Introduction
Enhanced recovery after surgery (first introduced by Danish anesthetist
Henrik Kehlet in 1997) is a range of optimized, perioperative management
approach throughout a patient’s stay in the hospital—including
extensive preoperative counseling, without bowel preparation,
preoperative carbohydrate loading, multimodal analgesia, minimally
invasive surgery, adequate perioperative fluid infusion, maintenance of
normothermia, early postoperative feeding, and ambulation. These steps
aim to mitigate the surgical stress response and accelerate
postoperative recovery and not compromise morbidity or the readmission
rate. Initially used in colorectal surgery, enhanced recovery after
surgery (ERAS) has now been widely adopted for multiple abdominal
procedures, including gynaecologic operations.1 The
implementation of ERAS in both benign and malignant gynaecologic
services has showed positive results, including a 1- to 2-day reduction
in length of stay (LOS) for all approaches, a 20.8% to 97.4% drop in
narcotic use, and a 9.25% to 21.7% reduction in the average hospital
cost, without compromising mortality or the readmission
rate.2
Another unprecedented intervention during the last two decades—the
laparoscopic approach—has proven its superiority over laparotomy and
is considered to be a key element in an ERAS program. ERAS combined with
laparoscopic techniques in colorectal surgery was also associated with
shorter hospital stay, a lower postoperative complication rate, and
reduced hospital costs.3
However, a large majority of randomized controlled trials (RCT) on ERAS
in the case of gynaecologic surgery have only included patients
undergoing an open abdominal approach, and there is a paucity of
evidence regarding the potential benefits of an ERAS program in
laparoscopic surgery.4-10 The possible overlap of
benefits between an ERAS program and laparoscopy has raised the question
of whether the combination of the two interventions further improves the
perioperative outcomes, particularly for those patients undergoing
simple procedures (i.e. laparoscopic ovarian cystectomy, myomectomy, and
hysterectomy, etc.) who might already have achieved a faster recovery.
In addition, a full ERAS program contains more than 20 different items,
and implementing those components can be demanding. The gynaecologic
service at our hospital has already embraced some of the ERAS concepts,
including early catheter removal, feeding, ambulation, and most
importantly, a laparoscopic approach—which collectively constitutes
the so-called “limited ERAS pathway.” This simplified ERAS management
has become the standard of care at many medical centers. However, the
lack of data with which to evaluate each component of the pathway makes
it difficult to determine the critical elements that benefit the
outcomes.11
In the present single-center, open-label, randomized trial, we aimed to
determine which form of perioperative treatment—either a full or
limited ERAS program combined with simple laparoscopic procedures—was
the optimal approach for patients in gynaecology department; and to
identify which elements of ERAS were critical for an improved
perioperative outcome.