Enhanced Recovery Program and Length of Stay After Laparotomy on a Gynecologic Oncology Service: A Randomized Controlled Trial

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Dickson et al1 report a randomized trial of enhanced recovery, concluding no improvement in length of stay. These results are at odds with a growing trove of literature in and outside of gynecologic oncology.2 Failure to acknowledge the many weaknesses of this study risks jeopardizing diffusion of best perioperative practices and patient benefits. In fact, this study serves as an excellent example of the potential pitfalls of implementing an enhanced recovery pathway into practice.
A strength of this study is the randomized design, but even randomized trials must be properly executed. The study arm described here implemented few of the enhanced recovery elements recommended in the international ERAS Society guidelines.3 Furthermore, those that were implemented were not assessed for compliance; it has been demonstrated that the greater the compliance, the better the outcomes.4 For example, although intraoperative fluid administration was planned for 1 mg/kg/h, the volume given was not reported and there is no evidence of a difference between arms. The use of spinal blocks and allowance of mechanical bowel preps, neither a necessary component of enhanced recovery, also may have compromised euvolemia, a critical component of any enhanced recovery after surgery pathway. In addition, only 64% of participants had a diagnosis of cancer. These cases were of low complexity, as demonstrated by the fact that only 3% underwent enteric resections and the median operative time was under 1 hour. Despite this low complexity, the morphine milligram equivalents administered in the first 48 hours (99 MME) were nearly three times that reported in a much higher complexity cohort managed without spinal or epidural analgesia.5 The method of pain assessment and whether or not the wound was infiltrated with analgesics at surgery was not provided. In short, the authors report a randomized trial not of enhanced recovery after surgery, but of spinal blocks compared with no spinal blocks. A reduction in hospital stay was observed compared with historic controls, likely due to the incorporation of some enhanced recovery elements into both cohorts. We encourage the authors to align their recovery pathway with international ERAS Society guidelines and audit compliance to optimize their patients' outcomes.
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