title: Enhanced recovery pathways in gynecologic oncology.
abstract: OBJECTIVE
  Many commonplace perioperative practices are lacking in scientific evidence and may interfere with the goal of optimizing patient recovery. Individual components of perioperative care have therefore been scrutinized, resulting in the creation of so-called "enhanced recovery" pathways (ERP), with the goal of hastening surgical recovery through attenuation of the stress response. In this review we examine the evidence for ERP in gynecologic oncology using data from our specialty and general surgery.
  
  
  METHODS
  We performed a systematic literature search on ERP in gynecologic oncology in June 2014 using PubMed/MEDLINE, EMBASE, and The Cochrane Library. All study types were included. References were hand reviewed to ensure completeness. The Enhanced Recovery After Surgery (ERAS) Society was contacted to identify any unpublished protocols.
  
  
  RESULTS
  Seven investigations were identified that examined the role of ERP in gynecologic oncology. Common interventions included allowing oral intake of fluids up to 2 hours before induction of anesthesia, solids up to 6 hours before anesthesia, carbohydrate supplementation, intra- and postoperative euvolemia, aggressive nausea/vomiting prophylaxis, and oral nutrition and ambulation the day of surgery. In addition, bowel preparations, the NPO after midnight rule, nasogastric tubes, and intravenous opioids were discontinued. While no randomized data are available in gynecologic oncology, significant improvements in patient satisfaction, length of stay (up to 4 days), and cost (up to $7600 in savings per patient) were observed in ERP cohorts compared to historical controls. Morbidity, mortality, and readmission rates were no different between groups.
  
  
  CONCLUSIONS
  Enhanced recovery is a safe perioperative management strategy for patients undergoing surgery for gynecologic malignancies, reduces length of stay and cost, and is considered standard of care at a growing number of institutions. Our specialty would benefit from a formalized ERP such as ERAS which audits compliance to protocol care elements to optimize patient outcomes and value.
authors.affiliation: Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada.
authors.forename: Gregg
authors.initials: G
authors.lastname: Nelson
authors.affiliation: Division of Gynecologic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA.
authors.forename: Eleftheria
authors.initials: E
authors.lastname: Kalogera
authors.affiliation: Division of Gynecologic Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA. Electronic address: dowdy.sean@mayo.edu.
authors.forename: Sean C
authors.initials: SC
authors.lastname: Dowdy
mesh_terms: D005260:Female; D005833:Genital Neoplasms, Female / Q000534:rehabilitation*; D006801:Humans; D017060:Patient Satisfaction; D020127:Recovery of Function
keywords: Enhanced recovery after surgery; Fast track surgery; Gynecologic oncology