Advertisement

Prehabilitation programs and ERAS protocols in gynecological oncology: a comprehensive review

  • S. SchneiderEmail author
  • Robert ArmbrustEmail author
  • C. Spies
  • A. du Bois
  • J. Sehouli
Review

Abstract

Purpose

The “Enhanced recovery after surgery” (ERAS) concept has been continuously developed for many surgical disciplines. Shorter length of stay (LOS) and associated cost savings have been achieved without an increase in the complication or readmission rate. Current guidelines helped to support an increasing standardisation of care. One innovation of the recently published update is the proposal to integrate prehabilitation (PREHAB) into the ERAS concept. On this basis, the authors provide an overview of the current data on ERAS concepts in gynecological oncology and review the evidence of prehabilitation concepts.

Methods

Systematic literature review of all comparative studies on ERAS concepts in gynecological oncology and prehabilitation undergoing abdominal cancer surgery was performed using the standard databases. Outcomes of interest included prehabilitation program composition (exercise, nutritional, and psychological interventions), duration and outcome measures used to determine impact of prehabilitation vs. standard care.

Results

Five studies reported on PREHAB programs in gynecology (three RCTs, one study protocol, one pilot study). There is no trial evaluating a pathway for patients with extensive ovarian or cervical cancer. Study protocols were heterogenous, but showed improvements in both physical and psychological parameters. ERAS protocols in ovarian cancer patients were investigated in 12 observational studies, mostly single center and only 1 RCT, in 4 studies patients with ovarian cancer or patients. Most studies showed improvement in complication rate and shorter LOS.

Discussion

PREHAB programs seem feasible in abdominal cancer surgery and may improve surgical outcome. However, there is no prospective trial in gynecological oncology so far. Furthermore, there is no concept combining ERAS and PREHAB interventions. Therefore, the authors encourage the further development of both by describing in a novel treatment algorithm.

Keywords

Gynecological oncology ERAS Prehabilitation Surgery Ovarian cancer 

Notes

Author contributions

The authors state that each of the authors have provided substantial contribution and are in agreement with all aspects of the final manuscript.

Compliance with ethical standards

Conflict of interest

All the authors declare that he/she has no conflict of interest.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

References

  1. 1.
    Zhuang CL et al (2013) Enhanced recovery after surgery programs vs. traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum 56(5):667–678PubMedGoogle Scholar
  2. 2.
    Kehlet H, Wilmore DW (2008) Evidence-based surgical care and the evolution of fast-track surgery. Ann Surg 248(2):189–198PubMedGoogle Scholar
  3. 3.
    Ansari D et al (2013) Fast-track surgery: procedure-specific aspects and future direction. Langenbecks Arch Surg 398(1):29–37PubMedGoogle Scholar
  4. 4.
    Spanjersberg WR et al (2011) Fast track surgery vs. conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2:CD00635Google Scholar
  5. 5.
    Bisch SP et al (2018) Enhanced recovery after surgery (ERAS) in gynecologic oncology: system-wide implementation and audit leads to improved value and patient outcomes. Gynecol Oncol 151:117–123PubMedGoogle Scholar
  6. 6.
    Gustafsson UO et al (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146(5):571–577PubMedGoogle Scholar
  7. 7.
    Wijk L et al (2019) International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery. Am J Obstet Gynecol 221(3):237.e1–237.e11.  https://doi.org/10.1016/j.ajog.2019.04.028 CrossRefGoogle Scholar
  8. 8.
    Nelson G et al (2017) Enhanced recovery after surgery (ERAS(R)) in gynecologic oncology—practical considerations for program development. Gynecol Oncol 147(3):617–620PubMedGoogle Scholar
  9. 9.
    Nelson G et al (2016) Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations—Part I. Gynecol Oncol 140(2):313–322PubMedGoogle Scholar
  10. 10.
    Nelson G et al (2016) Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS(R)) Society recommendations—Part II. Gynecol Oncol 140(2):323–332PubMedPubMedCentralGoogle Scholar
  11. 11.
    Nelson G et al (2019) Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 29:651–668PubMedGoogle Scholar
  12. 12.
    Agarwal R et al (2019) A prospective study evaluating the impact of implementing the ERAS protocol on patients undergoing surgery for advanced ovarian cancer. Int J Gynecol Cancer 29(3):605–612PubMedGoogle Scholar
  13. 13.
    Bergstrom JE et al (2018) Narcotics reduction, quality and safety in gynecologic oncology surgery in the first year of enhanced recovery after surgery protocol implementation. Gynecol Oncol 149(3):554–559PubMedGoogle Scholar
  14. 14.
    de Groot JJ et al (2016) Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 95(4):382–395PubMedGoogle Scholar
  15. 15.
    Nelson G et al (2017) Enhanced recovery program and length of stay after laparotomy on a gynecologic oncology service: a randomized controlled trial. Obstet Gynecol 129(6):1139PubMedGoogle Scholar
  16. 16.
    Lindemann K et al (2017) Enhanced recovery after surgery for advanced ovarian cancer: a systematic review of interventions trialed. Int J Gynecol Cancer 27(6):1274–1282PubMedGoogle Scholar
  17. 17.
    Aletti GD et al (2011) Identification of patient groups at highest risk from traditional approach to ovarian cancer treatment. Gynecol Oncol 120(1):23–28PubMedGoogle Scholar
  18. 18.
    Ataseven B et al (2018) Skeletal muscle attenuation (sarcopenia) predicts reduced overall survival in patients with advanced epithelial ovarian cancer undergoing primary debulking surgery. Ann Surg Oncol 25:3272–3379Google Scholar
  19. 19.
    Courtney-Brooks M et al (2012) Frailty: an outcome predictor for elderly gynecologic oncology patients. Gynecol Oncol 126(1):20–24PubMedGoogle Scholar
  20. 20.
    Hijazi Y, Gondal U, Aziz O (2017) A systematic review of prehabilitation programs in abdominal cancer surgery. Int J Surg 39:156–162PubMedGoogle Scholar
  21. 21.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213PubMedPubMedCentralGoogle Scholar
  22. 22.
    Carli F, Brown R, Kennepohl S (2012) Prehabilitation to enhance postoperative recovery for an octogenarian following robotic-assisted hysterectomy with endometrial cancer. Can J Anaesth 59(8):779–784PubMedGoogle Scholar
  23. 23.
    Smits A et al (2015) Exercise programme in endometrial cancer; protocol of the feasibility and acceptability survivorship trial (EPEC-FAST). BMJ Open 5(12):e009291PubMedPubMedCentralGoogle Scholar
  24. 24.
    Carli F et al (2010) Randomized clinical trial of prehabilitation in colorectal surgery. Br J Surg 97(8):1187–1197PubMedGoogle Scholar
  25. 25.
    Gillis C et al (2014) Prehabilitation vs. rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer. Anesthesiology 121(5):937–947PubMedGoogle Scholar
  26. 26.
    Kim DJ et al (2009) Responsive measures to prehabilitation in patients undergoing bowel resection surgery. Tohoku J Exp Med 217(2):109–115PubMedGoogle Scholar
  27. 27.
    Li C et al (2013) Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc 27(4):1072–1082PubMedGoogle Scholar
  28. 28.
    West MA et al (2015) Effect of prehabilitation on objectively measured physical fitness after neoadjuvant treatment in preoperative rectal cancer patients: a blinded interventional pilot study. Br J Anaesth 114(2):244–251PubMedGoogle Scholar
  29. 29.
    Paterson C et al (2018) Development of a prehabilitation multimodal supportive care interventions for men and their partners before radical prostatectomy for localized prostate cancer. Cancer Nurs 42:E47–E53Google Scholar
  30. 30.
    Bruns ERJ et al (2018) Improving outcomes in oncological colorectal surgery by prehabilitation. Am J Phys Med Rehabil 98:231–238Google Scholar
  31. 31.
    Jensen BT et al (2015) Efficacy of a multiprofessional rehabilitation programme in radical cystectomy pathways: a prospective randomized controlled trial. Scand J Urol 49(2):133–141PubMedGoogle Scholar
  32. 32.
    Banerjee S et al (2013) O2 preoperative exercise protocol to aid recovery of radical cystectomy: results of a feasibility study. Eur Urol Supp 12(6):125Google Scholar
  33. 33.
    Dunne D et al (2014) 111 Prehabilitation before liver surgery. Eur J Surg Oncol EJSO 40(11):S52Google Scholar
  34. 34.
    Dewberry LC et al (2019) Pilot prehabilitation program for patients with esophageal cancer during neoadjuvant therapy and surgery. J Surg Res 235:66–72PubMedGoogle Scholar
  35. 35.
    Dronkers JJ et al (2010) Preoperative therapeutic programme for elderly patients scheduled for elective abdominal oncological surgery: a randomized controlled pilot study. Clin Rehabil 24(7):614–622PubMedGoogle Scholar
  36. 36.
    Allen S et al (2018) A randomised controlled trial to assess whether prehabilitation improves fitness in patients undergoing neoadjuvant treatment prior to oesophagogastric cancer surgery: study protocol. BMJ Open 8(12):e023190PubMedPubMedCentralGoogle Scholar
  37. 37.
    van Rooijen S et al (2019) Multimodal prehabilitation in colorectal cancer patients to improve functional capacity and reduce postoperative complications: the first international randomized controlled trial for multimodal prehabilitation. BMC Cancer 19(1):98PubMedPubMedCentralGoogle Scholar
  38. 38.
    Bingener-Casey J et al (2019) The feasibility of individualized prehabilitation for patients undergoing gastrointestinal cancer resections: a pilot study. Minerva Chir 74(1):112–113PubMedGoogle Scholar
  39. 39.
    Dickson EL et al (2017) Enhanced recovery program and length of stay after laparotomy on a gynecologic oncology service: a randomized controlled trial. Obstet Gynecol 129(2):355–362PubMedPubMedCentralGoogle Scholar
  40. 40.
    Gerardi MA et al (2008) A clinical pathway for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for advanced ovarian and primary peritoneal cancers. Gynecol Oncol 108(2):282–286PubMedGoogle Scholar
  41. 41.
    Arends J et al (2017) ESPEN guidelines on nutrition in cancer patients. Clin Nutr 36(1):11–48PubMedGoogle Scholar
  42. 42.
    Marx C et al (2006) The effect of accelerated rehabilitation on recovery after surgery for ovarian malignancy. Acta Obstet Gynecol Scand 85(4):488–492PubMedGoogle Scholar
  43. 43.
    Cascales Campos PA et al (2011) Perioperative fast track program in intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery in advanced ovarian cancer. Eur J Surg Oncol 37(6):543–548PubMedGoogle Scholar
  44. 44.
    de Groot JJ et al (2014) Diffusion of enhanced recovery principles in gynecologic oncology surgery: is active implementation still necessary? Gynecol Oncol 134(3):570–575PubMedGoogle Scholar
  45. 45.
    Sidhu VS et al (2012) Implementation and audit of 'Fast-Track Surgery' in gynaecological oncology surgery. Aust N Z J Obstet Gynaecol 52(4):371–376PubMedGoogle Scholar
  46. 46.
    Chase DM et al (2008) A clinical pathway for postoperative management and early patient discharge: does it work in gynecologic oncology? Am J Obstet Gynecol 199(5):541 (e1–7) PubMedGoogle Scholar
  47. 47.
    Carter J et al (2010) Fast track surgery: a clinical audit. Aust N Z J Obstet Gynaecol 50(2):159–163PubMedGoogle Scholar
  48. 48.
    Kalogera E et al (2013) Enhanced recovery in gynecologic surgery. Obstet Gynecol 122(2 Pt 1):319–328PubMedPubMedCentralGoogle Scholar
  49. 49.
    Maessen J et al (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94(2):224–231PubMedGoogle Scholar
  50. 50.
    Ripolles-Melchor J et al (2016) Goal directed hemodynamic therapy based in esophageal Doppler flow parameters: a systematic review, meta-analysis and trial sequential analysis. Rev Esp Anestesiol Reanim 63(7):384–405PubMedGoogle Scholar
  51. 51.
    Chattopadhyay S et al (2013) The role of intraoperative fluid optimization using the esophageal Doppler in advanced gynecological cancer: early postoperative recovery and fitness for discharge. Int J Gynecol Cancer 23(1):199–207PubMedGoogle Scholar
  52. 52.
    Calvo-Vecino JM et al (2018) Effect of goal-directed haemodynamic therapy on postoperative complications in low-moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial). Br J Anaesth 120(4):734–744PubMedGoogle Scholar
  53. 53.
    Helander EM et al (2017) Use of regional anesthesia techniques: analysis of institutional enhanced recovery after surgery protocols for colorectal surgery. J Laparoendosc Adv Surg Tech A 27(9):898–902PubMedGoogle Scholar
  54. 54.
    Yoo YC et al (2012) Total intravenous anesthesia with propofol reduces postoperative nausea and vomiting in patients undergoing robot-assisted laparoscopic radical prostatectomy: a prospective randomized trial. Yonsei Med J 53(6):1197–1202PubMedPubMedCentralGoogle Scholar
  55. 55.
    Vermeiren S et al (2016) Frailty and the prediction of negative health outcomes: a meta-analysis. J Am Med Directors Assoc 17(12):1163.e1–1164.e17Google Scholar
  56. 56.
    Kumar A et al (2017) Functional not chronologic age: frailty index predicts outcomes in advanced ovarian cancer. Gynecol Oncol 147(1):104–109PubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Gynecology with Center for Oncological SurgeryCharité-University Hospital BerlinBerlinGermany
  2. 2.Department of Gynecology and Gynecological OncologyKliniken Essen MitteEssenGermany
  3. 3.Department of AnaesthesiologyCharité Medical University of BerlinBerlinGermany

Personalised recommendations