Okay, so I'll just... Okay, great. Well, thank you so much for the opportunity to present to you today on enhanced recovery after surgery, key concepts in gynecological oncology. So these are my disclosures. I'm the treasurer of the ERAS Society, but I don't receive any funding for this work. So the objectives for today's talk are to briefly describe the history and rationale of ERAS, describe some of the core ERAS concepts, identify the main evidence supporting ERAS in GYN oncology, and also give you some ideas about what it takes to create a successful ERAS program at your hospital. So first of all, have you heard of ERAS? Well, definitely we should mention fast-track surgery, which as you all know, was initially championed by Henry Kellett. This was one of the first studies where he actually combined laparoscopic colon surgery with a number of ERAS elements. And these patients actually went home as early as post-op day two, remembering that back in 1995, most patients undergoing colonic surgery were sticking around for 15 to 20 days in hospital. So this was quite revolutionary at the time. And then in the early 2000s, a group of European surgeons led by Professor Ollie Lundquist started to challenge some of the historical practices such as NPO after midnight. And then ultimately the ERAS Society was formed where the mission was to improve recovery through education, research, audit, and implementation of evidence-based practice. So this is a snapshot of the ERAS Society in late 2021, basically a global surgical quality improvement initiative with lots of activity all across the world. And I think as many of you know, the first guideline was in colorectal surgery and has now since spread to many other disciplines. So this is a schematic of the preoperative, intraoperative and postoperative components. This was actually from one of the original colorectal papers. And I usually get people in the audience at this point to just kind of briefly look at these components to say, what am I currently doing in my practice and where am I willing to change? So there might be something that, if you're doing surgery later today, you might say, yeah, maybe today I'll try not putting in a drain or maybe trying less use of opioids. So it's always good to get a bit of a checkpoint to see what's going on in your practice currently. So as we know, surgery is really, really stressful and has often been likened to preparing for a marathon. And just imagine if we asked these elite athletes prior to their marathon to have a two-day mechanical bowel prep, to have nothing to eat or drink after midnight. I think we would all think that's a little silly. So why aren't we asking our surgery patients to prepare for their marathon? And we know that surgery is stressful. Obviously this schematic illustrates, we see a rise in glucocorticoids, catecholamines that are elicited by activation of the HPA axis. We see afferent nerves and neural factors generated from surgical injury. We have mobilization of energy reserves that promotes hyperglycemia and catabolism, which is bad. We also have hyperglycemia that develops as a consequence of insulin resistance. Again, something that we're always trying to counteract with ERAS. And then ultimately you have proteolysis and lipolysis that develops, again, leading to a breakdown. So one of the, another take home messages is that many of the components of ERAS help to attenuate or decrease the stress response of surgery. So let's shift gears now and talk about some of the ERAS core concepts that I think apply to many, many surgery types. And another key concept is what you do within your own area affects the patient down the line. So one of the things that we like to have people think about is that rather than working within your own silo, try to think about how the different components that you do for the patient might be affecting the patient further along down the surgical continuum. So first thing to talk about would be modern fasting, carbohydrate loading. So it's generally well accepted that clear fluids can be safely given up to two hours and a light meal up to six hours before elective procedures. And sometimes anesthesiologists will push back on this, but it's good to remind them that these guidelines were actually created by anesthesiologists. In terms of carbohydrate loading, typically we're looking at a complex carbohydrate that's given two to four hours before surgery. And this has been shown to decrease the catabolic response that's induced by overnight fasting. And in general, patients who receive these types of treatments have improved preoperative wellbeing, reduced postoperative insulin resistance, and also decrease protein breakdown. We all know that postoperative nausea and vomiting affects 30 to 50% of all surgical patients and up to 80% of those who are at high risk. And especially in GYN oncology, obviously we're operating on females and those who have a past history of nausea and vomiting or motion sickness, non-smokers are at particular risk. So I would encourage you if you've not used the APFEL score shown here, which basically gives you things to look for and to grade patients for risk, to be particularly aggressive with your nausea and vomiting prophylaxis. Mechanical bowel prep, which still continues to be used throughout the world. Just a reminder, it does cause a significant preoperative dehydration, electrolyte disturbance, and also patient discomfort. And despite that, people are still using it. And yet we have a lot of evidence that shows that mechanical bowel prep on its own is not associated with any improvement in anastomotic leak rates or surgical site infection. Now there is some emerging evidence that potentially oral antibiotic prep plus mechanical bowel prep may have some evidence for benefit, but we don't have any level one evidence to distinguish that benefit from oral antibiotic prep alone. So stay tuned for that. But again, main take-home message, try to avoid using mechanical bowel prep on its own. So use of drains in the pelvic cavity after surgery has historically been advocated to evacuate or prevent blood or serous collections, and also to detect anastomotic leakage. But again, many studies have shown that this really has not shown to be the case and really is not associated with any early warning signs. So I always say to my trainees or colleagues, ask yourself why you're actually specifically putting that drain in, because in the majority of cases, it's really not required. Again, nasogastric intubation has been used with the aim of reducing postoperative discomfort from gastric distention and vomiting. But many, many trials and meta-analyses have actually shown that patients undergoing abdominal surgery have confirmed earlier return of bowel function and a decrease in pulmonary complications if a nasogastric tube is actually avoided. So in some cases, especially in laparoscopic surgery, or other surgeries, you may ask the anesthesiologist to place an NG tube or they might put it in, but it's always important to try to remove that before the reversal of anesthesia. I often wonder, it seems like we've forgotten the pain treatment pyramid, as shown here on the right-hand side of the slide. Seems like there's an ever-increasing use of opioids, particularly in North America, but this is increasing across the world. Try to employ an opioid sparing multimodal approach. This is one of the key tenets of the ERAS program. And it's really nice, if you can, to try to avoid using a patient-controlled opioid analgesia, or PCA. Many patients can tolerate scheduled non-narcotic meds, such as acetaminophen or ibuprofen. And it's also important to evaluate the narcotic use of the patient in hospital, especially before you give a prescription for opioids. Many patients are not using narcotics in the last 24 hours before discharge, and so they may not actually require that. And another reminder that 7% of patients will fill opioid prescriptions more than three months after surgery, which is sort of essentially a surrogate for dependency. So try your best not to contribute to opioid dependency. Post-operative fluids, again, intravenous fluid is usually not necessary the day after the operation for most patients undergoing surgery. Patients should be encouraged to drink right after surgery. And my rule of thumb, and others as well, have said that basically, you can get rid of that IV once patients are tolerating about 500 cc's of fluid. I also try to explain to my trainees and my colleagues to think of IV fluids as medications. Don't just order them and forget. And try as well to avoid giving IV normal saline, which can cause a hyperchloramic acidosis, and is also associated with multiple other adverse events. And when we think back to what I said earlier around what you do early in the surgical continuum can affect what happens later on. So patients who are fluid overloaded, especially with IV normal saline, can have associated bowel edema and nausea, which then ultimately leads to an inability to tolerate food and mobilize. Urinary drainage has been used traditionally to prevent urinary retention and monitoring of urine output. But also catheterization is directly related to risk of UTI, and can also be a barrier to post-operative mobilization. Again, when you're rounding on patients, ask yourself, why does this patient currently have a urinary catheter? And is it possible that it could come out? And urinary output and oliguria alone are not reliable indicators of hypovolemia, especially in that first 48 hours when the post-operative response to stress really is to hang on to that urine. So I always encourage people to use a good clinical exam when you're trying to assess for hydration status. Post-operative nutrition, a reminder that early oral diet has been shown to be safe four hours after surgery, even in those who undergo a bowel resection. But it is important to remind patients that if they're nauseated and not feeling well, force feeding is actually also not going to help them. And then finally, early mobilization. We know that prolonged bed rest is associated with a whole host of complications, and early mobilization after surgery is widely regarded as a risk factor. It's widely regarded as an important component of perioperative care. And again, the patient's ability to mobilize is multifactorial. And so again, if you've done a bunch of things early on that may not be a promoting of early mobilization, basically everything is kind of connected. So if a patient is free of pain, nausea, has good energy, doesn't have any drains and tubes in, then those patients are more likely to freely mobilize. So we're just gonna shift gears now and look at some of the evidence supporting ERAS in gynecologic oncology. So I had the opportunity to lead the group that put forward the guidelines in 2016, as shown here. And consistent with many of the core concepts that I've just described, these are the preoperative and intraoperative components of the guidelines. And these guidelines are available for free at the ERAS Society website. And again, the postoperative components as shown here. We also updated the guidelines in 2019. So I would encourage you to check these guidelines out as well. Again, available at the ERAS Society website and also at the IJGC website. So who benefits from ERAS? So this is my own personal experience. This is a stock photo, but this is an actual patient of mine who did undergo debulking for ovarian cancer. She had a couple of bowel resections. We did some urologic work. She did not have a patient-controlled analgesia or epidural. I placed the transversus abdominus plane block myself. She had scheduled medications. I presented solid food to her post-op day zero. She had no drains or nasogastric tube. And she went home post-op day four with no complications. Now, is this really the typical experience? Let's look to see what other people have found. We did test our guidelines in this particular study. It's really important to know if the guidelines work. So this was a multi-institutional, multinational study where we entered over 2,000 patients into the ERAS database, stratified for complexity, and also accounted for the usual covariates. And this is really the take-home message. The key concept is that we established a dose-response relationship. Basically, every unit increase in ERAS guideline score was associated with an 8% decrease in days in hospital among the low-complexity patients, and a 12% decrease among patients with medium to high-complexity scores. So basically what that means is the more ERAS you do, the better the outcome for the patient. Other people have looked at ERAS as well. So Dr. Sean Dowdy from his team at the Mayo Clinic confirmed a reduction in length of stay and also cost savings for patients. Pedro Ramirez and his team at MD Anderson confirmed length of stay reduction and also reduction in opioids and faster functional recovery. We confirmed those findings as well from our Calgary group and also showed reduction in complications. And then Kevin Elias and his team also showed that ERAS was the strongest predictor of return to intended oncology treatment. So patients who had advanced ovarian cancer surgery who were on ERAS were actually able to return to their adjuvant treatment sooner than those that were not treated with ERAS. We also have some new level one evidence studies. So the Ferrari trial, again, had randomized women to ERAS or non-ERAS, and that trial confirmed reduction in length of stay, fewer complications, and more importantly, improved patient satisfaction. And also the PROFAST team from Spain also confirmed these findings specifically in advanced ovarian cancer surgery. Recently, we completed a meta-analysis with our colleagues at MD Anderson and also the Mayo Clinic. Again, in over 6,700 patients, showing that ERAS was associated with the reduction in length of stay, complications, readmissions, there was no difference in 30-day postoperative mortality, and also showed mean cost savings for ERAS patients of over $2,000 per patient. So just some final slides now to give you key steps for successful ERAS implementation at your institution. I have had a number of people tell me that they've read the guidelines, but we're not really sure what to do now. So to address that, we did publish an ERAS protocol in GYN Oncology as shown here, and I would encourage you to look at this publication and download it, because essentially what we did is we took the guidelines and we created an actual ERAS order set that covers all the components of surgery. And really what you can do is you can simply copy paste this order set, use your institutional logo, and you can actually start using it as soon as tomorrow or the next day. It's also important to create an ERAS clinical team. So these are the people who will actually be doing the work. So at minimum, you need a gynecological oncologist, an anesthesiologist, and a nurse. And it's important to choose people who are passionate about quality improvement. It's also important to audit your program. So it's not just good enough to have a protocol and an ERAS team. Probably good to kind of know where you're starting and where you want to end up. So basically what does that mean? So I'll often say we don't know what we don't measure. So I think it's important to really be collecting some data in the preoperative and intraoperative phases, and then also collecting some outcomes data of the 30 days post-discharge. And you really can use any audit system for this. You could use REDCap, you could use Excel. But the most important thing is you're really trying to go from low ERAS compliance to high ERAS compliance. And you can use plan-do-study-act cycles, which are essentially concrete action plans targeted towards areas of low compliance. So these are the key components that are required for successful ERAS implementation. You need an ERAS protocol, an ERAS team. It's important to audit your baseline compliance and outcomes, and then you use PDSA cycles to increase compliance. And this, according to the evidence that I've shown you, should be associated with clinical outcomes, which are improved. So in conclusion, ERAS is a global surgical quality improvement program, changing the course of gynecological oncology as we know it. And ERAS guidelines combined with a team and an audit system help integrate knowledge into practice, align perioperative care, and also improve outcomes for patients and achieves cost savings to the healthcare system. And just a final plug for this particular book that's recently been published, that will give you all sorts of information about ERAS in obstetrics and gynecology across all the disciplines. And all proceeds of this go to the ERAS Society. I don't receive any funding for this. So thank you very much, and I'm happy to take questions.

enhanced recovery after surgery

gynecological oncology

patient journey

ERAS protocols

patient outcomes