Enhanced recovery after surgery (ERAS) protocols in patients with advanced ovarian cancer undergoing ultra-radical cytoreductive surgery with intestinal resection and anastomosis: a retrospective study

To evaluate the feasibility and effectiveness of enhanced recovery after surgery (ERAS) in the perioperative management of patients with advanced ovarian cancer. We collected and retrospectively analyzed the data of patients with advanced ovarian cancer who underwent tumor debulking surgery with intraoperative intestinal resection and anastomosis at our center from May 2020 to May 2022. All patients achieved R0 tumor debulking and were divided into an ERAS and a control group based on their perioperative interventions. The feasibility and effectiveness of ERAS were evaluated by comparing intensive care unit (ICU) admission rates, ICU stay time, hospital stay, time from surgery to postoperative chemotherapy, and incidence of postoperative complications. A total of 40 patients with advanced ovarian cancer, 18 in the ERAS group and 22 in the control group, were eligible for this study. We observed no significant differences in baseline data and surgical conditions. Regarding postoperative recovery, there was no significant difference in the ICU admission rate, length of ICU stay, and the incidence of postoperative complications. While the ERAS group had a shorter time interval from surgery to postoperative chemotherapy, 16 (9–18) days vs. 20 (10–24) days (p = 0.042), and a shorter hospital stay, 20 (18–21) days vs. 24 (19–28) days (p = 0.025). The ERAS strategy might improve postoperative recovery and shorten the time interval from surgery to postoperative chemotherapy and hospital stay in patients with advanced ovarian cancer who underwent ultra-radical cytoreductive surgery, without increasing the incidence of complications.

Enhanced recovery after surgery; Cytoreductive surgery; Intestinal resection; Ovarian cancer

[1] Zheng R, Zhang S, Zeng H, Wang S, Sun K, Chen R, et al. Cancer incidence and mortality in China, 2016. Journal of the National Cancer Center. 2022; 2: 1–9.

[2] Jiang X, Tang H, Chen T. Epidemiology of gynecologic cancers in China. Journal of Gynecologic Oncology. 2018; 29: e7.

[3] Kurnit KC, Avila M, Hinchcliff EM, Coleman RL, Westin SN. PARP inhibition in the ovarian cancer patient: Current approvals and future direction. Pharmacology & Therapeutics. 2020; 213: 107588.

[4] Vergote I, Amant F, Kristensen G, Ehlen T, Reed NS, Casado A. Primary surgery or neoadjuvant chemotherapy followed by interval debulking surgery in advanced ovarian cancer. European Journal of Cancer. 2011; 47: S88–S92.

[5] Giorda G, Gadducci A, Lucia E, Sorio R, Bounous VE, Sopracordevole F, et al. Prognostic role of bowel involvement in optimally cytoreduced advanced ovarian cancer: a retrospective study. Journal of Ovarian Research. 2014; 7: 72.

[6] Di Donato V, Giannini A, D’Oria O, Schiavi MC, Di Pinto A, Fischetti M, et al. Hepatobiliary disease resection in patients with advanced epithelial ovarian cancer: prognostic role and optimal cytoreduction. Annals of Surgical Oncology. 2021; 28: 222–230.

[7] Norppa N, Staff S, Helminen M, Auranen A, Saarelainen S. Improved survival after implementation of ultra-radical surgery in advanced epithelial ovarian cancer: results from a tertiary referral center. Gynecologic Oncology. 2022; 165: 478–485.

[8] Sioulas VD, Schiavone MB, Kadouri D, Zivanovic O, Roche KL, O’Cearbhaill R, et al. Optimal primary management of bulky stage IIIC ovarian, fallopian tube and peritoneal carcinoma: are the only options complete gross resection at primary debulking surgery or neoadjuvant chemotherapy? Gynecologic Oncology. 2017; 145: 15–20.

[9] Searle G, Pounds R, Phillips A, Kehoe S, Balega J, Singh K, et al. Prolonged interruption of chemotherapy in patients undergoing delayed debulking surgery for advanced high grade serous ovarian cancer is associated with a worse prognosis. Gynecologic Oncology. 2020; 158: 54–58.

[10] Benedetti Panici P, Di Donato V. ASO author reflections: ultra-radical resection in ovarian cancer: where are we and where are we going?Annals of Surgical Oncology. 2021; 28: 231–232.

[11] Turnbull HL, Akrivos N, Wemyss-Holden S, Maiya B, Duncan TJ, Nieto JJ, et al. The impact of ultra-radical surgery in the management of patients with stage IIIC and IV epithelial ovarian, fallopian tube, and peritoneal cancer. Archives of Gynecology and Obstetrics. 2017; 295: 681–687.

[12] Phillips A, Sundar S, Singh K, Pounds R, Nevin J, Kehoe S, et al. The NICE classification for ’Ultra-radical (extensive) surgery for advanced ovarian cancer’ guidance does not meaningfully predict postoperative complications: a cohort study. BJOG: An International Journal of Obstetrics and Gynaecology. 2019; 126: 96–104.

[13] Ye S, Wang Y, Chen L, Wu X, Yang H, Xiang L. The surgical outcomes and perioperative complications of bowel resection as part of debulking surgery of advanced ovarian cancer patients. BMC Surgery. 2022; 22: 81.

[14] Tozzi R, Casarin J, Baysal A, Pinelli C, Matak L, Ghanbarzadeh N, et al. Morbidity of multiple bowel resection compared to single bowel resection after debulking surgery for ovarian cancer. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2019; 240: 215–219.

[15] Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma—analysis of patient data in the prospective OVCAD study. Gynecologic Oncology. 2013; 131: 15–20.

[16] Practice C. ACOG committee opinion No. 750: perioperative pathways: enhanced recovery after surgery. Obstetrics and Gynecology. 2018; 132: e120–e130.

[17] Dottino JA, He W, Sun CC, Zhao H, Fu S, Rauh-Hain JA, et al. National trends in bowel and upper abdominal procedures in ovarian cancer surgery. International Journal of Gynecologic Cancer. 2020; 30: 1195–1202.

[18] Balescu I, Dima S. Rectosigmoidian involvement in advanced-stage ovarian cancer—intraoperative decisions. In Vivo. 2017; 31: 973–977.

[19] Tozzi R, Traill Z, Campanile RG, Kilic Y, Baysal A, Giannice R, et al. Diagnostic flow-chart to identify bowel involvement in patients with stage IIIC–IV ovarian cancer: can laparoscopy improve the accuracy of CT scan? Gynecologic Oncology. 2019; 155: 207–212.

[20] McNamara B, Guerra R, Qin J, Craig AD, Chen L, Varma MG, et al. Survival impact of bowel resection at the time of interval cytoreductive surgery for advanced ovarian cancer. Gynecologic Oncology Reports. 2021; 38: 100870.

[21] Bernard L, Boucher J, Helpman L. Bowel resection or repair at the time of cytoreductive surgery for ovarian malignancy is associated with increased complication rate: an ACS-NSQIP study. Gynecologic Oncology. 2020; 158: 597–602.

[22] Llueca A, Serra A, Maiocchi K, Delgado K, Jativa R, Gomez L, et al. Predictive model for major complications after extensive abdominal surgery in primary advanced ovarian cancer. International Journal of Women’s Health. 2019;11: 161–167.

[23] Delga B, Classe JM, Houvenaeghel G, Blache G, Sabiani L, El Hajj H, et al. 30 years of experience in the management of stage III and IV epithelial ovarian cancer: impact of surgical strategies on survival. Cancers. 2020; 12: 768.

[24] Xu Z, Becerra AZ, Justiniano CF, Aquina CT, Fleming FJ, Boscoe FP, et al. Complications and survivorship trends after primary debulking surgery for ovarian cancer. Journal of Surgical Research. 2020; 246: 34–41.

[25] Vincent L, Jankowski C, Ouldamer L, Ballester M, Bendifallah S, Bolze PA, et al. Prognostic factors of overall survival for patients with FIGO stage IIIc or IVa ovarian cancer treated with neo-adjuvant chemotherapy followed by interval debulking surgery: a multicenter cohort analysis from the FRANCOGYN study group. European Journal of Surgical Oncology. 2020; 46: 1689–1696.

[26] Rafii A, Stoeckle E, Jean-Laurent M, Ferron G, Morice P, Houvenaeghel G, et al. Multi-center evaluation of post-operative morbidity and mortality after optimal cytoreductive surgery for advanced ovarian cancer. Plos One. 2012; 7: e39415.

[27] Ferrari F, Forte S, Sbalzer N, Zizioli V, Mauri M, Maggi C, et al. Validation of an enhanced recovery after surgery protocol in gynecologic surgery: an Italian randomized study. American Journal of Obstetrics and Gynecology. 2020; 223: 543.e1–543.e14.

[28] Bisch SP, Nelson G. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology: areview. Current Oncology. 2022; 29: 631–640.

[29] Bisch SP, Jago CA, Kalogera E, Ganshorn H, Meyer LA, Ramirez PT, et al. Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology—a systematic review and meta-analysis. Gynecologic Oncology. 2021; 161: 46–55.

[30] Tankou JI, Foley O, Falzone M, Kalyanaraman R, Elias KM. Enhanced recovery after surgery protocols improve time to return to intended oncology treatment following interval cytoreductive surgery for advanced gynecologic cancers. International Journal of Gynecologic Cancer. 2021; 31: 1145–1153.

[31] Lu PW, Fields AC, Shabat G, Bleday R, Goldberg JE, Irani J, et al. Cytoreductive surgery and HIPEC in an enhanced recovery after surgery program: a feasibility study. Journal of Surgical Research. 2020; 247: 59–65.

[32] Sánchez-Iglesias JL, Carbonell-Socias M, Pérez-Benavente MA, Monreal Clua S, Manrique-Muñoz S, García Gorriz M, et al. PROFAST: a randomised trial implementing enhanced recovery after surgery for highcomplexity advanced ovarian cancer surgery. European Journal of Cancer. 2020; 136: 149–158.

[33] Sánchez-Iglesias JL, Gómez-Hidalgo NR, Pérez-Benavente A, Carbonell-Socias M, Manrique-Muñoz S, Serrano MP, et al. Importance of enhanced recovery after surgery (ERAS) protocol compliance for length of stay in ovarian cancer surgery. Annals of Surgical Oncology. 2021; 28: 8979–8986.

[34] Bogani G, Sarpietro G, Ferrandina G, Gallotta V, DI Donato V, Ditto A, et al. Enhanced recovery after surgery (ERAS) in gynecology oncology. European Journal of Surgical Oncology. 2021; 47: 952–959.

[35] Lee JH, Ahn BK, Ryu J, Lee KH. Mechanical bowel preparation combined with oral antibiotics in colorectal cancer surgery: a nationwide population-based study. International Journal of Colorectal Disease. 2021; 36: 1929–1935.

[36] Jochum SB, Ritz EM, Bhama AR, Hayden DM, Saclarides TJ, Favuzza J. Early feeding in colorectal surgery patients: safe and cost effective. International Journal of Colorectal Disease. 2020; 35: 465–469.

[37] Rizvanović N, Nesek Adam V, Čaušević S, Dervišević S, Delibegović S. A randomised controlled study of preoperative oral carbohydrate loading versus fasting in patients undergoing colorectal surgery. International Journal of Colorectal Disease. 2019; 34: 1551–1561.

[38] Lau WC, Shannon FL, Bolling SF, Romano MA, Sakwa MP, Trescot A, et al. Intercostal cryo nerve block in minimally invasive cardiac surgery: the pospective randomized FROST trial. Pain and Therapy. 2021; 10: 1579–1592.