Investigation of the contribution of ERAS protocol integration to postoperative recovery in gynecological surgeries over the years

Objective: This study aims to examine the compliance and outcomes of the ERAS protocol, which was integrated in 2020, in patients who underwent surgery in our gynecology and gynecologic oncology clinic between 2017-2020 and 2020-2023. Materials and Methods: A total of 1,799 patients who underwent surgery at the Department of Obstetrics and Gynecology, Division of Gynecology and Gynecologic Oncology, Çukurova University Faculty of Medicine between 2017-2020 and 2020-2023 were retrospectively analyzed. The integration and outcomes of 9 components of the ERAS protocol - including use of chlorhexidine for skin preparation, avoiding the use of drains and nasogastric (NG) catheters, administration of oral carbohydrate solution, intake of clear fluids up to 2 hours before surgery, avoidance of mechanical bowel preparation, and informed consent - were compared between the two time periods. Results: The study population was divided into two main groups: pre-ERAS integration (before 2020) and post-ERAS integration (after 2020). Post-2020, significant improvements were observed in the use of chlorhexidine for skin preparation, avoidance of drains, administration of oral carbohydrate solutions, clear fluid intake up to two hours before surgery, and avoidance of mechanical bowel preparation, as well as a reduction in colorectal anastomotic leakage (p<0.05). No significant differences were found in the use of minimally invasive surgery, thromboembolism prophylaxis, and informed consent, as these practices were already in place before 2020. Patients were categorized into three groups based on pathology: benign, ovarian cancer, and other malignancies. A total of 1,769 patients were included in the study, excluding 30 patients with borderline tumors or non-gynecological cancers. The integration rate of the 9 ERAS protocol components increased from 55% to 90% in benign cases, from 45% to 85% in ovarian cancer cases, and from 45% to 85% in other malignancies after 2020. In benign cases, significant improvements were observed post-2020 in the use of chlorhexidine for skin preparation, reduced drain use, administration of oral carbohydrate solutions, allowance of clear fluid intake up to two hours before surgery, and avoidance of mechanical bowel preparation (p<0.05). Additionally, hospital stay and operation duration were significantly reduced post-2020 (p<0.05). There were no statistically significant changes in wound infections or readmissions (p>0.05). In ovarian cancer patients, significant improvements post-2020 were observed in skin preparation with chlorhexidine, administration of oral carbohydrates, preoperative fluid intake, and avoiding mechanical bowel preparation (p<0.05). However, operation duration, hospital stay, wound infections, and readmissions remained unchanged (p>0.05). In patients with other malignancies, significant improvements post-2020 were noted in skin preparation with chlorhexidine, administration of oral carbohydrates, preoperative fluid intake, use of thromboembolism prophylaxis, and avoidance of mechanical bowel preparation (p<0.05). However, there were no significant changes in operation duration, hospital stay, wound infections, or readmissions (p>0.05). Conclusion: Since the integration of the ERAS protocol in 2020, hospital stay durations have decreased in benign cases, although no significant change was observed in malignant cases. This may be attributed to lower integration rates of certain ERAS components in malignancies, as well as factors such as BMI, comorbidities, age, smoking, primary cytoreductive surgery, high surgical complexity and ASA scores. Ultimately, the adoption of the ERAS protocol, with its patient-friendly approach, appears to contribute to faster recovery through more comfortable preoperative and postoperative processes. Keywords: ERAS protocol, Benign gynecology, Gynecological Oncology, Ovarian cancer, Gynecological surgery