Interpretation
There have been seven RCTs in which the investigators evaluated ERAS
implementation in gynaecologic surgery, and they have proven its
benefits with respect to the length of stay and postoperative pain
control4-10; however, a majority of the aforementioned
studies focused on an open approach, and high-quality evidence
supporting the combination of ERAS and laparoscopy is still lacking.
This is especially true for patients undergoing an simple and efficient
laparoscopic procedures, and those who have already experienced a fast
postoperative recovery may therefore not benefit as greatly from the
implementation of an ERAS pathway.
Previous systematic reviews have set a threshold of at least four items
to identify a qualified ERAS program.2 For the control
group in our study, we adopted more than four interventions—including
minimally invasive surgery, multimodal PONV prophylaxis, intraoperative
fluid restriction, maintenance of normothermia, early postoperative
diet, and ambulation—and it is reasonable to assume that the
perioperative managements outlined above constituted the limited ERAS
pathway. As for the intervention group, we introduced additional
components comprising a full ERAS protocol that were unconventional or
difficult to carry out in daily practice.
In our study we demonstrated a 1-day reduction in postoperative LOS in
the intervention group, indicating that patients enrolled in a full ERAS
program met the discharge criteria more quickly. Preoperative
carbohydrate loading and opioid-sparing analgesia were found to be
associated with an increased odds of discharge on POD 1. Fortunately,
these beneficial items are relatively easier and more cost effective to
implement.
It is worth noting that the length of stay in our intervention group was
in accordance with the literature but longer in the control group than
that reported in previous studies.2 The length of stay
in our trial was standardized by predefined, objectively quantified
discharge criteria, which were stricter than those used in previous
studies. These criteria included adequate pain control with oral
analgesics and the absence of vomiting or severe nausea; thus our study
might more accurately reflect daily practice. The incidence of overall
PONV and severe PONV in the control group was higher than in the
intervention group (although not to a statistically significant degree),
which may have contributed to the delayed discharge. Patients on the
gynaecologic service possess nearly all the risk factors for
PONV—including being female, exhibiting younger age and nonsmoking
status, experiencing motion sickness, and undergoing laparoscopic or
pelvic surgery.16 We found that the introduction of
TIVA may reduce the chance of severe PONV; yet even in the full ERAS
group, compliance with respect to TIVA was only 75.0%. This percentage
was not as high as for the other elements, which may be attributable to
the anesthetists’ concerns with TIVA since it has not become a routine
anesthesia approach in our center. It is thus predictable that the
occurrence and severity of PONV would be further reduced by promoting
TIVA implementation in gynaecologic surgery.
The multimodal analgesic regimen that we used in our study proved to
markedly improve the postoperative NRS score at all of the time-points
and also reduced narcotics consumption. Satisfactory pain control on POD
1 (NRS ≤ 3 points) is one of the key factors allowing patients to be
discharged on time. A standard multimodal analgesic strategy consists of
the concurrent use of nonopioid analgesics and various techniques
throughout the entire perioperative period. Interestingly, we found that
preoperative analgesia was the only independent factor associated with
better pain control on POD 1, which is consistent with the hypothesis
that analgesics given before a nociceptive stimulus are more effective
than after the stimulus.17 Therefore, it appears to be
extremely important to strengthen compliance with the preoperative
analgesia in simple laparoscopic gynaecologic surgery.
In our study, the hospitalization expenditures for the full ERAS program
slightly exceeded that of the control group, but this was not
statistically significant. The higher cost of medication in the full
ERAS program—particularly the extra expenses produced by the
multimodal analgesic protocol—were most likely counterbalanced by a
shorter hospital stay.
Length of hospital stay is certainly an important indicator but not the
only one that is a measure of the effect of ERAS, the primary goal of
which is to accelerate the patient’s recovery instead of discharging
patients earlier. It is additionally important to include the patient’s
personal concerns, and we therefore introduced the QoR-15 scale to
evaluate the patient’s quality of life on POD 3. Patients in both of the
groups recovered well as demonstrated by the QoR-15 score; however, we
still observed a statistically significant improvement in the full ERAS
group. As differences in the quality of life are expected to be the most
prominent in the first week after surgery, we did not investigate
time-course further.