1. Introduction
The “Guidelines for Pre- and Intra-operative Care in Gynecologic/Oncology Surgery:
Enhanced Recovery After Surgery (ERAS®) Society Recommendations — Part I,” [1] examined
the evidence surrounding care elements including preoperative medical optimization,
bowel preparation, carbohydrate loading, thromboembolism prophylaxis, skin preparation,
standard anesthetic protocol and intraoperative fluid management. The goal of this
article is to critically review existing evidence and make recommendations for elements
of postoperative care. This effort forms the basis of the ERAS® Guideline for postoperative
care in gynecologic/oncology surgery.
2. Methods
2.1. Literature search
The authors convened in July 2014 to discuss topics for inclusion — the topic list
was based on the ERAS® Colonic Surgery [2] and Rectal/Pelvic [3] Guidelines which
were used as templates. After the topics were agreed upon they were then allocated
amongst the group according to expertise. The literature search (1966–2014) used Embase
and PubMed to search medical subject headings including “gynecology”, “gynecologic
oncology” and all postoperative ERAS® items (see Table 1). Reference lists of all
eligible articles were crosschecked for other relevant studies.
2.2. Study selection
Titles and abstracts were screened by individual reviewers to identify potentially
relevant articles. Discrepancies in judgment were resolved by the lead (GN) and senior
authors (OL, SD). Meta-analyses, systematic reviews, randomized controlled studies,
non-randomized controlled studies, reviews, and case series were considered for each
individual topic.
2.3. Quality assessment and data analyses
The quality of evidence and recommendations were evaluated according to the Grading
of Recommendations, Assessment, Development and Evaluation (GRADE) system (see Tables
2a and 2b) [4] whereby recommendations are given as follows: Strong recommendations
indicate that the panel is confident that the desirable effects of adherence to a
recommendation outweigh the undesirable effects. Weak recommendations indicate that
the desirable effects of adherence to a recommendation probably outweigh the undesirable
effects, but the panel is less confident. Recommendations are based on quality of
evidence: high, moderate, low and very low but also on the balance between desirable
and undesirable effects; and on values and preferences. As such, consistent with other
ERAS® Guideline Working groups [2,5], in some cases strong recommendations may be
reached from low-quality data and vice versa. Of note, this would be considered a
modified GRADE evaluation since we did not consider resource utilization when making
our recommendations [6].
3. Results
The evidence base, recommendations, evidence level, and recommendation grade are provided
for each individual ERAS® item below.
4. Postoperative thromboembolism prophylaxis
4.1. Immediate postoperative prophylaxis
Pneumatic compression stockings reduce the rate of VTE (venous thromboembolism) when
compared to observation [7]. The risk reduction is equivalent when compared to heparin
[8] and improved when combined with heparin [9] in gynecologic oncology patients.
Graduated compression stockings decrease the rate of DVT in hospitalized patients,
especially when combined with another method [10].
4.2. Extended postoperative prophylaxis
A large prospective cohort trial showed an increased rate of VTE within 30 days of
surgery in cancer patients [11], and extended prophylaxis (28 days) is now considered
a common practice within major gynecologic oncology surgery [12]. A Cochrane review
of 4 randomized controlled trials examining extended prophylaxis has shown a decrease
in VTE (14.3% vs. 6.1%; p b 0.0005) and a decrease in symptomatic VTE (1.7% vs. 0.2%;
p = 0.02) [13]. The role of extended prophylaxis in minimally invasive surgery is
likely not necessary without other high-risk features (elevated BMI, previous VTE,
coagulopathy, decreased mobility) [14].
4.2.1. Summary and recommendations
Patients should wear well-fitting compression stockings and have intermittent pneumatic
compression. Extended prophylaxis (28 days) should be given to patients after laparotomy
for abdominal or pelvic malignancies.
4.2.2. Evidence level
High.
4.2.3. Recommendation grade
Strong.
5. Postoperative fluid therapy
Oral intake of fluid and food should be started the day of surgery whenever possible.
With the commencement of oral diet and oral analgesia as soon as tolerated after surgery
the need for postoperative intravenous fluids beyond 12–24 h is rarely needed in an
uncomplicated recovery. Patients can drink immediately after surgery. Flavored high
energy protein drinks prescribed three times a day are safe and can bridge the postoperative
period of building back up to a normal diet to ensure some protein and calorie intake
early in the recovery process. They are usually 200–250 ml in volume with around 150
kJ/100 ml of carbohydrate and 3–6 g/100 mL of protein with the addition of vitamins,
mineral and trace elements. If intravenous fluids must be maintained then a total
hourly volume of no more than 1.2 mL/kg (including drugs, approximately 90 mL/h for
a 75 kg female) should be given [15]. Balanced crystalloid solutions are preferred
to 0.9% normal saline due to the cumulative risk of hyperchloremic acidosis. The use
of starch solutions during the perioperative period should be limited by dose and
duration to avoid the adverse effects seen in studies on intensive care patients such
as bleeding and renal dysfunction [16]. Oliguria as low as 20cm3/h is a normal response
to surgery, and the need for further intravenous fluid boluses should be assessed
within clinical context. A small proportion of patients undergoing major surgery will
develop SIRS (Systemic Inflammatory Response Syndrome) causing marked vasodilation
and hypotension without sepsis. These patients will require vasopressor therapy such
as a noradrenaline infusion during surgery and postoperatively until resolution.
5.1. Summary and recommendations
Intravenous fluids should be terminated within 24 h after surgery. Balanced crystalloid
solutions are preferred to 0.9% normal saline.
5.2. Evidence level
Moderate.
5.3. Recommendation grade
Strong.
6. Perioperative nutritional care
A number of randomized trials on the subject of early feeding (defined as having oral
intake of fluids or food within the first 24 h after surgery) have been performed
in gynecologic oncology [17–20]. Effects include accelerated return of bowel activity,
reduced length of stay, with no evidence of higher complication rates related to wound
healing, anastomotic leaks, or pulmonary complications. A randomized study in patients
with ovarian cancer showed a significantly lower rate of complications for patients
receiving early feeding. However, complication rates were not different between groups
when the analysis was limited to a smaller cohort of patients undergoing intestinal
resections [18,19]. It is important to note that early feeding is associated with
a higher rate of nausea, but not vomiting, abdominal distension, or nasogastric tube
use. Patient satisfaction with control of vomiting in one series was over 90% with
early feeding despite a higher incidence of nausea in the enhanced recovery group
[21].
6.1. Summary and recommendation
A regular diet within the first 24 h after gynecologic/oncology surgery is recommended.
6.2. Evidence level
High.
6.3. Recommendation grade
Strong.
7. Prevention of postoperative ileus
Laxatives are commonly used within enhanced recovery protocols to hasten the return
of bowel function, but no high quality data is available in gynecologic oncology.
In one prospective, but nonrandomized trial of 20 patients undergoing open radical
hysterectomy, milk of magnesia and biscolic suppositories were well tolerated and
associated with a reduction in hospital stay compared with historical controls [22].
In 68 patients undergoing hepatic resection via laparotomy, patients randomized to
magnesium hydroxide experienced a median one-day reduction in time to passage of stool
[23]. Although data are limited and effects appear modest, continued use of laxatives
is reasonable given the low cost and side effect profile.
In patients undergoing hysterectomy and colonic resection, randomized trials have
shown improved recovery when a peripheral mu antagonist was administered [24]. Its
use in patients undergoing planned enteric resections is reasonable, but we cannot
provide a recommendation for its use at the present time as cost-effectiveness and
efficacy data in patients with gynecologic malignancies continues to be collected.
Perioperative use of chewing gum had a positive effect on the incidence of postoperative
ileus (36% vs. 15%) and length of stay (1 day reduction) in a randomized trial of
patients undergoing staging for gynecologic malignancies [25]. A meta-analysis of
randomized trials investigating prokinetics such as erythromycin, the cholecystokinin-like
drugs, cisapride, dopamine-antagonists, propranolol, vasopressin, and intravenous
lidocaine [26] or neostigmine [27] failed to demonstrate benefit.
7.1. Summary and recommendations
The use of postoperative laxatives and chewing gum should be considered.
7.2. Evidence level
Laxatives: Low.
Chewing gum: Moderate.
7.3. Recommendation grade
Weak.
8. Postoperative control of glucose
Perioperative hyperglycemia, classically defined as blood glucose levels greater than
180 to 200 mg/dL is associated with poor clinical outcomes including increased perioperative
mortality, hospital length of stay, ICU length of stay and postoperative infection
[28,29]. Most clinicians would agree that prevention of perioperative hyperglycemia
is a desirable intervention, the optimal blood glucose range remains controversial
due to the potential adverse events related to iatrogenic hypoglycaemia [30]. Clinical
trials in adult surgical patients illustrate this paradigm of outcomes with intensive
insulin therapy (IIT) defined as 140 to 200 mg/dL by the American College of Physicians.
The Leuven surgical trial randomly assigned patients to IIT or conventional glucose
management with a decrease in mean blood glucose levels and ICU mortality in the IIT
group [31]. However, hypoglycemia was more frequent in the IIT group. These findings
were supported by meta-analytical data from 5 randomized trials, which compared IIT
to less stringent glycemic control and demonstrated significantly lower mortality
[32]. In contrast, the Normoglycemic in Intensive Care Evaluation Survival Glucose
Algorithm Regulation (NICE-SUGAR) trial demonstrated a higher rate of severe hypoglycemia
and higher 90-day mortality in those patients who received IIT compared to conventional
glucose management [33]. Hypoglycemia is the most common adverse effect of IIT and
can lead to unwanted morbidity such as seizures, brain damage, and cardiac arrhythmias.
As a result, more liberal blood glucose targets of 180 to 200 mg/dL are typically
recommended in effort to prevent significant hyperglycemia whilst avoiding iatrogenic
hypoglycemia [34–36].
The surgical stress response triggers a cascade of sympathetic nervous system and
endocrine responses that include activation of the HPA axis and increased cortisol
secretion, which leads to a net increase in peripheral insulin resistance [37]. Traditional
perioperative interventions such as mechanical bowel preparation, pre-operative fasting,
and slow resumption of normal diet all contribute to the relative insulin resistant
state noted perioperatively and have been shown to correlate with perioperative complications
and increased length of hospital stay [38]. Several elements of enhanced recovery
protocols abrogate postoperative insulin resistance and thereby result in lower perioperative
glucose levels without resulting hypoglycemia. Examples of key elements include avoidance
of oral mechanical preoperative bowel preparation and avoidance of preoperative fasting
until 2 h prior to surgery, pre-operative carbohydrate loading along with stimulation
of gut function by early resumption of postoperative oral intake and optimal fluid
balance [1].
8.1. Summary and recommendation
ERAS elements that reduce metabolic stress should be employed to reduce insulin resistance
and the development of hyperglycemia. Perioperative maintenance of blood glucose levels
(<180–200 mg/dL) results in improved perioperative outcomes. Glucose levels above
this range should be treated with insulin infusions and regular blood glucose monitoring
to avoid the risk of hypoglycemia.
8.2. Evidence level
Use of stress reducing elements: High.
Treating hyperglycemia above 180–200 mg/dL: High.
8.3. Recommendation grade
Strong.
9. Postoperative analgesia
Pain following gynecological abdominal surgery can be severe [39]. Uncontrolled acute
post-operative pain is associated with dissatisfaction [40], post-operative complications,
and is a strong risk factor for development of chronic pain [41]. Morphine is commonly
used to control post-operative pain but is associated with nausea, sedation [42],
fatigue [43] and poorer quality of recovery [44] and may prolong time to mobilization.
Opioid analgesics also contribute to the development of ileus. Therefore an enhanced
recovery pathway for gynecological surgery must employ a strategy to effectively control
post-operative pain and allow attainment of other ERAS targets such as early mobilization
and return to oral diet whilst reducing the need for opiates. Many RCTs in the last
20 years in open surgery have focused on epidural analgesia, which can offer excellent
analgesia, reduction in the surgical stress response, and earlier return of gut function.
However the role of epidural analgesia is now a matter of debate. With the increasing
uptake of laparoscopic and robotic assisted surgery the magnitude and duration of
visceral and wound pain have been markedly reduced such that good post-operative pain
control is achievable by many different analgesic techniques, often used in combination
to tackle both the visceral and wound elements. The literature base is developing
rapidly and may well impact on future recommendations.
9.1. Multimodal analgesia
The concept of achieving analgesia through the additive or synergistic effects of
different types of analgesics is not new [45]. Non-steroidal anti-inflammatory drugs
(NSAIDs) have been extensively investigated, both as part of a multi-modal analgesic
regime as well as for gynecologic surgery, and are effective at reducing pain and
opioid consumption and improving patient satisfaction [46,47], and a combination of
NSAID and acetaminophen is more effective than either drug alone [48]. Both should
be administered regularly unless contraindication exists. Gabapentin has recently
become popular for treatment of postoperative pain. A recent systematic review found
that pre-emptive administration of gabapentin for abdominal hysterectomy was effective
in reducing post-operative pain, opioid consumption and side effects [49] and has
been used in one gynecologic enhanced recovery program [21]. However, studies have
not yet identified the optimal dose, or timing of administration. Dexamethasone appears
to have analgesic effects [50,51], as well as preventing post-operative nausea and
vomiting, so may be useful as part of an ERP for gynecologic surgery. However its
analgesic effects are yet to be fully investigated and it may cause transient post-operative
hyperglycemia. Chronic administration of steroids are known to impair wound healing,
although this has not been demonstrated following administration of a course <10 days
duration [52]. Intravenous lidocaine is gaining popularity as an analgesic adjunct
in abdominal surgery. A Cochrane analysis concluded that there was low quality evidence
of an early reduction in pain, and opioid consumption and time to bowel recovery were
reduced, though the effect on these outcomes was small [26].
9.1.1. Summary and recommendations
A multimodal analgesia strategy should be employed with the aim of reducing post-operative
opioid requirement. Post-operatively, opioids should be given orally to patients who
can tolerate diet. For patients unable to tolerate diet following surgery, then an
opioid IV PCA can be used until resumption of GI function, but the oral route should
be used as soon as possible.
Acetaminophen and NSAIDs in combination should be administered regularly to all patients
unless contraindication exists.
Dexamethasone may be administered to prevent PONV and reduce pain, but should be used
with caution in diabetic patients.
Gabapentin may reduce pain and side effects and may be considered, although the optimal
dose is not known.
9.1.2. Level of evidence
Use of multimodal analgesia: High.
Combination of acetaminophen and NSAIDs: High.
Gabapentin: Moderate.
Dexamethasone as an analgesic: Low.
9.1.3. Recommendation grade
Strong.
9.2. Analgesia for vaginal hysterectomy
Few rigorous studies have been performed investigating analgesia in patients undergoing
vaginal hysterectomy. In one study, intra-operative paracervical nerve block appeared
to reduce post-operative pain and morphine consumption, and although the analgesic
benefit appears to be limited to the first few hours after surgery, patients mobilized
more quickly [53]. However a Cochrane review concluded that paracervical nerve block
was ineffective for cervical dilatation [54]. One study investigated high-volume local
anesthetic infiltration of the surrounding tissues and found that although the analgesic
benefit was limited to the first four hours post-operatively, patients used less opioid
analgesics and mobilized earlier [55]. In another study, spinal anesthesia with intrathecal
morphine and clonidine also reduced early post-operative pain and morphine consumption,
though the effect was modest [56]. Both spinal morphine and paracervical nerve block
have been used to facilitate early discharge in enhanced recovery vaginal hysterectomy
pathways [57,58].
9.2.1. Summary and recommendations
Local anesthetic infiltration may be effective at reducing early post operative pain
and opioid consumption, and facilitating early mobilization. Either paracervical nerve
block or intrathecal morphine may reduce pain and opioid consumption after vaginal
hysterectomy. However, the effect is small.
9.2.2. Evidence level
Low.
9.2.3. Recommendation grade
Weak.
9.3. Analgesia for open general gynecologic surgery
The optimal analgesic regimen for open gynecologic surgery is currently a subject
of debate. Thoracic epidural analgesia (TEA) has gained widespread acceptance in providing
post-operative analgesia for major abdominal surgery [2], and has been shown to be
superior to intravenous PCA [59]. TEA is effective in attenuating the surgical stress
response and reducing pain and opioid consumption for up to 72 h [59, 60] following
abdominal incisions, and also has an impact on complications following abdominal surgery,
reducing the time to bowel recovery by up to 36 h and may reduce cardiac and respiratory
complications in high risk patients. TEA has been shown to effectively reduce pain
following abdominal hysterectomy [61] and gynecologic cancer surgery [62], and reduces
time to return of gut function. However the role of TEA in enhanced recovery surgery
is now less clear: whilst analgesia and recovery seem to be better with TEA than IV
PCA, epidural failure rates may be as high as 30% [63], and many of these patients
will require supplemental opiates. Even if patients are normovolemic the sympathetic
block that results from TEA may result in hypotension that may require treatment with
vasopressors [64]. Patients who undergo abdominal hysterectomy in ERAS protocols can
target a length of hospital stay of 1–2 days, in which case TEA may hinder achievement
of other ERAS goals such as mobilization [65] and removal of urinary catheter, and
TEA has been shown to increase hospital stay and complication rates in gynaecologic
cancer surgery [66].
Where TEA is to be used local anesthetic should be of low concentration, and should
be combined with an opioid such as fentanyl. Postoperative hypotension may require
treatment with vasopressors. Some consideration must be made to the impact on early
ERAS goals and how they will be achieved, and expert post-operative input may be required
to ensure reliable analgesia. Although epidurals sited in the lumbar spine have an
evidence base for analgesic benefit in gynecologic surgery, thoracic epidurals are
preferred: epidurals should be sited at the level appropriate for innervation of the
surgical area, and thoracic epidurals are likely to cause less hypotension [67] and
motor block [68] than those in the lumbar segments.
An alternative to TEA is spinal anesthesia with low-dose intrathecal morphine (ITM).
As a single injection, this has benefits over TEA in allowing early mobilization and
removal of urinary catheter as well as facilitating early discharge from hospital
[69]. When compared to a general anesthetic without neuraxial block, spinal anesthesia
with ITM significantly reduces pain and morphine consumption both for hysterectomy
[39,44,70] and this analgesic benefit may persist for up to 48 h post-operatively
[39,44]. The added benefit of reduced morphine consumption is the reduced risk of
post-operative ileus. Additionally ITM appears to reduce peri-operative stress hormone
release [71], improve post-operative recovery [44,72] and reduce post-operative drowsiness
and fatigue, though at the expense of increased pruritus [73]. Most studies do not
indicate an increase in vomiting with low-dose ITM when compared with IV PCA [39,74].
Dose-finding studies appear to show a ceiling of effect at 200 mcg [74] and doses
of ITM within this range do not appear to increase the risk of respiratory depression
[75]. Spinal anesthesia without long-acting opioids does not improve post-operative
pain when compared to general anesthesia [76].
Experience dictates that to improve patient acceptability of spinal anesthesia with
ITM, general anesthesia may need to be offered in addition, in which case the dose
of intrathecal local anesthetic should be reduced to avoid intra-operative hypotension
and intraoperative narcotics should be minimized to reduce side effects.
Where patients have undergone general anesthesia without neuraxial blockade, truncal
nerve blocks may serve to reduce pain and reduce post-operative morphine requirement.
Transversus abdominis plane (TAP) blocks involve the injection of a large volume of
local anesthetic in between the muscle layers of the trunk, and may now be performed
under ultrasound guidance to ensure accurate delivery of local anesthetic. This technique
has been shown to be efficacious for abdominal incisions [77], including abdominal
hysterectomy [78], and a meta-analysis concluded that TAP blocks reduce pain and morphine
requirement up to 24 h after open gynecologic surgery [79]. In patients undergoing
Cesarean section, TAP blocks appear to be less effective than intrathecal morphine
at controlling post-operative pain, although side effects were fewer than ITM [80]
and TAP blocks do not appear to add any analgesic benefit when used in combination
with ITM [81]. Bilateral ilioinguinal nerve blocks also appear to reduce post-operative
morphine requirement, however may not reduce morphine-related side effects [82].
Wound infiltration with local anesthetic is safe and easy to perform, though any effect
on post-operative pain and opioid consumption is modest and short-lived [83]. Prolongation
of this analgesic effect may be achieved through insertion of sub-cutaneous wound
catheters [84]. A meta-analysis concluded that continuous wound infiltration (CWI)
reduced pain and opioid consumption and improved recovery after major abdominal surgery
[85], and may provide analgesia equivalent to TEA for abdominal surgery [86]. Another
study found that, when compared to TEA for open colorectal surgery, CWI reduced opioid
usage, vomiting and time to bowel recovery, and improved patient satisfaction [87].
However for gynecologic surgery the data is less clear, and although CWI has been
shown to improve analgesia, reduce opioid requirements and reduce time to return of
gut function [88] a number of studies have either only demonstrated benefit in the
first few hours after surgery [84], or failed to demonstrate benefit at all [89–91].
There is lack of agreement concerning ideal catheter placement [92, 93], though in
most studies the infusion catheter was placed below the abdominal fascia. The impact
of continuous wound infiltration on wound healing has not been fully studied, though
existing data has not shown an increase in wound complication rates. More research
with this technique is required in this patient group before any conclusions may be
drawn.
Intraperitoneal local anesthetic (IPLA) has been utilized to reduce post-operative
pain, and one trial demonstrated reduced opioid consumption and improved surgical
recovery score when used alongside TEA following colorectal surgery [94]. A systematic
review of other trials concluded that IPLA reduces post-operative pain but not opioid
consumption, and recovery parameters were unchanged [95]. IPLA has also been tested
for open hysterectomy and has been found to reduce post-operative pain [96] and morphine
consumption [97], however the benefit was limited to the first few hours after surgery,
and analgesia from IPLA does not seem to be dose-responsive [98].
9.3.1. Summary and recommendations
For open surgery a multimodal, opiate sparing analgesic strategy should be utilized.
TEA or spinal anesthesia with intrathecal morphine may improve recovery parameters
and are recommended. However TEA may increase time to mobilization and removal of
urinary catheter, and may potentially impact on hospital stay.
Where patients have undergone general anesthesia without neuraxial blockade, a truncal
block, such as TAP blocks, may reduce pain and opioid consumption for up to 24 h and
should be employed. Continuous wound infiltration or intraperitoneal instillation
of local an-esthetic may improve recovery for colorectal surgery and may be considered
as an alternative to TAP blocks or TEA, however the evidence of benefit in gynecologic
surgery is lacking.
Post-operatively, multimodal analgesia should be used. Systemic opioids may be given
either orally or by intravenous PCA. The IV PCA should be discontinued when normal
gut function resumes.
9.3.2. Evidence level
Intrathecal morphine: Moderate.
Thoracic epidural analgesia:
High. TAP blocks: Moderate.
CWI: Moderate.
9.3.3. Recommendation grade
Strong.
9.4. Analgesia for major oncologic surgery
In patients undergoing cytoreductive surgery, the large surgical area and complex
patient pain history means that post-operative pain is often severe. TEA is widely
used, and was associated with superior pain control at rest and on movement for the
first 3 post-operative days in one observational study [99], and a randomized controlled
study [100] found improved pain control on coughing for the first 3 post-operative
days. However other investigators found no benefit in pain, bowel recovery or length
of stay in patients with peri-operative TEA, and an increase in vasopressor requirement
[101]. In patients undergoing heated intraperitoneal chemotherapy (HIPEC), the use
of TEA is controversial. TEA may reduce opioid consumption and reduce time to extubation
[102] although an IV PCA is often required in addition to TEA to achieve adequate
analgesia [103]. HIPEC may be associated with a post-operative coagulopathy that may
complicate removal of the epidural catheter, however in one study removal of epidural
catheter was delayed in only 0.5% of cases [104]. Some centers use intravenous PCA
in preference to TEA, citing adequate analgesia with fewer hemodynamic effects [105].
TAP blocks were examined in one retrospective study and appeared to reduced opioid
consumption on postoperative day 1 only [106].
9.4.1. Summary and recommendations
TEA is effective in reducing post-operative pain after gynecologic laparotomy. However
TEA may not improve other post-operative outcomes and patients may require additional
IV opioids in addition to TEA to achieve adequate analgesia. TEA may compound hypotension
that requires vasopressor support. Intravenous PCA appears to be a suitable alternative.
9.4.2. Evidence level
Low.
9.4.3. Recommendation grade
Weak.
9.5. Analgesia for laparoscopic gynecologic/oncology surgery
A meta-analysis examining TAP blocks for laparoscopic surgery across a range of abdominal
procedures [107] found only pain at rest, and not dynamic pain, was reduced. For laparoscopic
hysterectomy, one trial showed that TAP blocks improved post-operative quality of
recovery (QoR40) score [108] however 3 further trials did not show benefit [109–111].
Intra-peritoneally administered local anesthetic has been used successfully for minor
gynecologic laparoscopic procedures but this technique does not seem to be effective
for major gynecologic laparoscopic surgery, either by single instillation or continuous
infusion [112–116]. Additionally, a Cochrane analysis of intraperitoneal local an-esthetic
for laparoscopic cholecystectomy found low quality evidence of benefit, though the
effect was likely to be clinically insignificant [117]. ITM showed a small benefit
in robotic surgery [118]. TEA has been investigated for laparoscopic colorectal surgery
and appeared to prolong hospital stay without improving patient outcomes [69].
9.5.1. Summary and recommendations
For laparoscopic gynecologic/oncology surgery, neither TAP blocks nor intraperitoneal
instillation of local anesthetic are recommended on the current level of evidence.
For laparoscopic abdominal surgery, TEA may prolong hospital stay without improving
outcomes. Multi-modal analgesia should be employed, and post-operative opioids may
be given either orally or by IV PCA depending on magnitude of surgery and predicted
post-operative gut function.
9.5.2. Level of evidence
Low.
9.5.3. Recommendation grade
Weak.
10. Peritoneal drainage
Peritoneal drainage has traditionally been used to prevent accumulation of fluid in
the bed of dissection, to evacuate blood, serous collections, or infection, and in
colorectal surgery it has been thought to prevent anastomotic leakage. However, peritoneal
drainage has not been shown to prevent anastomotic leaks or improve overall outcome,
and is not recommended routinely after either colonic or rectal surgery [119–121].
There is little research regarding drains after colonic or rectal anastomosis in gynecologic
oncology surgery [122]. It is difficult to extrapolate the results from the colorectal
literature directly to all gynecological surgery. For patients with metastatic ovarian
cancer, the scope of surgery is larger, encompassing other organ resections, most
of the peritoneal surfaces, and the risk factor profile for postoperative morbidity
is elevated with poor nutritional status, ascites, peritoneal carcinomatosis, extended
operative times, and cytotoxic therapy. Regardless, the rate of anastomotic leakage
in ovarian cancer surgery in the literature ranges from 1 to 7%, in the range found
in colorectal surgery [122–124]. In summary, we did not find evidence that drainage
gives better outcomes after gynecological surgery. Furthermore, a Cochrane systematic
review including 4 studies with 571 participants [125] concluded that drains did not
prevent lymphocysts, but were rather associated with a higher risk of cyst formation
after pelvic lymphadenectomy. Fewer studies have investigated para-aortic lymphadenectomy,
but no evidence exists to recommend drainage [126]. Urological surgical techniques
are frequently employed during major gynecologic oncology cases. Historically drains
have been placed at the site of bladder resection/reconstruction, ureteral reimplantation,
and urinary diversion (ileal conduit, continent reservoir) with the aim of identifying
early urine leaks. Nevertheless, there are no specific studies that have evaluated
the use of drains in such surgeries in our patient population. Looking to the urological
literature, it should be noted that the ERAS Radical Cystectomy guideline found no
evidence to support or refute the use of drains in this setting and as such further
research is required in this area [5].
10.1.1. Summary and recommendation
Peritoneal drainage is not recommended routinely in gynecologic/oncology surgery including
for patients undergoing lymphadenectomy or bowel surgery.
10.1.2. Evidence level
Moderate.
10.1.3. Recommendation grade
Strong.
11. Urinary drainage
The primary indications for postoperative bladder drainage are to monitor urine output
and prevent urinary retention. However, there is considerable variation in the method
and duration of bladder drainage following surgery for gynecological cancers. In addition,
there is a high incidence of bladder related morbidity to the lower genital tract
following such surgery, which may include effects on urinary voiding and bladder capacity
[127].
A review of policies for removal of short-term urinary catheters identified only a
small number of studies including patients undergoing gynecologic surgery [128]. When
comparing the timing of removal of the catheter, time to first voiding was longer,
but larger volumes of urine were passed following midnight removal compared to early
morning. In one study, midnight removal of catheters was also associated with significantly
shorter length of stay [129]. A recent single center study following uncomplicated
total abdominal hysterectomy compared removal of urethral catheters immediately after
surgery, 6 h, or 24 h postoperatively. The intermediate group had fewer re-catheterizations
compared to the immediate removal group, and lower rates of urinary tract infection
than the prolonged users [130]. These findings are supported by a recent review [131].
In the same review, a greater number of patients required re-catheterization following
a urethral compared to a suprapubic catheter. Two small studies focusing on patients
undergoing radical hysterectomy for cervical cancer showed the suprapubic route to
be associated with fewer bladder infections [132,133]. In one of these studies intermittent
self- catheterization was associated with a higher infection rate but patients found
the technique to be catheterization [133].
11.1.1. Summary and recommendation
Urinary catheters should be used for postoperative bladder drainage for a short period
preferably <24 h postoperatively.
11.1.2. Evidence level
Low.
11.1.3. Recommendation grade
Strong.
12. Early mobilization
There are multiple hypothesized benefits to early mobilization, including a reduction
in pulmonary complications, decreased insulin resistance, less muscle atrophy, and
reduced length of hospital stay [134, 135]. Early mobilization has been shown to be
an integral part of systematic efforts to reduce venous thromboembolic complications
in the surgical patient [136]. Foley catheters, poor pain control, and IV poles, have
been identified by gynecologic surgical patients as barriers to ambulation [137].
Therefore, compliance with other aspects of enhanced recovery protocols may improve
early mobilization by limiting these barriers [138]. A care plan listing daily mobilization
goals and patient engagement with an activity diary may be helpful [135,139].
12.1.1. Summary and recommendation
Patients should be encouraged to mobilize within 24 h of surgery.
12.1.2. Evidence level
Low.
12.1.3. Recommendation grade
Strong.
13. Discussion
This guideline outlines the recommendations of the ERAS® Group for the postoperative
management of patients undergoing gynecologic/oncology surgery, and is based on the
best available evidence. As was the case in Part I [1], in some instances good quality
data was not available. This was particularly true for the evidence surrounding urinary
drainage, early mobilization and postoperative analgesia in which the optimal analgesic
regimen for vaginal surgery/MIS and open gynecologic surgery is currently a subject
of debate. In some instances recommendations were made based on findings from other
surgical disciplines in which major abdominal surgery is routinely utilized.
We are hopeful that these gynecologic/oncology ERAS® guidelines will help integrate
existing knowledge into practice, align perioperative care, and encourage future investigations
to address existing knowledge gaps. Measuring compliance has proven to be a key factor
required for success and sustainability of ERAS® protocols [140]. A process is currently
underway whereby the gynecologic/oncology guidelines are being translated into their
corresponding audit system (ERAS Interactive Audit System, EIAS) which will help to
ensure compliance [141] and allow surgeons/clinicians to improve the care delivered
to our patient population.