Strengths and limitations
The perioperative data in this study reinforced the evidence for a full ERAS program providing additional benefits for patients after simple gynaecologic laparoscopic surgery. Furthermore, we identified the key elements associated with an improved perioperative outcome, which may require additional focus when introducing an ERAS program.
Our study has several limitations. First, this study was an open-label trial, and it was therefore difficult to blind the clinical practitioners or the patients to interventions such as preoperative carbohydrate loading, multimodal analgesia, early postoperative diet, or ambulation. Unblinded treatment might theoretically introduce observer bias and the Hawthorne effect. Nonetheless, those possible biases have been minimized by several measures: an independent doctor who decided discharge time-points using preestablished criteria and separated ward sections to avoid contamination between the two groups. Second, this study was a single-center, randomized clinical trial. Thus, the external validity of the study might have been compromised, particularly when extending our results to other patient populations. However, a single-center trial might also be beneficial in several respects: compliance with an ERAS program is better controlled in a single center than in multiple centers, and the Department of Gynecology of Peking Union Medical College Hospital is one of the leading and largest gynecology centers in China, accepting patients from all over the country, such that the sample population in this trial was truly representative of the larger patient population.