RACCE Study: Impact of an enhanced recovery after surgery program (ERAS) in the management of endometrial cancer: A single-center retrospective study.

OBJECTIVE: This study evaluates the implementation of an ERAS program in the gynecological surgery department of Caen University Hospital and its impact on the management of endometrial cancer. The objective was to show its impact on the length of hospitalization of patients before and after its implementation. PATIENTS AND METHOD: We conducted a retrospective study including all women treated surgically for endometrial cancer at Caen University Hospital between January 1, 2015 and December 31, 2021. The ERAS program started in September 2017. We compared the pre-, intra- and postoperative characteristics of two groups: the first one concerning the period before the implementation of ERAS called « prior ERAS group ¼ and the second one after implementation called « post ERAS group ¼. RESULTS: A total of 198 patients were included in our study. 139 patients were included after ERAS implementation. Our study shows that there is a significant reduction in median length of stay between the post ERAS and prior ERAS groups respectively 3 and 4 days (p = 0.004). There was also a reduction of time to resume ambulation (p < 0.001) and re-feeding (p < 0.001) for the post ERAS group compared to the prior ERAS group. Complication rates (p = 0.87) and readmission rates (p = 0.28) were not significant. Overall survival was not significant (p = 0.28). CONCLUSION: ERAS is a safe and effective method in the overall management of patients allowing an improvement in the quality of patient care and accelerating recovery to a previous physiological state. Finally, this results in a reduction in the patient's length of stay, without impacting morbidity and readmission rate.

Definition, general principles and expected benefits of enhanced recovery in surgery.

A multimodal approach to promoting recovery from surgery was first described by Henrik Kehlet in 1995. This approach has since been significantly developed and refined, and is now referred to as Enhanced Recovery in Surgery (ERS). The goal of ERS is to enable a patient to regain his/her pre-surgery physical and psychological state after a surgical procedure - notably by reducing the stress and the inflammatory response inevitably triggered by surgery. ERS protocols include anesthesia-related items (such as reducing the use of morphine) and surgical items (such as the use of minimally invasive routes, and limiting the postoperative use of drains and probes). Each step is essential - from patient information, education and adherence during the preoperative phase to involvement of the family circle and the attending physician with a view to early discharge. The term ERS corresponds to a set of principles for optimizing pre-, per- and postoperative care, the aim of which is to improve the post-operative course and the patient's experience by decreasing per- and postoperative complications and accelerating a return to the patient's pre-operative physical and psychological state. The use of ERS protocols is associated with a lower complication rate and a shorter hospital stay, regardless of the patient's age and comorbidities.

Combining prehabilitation with enhanced recovery programs in gynecological surgery.

Prehabilitation is a multimodal approach to preoperative care based on physical exercise, dietary/nutritional interventions, smoking and alcohol cessation, and psychological care. The goal is to reduce stress and apprehension, encourage general well-being, and thus optimize the patient's state of health before surgery. Prehabilitation encompasses all the actions undertaken between the diagnosis of the disease and the initiation of surgery to reduce the morbidity attributable to the latter. Although there are few literature data on prehabilitation in gynecological surgery, the management of moderate-to-severe undernutrition prior to gynecological oncology surgery reduces the risk of postoperative complications and increases the overall survival rate.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery).

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

To what extent is enhanced recovery in surgery used in French obstetrics and gynecology departments?

The objective of the present study was to evaluate the implementation of Enhanced Recovery in Surgery (ERS) in French obstetrics and gynecology departments. To achieve this objective, we drafted an online questionnaire about ERS protocols for cesarian sections and hysterectomies with a benign indication and put a hyperlink on the 'French National College of Gynecologists and Obstetricians' (Collège National des Gynécologues et Obstétriciens Français) website. We obtained 112 analyzable responses. Respectively 66% and 34% of the surveyed departments had established ERS protocols for cesarean sections and for hysterectomies with a benign indication. However, not all of the key ERS items were sufficiently implemented: despite the establishment of written protocols, the degree of compliance with the guidelines issued by the French-Speaking Group for Enhanced Recovery After Surgery (Groupement Francophone de Réhabilitation Améliorée Après Chirurgie) was variable. There are few published data on the implementation of ERS in obstetrics and gynecology departments worldwide. In 2010, the Enhanced Recovery After Surgery® Society issued guidelines and a checklist for an ERS protocol. The literature data suggest that for most surgical disciplines, the main ERS criteria are not well known or not widely applied. ERS protocols are still not widespread in French gynecologic surgery departments. Moreover, the application of some of the major ERS items differs markedly from one ERS program to other, which is likely to reduce the level of effectiveness. It therefore appears to be essential to formalize and promote ERS protocols in gynecological surgery.

Effect of patient-controlled epidural analgesia with and without automatic intermittent bolus on levobupivacaine consumption during labour: A single-centre prospective double-blinded randomised controlled study.

BACKGROUND: During labour, the effects of adding a programmed intermittent epidural bolus (PIEB) baseline analgesic regimen to patient-controlled epidural analgesia (PCEA) remain uncertain. METHODS: This single centre prospective double-blinded controlled study randomised nulliparous women over 35 weeks of gestational age in a PCEA + PIEB or PCEA only group. After an epidural analgesia catheter was inserted, a specific pump administered a solution of levobupivacaine 0.625 mg mL-1, sufentanil 0.25 µg mL-1, and clonidine 0.375 µg mL-1. In both groups the PCEA mode delivered an 8 mL bolus with a lockout period of 8 min. In the PCEA + PIEB group, women also received a programmed 8 mL bolus every 60 min. Additional bolus were allowed if required. The primary outcome was the hourly consumption of levobupivacaine from epidural catheter placement to new-born delivery. Secondary outcome were motor block, oxytocin use, sufentanil consumption, additional bolus required, instrumental vaginal delivery, unplanned caesarean section, pain during labour and women's satisfaction. RESULTS: Analysis included 162 and 155 women in the PCEA and PCEA + PIEB groups, respectively. The median [IQR] hourly consumption of levobupivacaine was significantly lower in the PCEA group (9.9 (7.8-12.4] mg h-1) as compared to the PCEA + PIEB group (11.2 [7.9-14.3] mg h-1; p = 0.046). The difference between medians was 1.3 mg h-1 95 % CI (0.1-2.9). There was no difference between groups for secondary outcomes. CONCLUSIONS: PCEA only modestly decreased the hourly consumption of local anaesthetic as compared to PCEA + PIEB but the difference was not clinically relevant.

AMeTHYST (AMbulatory HYsterectomy surgery). Feasibility of minimally invasive outpatient hysterectomy, a preliminary study.

OBJECTIVES: Hysterectomy, one of the most frequent surgical procedures in women, is commonly performed by a minimally-invasive approach (laparoscopic or vaginal) as recommended by the French guidelines. The French authorities aim to have 66 % of all procedures performed as same-day surgery in 2020. The aim of this study was to evaluate the feasibility and identify factors associated with success or failure of same-day surgery for minimally-invasive hysterectomy. STUDY DESIGN: We conducted a prospective double-center observational study at the Caen and Amiens University Hospitals between September 2017 and May 2018 including hospitalized patients managed for a laparoscopic or vaginal hysterectomy. Patients were younger than 70 and have no major medical problems. The patients were placed into a "fit" or "unfit" group according to their Post Anaesthetic Discharge Scoring System (PADSS) score 6 h post-surgery. All the patients were asked to complete an assessment questionnaire during their hospitalization. RESULTS: Of the 50 included patients, half were placed in the "fit" group. A history of laparotomy was significantly predictive of failure of same-day discharge (p = 0.003) but not uterine size or Body Mass Index (BMI). The main barriers for discharge were pain (p<0.001) and postoperative nausea/vomiting (PONV) (p<0.001). Four patients, all in the "unfit" group, had Clavien-Dindo grade 1 postoperative complications. CONCLUSION: Same-day minimally invasive hysterectomy is a feasible and safe procedure. Factors associated with same-day hysterectomy failure were laparotomy, pain and postoperative nausea/vomiting.

Effect of Oral Carbohydrate Intake During Labor on the Rate of Instrumental Vaginal Delivery: A Multicenter, Randomized Controlled Trial.

BACKGROUND: Carbohydrate intake during physical exercise improves muscle performance and decreases fatigue. We hypothesized that carbohydrate intake during labor, which is a period of significant physical activity, can decrease the instrumental vaginal delivery rate. METHODS: In a multicenter, prospective, randomized, controlled trial, healthy adult pregnant women presenting with spontaneous labor were assigned to a "Carbohydrate" group (advised to drink 200 mL of apple or grape juice without pulp every 3 hours) or a "Fasting" group (water only). The primary outcome was the instrumental vaginal delivery rate. Secondary outcomes included duration of labor, rate of cesarean delivery, evaluation of maternal hunger, thirst, stress, fatigue, and overall feeling during labor by numeric rating scale (0 worst rating to 10 best rating), rate of vomiting, and hospital length of stay. Statistical analysis was performed on an intention-to-treat basis. The primary outcome was tested with the "Fasting" group as the reference group. The P values for secondary outcomes were adjusted for multiple comparisons. The differences between groups are reported with 99% confidence interval (CI). RESULTS: A total of 3984 women were analyzed (2014 in the Carbohydrate group and 1970 in the Fasting group). There was no difference in the rate of instrumental delivery between the Carbohydrate (21.0%) and the Fasting (22.4%) groups (difference, -1.4%; 99% CI, -4.9 to 2.2). No differences were found between the Carbohydrate and the Fasting groups for the duration of labor (difference, -7 minutes; 99% CI, -25 to 11), the rate of cesarean delivery (difference, -0.3%; 99% CI, -2.4 to 3.0), the rate of vomiting (difference, 2.8%; 99% CI, 0.2-5.7), the degree of self-reported fatigue (difference, 1; 99% CI, 0-2), self-reported hunger (difference, 0; 99% CI, -1 to 1), thirst (difference, 0; 99% CI, -1 to 1), stress (difference, 0; 99% CI, -1 to 1), overall feeling (difference, 0; 99% CI, 0-0), and the length of hospitalization (difference, 0; 99% CI, -1 to 0). CONCLUSIONS: Carbohydrate intake during labor did not modify the rate of instrumental vaginal delivery.

Neonatal and maternal outcomes of pregnancy with maternal cardiac disease (the NORMANDY study) : Years 2000-2014.

Pregnancies complicated by congenital or acquired heart diseases are at high risk of maternal, obstetrical and neonatal poor outcomes. During the period 2000-2014, 197 pregnancies occurring in 147 women with heart disease were managed in our institution. A maternal cardiac event complicated 13 pregnancies. Obstetrical and neonatal complications occurred respectively in 35.0% (95% CI [28.3-41.7]) and 37.0% (95% CI [30.3-43.7]) of pregnancies. All complications were more frequent amongst cardiomyopathies or obstructive and conotruncal lesions, whereas left-to-right shunts were less prone to present with complications. Complications occurred between the end of the second trimester and the middle of the third trimester or during the post-partum period. Caesarean section was the mode of delivery in 37% (95% CI [30.3-43.7]) of cases, and general anaesthesia was performed in 8.6% of cases (95% CI [4.7-12.5]). Although reporting relatively mild heart diseases, this retrospective study shows an evolution in the management of pregnancies complicated by cardiopathies. Vaginal delivery under locoregional anaesthesia can be achieved in many pregnancies, whereas others require strict multi-disciplinary follow-up in a specialized centre. The creation of a large, multi-centric registry might help improve and personalize the management of these high-risk pregnancies.

Comparison of the Mallampati Classification in Sitting and Supine Position to Predict Difficult Tracheal Intubation: A Prospective Observational Cohort Study.

BACKGROUND: The Mallampati classification (MLPT) is normally evaluated in the sitting position. However, many patients cannot be evaluated in the sitting position for medical reasons. Thus, we compared the MLPT in sitting and supine positions in predicting difficult tracheal intubation (DTI). We hypothesized that the diagnostic accuracy of the MLPT performed in sitting and supine positions would differ. METHODS: We performed a single-center prospective observational study in adult patients who received general anesthesia and orotracheal intubation for noncardiac surgery. During the preanesthesia consultation, the MLPT in the sitting position was recorded. The day of surgery, the MLPT in the supine position and the difficulty of intubation (DTI) were recorded by an independent observer. The diagnostic performance of the MLPT for the prediction of DTI was evaluated in the sitting and supine positions through the area under the receiver operating characteristic (ROC) curve. The performance of the Naguib score in predicting DTI was calculated with the MLPT in sitting and supine positions. RESULTS: Among the 3036 patients, 157 (5.1%) had DTI. The area under the ROC curve for the MLPT in supine position (0.82 [0.78-0.84]) was greater than that for the MLPT in the sitting position (0.70 [0.66-0.75]; P < .001). The relationship between the sitting and supine MLPTs was moderate (Spearman rank correlation coefficient: 0.50; P < .001). The area under ROC curve for predicting DTI by the Naguib score calculated with the supine MLPT (0.78 [95% confidence interval, 0.74-0.82]) was greater than that for the Naguib score calculated with MLPT in the sitting position (0.69 [95% confidence interval, 0.63-0.74)]; P < .001). CONCLUSIONS: The MLPT performed in the supine position is possibly superior to that performed in the sitting position for predicting difficult intubation in adults.

Comparison of plastic and metallic single-use and metallic reusable laryngoscope blades: a randomised controlled trial.

CONTEXT: Plastic single-use laryngoscope blades have been found to increase the difficulty of intubation. Metallic single-use blades may represent an alternative. OBJECTIVE: To compare the rates of intubation failure at first laryngoscopy using metallic single-use, plastic single-use and metallic reusable laryngoscope blades. DESIGN: Randomised, superiority, single-centre, controlled trial. SETTING: Operating theatres at a University Hospital from January 2008 to August 2009. PATIENTS: A total of 1863 adults requiring general anaesthesia. INTERVENTION: Patients were randomised to one of three laryngoscope blades: metallic single-use, plastic single-use or metallic reusable. MAIN OUTCOME MEASURE: The primary end-point was the number of intubation failures at first laryngoscopy. Secondary end-points were glottic exposure and the Intubation Difficulty Scale. RESULTS: The failure rate (absolute difference: 95% confidence interval) at the first attempt was greater for the plastic single-use blades (8.1%) than for the metallic reusable [3.2% (4.9%: 2.2 to 7.6%); P < 0.001] and metallic reusable blades [4.0% (4.0%: 1.2 to 6.9%); P < 0.006]. No difference was found between the metallic reusable and metallic single-use groups (0.9%: -1.3 to 3.1%). Scoring on the Intubation Difficulty Scale [median (interquartile range)] was higher in the plastic single-use group [1 (0 to 2)] than in the metallic groups [metallic reusable: 0 (0 to 1); P < 0.001 and metallic single-use: 0 (0 to 1); P < 0.007] groups. Glottic exposure was significantly better in the metallic reusable group (modified Cormack & Lehane score III and IV: 3.7%) compared with the plastic single-use group (modified Cormack & Lehane score III and IV: 9.4%; P < 0.03). CONCLUSION: The rates of failed intubation at first laryngoscopy were similar in the metallic reusable and metallic reusable groups, but greater in the plastic single-use group.