperative mean oral morphine equivalents compared to the historic cohort (0.3 vs. 12.7mg, P<0.001) [26]. Of the 6 studies that implemented a non-opioid centric multimodal postoperative analgesia protocol [17-19, 22, 25, 26], only two studies
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reported results on opioid use [18, 26]. While Modesitt et al. did not find a difference in postoperative opioid use between the ERAS and historic cohorts [26], Champan et al. reported a statistically significant decrease in postoperative oral morphine equivalents after ERAS implementation
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compared to the historic referent cohort (30.7 vs. 44.3mg, P<0.01). Hospital costs
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We found two studies that reported hospital costs [18, 26]. Both showed significant cost reductions associated with ERAS implementation. Chapman et al. found a 12% decrease in mean total hospital costs for gynecologic oncology patients undergoing MIGS in the ERAS group compared to the historic referent group ($13,771 vs. $15,649, P=0.01) [18]. In the second study, Modesitt et al. estimated a median 30-day total
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hospital cost per patient rate of $7,606 after ERAS compared to $8,277 before ERAS among patients undergoing MIGS for benign or malignant indications (P=0.014) [26]; of note, vaginal surgery was performed in approximately 20%.
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Patient satisfaction
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Kalogera 7 ` Although limited data exists regarding patient satisfaction and ERAS pathways, two studies demonstrated that ERAS maintained or improved patients’ postoperative experience [21, 26]. Ali et al. reported that 94% (47/50) of patients undergoing laparoscopic hysterectomy for benign or malignant indications were “exactly happy with the experience” [21]. Modesitt et al. observed that patient satisfaction scores specifically on the pain control question showed a significant improvement from the 34th to the 99th percentile (P<0.001) [26].
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ERAS in MIGS with bowel surgery
We identified one study that investigated the implementation of ERAS in MIGS with bowel surgery. Kondo et al. evaluated the outcomes of 161 patients undergoing laparoscopic surgery for treatment of intestinal deep infiltrating endometriosis under an ERAS pathway (Table 1.) [27]. The cohort was divided into those who underwent segmental bowel resection (n=59) and those undergoing less radical bowel surgery, which included
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rectal shaving, mucosal skinning or anterior disk resection (n=102). Among patients who received a bowel resection, median length of stay was 1 day, identical to both the cohort with the less radical bowel surgery, and to patients undergoing MIGS without bowel surgery as discussed above. Importantly, 91.5% of patients who underwent bowel resection were discharged within 2 days after surgery. Although the readmission rate was
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significantly higher in the group undergoing bowel resection compared to the less radical group [6.8% (4/59) vs. 1% (1/102), P=0.04], this readmission rate was within the range observed among the ERAS studies in MIGS without bowel surgery (0-9.1%). Rates of return to the operating
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room did not differ between groups [3.4% (2/59) vs. 1% (1/102), P=0.28]. The authors concluded that implementation of an ERAS protocol resulted in a short length of stay and readmission rate after laparoscopic surgery for treatment of intestinal deep infiltrating endometriosis including bowel
ERAS in MIS CRS
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resection.
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Given the paucity of data reporting on ERAS in MIGS that included bowel surgery, we expanded our review to the colorectal surgery literature. In 2017, Wang et al. published a meta-analysis of 10 clinical trials comparing outcomes between fast-track surgery and conventional care following
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Kalogera 8 ` laparoscopic CRS for cancer [28]. The authors found that fast-track surgery was associated with significantly shorter LOS [weighted mean difference (WMD) -0.64 days, 95% confidence interval (CI) -0.76, -0.53], significantly shorter time to first flatus (WMD -1.91, 95% CI -3.31, -0.50) and first bowel movement (WMD -0.70, 95% CI -0.85, -0.55), lower complication rates [relative risk (RR) 0.73, 95% CI 0.60, 0.88) with no difference in the readmission rate (RR 0.66, 95% CI 0.42, 1.05) or mortality rate (RR 1.53, 95% CI 0.42, 5.66). These findings are corroborated by other
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studies on ERAS in MIS CRS for both malignant [29, 30] and benign indications [31-35]. Importantly, the type of bowel surgery performed does not impact safety. Patients in these studies underwent a wide range of procedures including ileocecal resection [35], large bowel resection including subtotal colectomy/ileal pouch-anal anastomosis [31], high anterior resection [32], abdominoperineal resection and proctocolectomy [29]. Similarly, Kisialeuski et al. found that implementation of ERAS in the setting of MIS CRS is feasible irrespective of the patients’ age; LOS was lower among elderly patients (defined as > 65 years) without an increase in postoperative complications or readmissions compared to patients 65 years or
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younger [36].
ERAS pathways were also found to be cost-effective in MIS CRS. Lovely et al. observed a statistically significant decrease of $1,039 in the mean
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patient care cost (P=0.021) but a mean increase of $409 in anesthesia costs (P<0.001) in a case-matched series of patients following MIS CRS for benign and malignant indications. The increase in anesthesia costs was attributed to the preemptive use of intrathecal analgesia [31]. In the LAFA trial (LAparoscopy and/or FAst track multimodal management versus standard care), Vlug et al. sought to investigate which form of perioperative
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treatment, laparoscopic or open surgery with fast-track or standard care is the optimal approach (4 treatment groups) [37]. Although they did not directly compare MIS with fast-track vs. MIS with standard of care, they found that median in-hospital costs among University hospitals were
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$10,594 vs. $11,967 and among teaching hospitals $5,768 vs. $6,228, respectively, suggesting cost reductions favoring fast-track surgery. These early findings have been confirmed with recent studies showing statistically significant cost reductions with implementation of ERAS in MIS CRS
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[34, 38, 39].
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Kalogera 9 ` The use of oral mechanical and antibiotic bowel preparations varied between studies. In a recent meta-analysis of patients undergoing MIS CRS, 7 out of the 10 studies omitted its use within an ERAS pathway with no adverse postoperative outcomes [28]. The majority of the above-mentioned studies similarly either did not use oral bowel preparation [30, 34, 35, 37, 40] or used it only for specific indications such as low anterior resection [36], total mesorectal excision [39], planned diverting ileostomy, or intraoperative colonoscopy [38]. Bowel preparation was used routinely as part of
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the ERAS pathway in only one study [33] whereas two studies did not comment on its use [29, 31]. Importantly, no differences were observed in overall postoperative complications, anastomotic leak rate, or postoperative infectious morbidity in those studies where bowel preparation was omitted with ERAS compared to conventional care. Discussion
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Since the introduction of the concept of fast-track surgery and subsequently the development of ERAS pathways in CRS, a growing body of high quality literature continues to support adoption of ERAS in gynecologic surgery. The vast majority of the literature investigating ERAS has focused on open gynecologic surgery, which offers a greater opportunity for measureable benefit compared to MIS given the greater physiologic insult. In
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our systematic review, we identified 12 studies reporting outcomes specific to ERAS in MIGS and only 1 study on ERAS in MIGS with bowel surgery confirming this imbalance in the literature. Interestingly, we did not identify any studies assessing ERAS in minimally invasive non-hysterectomy
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procedures which demonstrates a need for additional research. In keeping with findings for ERAS in open gynecologic surgery, ERAS pathways shortened hospital length of stay and/or increased the proportion of same-day discharges, improved patient satisfaction, and significantly reduce
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hospital costs without increasing postoperative complications or readmission rates. Although previous studies have shown that ERAS following open gynecologic surgeries is associated with significant reduction in opioid requirements while maintaining adequate pain management, most studies on ERAS following MIGS did not report on opioid use. The difference in outcomes in opioid use between the two studies which looked at
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oral morphine equivalents consumption postoperatively likely represents the different threshold of opioid use for pain management before
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Kalogera 10 ` attempting other non-opioid medication. Of the 12 studies, only one included a cohort of patients undergoing MIGS with bowel surgery, which mirrored the findings of ERAS in both MIGS without bowel surgery and MIS CRS supporting the safety and efficacy of ERAS in this subset. Given the paucity of data for patients with MIGS and bowel surgery, we reviewed results from studies in the colorectal literature that investigated patients undergoing MIS without gynecologic surgery. While the value of applying findings from CRS may be questioned, it is important to consider
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that one of the sentinel premises of ERAS is to support evidence-based interventions (or lack thereof) that decrease surgical stress (omission of preoperative fasting) or enhance the body’s ability to mitigate the negative consequences of surgery (euvolemia, normothermia). Interestingly, laparoscopy combined with a fast-track pathway has been shown to support the highest level of immune function postoperatively [41]. Thus, extrapolating results across similar surgical disciplines appears to be justified from a physiologic perspective. Although the magnitude of improvement with ERAS is certainly lower in MIS than open surgery compared to traditional management, the evidence supports a synergistic effect
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of combining MIS with ERAS [42]. While length of stay and cost are seminal endpoints in perioperative recovery, other endpoints such as PACU stay, time to return to work, and patient reported outcomes will take on larger importance in future studies of perioperative optimization for patients
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undergoing MIS.
One of the difficulties with successful widespread dissemination of the ERAS approach stems from the lack of standardization. As noted in the
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current review, there was considerable variation in the number and type of ERAS elements included in the published ERAS protocols in MIGS, which may also explain variations in improvement. Over the past few years, there have been increasing efforts towards ERAS standardization.
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Though not specific to MIGS, the ERAS Society published guidelines for ERAS pathways in gynecologic surgery [14, 15], which was followed by an article on practical considerations specific to the development of ERAS in gynecologic oncology [43]. The American College of Surgeons in collaboration with the Armstrong Institute developed the Safety Program for Improving Surgical Care and Recovery sponsored by the Agency for
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Healthcare Research and Quality with the goal of supporting hospitals nationwide in implementing ERAS pathways across 5 surgical specialties including gynecologic surgery [44-47]. Finally, a protocol customized for MIGS has been proposed which includes the components we identified as
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Kalogera 11 ` most frequent in the investigations included in our systematic review including patient education, preoperative oral hydration and carbohydrate loading, SSI bundle interventions, limiting use of drains and catheters, opioid-limiting multimodal analgesia, early alimentation and early mobilization [48]. Importantly, dissemination of a standardized ERAS protocol will help eliminate or at least reduce the considerable variation in perioperative care models including length of stay across practices and geographic locations.
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One point of contention in need of further study and objective assessment of risk and benefit is the use of bowel preparation. While the use of mechanical bowel preparation alone has been shown in many randomized trials to not offer benefit, the efficacy of combined mechanical and oral antibiotic prep, or oral antibiotic alone is unclear [49, 50]. In the single study we identified investigating ERAS in MIGS with bowel surgery, use of bowel preparation was not included in the list of ERAS components, and the authors referenced the ERAS group guidelines in CRS which advise against their routine use [27, 51]. In a recent systematic review of the gynecologic surgical literature conducted for the Agency for Healthcare
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Research and Quality Safety Program for Improving Surgical Care and Recovery, we identified 1 systematic review, 2 meta-analyses and 2 randomized controlled trials that provided strong evidence that oral mechanical bowel preparation before MIGS without bowel surgery does not offer
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benefit, including no benefit in intraoperative visualization and bowel handling [47]. However, no data specifically focused on the use of preoperative bowel preparation before MIGS with bowel surgery. Even when reviewing the CRS literature, controversy still exists over the use of bowel preparation in MIS, particularly when an ERAS pathway is utilized. In the systematic review focused on CRS conducted within the same initiative by
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the Agency for Healthcare Research and Quality Safety, the authors concluded that combined oral antibiotics and mechanical bowel preparations is recommended within an ERAS protocol for CRS, as evidence supports that this practice decreases surgical site infection rates despite the
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possibility that they may cause physiologic derangements [44]. This recommendation is in agreement with guidelines published by the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons [52, 53]. However, the authors note that this is a weak recommendation based on moderate quality evidence, and sub-analysis of laparoscopic cases was not performed. Importantly,
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bowel preparation is frequently used before MIS CRS to facilitate intraoperative colonoscopy [53, 54], which is not a common consideration in MIGS. In agreement with the ERAS society recommendations for CRS [55, 56], many groups omitted preoperative bowel preparations in ERAS
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Kalogera 12 ` protocols in MIS CRS without an increase in infectious morbidity [39, 57-60]. Given the lack of high quality data to guide the decision to include or omit bowel preparations before MIGS and the ongoing controversy in the CRS literature, it is important for clinicians to weigh the risks associated with their use against the theoretical benefit of decreasing infectious morbidity in a group of patients with extremely low rates of surgical site infection.
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In conclusion, ERAS represents best clinical practice and should be adopted across gynecologic surgical specialties irrespective of operative approach. Although the data is limited on ERAS following MIGS with bowel surgery, the one relevant study demonstrated that the length of stay remained low with stable postoperative morbidity and readmission rates. This is consistent with data derived from the ERAS literature for patients undergoing MIS CRS as well as open gynecologic oncology surgery with bowel resection. Systematic efforts are needed to standardize
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perioperative pathways and encourage widespread dissemination in order to maximize patient outcomes. References
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[1] ACOG Committee Opinion No. 444: choosing the route of hysterectomy for benign disease. Obstet Gynecol. 2009;114:1156-8. [2] Worldwide AAMIG. AAGL position statement: route of hysterectomy to treat benign uterine disease. J Minim Invasive Gynecol. 2011;18:1-3. [3] Cohen SL, Ajao MO, Clark NV, Vitonis AF, Einarsson JI. Outpatient Hysterectomy Volume in the United States. Obstet Gynecol. 2017;130:130-
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[26] Modesitt SC, Sarosiek BM, Trowbridge ER, Redick DL, Shah PM, Thiele RH, et al. Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization. Obstetrics and gynecology. 2016;128:457-66.
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[27] Kondo W, Ribeiro R, Zomer MT. Fast-track surgery in intestinal deep infiltrating endometriosis. Journal of minimally invasive gynecology.
[28] Wang Y, Zhao GH, Zhao J, Yang H, Lin J. A pooled analysis of fast track procedure vs. Conventional care in laparoscopic colorectal cancer
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surgery. International Journal of Clinical and Experimental Medicine. 2017;10:5778-87.
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Kalogera 15 ` [29] Khreiss W, Huebner M, Cima RR, Dozois ER, Chua HK, Pemberton JH, et al. Improving conventional recovery with enhanced recovery in minimally invasive surgery for rectal cancer. Diseases of the colon and rectum. 2014;57:557-63.
[30] Taupyk Y, Cao X, Zhao Y, Wang C, Wang Q. Fast-track laparoscopic surgery: A better option for treating colorectal cancer than conventional laparoscopic surgery. Oncology Letters. 2015;10:443-8.
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[31] Lovely JK, Maxson PM, Jacob AK, Cima RR, Horlocker TT, Hebl JR, et al. Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery. The British journal of surgery. 2012;99:120-6.
[32] Mari GM, Costanzi A, Maggioni D, Origi M, Ferrari GC, De Martini P, et al. Fast-track versus standard care in laparoscopic high anterior resection: a prospective randomized-controlled trial. Surgical laparoscopy, endoscopy & percutaneous techniques. 2014;24:118-21. [33] Martin TD, Lorenz T, Ferraro J, Chagin K, Lampman RM, Emery KL, et al. Newly implemented enhanced recovery pathway positively impacts
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[34] Scioscia M, Ceccaroni M, Gentile I, Rossini R, Clarizia R, Brunelli D, et al. Randomized Trial on Fast Track Care in Colorectal Surgery for Deep
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Infiltrating Endometriosis. Journal of minimally invasive gynecology. 2017;24:815-21. [35] Spinelli A, Bazzi P, Sacchi M, Danese S, Fiorino G, Malesci A, et al. Short-term outcomes of laparoscopy combined with enhanced recovery pathway after ileocecal resection for Crohn's disease: a case-matched analysis. Journal of gastrointestinal surgery : official journal of the Society for
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Surgery of the Alimentary Tract. 2013;17:126-32; discussion p.32. [36] Kisialeuski M, Pedziwiatr M, Matlok M, Major P, Migaczewski M, Kolodziej D, et al. Enhanced recovery after colorectal surgery in elderly
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patients. Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques. 2015;10:30-6. [37] Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, et al. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Annals of surgery. 2011;254:868-75.
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[38] Baker C, Tomlinson F, Berry J, Tsepov D. Should all suitable women be offered laparoscopic hysterectomy over abdominal hysterectomy? Gynecological Surgery. 2015;12:S383.
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Kalogera 16 ` [39] Pedziwiatr M, Wierdak M, Nowakowski M, Pisarska M, Stanek M, Kisielewski M, et al. Cost minimization analysis of laparoscopic surgery for colorectal cancer within the enhanced recovery after surgery (ERAS) protocol: a single-centre, case-matched study. Wideochirurgia i inne techniki maloinwazyjne = Videosurgery and other miniinvasive techniques. 2016;11:14-21.
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[41] Veenhof AA, Vlug MS, van der Pas MH, Sietses C, van der Peet DL, de Lange-de Klerk ES, et al. Surgical stress response and postoperative immune function after laparoscopy or open surgery with fast track or standard perioperative care: a randomized trial. Ann Surg. 2012;255:216-21. [42] Pache B, Hubner M, Jurt J, Demartines N, Grass F. Minimally invasive surgery and enhanced recovery after surgery: The ideal combination? Journal of surgical oncology. 2017;116:613-6.
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[44] Ban KA, Gibbons MM, Ko CY, Wick EC. Surgical Technical Evidence Review for Colorectal Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. J Am Coll Surg. 2017;225:548-57 e3. [45] Siletz A, Childers CP, Faltermeier C, Singer ES, Hu QL, Ko CY, et al. Surgical Technical Evidence Review of Hip Fracture Surgery Conducted
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Kalogera 17 ` [49] Pirro N, Ouaissi M, Sielezneff I, Fakhro A, Pieyre A, Consentino B, et al. [Feasibility of colorectal surgery without colonic preparation. A prospective study]. Ann Chir. 2006;131:442-6.
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[51] Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, et al. Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg. 2009;144:961-9.
[52] Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, et al. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Diseases of the colon and rectum. 2017;60:761-84.
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2017;31:4393-9.
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Kalogera 18 ` [58] Keller DS, Tantchou I, Flores-Gonzalez JR, Geisler DP. Predicting delayed discharge in a multimodal Enhanced Recovery Pathway. American journal of surgery. 2017;214:604-9.
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[60] Pirrera B, Alagna V, Lucchi A, Berti P, Gabbianelli C, Martorelli G, et al. Transversus abdominis plane (TAP) block versus thoracic epidural
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analgesia (TEA) in laparoscopic colon surgery in the ERAS program. Surgical endoscopy. 2018;32:376-82.
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Figure 1. Study Selection Flow Diagram
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`
Clemente† [16]
2016
Prospective cohort
LH
Malignant Lambaudie [19]
2017
Prospective cohort
LH/RAH +/- PELND +/- PALND
Chapman [18]
2016
Comparator
Complication rate*
Readmission rate*
ERAS 165 Historic 90
Mean LOS: 20 vs. 34 hours (P<0.001) Same-day discharge: 56 vs. 9% (P<0.001)
30-day: 3.6 vs. 5.6% (NS) 90-day: 5.4 vs. 5.6% (NS)
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<1 day stay 90%
30-day urgent clinic visit: 12 vs. 9% (NS) 30-day ER visits: 13 vs. 14% (NS) 90-day reoperation: 4 vs. 3% (NS) Reoperation 2.4%
Traditional care Historic cohort matched on age, ASA score, type of procedure (LH/RAH)
LH: ERAS 53 Historic 53 RAH: ERAS 34 Historic 35
Median LOS LH: 2 vs. 3 days (P=0.022) RAH: 3 vs. 4 days (P=0.028)
30-day overall 6 vs. 4% (NS)
Traditional care Historic cohort matched 2:1 on age, type of surgery to ERAS
ERAS 55 Historic 110
Median LOS 30 vs. 34 hours (P<0.01) Discharge on POD1 93 vs. 60% (P<0.01)
30-day overall LH: 17 vs. 13.2% (NS) RAH: 14.7 vs. 14.3% (NS) Grade 3/4 (Clavien Dindo classification) LH: 5.7 vs. 1.9% (NS) RAH: 0 vs. 2.9% (NS) Reoperation 0% Morbidity 0% (in both groups)
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Retrospective cohort
LH/RAH +/- LND; L/R LND +/- SO
Kalogera 20
Length of stay*
Traditional care Historic cohort
Number of patients
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Table 1. Main Characteristics of included studies First author Year Study design Type of surgery Benign Keil [17] 2018 Prospective LH/RAH +/cohort SO
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7.9%
30-day: 5.5 vs. 8.2% (NS)
` 2016
Prospective cohort
Mixed (benign and malignant) Modesitt [26] 2016 Retrospective cohort
Traditional care Historic cohort
ERAS 33 Historic 24
Mean LOS 2.7 vs. 2.7 days (NS)
30-day overall 21.2 vs. 8.3% (NS) Grade 3/4 (ClavienDindo classification) 0 vs. 3% (NS)
9.1 vs. 4.2% (NS)
LH +/- BSO +/-LND; TVH +/- BSO; L colpopexy
Traditional care Historic cohort
ERAS 249 Historic 324
Median LOS 1 vs. 1 day (NS)
30-day: 6.8 vs. 3.4% (NS)
Initial ERAS
Updated ERAS 70 Initial ERAS 57
<24 hours 49 vs. 27% Discharge on POD1 74 vs. 56% (no P reported) Same-day discharge 6% <48 hours 100% Median LOS 22.7 hours Same-day discharge 27% Discharge on POD1 58% (90% due to patient preference) ≥36 hours discharge 15% (45% due to patient preference) Same-day discharge 90.9% (2/22 overnight stay due to patient
30-day overall 18.1 vs. 10.8% (P=0.01); attributed to UTI rate 5.2 vs. 1.9% (P=0.03) Updated ERAS: reoperation 1.4%
12% (all “minor”; no grading system mentioned)
0%
Grade 2: 6.8% Grade 3: 10.2% (Accordion classification)
3%
Grade 2: 4.5% (Accordion classification)
0%
2015
Retrospective cohort
LH
Ali† [21]
2015
Retrospective cohort
LH
Minig [25]
2015
Prospective cohort
LH +/- BSO
Dinesen [22]
2015
-
50
-
88
-
22
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Johnston† [23]
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Prospective cohort
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L (included radical H/ trachelectomy)
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Myriokefalitaki [20]
CR IP T
ACCEPTED MANUSCRIPT
RAH + BSO
Updated ERAS: 30-day 5.7%
` Kent† [24]
Bowel surgery Kondo [27]
2012
Prospective cohort
LH
-
376
2013
Retrospective cohort
L for complete treatment of intestinal deep infiltrative endometriosis
-
161 Segmental bowel resection 59 Conservative bowel surgery 102
CR IP T
ACCEPTED MANUSCRIPT
preference) Mean LOS 1.2 days <23 hours 90%
Reoperation 2.3%
Kalogera 22
7.8%
AC
CE
PT
ED
M
AN US
Median LOS/ Segmental Segmental Discharge on resection: resection: 6.8% POD1 Grade 1/2 3.4% Conservative Segmental surgery: 1% Grade 3 3.4% resection: 1 day/ Conservative 64.4% surgery: Conservative Grade 3 1% surgery 1 day/ 90.2% Abbreviations: LH laparoscopic hysterectomy; RAH robot-assisted hysterectomy; (B)SO (bilateral) salpingo-oophorectomy; ERAS enhanced recovery after surgery; LOS length of stay; NS non-significant; (PE)/(PA)LND (pelvic)/(para-aortic) lymphadenectomy; POD postoperative day; L laparoscopy; H hysterectomy. *For all comparisons: ERAS vs. respective comparator † Meeting abstract
`
Table 2. ERAS pathway elements across included studies* Benign Malignant Keil Clemente† Lambaudie Chapman Myriokefalitaki
Mixed (benign and malignant) Modesitt Johnston† Ali† Minig Dinesen Kent†
+
+
+
+
+
+ +
+ + No
+ No
+ + No
+ + Yes <5% +
AN US
Preoperative Patient education mmediate preoperative Limiting fasting Carbohydrate loading Bowel preparation
CR IP T
ACCEPTED MANUSCRIPT
+
+
+
M
ED
PT
CE
Bowel surgery Kondo + +
No
Preemptive analgesia + + PONV prophylaxis + + + + + ntraoperative Fluid management + + + + + Normothermia + + Pain management + + + + + + + PONV prophylaxis + + + + + Opioid-sparing TIV + + Remove NG/OGT‡ + + + + Remove Foley‡ + +1 +2 +1 + + Limit peritoneal drains + + Postoperative Early mobilization + + + + + + Early alimentation + + + + + + Multimodal analgesia + + + + + + + Non-opioid centric + + + + + + Fluid management + + + + Laxative use + + Strict discharge criteria + + + + + + Abbreviations: PONV postoperative nausea and vomiting; TIV total intravenous anesthesia; NG/OGT nasogastric/orogastric tube. *If entry is empty, there was no mention of the respective element in the manuscript † Abstract - detailed protocol not available; ‡At the end of the case unless differently indicated
AC
Kalogera 23
+ + +
+ + + + +
+
AC
CE
PT
ED
M
AN US
` 1 Discontinued on postoperative day 1; 2Discontinued within 6 hours of surgery
CR IP T
ACCEPTED MANUSCRIPT
Kalogera 24
ACCEPTED MANUSCRIPT
Kalogera 25
CR IP T
` 1 2
AC
CE
PT
ED
M
AN US
3