What is the clinical evidence from this study?

Study design: Cohort. Population: Minimally invasive gynecologic surgery (n=328). Intervention: Enhanced Recovery After Surgery (ERAS) protocol with Quadratus Lumborum blocks vs. Non-ERAS historical controls. Primary outcome: Total opioid use (morphine milligram equivalents) (p=<0.001).

November 21, 2023Open Access

Benefits of the Enhanced Recovery After Surgery (ERAS) Pathway With Quadratus Lumborum Blocks for Minimally Invasive Gynecologic Surgery Patients: A Retrospective Cohort Study

Q: What are the key findings of this study?

The Enhanced Recovery After Surgery (ERAS) protocol significantly reduced median total opioid use from 36.2 mg to 17.4 mg (p<0.001) and shortened hospital length of stay compared to historical controls.

Key Result

The Enhanced Recovery After Surgery (ERAS) protocol significantly reduced median total opioid use from 36.2 mg to 17.4 mg (p<0.001) and shortened hospital length of stay compared to historical controls.

Study Design

Type

Cohort (n=328)

Multicenter

Structured PICO

Does an ERAS protocol with quadratus lumborum blocks reduce total opioid use and length of hospital stay in female patients undergoing minimally invasive gynecologic surgery?

Population

328 female patients undergoing minimally invasive gynecologic surgeries requiring at least one overnight stay, evaluated retrospectively to compare outcomes before and after ERAS protocol implementation.

Exposure

Enhanced Recovery After Surgery (ERAS) protocol including preoperative education, carbohydrate loading, multimodal analgesia (acetaminophen 1 g, gabapentin 300 mg, celecoxib 200 mg), intraoperative bilateral quadratus lumborum (QL) block (bupivacaine and liposomal bupivacaine), antiemetics, early feeding, early ambulation, and scheduled postoperative non-opioid analgesics.

Comparator

Historical controls (non-ERAS group) receiving standard perioperative care prior to ERAS implementation.

Outcome

Total morphine milligram equivalents (MME) used until hospital discharge.

Implementation of an ERAS protocol in minimally invasive gynecologic surgery significantly reduces postoperative opioid consumption and hospital length of stay, particularly in patients with malignant diagnoses.

Main Result

Absolute Event Rate: 17.4% vs 36.2%

p-value: p=<0.001

Limitations

Retrospective study design
Significantly shorter operative time among patients in the ERAS group, which may reflect changes in learning curves or practice patterns over time
Inability to collect data on protocol compliance or other specific outcomes such as nausea, time to ambulation, or patient satisfaction
Exclusion of patients with a laparotomy and chronic opioid use limits generalizability

Abstract

Study objective: This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery. Design and setting: This retrospective cohort study was performed in a tertiary care hospital. Patients: A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck Hospital of University of Southern California (USC), California, USA, from 2016 to 2020 were included in this study. Interventions: The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared toward a satisfactory, safe, and expeditious discharge. Measurements and main results: The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block. Conclusions: The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.

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