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.