Snehal Bhoola, MD, discusses the implementation of enhanced recovery after surgery in ovarian cancer.
Snehal Bhoola, MD
Protocols for enhanced recovery after surgery (ERAS) across gynecologic malignancies are reflective of shorter hospital stays and quicker recoveries. The use of this approach has changed patient expectations for the better, says Snehal Bhoola, MD, who noted that ERAS is associated with better patient satisfaction scores.
Although numerous practices and programs are implementing enhanced recovery programs, many institutions have yet to follow their lead. “That is largely because of personal biases and historic treatment of patients,” said Bhoola.
In an interview during the 2018 OncLive® State of the Science Summit™ on Ovarian Cancer, Bhoola, an assistant professor at Mercer University School of Medicine, and an associate professor at the University of Arizona, Arizona Oncology, discussed the implementation of ERAS in ovarian cancer.Bhoola: I’ve been an advocate of ERAS for some time. My hope for the discussion [at the meeting was] to demonstrate that we should all be using the ERAS protocols. There have been several retrospective studies, meta-analyses, and randomized trials that have looked at patients prospectively undergoing ERAS protocols.
In general, patients experience better outcomes. I outlined some of the historical data that support the development of programs that enable ERAS. It is a multifactorial and complex process because it involves multiple specialties, including anesthesiologists, surgeons, and patients. The hospital staff are involved, as well. I spoke of some of the limitations with regards to the implementation of these programs.If you look at the literature, there are descriptions of facets of ERAS as early as the 1990s. Studies from Europe have shown that early refeeding, epidural anesthesia, and limiting certain types of anesthesia help patients with colorectal cancer (CRC) recover quicker. These early retrospective studies looked at randomized trials with meta-analyses and showed some benefit. They did, however, demonstrate a need for additional studies. Over the years, we have had more retrospective and prospective studies looking at ERAS.
A number of programs throughout our country have already established these protocols in their practices. ERAS is becoming more mainstream, but there is still a long way to go.The best way is for the surgeon or anesthesiologist—but generally the surgeon—to demonstrate to the hospital and staff the benefit to the patient and to the hospital in terms of cost, savings, etc. At that point, getting buy-in from the staff and hospital requires creating a committee. This ensures that the anesthesiologist is engaged and isn’t reliant on 1 physician; it’s better rolled out throughout the system. It requires buy-in from a committee, as well as an evaluation process, to see if the implementation is going as well as it should and whether the expected outcomes are met.ERAS starts at the office visit. It requires patient education and setting expectations. Historically, patients have expected to come in for surgery and be in the hospital for 2 to 3 days or even longer. With ERAS, you can explain to the patient that they’re going to do well and will most likely be able to leave in 1 or 2 days. Anesthesia is the other component that makes buy-in from the anesthesiologist very important. Traditionally, most anesthesiologists want patients to stop drinking any fluids up to 6 hours before surgery. With the ERAS protocol, patients can drink clear liquids up to 2 hours prior to surgery.
Some of the older anesthesiologists, or some of those who haven’t bought into that yet, would have reservations about that. Carbo-loading, or drinking carbohydrate drinks just prior to surgery, for general surgery is also something that you would have to get buy-in from physicians for. The protocol also limits long-acting or high-opioid anesthesia. Postoperatively, the protocol would involve early refeeding and limiting the use of opioids.The practice of ERAS initially started with a lot of CRC data and studies. Since its advent in CRC, it has been translated to gynecology and gynecologic oncology. Several studies in particular looked at patients with gynecologic cancers. The study reflected significant reductions in length of stay, as well as no difference in readmission rates.