Enhanced Recovery After Surgery in Gynecologic Oncology Surgery

Enhance Recovery After Surgery (ERAS) is a multimodal perioperative care pathway to improve functional rehabilitation after surgery, reducing patient’s stress response in reaction to surgery and postoperative catabolism. ERAS is a paradigm shift in perioperative patient care that results in accelerated recovery and reduced postoperative morbidity and costs. The program includes a set of guideline items that are evidence-based modifications in traditional perioperative care that focus on reduction of perioperative stress, achievement of satisfactory pain control, resumption of normal gastrointestinal function, and early mobilization. The main goals of ERAS programs are to improve functional and emotional recovery of the patient, to reduce the length of hospital stay after surgery with no increase in complications or readmission rates, and to lower cost. In this chapter, we aim to introduce the reader to the basic principles of an ERAS program with a focus on gynecologic oncology surgery. Evidence-based published data in gynecologic oncology are described, and components of an ERAS pathway are addressed that highlight the ERAS Society Gynecologic Oncology guidelines, Part I and Part II. The core elements of a standard ERAS program are divided into three groups: preoperative, intraoperative, and postoperative patient care. The preoperative components of an ERAS program include preoperative counseling and optimization, avoidance of mechanical bowel preparation and of preoperative fasting, implementation of carbohydrate loading, use of preanesthetic medication with a focus on multimodal analgesia, thromboembolism prevention, and antimicrobial prophylaxis. Intraoperative components include short-acting anesthesia, multimodal opioid-sparing regimens, maintenance of normothermia, no routine nasogastric intubation or drainage of the peritoneal cavity, avoidance of salt and water overload, and integration of minimally invasive surgery. Postoperative elements include postoperative nausea and vomiting (PONV) prophylaxis, multimodal opioid-sparing analgesia, avoidance of salt and water overload, early oral nutrition, early removal of urinary catheter and mobilization, postoperative glucose control, and audit of compliance.