Enhanced recovery after surgery protocols improve time to return to intended oncology treatment following interval cytoreductive surgery for advanced gynecologic cancers

Abstract

ObjectiveThe objective of this study was to determine whether the implementation of an enhanced recovery after surgery (ERAS) protocol is associated with earlier return to intended oncology treatment following interval cytoreductive surgery for advanced gynecologic cancers.MethodsParticipants comprised consecutive patients (n=278) with a preoperative diagnosis of stage IIIC or IV ovarian cancer, divided into those that received treatment before versus after implementation of an ERAS protocol at our institution. All patients received at least three cycles of neoadjuvant chemotherapy with a platinum based regimen and underwent interval cytoreduction via laparotomy with the intent to deliver additional cycles of chemotherapy postoperatively. The primary outcome was defined as the timely return to intended oncologic treatment, defined as the percentage of patients initiating adjuvant chemotherapy within 28 days postoperatively.ResultsThe study cohorts included 150 pre-ERAS patients and 128 post-ERAS patients. Median age was 65 years (range 58–71). Most patients (211; 75.9%) had an American Society of Anesthesiologists score of 3, and the median operative time was 174 min (range 137–219). Median length of stay was 4 days (range 3–5 days) in the pre-ERAS cohort versus 3 days (range 3–4) in the post-ERAS cohort (p<0.0001). At 28 days after operation, 80% of patients had resumed chemotherapy in the post-ERAS cohort compared with 64% in the pre-ERAS cohort (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.36 to 3.84; p=0.002). In multivariate logistic regression analysis, the ERAS protocol was the strongest predictor of timely return to intended oncology treatment (OR 10.18, 95% CI 5.35 to 20.32).ConclusionAn ERAS protocol for gynecologic oncology patients undergoing interval cytoreductive surgery is associated with earlier resumption of adjuvant chemotherapy.

Factors predicting postoperative morbidity after cytoreductive surgery for ovarian cancer: a systematic review and meta-analysis

“…During the last several years, Enhanced Recovery After Surgery (ERAS) programs have been introduced. In patients with gynecologic malignancies, the use of ERAS protocols have been shown to reduce the postoperative length of hospital stay as well as the incidence of postoperative complications [ 44 ]. However, the program is inhomogeneous between institutes and mainly focuses on the perioperative and immediate postoperative period.…”

Outcomes of Enhanced Recovery after Surgery (ERAS) in Gynecologic Oncology: A Review

“…Finally, given that gynecologic oncology patients often require time-sensitive adjuvant treatment in the form of chemotherapy and/or radiation therapy, improved recovery after surgery is essential in allowing patients to continue with intended treatment. A study by Tankou and colleagues demonstrated that ERAS-guided perioperative care was the strongest predictor of return to intended oncologic treatment (RIOT) for patients undergoing interval cytoreductive surgery [ 25 ] with 10-fold greater odds of returning to chemotherapy 28 days following operation than those patients undergoing conventional care.…”

Where Enhanced Recovery after Surgery (ERAS) Protocols Meet the Three Major Current Pandemics: COVID-19, Obesity and Malignancy

“…According to a recent meta-analysis by Bisch et al, the application of ERAS protocols in patients with gynecologic malignancy has been associated with significant benefits for the patients’ postoperative course by reducing the length of hospital stays and postoperative complications with no impact in readmission rates and mortality [ 36 ]. Additionally, Tankou et al compared the postoperative outcomes of patients with advanced ovarian cancer who had interval debulking surgery after the application of neoadjuvant chemotherapy before and after ERAS [ 10 ]. They showed a significantly elevated proportion of patients that resumed chemotherapy at 28 days after surgery in the post-ERAS group compared with those in the pre-ERAS group (80% vs. 64%, odds ratios 2.29, p = 0.002) [ 10 ].…”

“…Additionally, Tankou et al compared the postoperative outcomes of patients with advanced ovarian cancer who had interval debulking surgery after the application of neoadjuvant chemotherapy before and after ERAS [ 10 ]. They showed a significantly elevated proportion of patients that resumed chemotherapy at 28 days after surgery in the post-ERAS group compared with those in the pre-ERAS group (80% vs. 64%, odds ratios 2.29, p = 0.002) [ 10 ]. The ERAS Society has issued and updated guidelines on the optimal perioperative care of patients with gynecologic malignancy that aimed to improve patients’ postoperative outcomes [ 37 ].…”

“…During recent decades, Enhanced Recovery After Surgery (ERAS) protocols have been applied in a variety of surgical subspecialties. They were initially proposed for patients who underwent surgery for colorectal cancer and aimed to hasten postoperative recovery while simultaneously decreasing postoperative morbidity and readmissions [ 10 , 11 ]. By introducing a variety of standardized pre-, intra-, and postoperative modalities, the ERAS protocols have shown expedited functional recovery through attenuation of the stress response [ 11 ].…”