Enhanced Recovery After Surgery (ERAS®) Society Guidelines for Gynecologic Oncology: Addressing Implementation Challenges - 2023 Update

ABSTRACT Implementation of the Enhanced Recovery after Surgery (ERAS) Society Guidelines in 2016 has resulted in an approximate decrease in hospital length of stay (LOS), reduction in complications and readmission, and cost saving. Recent publications however have demonstrated that barriers and gaps in understanding may result in many ERAS recommendations being poorly adhered to in gynecologic oncology patients. The aims of this second update to the ERAS Society Guidelines for gynecologic oncology is to summarize and update the evidence investigating specific implementation challenges to increase ERAS uptake and improve clinical outcomes for patients. A literature search was conducted for topics specified to 9 ERAS implementation challenges identified: perioperative oral intake safety, preoperative medication importance, penicillin allergies, intraoperative analgesia, how to manage urinary drainage, venous thromboembolism prophylaxis, postoperative opioid prescription practices, same-day discharge programs, and how can I overcome barriers to ERAS implementation. The quality of evidence and recommendations was evaluated, and recommendations graded as strong or weak based on quality, balance between desirable and undesirable effects on holistic clinical outcomes, and on values and preferences of practitioners. Regarding perioperative oral intake safety, patients should be encouraged to consume clear liquids in 2 hours before surgery and preoperative carbohydrate loading improves satisfaction and comfort. Optimal preoperative medications include nonsteroidal anti-inflammatory drugs, acetaminophen, and gabapentinoids. Patients with penicillin allergies should receive standard surgical antibiotic prophylaxis. For intraoperative analgesia, wound infiltration with local anesthetic and TAP block are preferred over thoracic epidural analgesia. Indwelling bladder catheters should be removed as early as possible in the postoperative period such as on the day of surgery for minimally invasive procedures and no later than postoperative day 1 for laparotomy. Patients at increased risk of venous thromboembolism should receive dual prophylaxis with compression and medications, and extended chemoprophylaxis should be prescribed to those with high-risk criteria or after laparotomy. Multimodal opioid-reduction is critical for all patients, and decreased postdischarge opioid proscribing is improved with a team approach and does not affect pain control or patient satisfaction. Patient controlled analgesia is a last resort for those requiring repeated treatment with intravenous opioids. Multidisciplinary same-day discharge programs should be considered in minimally invasive surgeries, and implementation requires a multidisciplinary team approach with patient education, case selection, and ERAS principles. Overcoming barriers to ERAS principles is more successful with changes at the management level and education. Communication of the economic benefits of ERAS to administrators may be a strong incentive to garner support. Although the evidence level varied between moderate and strong for each of these recommendations, the recommendation grade for each was strong. This updated ERAS guideline focuses on addressing implementation challenges and controversial aspects of ERAS defined by a stakeholder clinician group and offers suggestions based on objective data for overcoming these barriers.