Historically, surgical management of advanced uterine and ovarian cancer has been associated with a high risk of complications and readmissions, leading to long hospital stays and patient dissatisfaction. But with the recent advent of Enhanced Recovery After Surgery (ERAS) pathways, perioperative management has changed. Cleveland Clinic physicians have been at the forefront in adapting their practices to the latest recommendations for ERAS in gynecologic oncology surgery.
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The result: more consistent care, better pain management, and fewer complications and readmissions.
Standardizing perioperative procedures
“The fear with a big operation is that if a patient is sent home early, she may just come back with complications,” says Robert L. DeBernardo, MD, Section Head of Gynecologic Oncology, in the Cleveland Clinic Ob/Gyn & Women’s Health Institute. “But by using ERAS pathways coupled with interventions to decrease wound infections, we’re getting our surgical patients out of the hospital quicker and there does not appear to be an increase in reoperation or readmission.”
ERAS pathways are standardized perioperative procedures and practices applied to all patients undergoing a particular elective surgery that are designed to improve patient outcomes. Since release of the first EARS pathway in 2005, for colorectal surgery, more than 600 have been published, in 12 specialties, according to the ERAS® Society. The newest is a 2019 update to recommendations for perioperative care in gynecologic oncology. Published in The International Journal of Gynecological Cancer, it represents the best current evidence of care for patients undergoing surgery for gynecologic malignancy.
“We started looking at ERAS pathways several years ago, and we based our in-house protocols on what was being done in colorectal surgery,” says Dr. DeBernardo. “Some of the work in that area was by Conor Delaney, MD, PhD, Chairman of the Cleveland Clinic Digestive Disease & Surgery Institute.”
At first, whether ERAS even made sense in ovarian cancer surgery was the subject of debate, according to Dr. DeBernardo. “Patients with colorectal cancer typically have an isolated tumor in their colon,” he says. “But our ovarian cancer patients tend to have fairly extensive disease and multi-visceral resections are common, plus they have to start chemotherapy within three weeks after surgery.”
Developing an ERAS hybrid
Over time, the Gynecologic Oncology section’s surgical approach has evolved to what Dr. DeBernardo calls “a hybrid system” that borrows from evidence-based work done at other institutions. Bowel preparations, fasting and fluid restriction for patients prior to surgery are a thing of the past. Anticoagulation therapy is aggressive. Antibiotics are given prophylactically and the surgeons take a multimodal preoperative and postoperative approach to infection reduction. They have also reduced their use of Jackson-Pratt drains and nasogastric tubes and instituted early feeding and ambulation.
“Drains and tubes tend to slow down people’s recovery and keep them tethered to the bed,” says Dr. DeBernardo. “Postoperatively, we’re fairly aggressive with our management. We get them up and out of bed after they leave the recovery room, push for early ambulation, and encourage patients to chew gum or drink coffee.”
A significant focus of the department’s ERAS adoption efforts has been on pain management — with an opioid-sparing approach. Preoperatively, all patients undergoing surgery for gynecologic malignancy at Cleveland Clinic get celecoxib, gabapentin, and oral acetaminophen, in addition to heparin to reduce their risk of blood clots. “Those simple interventions,” says Dr. DeBernardo, “decrease intraoperative analgesic need, which we think potentially translates into fewer cases of postoperative ileus.”
The multimodal approach to pain, according to Roberto Vargas, MD, a gynecologic oncologist at Cleveland Clinic, is the likely the most important element of the ERAS pathway. “Many of our surgical patients used to get an IV patient-controlled anesthetic (PCA) pump for delivery of morphine or hydromorphone. Now, the use of PCAs is rare,” he says. In laparotomy patients, transverse abdominis (TAP) blocks are preferred — in keeping with the 2019 ERAS recommendations. In selected cases, epidural anesthesia is used. Both measures help reduce postoperative pain and need for narcotics.
Dr. Vargas emphasizes, however, that the pathways “are not a cookie cutter approach. Physicians can tailor it based on their intuition and a patient’s specific medical situation or intra-operative findings.” Both he and Dr. DeBernardo note that one of the keys to their department’s success with ERAS has been patient counseling.
“Data in the literature suggest that patient expectations come into play with surgical outcomes,” says Dr. DeBernardo. “We do fairly extensive counseling preoperatively because for many women, this is not their first operation, and their previous experience was a long inpatient stay, restricted diet and significant pain. Most of them are happy to hear that things have changed.”
One instruction patients are given is to wash the surgical area with Hibiclens the day before their procedure. That simple step has been shown to help reduce the likelihood of postsurgical infection, which is another area of emphasis for the Cleveland Clinic surgical team. Soon they hope to publish their experience with closed incision negative-pressure therapy (ciNPT) dressings in a series of gynecologic oncology patients.
“As part of our ERAS approach, we’ve been incorporating ciNPT, namely the Prevena system, in laparotomy patients at high risk for wound complications,” says Dr. Vargas. “In a recent review of our laparotomy cases by our fellow, Laura Chambers, DO, we found that ciNPT dressings were associated with a 60% reduction in the incidence of superficial cellulitis. Interestingly, the patients who received a ciNPT dressing were higher risk, based on rates of diabetes and BMI, compared to those who received standard dressings. This risk reduction was statistically significant even after controlling for other variables that increase risk of wound infection such as age, bowel surgery and steroid use.”
Information on Cleveland Clinic’s gynecologic oncology ERAS pathway is available on the institution’s intranet. Similar pathways also are in use in other surgical disciplines, such as digestive disease, cardiology, vascular disease, urology, neurology and orthopedics. The institution’s overall formula for surgical success with them is threefold:
- Before surgery: The surgical team should standardize patient assessments and preoperative care. By fully educating patients before surgery, the surgeon can set consistent, realistic expectations for the procedure.
- During surgery: Intraoperative care should include controlling administered fluids and using nerve blocks to control pain after surgery.
- After surgery: The patient should start walking soon after surgery to preserve strength and reduce pain. The patient should also start to eat and drink shortly after surgery to encourage gut recovery. Since opioids have been proven to slow gut recovery and function, most physicians prefer using multimodal analgesics to control pain.