Implementation of Enhanced Recovery After Surgery (ERAS) Pathways in Gynecologic Oncology. A NOGGO-AGO* survey of 144 Gynecological Departments in Germany

Results

One hundred forty-four (22%) from the 654 addressed gynecological departments have been taken part in the survey: 37% were primary health care units, 40% were hospitals of secondary health care and 23% were hospitals of maximal health care.

One third of the departments were certified as gynecological oncological centers and the majority of the certified hospitals were units of maximal health care. More than 90% of all departments followed their own standard operating procedures (SOPs). About two-thirds of the participating maximal-care hospitals and more than a third of second-care participating hospitals were certified as oncological gynecological centers.

The implementation of ERAS principles was compared for all cases between the three types of hospitals. Table I describes the management of the ovarian cancer case and Table II the management of the LMP patient.

There were no major differences between the departments regarding the perioperative care of gynecological malignancies. More than 90% of the departments perform a bowel preparation before surgery for patients with ovarian cancer. In contrast, in the case of the LMP patient, only 72% of the departments would perform a bowel preparation.

Approximately, two thirds of the hospitals maintain a fasting period more than 6 h for fluids and more than 12 h for solid food before surgery.

Almost 80% of patients after ovarian cancer surgery will begin with fluid re-uptake within the first 6 h after surgery and for the majority of ovarian cancer patients the first solid meal will be offered after 24 h. For the LMP patient, more than 90% of the hospitals will begin with fluid re-uptake within the first 6 h after the surgery and the first solid meal will be after 24 h.

The majority of ovarian and LMP patients will receive an epidural anesthesia before the surgery and the average time to remove the epidural catheter will be the third day after surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs) were combined with opioids in most of cases for pain control after the surgery for both types of patients.

Almost all participants will apply a single dose antibiotic prophylaxis before the surgery. More than two thirds of all addressed departments will restrict the fluid uptake under 2 liters at the day of surgery and more than 90% will use postoperative nausea and vomiting (PONV) and hypothermia prevention in case of extended ovarian cancer surgery.

The departments differ significantly in respect of application of nasogastric intubation with highest rates of patients who received a nasogastric intubation at the hospitals of maximal care. The nasogastric tubes are removed significantly earlier at the hospitals of maximal care.

The majority of participating departments will apply abdominal drains at the surgery and only one third of them will remove the drains in case of ovarian cancer surgery within 3 days.

One third of hospitals will begin the postoperative mobilization directly at the day of surgery, in case of ovarian cancer surgery. For the LMP case, 60% of hospitals will begin the postoperative mobilization at the day of surgery.

The average hospital stay after ovarian cancer surgery is 9 to 11 days and 2 days shorter after LMP surgery.

In case of primary cytoreductive surgery by ovarian cancer, the number of treated patients, status of medical care and certification for oncological center were not significant factors influencing long hospital stay in multivariate analysis. In a score analysis developed in this study depending on the most important 10 ERAS elements (bowel preparation, duration of preoperative fluids fasting, duration of preoperative fasting for solid food, nasogastric intubation, antimicrobial prophylaxis, PONV and hypothermia prophylaxis, time of fluids re-uptake after surgery, time of food re-uptake after surgery, time of mobilisation after surgery) in order to evaluate the degree of ERAS elements implementation in each hospital, we found that only 49.5% of surveyed hospitals claimed to be adherent to more than 70% of ERAS elements in managing perioperative period of primary cytoreductive surgery in ovarian cancer patients. Twenty-one percent of these hospitals implemented more than 80% and only 8.4% implemented more than 90% of ERAS elements. The results in borderline tumors operations did not differ from those of ovarian cancer operations (50% implemented more than 70% of elements, 23.5% implemented more than 80%).