Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review

Eleftheria Kalogera; Gretchen E. Glaser; Amanika Kumar; Sean C. Dowdy; Carrie L. Langstraat

doi:10.1016/j.jmig.2018.10.016

Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review

Eleftheria Kalogera, Gretchen E. Glaser, Amanika Kumar, Sean C. Dowdy, Carrie L. Langstraat

Gynecologic Surgery

Research output: Contribution to journal › Review article › peer-review

10 Scopus citations

Abstract

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 undergoing minimally invasive surgery also derive benefit. Our aim was to systematically review the literature on ERAS after minimally invasive gynecologic surgery (MIGS) with and without bowel surgery. Given the paucity of studies on ERAS in MIGS with bowel surgery (1 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 MIGS for benign and/or malignant indications and showed that ERAS pathways decreased length of stay and/or increased the proportion of same-day discharge surgeries, improved patient satisfaction, and reduced hospital costs while maintaining low postoperative complication and readmission rates. Although limited, data from a single study suggest that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity, and less readmissions. Although the variation between the published protocols underscores the need for standardization, existing literature supports the adoption of ERAS as safe and effective when planning MIGS.

Original language	English (US)
Pages (from-to)	288-298
Number of pages	11
Journal	Journal of Minimally Invasive Gynecology
Volume	26
Issue number	2
DOIs	https://doi.org/10.1016/j.jmig.2018.10.016
State	Published - Feb 2019

Keywords

Bowel surgery
Enhanced recovery
Enhanced recovery pathway
Gynecologic surgery
Minimally invasive
Minimally invasive gynecologic surgery

ASJC Scopus subject areas

Obstetrics and Gynecology

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10.1016/j.jmig.2018.10.016

Cite this

@article{ab309a6ef7944f6f941ead32c82f0166,

title = "Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review",

abstract = "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 undergoing minimally invasive surgery also derive benefit. Our aim was to systematically review the literature on ERAS after minimally invasive gynecologic surgery (MIGS) with and without bowel surgery. Given the paucity of studies on ERAS in MIGS with bowel surgery (1 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 MIGS for benign and/or malignant indications and showed that ERAS pathways decreased length of stay and/or increased the proportion of same-day discharge surgeries, improved patient satisfaction, and reduced hospital costs while maintaining low postoperative complication and readmission rates. Although limited, data from a single study suggest that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity, and less readmissions. Although the variation between the published protocols underscores the need for standardization, existing literature supports the adoption of ERAS as safe and effective when planning MIGS.",

keywords = "Bowel surgery, Enhanced recovery, Enhanced recovery pathway, Gynecologic surgery, Minimally invasive, Minimally invasive gynecologic surgery",

author = "Eleftheria Kalogera and Glaser, {Gretchen E.} and Amanika Kumar and Dowdy, {Sean C.} and Langstraat, {Carrie L.}",

note = "Funding Information: 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. Most of the literature investigating ERAS has focused on open gynecologic surgery, which offers a greater opportunity for measureable benefit compared with MIS given the greater physiologic insult. In 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 nonhysterectomy 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 hospital costs without increasing postoperative complications or readmission rates. Although previous studies have shown that ERAS after open gynecologic surgeries is associated with significant reduction in opioid requirements while maintaining adequate pain management, most studies on ERAS after MIGS did not report on opioid use. The difference in outcomes in opioid use between the 2 studies that looked at oral morphine equivalents consumption postoperatively likely represents the different threshold of opioid use for pain management before attempting other nonopioid medication. Of the 12 studies, only 1 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. Although the value of applying findings from CRS may be questioned, it is important to consider that 1 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 with traditional management, the evidence supports a synergistic effect of combining MIS with ERAS [42] . Although length of stay and cost are seminal endpoints in perioperative recovery, other endpoints such as postanesthesia care unit stay, time to return to work, and patient-reported outcomes will take on larger importance in future studies of perioperative optimization for patients undergoing MIS. One of the difficulties with successful widespread dissemination of the ERAS approach stems from the lack of standardization. As noted in the 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 toward ERAS standardization. Although 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 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 that includes the components we identified as most frequent in the investigations included in our systematic review, such as patient education, preoperative oral hydration and carbohydrate loading, surgical site infecti 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. One point of contention in need of further study and objective assessment of risk and benefit is the use of bowel preparation. Although 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 that advise against their routine use [27,51] . In a recent systematic review of the gynecologic surgical literature conducted for the Agency for Healthcare 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 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 used. In the systematic review focused on CRS conducted within the same initiative by 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, because evidence supports that this practice decreases surgical site infection rates despite the 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 subanalysis of laparoscopic cases was not performed. Importantly, 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 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. In conclusion, ERAS represents best clinical practice and should be adopted across gynecologic surgical specialties irrespective of operative approach. Although the data are limited on ERAS after MIGS with bowel surgery, the 1 relevant study [27] 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 and open gynecologic oncology surgery with bowel resection. Systematic efforts are needed to standardize perioperative pathways and encourage widespread dissemination in order to maximize patient outcomes. Publisher Copyright: {\textcopyright} 2018",

year = "2019",

month = feb,

doi = "10.1016/j.jmig.2018.10.016",

language = "English (US)",

volume = "26",

pages = "288--298",

journal = "Journal of the American Association of Gynecologic Laparoscopists",

issn = "1553-4650",

publisher = "Elsevier",

number = "2",

}

TY - JOUR

T1 - Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery

T2 - A Systematic Review

AU - Kalogera, Eleftheria

AU - Glaser, Gretchen E.

AU - Kumar, Amanika

AU - Dowdy, Sean C.

AU - Langstraat, Carrie L.

N1 - Funding Information: 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. Most of the literature investigating ERAS has focused on open gynecologic surgery, which offers a greater opportunity for measureable benefit compared with MIS given the greater physiologic insult. In 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 nonhysterectomy 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 hospital costs without increasing postoperative complications or readmission rates. Although previous studies have shown that ERAS after open gynecologic surgeries is associated with significant reduction in opioid requirements while maintaining adequate pain management, most studies on ERAS after MIGS did not report on opioid use. The difference in outcomes in opioid use between the 2 studies that looked at oral morphine equivalents consumption postoperatively likely represents the different threshold of opioid use for pain management before attempting other nonopioid medication. Of the 12 studies, only 1 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. Although the value of applying findings from CRS may be questioned, it is important to consider that 1 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 with traditional management, the evidence supports a synergistic effect of combining MIS with ERAS [42] . Although length of stay and cost are seminal endpoints in perioperative recovery, other endpoints such as postanesthesia care unit stay, time to return to work, and patient-reported outcomes will take on larger importance in future studies of perioperative optimization for patients undergoing MIS. One of the difficulties with successful widespread dissemination of the ERAS approach stems from the lack of standardization. As noted in the 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 toward ERAS standardization. Although 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 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 that includes the components we identified as most frequent in the investigations included in our systematic review, such as patient education, preoperative oral hydration and carbohydrate loading, surgical site infecti 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. One point of contention in need of further study and objective assessment of risk and benefit is the use of bowel preparation. Although 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 that advise against their routine use [27,51] . In a recent systematic review of the gynecologic surgical literature conducted for the Agency for Healthcare 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 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 used. In the systematic review focused on CRS conducted within the same initiative by 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, because evidence supports that this practice decreases surgical site infection rates despite the 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 subanalysis of laparoscopic cases was not performed. Importantly, 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 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. In conclusion, ERAS represents best clinical practice and should be adopted across gynecologic surgical specialties irrespective of operative approach. Although the data are limited on ERAS after MIGS with bowel surgery, the 1 relevant study [27] 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 and open gynecologic oncology surgery with bowel resection. Systematic efforts are needed to standardize perioperative pathways and encourage widespread dissemination in order to maximize patient outcomes. Publisher Copyright: © 2018

PY - 2019/2

Y1 - 2019/2

N2 - 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 undergoing minimally invasive surgery also derive benefit. Our aim was to systematically review the literature on ERAS after minimally invasive gynecologic surgery (MIGS) with and without bowel surgery. Given the paucity of studies on ERAS in MIGS with bowel surgery (1 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 MIGS for benign and/or malignant indications and showed that ERAS pathways decreased length of stay and/or increased the proportion of same-day discharge surgeries, improved patient satisfaction, and reduced hospital costs while maintaining low postoperative complication and readmission rates. Although limited, data from a single study suggest that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity, and less readmissions. Although the variation between the published protocols underscores the need for standardization, existing literature supports the adoption of ERAS as safe and effective when planning MIGS.

AB - 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 undergoing minimally invasive surgery also derive benefit. Our aim was to systematically review the literature on ERAS after minimally invasive gynecologic surgery (MIGS) with and without bowel surgery. Given the paucity of studies on ERAS in MIGS with bowel surgery (1 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 MIGS for benign and/or malignant indications and showed that ERAS pathways decreased length of stay and/or increased the proportion of same-day discharge surgeries, improved patient satisfaction, and reduced hospital costs while maintaining low postoperative complication and readmission rates. Although limited, data from a single study suggest that ERAS in MIGS with bowel surgery leads to shortened hospital stay, stable postoperative morbidity, and less readmissions. Although the variation between the published protocols underscores the need for standardization, existing literature supports the adoption of ERAS as safe and effective when planning MIGS.

KW - Bowel surgery

KW - Enhanced recovery

KW - Enhanced recovery pathway

KW - Gynecologic surgery

KW - Minimally invasive

KW - Minimally invasive gynecologic surgery

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Enhanced Recovery after Minimally Invasive Gynecologic Procedures with Bowel Surgery: A Systematic Review

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