Background
Gynaecological cancers lead to a significant amount of morbidity and mortality. Surgery, either by laparoscopic (key-hole surgery) or open surgical techniques, is one of the most important approaches in the treatment of gynaecological cancer. Well-planned perioperative care (care at or around the time of surgery) is vital for recovery following surgery.
In recent years, researchers and doctors have suggested that many aspects of traditional perioperative care practice may be unnecessary or even harmful. For example, the use of oral laxative and enema could result in preoperative abnormalities in the levels of sodium, potassium or calcium, along with dehydration. The enhanced recovery after surgery (ERAS) programme aims to reduce surgical stress and avoid harmful aspects of traditional perioperative care. It has been introduced gradually to various surgical fields, particularly bowel surgery. ERAS programmes may help recovery after surgery, shorten time in hospital, and save hospital costs without putting the person at greater risk. However, less is known about the effects of ERAS programmes in women with gynaecological cancer. This review aims to evaluate the benefits and harms of perioperative ERAS programmes in gynaecological cancer care.
Study characteristics
We searched both Chinese and English databases (up to October 2020) and found seven trials of 747 women with gynaecological cancer, including cervical cancer, uterine cancer, ovarian cancer, and endometrial cancer. Five studies only recruited women with suspected or confirmed gynaecological cancer and two studies also included a small group of women with a benign or borderline tumour. Three studies recruited women who underwent laparotomy (where a surgeon makes one large incision in the abdomen) and two studies included those who underwent laparoscopic surgery (a minimally invasive procedure that requires only small incisions). Two of the studies used both types of surgery. Women then received either perioperative ERAS programmes or traditional care.
Key results
ERAS programmes may reduce time in hospital after the operation and readmission rates within 30 days of surgery. ERAS programmes may speed up recovery of bowel functions following surgery, measured by time to when the woman first breaks wind or opens her bowels. There may be no increase in complications within 30 days of operation using ERAS programmes. Due to limited evidence, we are very uncertain about the effects of ERAS programmes on death from any cause within 30 days of operation, or on how satisfied women were with their care. We did not find any evidence about their quality of life. ERAS might not increase hospital costs, but the evidence was very uncertain.
Conclusions
ERAS programmes may shorten time in hospital after the operation, reduce postoperative readmission rates, and facilitate bowel function recovery without compromising the safety of women with gynaecological cancer, although we have limited confidence in the findings due to the quality of the studies. Future well-conducted studies may increase the certainty of these findings.
Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.
Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015.
To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes.
We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references.
We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies.
Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty.
We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes.
ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants).