Enhanced Recovery After Surgery (ERAS): New Concepts in the Perioperative Management of Gynecologic Surgery

What is ERAS?

The Enhanced Recovery After Surgery (ERAS) program is a paradigm shift from traditional perioperative management initiated by Kehlet in 1997[1] as a multidisciplinary approach to the care of the surgical patient.[1] [2] [3] The program is based on perioperative medical optimization, including preoperative counseling, pain relief, carbohydrate loading, thromboembolism prophylaxis, standard anesthetic protocol and intraoperative fluid, recovery of normal gastrointestinal function, and early mobilization ([Table 1]). The primary goal of the protocol is to minimize the response to the stress of the operation by maintaining homeostasis, avoiding catabolism with consequent loss of protein and muscle strength, and cellular dysfunction.[3]

Table 1 Enhanced Recovery After Surgery (ERAS) program principles

Enhanced Recovery After Surgery (ERAS) program
What does it promote?	Why should it be implemented?	What is necessary for the implementation?
– Minimization of the stress response to the operation by controlling the perioperative physiology – Operative medical optimization: pre-operative counseling, pain relief, carbohydrate loading, thromboembolism prophylaxis, standard anesthetic protocol and intraoperative fluid, recovery of normal gastrointestinal function, and early mobilization	– Shorter length of hospital stay – No increase in readmissions and/or reoperations and/or complications rates – Faster and safer patient recovery – Improved quality of life and patient satisfaction – Reduction in overall healthcare costs	– Program coordinator (doctor/nurse) – Involvement of all units dealing with the surgical patient – Multidisciplinary team working together around the patient – Multimodal approach to resolving issues that delay recovery and cause complications – Scientific, evidence-based approach to care protocols – Change in management through interactive and continuous audits – Whenever possible, minimally invasive surgery

Source: Adapted from Kehlet (1997)[1] and Carey and Molder (2018).[2]

The main objectives of the ERAS program are to accelerate functional recovery, improve postoperative outcomes, shorten the length of stay (LOS) in the hospital, reduce the overall health care costs, and improve the satisfaction of the patients without increasing complications and/or hospital readmission rates.[4] The ERAS protocols resulted in a 30% to 50% reduction in the LOS and similar reductions in complications, as well as lower costs and readmission rates.[3] The protocols were developed for colorectal surgery, and variations are being adopted for surgical procedures of various specialties, including Gynecology.[5] [6]

The ERAS Society is an international nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations, and was officially registered in 2010 in Sweden (http://erassociety.org). Its mission is to develop perioperative care and to improve recovery through research, education, auditing and implementation of evidence-based practices. Throughout its history, the ERAS Society has developed and published numerous evidence-based protocols and implementation programs worldwide to enhance recovery after surgery. This society conducts structured implementation programs that are currently in use in more than 20 countries. The ERAS Society group published in 2016 the guidelines for pre- and intraoperative care in gynecologic oncology surgery.[7] [8] In 2005, the Department of Surgery of The Faculty of Medical Sciences of Universidade Federal do Mato Grosso, Brazil, adapted the ERAS program to our reality and created the Accelerating the Total Postoperative Recovery (ACERTO, in the Portuguese acronym) project. The application of the ACERTO multimodal protocol determined a significant improvement in morbidity and mortality in general surgery.[9]

• References

• 1 Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78 (05) 606-617 . Doi: 10.1093/bja/78.5.606
• 2 Carey ET, Moulder JK. Perioperative management and implementation of enhanced recovery programs in gynecologic surgery for benign indications. Obstet Gynecol 2018; 132 (01) 137-146 . Doi: 10.1097/AOG.0000000000002696
• 3 Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg 2017; 152 (03) 292-298 . Doi: 10.1001/jamasurg.2016.4952
• 4 Miralpeix E, Nick AM, Meyer LA. , et al. A call for new standard of care in perioperative gynecologic oncology practice: Impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016; 141 (02) 371-378 . Doi: 10.1016/j.ygyno.2016.02.019
• 5 Carter-Brooks CM, Du AL, Ruppert KM, Romanova AL, Zyczynski HM. Implementation of an Urogynecology-Specific Enhanced Recovery After Surgery (ERAS) Pathway. [published on line Jun 15, 2018] Am J Obstet Gynecol 2018; S0002-9378(18)30496-4 . Doi: 10.1016/j.ajog.2018.06.009
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• 7 Nelson G, Altman AD, Nick A. , et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part I. Gynecol Oncol 2016; 140 (02) 313-322 . Doi: 10.1016/j.ygyno.2015.11.015
• 8 Nelson G, Altman AD, Nick A. , et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations--Part II. Gynecol Oncol 2016; 140 (02) 323-332 . Doi: 10.1016/j.ygyno.2015.12.019
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• 12 Yoong W, Sivashanmugarajan V, Relph S. , et al; Enhanced Recovery After Surgery (ERAS) Team for Gynaecology and Anaesthesia. Can enhanced recovery pathways improve outcomes of vaginal hysterectomy? Cohort control study. J Minim Invasive Gynecol 2014; 21 (01) 83-89 . Doi: 10.1016/j.jmig.2013.06.007
• 13 Relph S, Bell A, Sivashanmugarajan V. , et al. Cost effectiveness of enhanced recovery after surgery programme for vaginal hysterectomy: a comparison of pre and post-implementation expenditures. Int J Health Plann Manage 2014; 29 (04) 399-406 . Doi: 10.1002/hpm.2182
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• 15 Keil DS, Schiff LD, Carey ET. , et al. Predictors of admission after the implementation of an Enhanced Recovery After Surgery pathway for minimally invasive gynecologic surgery. [published on line Apr 11, 2018] Anesth Analg 2018; DOI: 10.1213/ANE.0000000000003339.
• 16 Royal College of Obstetricians & Gynaecologists. Enhanced Recovery in Gynaecology . London: RCOG; 2013. Scientific Impact Paper 36. https://www.rcog.org.uk/globalassets/documents/guidelines/scientific-impact-papers/sip_36.pdf . Accessed March 10, 2017
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