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.