Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer

Kristina Lindemann; Andreas Kleppe; Brynhildur Eyjólfsdóttir; Svana Heimisdottir Danbolt; Yun Yong Wang; Anne Gjertine Heli-Haugestøl; Sara L Walcott; Odd Mjåland; Gerd-Anita Navestad; Silje Hermanrud; Knut Erling Juul-Hansen; Ulf Kongsgaard

doi:10.1136/ijgc-2023-004355

Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer

Int J Gynecol Cancer. 2023 Aug 7;33(8):1279-1286. doi: 10.1136/ijgc-2023-004355.

Authors

Affiliations

¹ Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway klinde@ous-hf.no.
² Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway.
³ Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway.
⁴ Department of Informatics, University of Oslo, Oslo, Norway.
⁵ Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway.
⁶ Department of Clinical Service, Oslo University Hospital, Oslo, Norway.
⁷ Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway.
⁸ Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway.

Abstract

Objective: This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts.

Methods: Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed.

Results: Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS.

Conclusions: ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.

Keywords: Gynecologic Surgical Procedures; Ovarian Cancer; Postoperative Care; Preoperative Care.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Carcinoma, Ovarian Epithelial
Enhanced Recovery After Surgery*
Female
Humans
Length of Stay
Ovarian Neoplasms* / complications
Ovarian Neoplasms* / surgery
Pelvic Neoplasms*
Postoperative Complications / epidemiology
Postoperative Complications / etiology
Prospective Studies
Retrospective Studies