Self-reported interference with walking during hospitalization was significantly lower in the ERAS group with the greatest difference in the mean seen on postoperative day 1 (Fig. 2B; P=.003). Total interference score is a calculated composite endpoint of both physical and emotional interference and includes interference scores with work, activity, walking, enjoyment of life, mood, and relations with others. Mean total interference after surgery was also lower in the ERAS group during hospital (Fig. 2C; P=.008). After hospital discharge, patients in the ERAS group returned to no or mild (less than 4) interference with walking at a median of 5 days (95% CI 2.2–7.8 days) compared with 13 days (95% CI 4.5–21.5 days, P=.003) in the pre-ERAS group (Fig. 3B). Similar improvements were seen in total interference scores with the ERAS group reporting a median return to mild or no interference in 3 days (95% CI 0.54–5.4 days) compared with 13 days (95% CI 3.6–22.4 days, P=.02; Fig. 3C).
Implementation of a robust ERAS program requires a team approach with active involvement of surgeons, anesthesiologists, nurses, dieticians, and pharmacists along with active engagement of the patient and their nonclinical caregivers. Although there are inherent limitations when using historical controls, we did not believe a randomized trial of ERAS would be feasible because of the extensive culture and practice shifts that occur with successful implementation. Therefore, we implemented a multidisciplinary quality improvement initiative based on ERAS principles for all patients undergoing laparotomy for gynecologic indications. Initially, only patients undergoing open surgery were included with a plan to expand to patients undergoing minimally invasive surgery at a later date.
Implementation of ERAS programs coupled with a continuous performance audit represents an effective approach to embracing multidisciplinary changes aimed to improve the delivery of surgical care. We have demonstrated how implementation of an enhanced recovery program for patients undergoing open abdominal surgery for gynecologic indications can improve patient-reported outcomes and significantly decrease the rate of intraoperative and postoperative opioid consumption without compromising pain control. Increasing compliance with individual ERAS protocol elements has been associated with reductions in length of stay and other postoperative complications.22 We demonstrated a high level of compliance with the ERAS pathway, which decreased length of stay without increasing complications. A significant proportion of patients undergoing open surgery for gynecologic malignancies will require postoperative chemotherapy or radiation. Delays in initiating adjuvant therapy have been associated with decreased survival in multiple cancer types, including gynecologic cancers.23–25 In colorectal surgery, improvements in 5-year survival were documented in patients who had high levels of compliance with ERAS protocols.26 Therefore, improvements in postoperative recovery may be especially meaningful in an oncologic patient population.
Multiple studies across disease sites and procedures have demonstrated improvements to patients on enhanced recovery programs, including decreased length of stay, complications, cost27–30 as well as an association with improved survival.26,31 Although our findings such as 25% reduction in length of stay with no increase in complication or readmission rates are similar to other findings and contribute to the growing literature on the effects of ERAS programs, the unique contribution of our study lies in the demonstration of “enhanced recovery” from the patient perspective with improvement in patient-reported outcomes such as fatigue, walking, and total interference after surgery. The MD Anderson Symptom Inventory interference score has been validated as a measure of symptom-related functional impairment in patients with cancer after surgery.32 Interference with walking has been further described as a sensitive marker for functional recovery after surgery.33 We found significant improvements both in the hospital and faster return to mild or no symptoms after hospital discharge for both walking and total interference score, a composite score that includes interference with work, activity, walking, enjoyment of life, mood, and relations with others.
A possible contributing factor to the demonstrated “enhancement” in recovery may be the decrease in opioid use and the effect it had on patients' symptoms and functional recovery. In our patient population, we demonstrated a striking 72% reduction in median opioid intake in patients on our ERAS pathway without an increase in patient-reported pain scores. Additionally, 16% of our patients who underwent laparotomy on an ERAS pathway were opioid-free during their hospital stay from the day of surgery up to postoperative day 3. This reduction in opioid intake and its related side effects likely contributed to the improvements identified in symptom burden and functional recovery. The Surgeon General has named the opioid epidemic as a major public health concern.34 Data suggest that those who receive an opioid prescription after surgery are 44% more likely to become long-term opioid users.35 For certain individuals with opioid overuse disorder, opioid pain medications prescribed after surgery provided their first exposure that develops into addiction.36 Implementation of multimodal analgesia through our enhanced recovery program was associated with both statistically and clinically meaningful decreases in opioid use and aligns with guidelines for safe and effective postoperative pain management.37 The Center for Medical Technology Policy has called for an “order-of-magnitude” change in U.S. adoption of enhanced recovery programs to dramatically reduce preventable complications and deaths for future surgical patients.38 Our findings suggest that not only can an ERAS program be safe and effective in the immediate and extended postoperative period, but from a patient's point of view, physical and affective aspects of recovery are improved. The reduction in opioid use within an enhanced recovery pathway is also an important contribution to multipronged efforts aimed to address the growing opioid epidemic39 and improved symptoms and functional recovery after surgery.
1. Agency for Healthcare Research and Quality. Table 96. Cost of hospital discharges with common hospital operating room procedures in nonfederal community hospitals, by age and selected principal procedure: United States, selected years 2000-2013, health, United States. Atlanta (GA): CDC/National Center for Health Statistics/Office of Analysis and Epidemiology; 2015.
2. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg 2017;152:292–8.
3. Thiels CA, Anderson SS, Ubl DS, Hanson KT, Bergquist WJ, Gray RJ, et al. Wide variation and overprescription of opioids after elective surgery. Ann Surg 2017;266:564–73.
4. Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg 2017;152:e170504.
5. Crowley R, Kirschner N, Dunn AS; Health and Public Policy Committee of the American College of Physicians. Health and public policy to facilitate effective prevention and treatment of substance use disorders involving illicit and prescription drugs: an American College of Physicians position paper. Ann Intern Med 2017;166:733–6.
6. Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005;24:466–77.
7. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—Part II. Gynecol Oncol 2016;140:323–32.
8. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—Part I. Gynecol Oncol 2016;140:313–22.
9. Snyder CF, Jensen RE, Segal JB, Wu AW. Patient-reported outcomes (PROs): putting the patient perspective in patient-centered outcomes research. Med Care 2013;51(suppl 3):S73–9.
10. Basch E. Patient-reported outcomes—harnessing patients' voices to improve clinical care. N Engl J Med 2017;376:105–8.
11. Porter ME. A strategy for health care reform—toward a value-based system. N Engl J Med 2009;361:109–12.
12. Basch E, Deal AM, Dueck AC, Scher HI, Kris MG, Hudis C. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment. JAMA 2017;318:197–8.
13. Smith AB, Basch E. Role of patient-reported outcomes in postsurgical monitoring in oncology. J Oncol Pract 2017;13:535–8.
14. Miralpeix E, Nick AM, Meyer LA, Cata J, Lasala J, Mena GE, et al. A call for new standard of care in perioperative gynecologic oncology practice: impact of enhanced recovery after surgery (ERAS) programs. Gynecol Oncol 2016;141:371–8.
15. Dripps R. New classification of physical status. Anesthesiology 1963;24:111.
16. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–83.
17. Aletti GD, Dowdy SC, Podratz KC, Cliby WA. Relationship among surgical complexity, short-term morbidity, and overall survival in primary surgery for advanced ovarian cancer. Am J Obstet Gynecol 2007;197:676.e1–7.
18. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13.
19. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81.
20. Sailors MH, Bodurka DC, Gning I, Ramondetta LM, Williams LA, Mendoza TR. Validating the M. D. Anderson Symptom Inventory (MDASI) for use in patients with ovarian cancer. Gynecol Oncol 2013;130:323–8.
22. ERAS Compliance Group. The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry. Ann Surg 2015;261:1153–9.
23. Bos AC, van Erning FN, van Gestel YR, Creemers GJ, Punt CJ, van Oijen MG. Timing of adjuvant chemotherapy and its relation to survival among patients with stage III colon cancer. Eur J Cancer 2015;51:2553–61.
24. Cattaneo R II, Hanna RK, Jacobsen G, Elshaikh MA. Interval between hysterectomy and start of radiation treatment is predictive of recurrence in patients with endometrial carcinoma. Int J Radiat Oncol Biol Phys 2014;88:866–71.
25. Seagle BL, Butler SK, Strohl AE, Nieves-Neira W, Shahabi S. Chemotherapy delay after primary debulking surgery for ovarian cancer. Gynecol Oncol 2016;144:260–5.
26. Gustafsson UO, Oppelstrup H, Thorell A, Nygren J, Ljungqvist O. Adherence to the ERAS protocol is associated with 5-year survival after colorectal cancer surgery: a retrospective cohort study. World J Surg 2016;40:1741–7.
27. Nelson G, Kalogera E, Dowdy SC. Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol 2014;135:586–94.
28. Madani A, Fiore JF Jr, Wang Y, Bejjani J, Sivakumaran L, Mata J. An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy. Surgery 2015;158:899–908.
29. Modesitt SC, Sarosiek BM, Trowbridge ER, Redick DL, Shah PM, Thiele RH. Enhanced recovery implementation in major gynecologic surgeries: effect of care standardization. Obstet Gynecol 2016;128:457–66.
30. Tanaka R, Lee SW, Kawai M, Tashiro K, Kawashima S, Kagota S, et al. Protocol for enhanced recovery after surgery improves short-term outcomes for patients with gastric cancer: a randomized clinical trial. Gastric Cancer 2017;20:861–71.
31. Savaridas T, Serrano-Pedraza I, Khan SK, Martin K, Malviya A, Reed MR. Reduced medium-term mortality following primary total hip and knee arthroplasty with an enhanced recovery program. A study of 4,500 consecutive procedures. Acta Orthop 2013;84:40–3.
32. Shi Q, Mendoza TR, Wang XS, Cleeland CS. Using a symptom-specific instrument to measure patient-reported daily functioning in patients with cancer. Eur J Cancer 2016;67:83–90.
33. Shi Q, Wang XS, Vaporciyan AA, Rice DC, Popat KU, Cleeland CS. Patient-reported symptom interference as a measure of postsurgery functional recovery in lung cancer. J Pain Symptom Manage 2016;52:822–31.
34. Hurley R. US surgeon general: doctors have central role in solving opioid epidemic. BMJ 2017;356:j715.
35. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med 2012;172:425–30.
36. Cicero TJ, Ellis MS. Understanding the demand side of the prescription opioid epidemic: does the initial source of opioids matter? Drug Alcohol Depend 2017;173(suppl 1):S4–10.
37. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016;17:131–57.
38. Moloney R, Conley R, Messner D, Mitchell K, Ganesan N, Tunis S. A multi-stakeholder agenda to advance enhanced recovery for U.S. surgical patients. Baltimore (MD): Center for Medical Technology Policy; 2014.
39. Volkow ND, Collins FS. The role of science in addressing the opioid crisis. N Engl J Med 2017;377:391–4.