Enhanced Recovery After Surgery (ERAS): New Concepts in the Perioperative Management of Gynecologic Surgery

What is ERAS? The Enhanced Recovery After Surgery (ERAS) program is a paradigm shift from traditional perioperative management initiated by Kehlet in 1997[ 1 ] as a multidisciplinary approach to the care of the surgical patient.[ 1 ] [ 2 ] [ 3 ] The program is based on perioperative medical optimization, including preoperative counseling, pain relief, carbohydrate loading, thromboembolism prophylaxis, standard anesthetic protocol and intraoperative fluid, recovery of normal gastrointestinal function, and early mobilization ([ Table 1 ]). The primary goal of the protocol is to minimize the response to the stress of the operation by maintaining homeostasis, avoiding catabolism with consequent loss of protein and muscle strength, and cellular dysfunction.[ 3 ] Table 1 Enhanced Recovery After Surgery (ERAS) program principles Enhanced Recovery After Surgery (ERAS) program What does it promote? Why should it be implemented? What is necessary for the implementation? – Minimization of the stress response to the operation by controlling the perioperative physiology – Operative medical optimization: pre-operative counseling, pain relief, carbohydrate loading, thromboembolism prophylaxis, standard anesthetic protocol and intraoperative fluid, recovery of normal gastrointestinal function, and early mobilization – Shorter length of hospital stay – No increase in readmissions and/or reoperations and/or complications rates – Faster and safer patient recovery – Improved quality of life and patient satisfaction – Reduction in overall healthcare costs – Program coordinator (doctor/nurse) – Involvement of all units dealing with the surgical patient – Multidisciplinary team working together around the patient – Multimodal approach to resolving issues that delay recovery and cause complications – Scientific, evidence-based approach to care protocols – Change in management through interactive and continuous audits – Whenever possible, minimally invasive surgery Source: Adapted from Kehlet (1997)[ 1 ] and Carey and Molder (2018).[ 2 ] The main objectives of the ERAS program are to accelerate functional recovery, improve postoperative outcomes, shorten the length of stay (LOS) in the hospital, reduce the overall health care costs, and improve the satisfaction of the patients without increasing complications and/or hospital readmission rates.[ 4 ] The ERAS protocols resulted in a 30% to 50% reduction in the LOS and similar reductions in complications, as well as lower costs and readmission rates.[ 3 ] The protocols were developed for colorectal surgery, and variations are being adopted for surgical procedures of various specialties, including Gynecology.[ 5 ] [ 6 ] The ERAS Society is an international nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations, and was officially registered in 2010 in Sweden ( http://erassociety.org ). Its mission is to develop perioperative care and to improve recovery through research, education, auditing and implementation of evidence-based practices. Throughout its history, the ERAS Society has developed and published numerous evidence-based protocols and implementation programs worldwide to enhance recovery after surgery. This society conducts structured implementation programs that are currently in use in more than 20 countries. The ERAS Society group published in 2016 the guidelines for pre- and intraoperative care in gynecologic oncology surgery.[ 7 ] [ 8 ] In 2005, the Department of Surgery of The Faculty of Medical Sciences of Universidade Federal do Mato Grosso, Brazil, adapted the ERAS program to our reality and created the Accelerating the Total Postoperative Recovery (ACERTO, in the Portuguese acronym) project. The application of the ACERTO multimodal protocol determined a significant improvement in morbidity and mortality in general surgery.[ 9 ]