Perioperative management in gynecological surgery based on the ERAS program.

The return of bowel function is usually the last milestone reached before hospital discharge after a laparotomy. Among the factors influencing the return of bowel function are the use of opioids, the balance of venous fluids, the extent of peritoneal disease in the case of cancer patients, the complexity of surgery, the need for blood transfusion and postoperative abdominopelvic complications. 32 The implementation of minimally invasive surgery reduces the rate of postoperative ileus, but not all patients are candidates for this surgical approach. Among patients who need laparotomy, interventions that stimulate the enteric nervous system and reduce the use of opioids, such as early feeding, coffee consumption and chewing gum have shown to be effective in reducing the time for the return of bowel function in some studies. Although the use of chewing gum is safe and inexpensive, a large, recent, well-conducted randomized trial has shown no benefit. The consumption of coffee in the postoperative period has shown to reduce from 30% to 10% the rate of postoperative ileus in women undergoing gynecological cancer surgery. Furthermore, measures such as early ambulation and modal analgesia have shown a two to five times decrease of the rate of postoperative ileus. 5 33 The ERAS protocol also considers the possibility of using laxatives in order to accelerate the return of gastrointestinal function, since an earlier time for the first evacuation was observed when bowel stimulation with oral osmotic laxatives was performed within six hours after abdominal hysterectomy, with no change in pain and PONV scores. 1 34 As for prokinetics, there is little or no evidence to support their use for the purpose of preventing postoperative ileus ( Chart 4 ). 1 5

The Enhanced Recovery After Surgery (ERAS) program is based on perioperative medical optimization, including pre-admission counseling, pain relief, carbohydrate intake, thromboembolism prophylaxis, standard anesthetic protocol, optimized intraoperative fluid administration, recovery of normal gastrointestinal function and early mobilization. The main objectives of the ERAS program are to reduce the length of hospital stay after surgery and accelerate the return of patients to normal daily activities without increasing complications, hospital readmission rates and cost. The ERAS program has been adopted in several surgical specialties and is associated with faster and safer recovery, better quality of life and patient satisfaction. The process of implementing this program involves a multidisciplinary team and all units dealing with the surgical patient. Postoperative adverse events, venous thromboembolism is an example, are associated with longer hospital stay and higher mortality rates. Furthermore, factors such as postoperative pain and resumption of bowel function continue to be barriers to early discharge and return to daily activities. The program provides safe, high-quality perioperative care and should become standard practice for all women undergoing elective gynecological surgery.

Early mobilization is a vital component of the ERAS protocol, as it protects against muscle and physical conditioning loss by avoiding prolonged bed rest and immobility. As a result, it helps to reduce pulmonary and venous thromboembolic complications, improves insulin resistance, and helps to reduce hospital stay. 1 In addition, early ambulation contributes to the return of bowel function, decreasing postoperative ileus rates. 5

Advances in anesthetic drugs and the expansion of outpatient care allowed the application of some of the principles of outpatient surgery to major surgery in order to mitigate the negative effects of surgical stress and pain, reduce side effects related to anesthetics and accelerate recovery. 1 Propofol has become the standard drug for induction of general anesthesia due to its rapid onset, favorable antiemetic profile, and rapid recovery. General anesthesia can be maintained with inhalation anesthesia or total IV anesthesia. 5 Short-acting inhalation agents such as sevoflurane or continuous infusion of propofol are recommended to allow rapid awakening from anesthesia, which is safely performed when these techniques are combined intraoperatively with short-acting opioid analgesics. Total IV anesthesia with propofol has been associated with fewer postoperative side effects and, specifically with a decrease in postoperative nausea and vomiting (PONV). 5 27 Regional anesthesia with or without concomitant general anesthesia has been associated with rapid awakening and decreased systemic opioid need. 5 Regional analgesic techniques include neuraxial anesthesia (eg, epidural, spinal), peripheral nerve blocks, and surgical wound infiltration. 28 Incisional infiltration with liposomal bupivacaine or bupivacaine has no systemic side effects when used properly and should be incorporated into all ERAS protocols as a component of multimodal analgesia. 1

The principles of the ERAS protocol are applicable to all surgical specialties, and constant innovation must be the keynote to allow for the improvement of processes. The implementation of the ERAS program represents a paradigm shift in the perioperative management of surgical patients and is a multidisciplinary evidence-based approach. The program is clinically effective and impacts patient outcomes, providing a safe, high-quality approach and cost-effective perioperative care. In addition, a successful program can lead to faster and safer recovery and better quality of life and patient satisfaction. Therefore, the ERAS program should become standard practice for all women undergoing elective gynecological surgery. National Specialized Commission on Ginecologic Endoscopy of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO) President: Paulo Augusto Ayroza Galvão Ribeiro Vice-President: Mariano Tamura Vieira Gomes Secretary: Thomas Moscovitz Membros: Fabio Ohara Francisco Eduardo Prota Gustavo Anderman Silva Barison Jean Pierre Barguil Brasileiro Karin Kneipp Costa Rossi Luciano Gibran Luiz Flavio Cordeiro Fernandes Raquel Papandreus Dibi Raquel Silveira da Cunha Araújo Ricardo Bassil Lasmar Rita De Cássia Barbosa Tavares Santos Romulo Muller dos Santos Melo National Specialized Commission on Endometriosis of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO) President: Julio Cesar Rosa e Silva Vice-President: Helizabet Salomao Abdalla Secretary: Márcia Mendonça Carneiro Membros: Carlos Alberto Petta Carlos Augusto Pires Costa Lino Corival Lisboa Alves de Castro Eduardo Schor João Nogueira Neto João Sabino Lahorgue da Cunha Filho Marco Aurélio Pinho de Oliveira Marcos Tcherniakovsky Maurício Simões Abrão Omero Benedicto Poli Neto Ricardo de Almeida Quintairos Sidney Pearce Furtado National Specialized Commission on Oncological Gynecology of the Brazilian Federation of Gynecology and Obstetrics Associations (FEBRASGO) President: Walquíria Quida Salles Pereira Primo Vice-President: Suzana Arenhart Pessini Secretary: Jesus Paula Carvalho Membros: Angélica Nogueira Rodrigues Caetano da Silva Cardial Delzio Salgado Bicalho Eduardo Batista Candido Etelvino de Souza Trindade Fernando Maluf Francisco José Cândido dos Reis Georgia Fontes Cintra Marcia Luiza Appel Binda Mirian Helena Hoeschl Abreu Macedo Renato Moretti Marques Ricardo dos Reis Sophie Françoise Mauricette Derchain Heloisa de Andrade Carvalho

Preoperative bowel preparation has traditionally been used to decrease postoperative infectious morbidity, including anastomotic leak after bowel surgery. Although this benefit has yet to be unequivocally proven, in addition to patient dissatisfaction, its use has been associated with preoperative dehydration and electrolyte abnormalities that can hamper postoperative recovery. Quality data from studies in colorectal surgery have shown that mechanical preparation alone does not reduce postoperative morbidity and should be abandoned. 5 More data are needed to guide the use of bowel preparation in elective rectal resections below the peritoneal reflection. 17 Bowel preparation with oral antibiotics may decrease infection rates in colorectal surgery, but high-quality evidence to support its use in gynecology is lacking. 1 Data from randomized clinical trials on the use of bowel preparation in gynecological surgery are limited to patients undergoing minimally invasive gynecological surgery. These studies conclusively showed that its use is not associated with better intraoperative visualization, ease of bowel handling or performance of procedures. 17 18 19 Surgeons who recommend bowel preparation should limit its use to patients with a colon resection planned. In such cases, the use of oral antibiotics alone should be considered or combined with mechanical bowel preparation. 5

The Enhanced Recovery After Surgery (ERAS – https://erassociety.org/ ) program represents a paradigm shift in conventional perioperative care, replacing, when necessary, some traditional practices with evidence-based practices and achieving better surgical quality, clinical improvements and lower costs to the health system. The program is based on perioperative optimization, including preoperative counseling, pain relief, carbohydrate intake, thromboembolism prophylaxis, standard anesthetic protocol, optimized fluid administration, recovery of normal gastrointestinal function, and early mobilization. 1 The ERAS program has been adopted in several surgical specialties and institutions around the world and was associated with a reduction in the average length of hospital stay and complication rates, in addition to a faster and safer recovery and improvement in quality of life and patient satisfaction. 1 An essential aspect for the implementation of an ERAS program is a multimodal and multidisciplinary approach. 2 The process of implementing this program involves a team composed of surgeons, anesthetists, an ERAS coordinator, nurses, nutritionists and physiotherapists of units that care for surgical patients. 3 Adherence to the program is crucial and the continuous auditing of the care process allows the team to have a comprehensive view of the patient's results ( Chart 1 ). 4 Source: Adapted from Silva Filho AL, Santiago AE, Derchain SF, Carvalho JP. Enhanced Recovery After Surgery (ERAS): new concepts in the perioperative management of gynecologic surgery. Rev Bras Ginecol Obstet. 2018;40(8):433-6. doi: 10.1055/s-0038-1668581. 4 The main objectives of the ERAS program are to reduce the length of hospital stay after surgery and accelerate the return of patients to normal daily activities without increasing complications, hospital readmission rates or cost. 2 To this end, the ERAS program focuses mainly on minimizing the stress response of the operation, maintaining homeostasis, preventing catabolism with consequent loss of protein and muscle strength, in addition to minimizing cell dysfunction. 5

Pre-admission counseling with information about the surgical procedure, anesthesia and postoperative care should be provided. Light meals can be taken up to six hours before surgery and clear liquids can be given up to two hours before surgery. Oral carbohydrates should be given two to three hours before induction of anesthesia. Bowel preparation should not be routinely performed. Perioperative thromboembolic prophylaxis should include dual-modality prophylaxis (heparin, pneumatic compression, and/or compression stockings) depending on the indication in each case. Intraoperative fluid overload should be avoided by adopting goal-directed therapy. Hypothermia should be avoided with intraoperative use of thermal blankets, circulating-water garments and warming of intravenous (IV) fluids. The use of drains, tubes and catheters should be avoided. If indispensable, their use should be limited to the shortest duration needed. Incisional infiltration with liposomal bupivacaine or bupivacaine should be incorporated into all ERAS protocols as a component of multimodal analgesia. Postoperatively, patients can drink immediately after surgery. Intravenous fluids should be discontinued when patients demonstrate ability to maintain oral hydration with at least 500 mL of oral fluid intake. Early mobilization and feeding should be encouraged. Multimodal opioid-sparing analgesia is recommended postoperatively, with greater emphasis on non-opioid drugs such as nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, and dexamethasone. Multimodal approach to prevention and treatment of postoperative nausea and vomiting should be considered, with intraoperative use of at least two agents from different classes of antiemetics.