To evaluate the effects of enhanced recovery after surgery (ERAS) protocols in laparoscopic cervical cancer surgery. The present study included 230 patients with early stage cervical cancer undergoing laparoscopic surgery, divided into the ERAS (n=103) and non-ERAS (n=127) groups. ERAS interventions included pre-admission education, nutritional optimization, effective pain management, early mobilization and goal-directed fluid therapy. The primary and secondary outcomes measured were length of hospital stay, surgical site infections, urinary tract infections and postoperative pain levels. The median length of surgery was longer in the ERAS group compared with the non-ERAS group. However, the ERAS group experienced a significantly shorter hospital stay (4.1±3.1 days) compared with the non-ERAS group (5.7±3.9 days; P=0.0005). There was a reduction in the overall complications and postoperative infections, although these differences were not statistically significant. Notably, ERAS protocols significant improved in postoperative pain management, reducing severe pain scores from days 1 to day 3 after surgery. In conclusion, the ERAS protocols shortened hospital stays and improved pain management in laparoscopic cervical cancer surgery, underscoring their role in optimizing surgical care and enhancing patient recovery.
Cervical cancer remains a significant public health issue, being the fourth most common cancer in women worldwide. It is primarily caused by persistent infection with high-risk types of human papillomavirus (HPV) transmitted through sexual contact (
Enhanced recovery after surgery (ERAS) protocols have significantly transformed perioperative care by minimizing the physiological stress of patients, reducing the number of complications and expediting recovery (
Despite a growing body of evidence, the application of ERAS in laparoscopic cervical cancer surgery remains underexplored. The present study aimed to address this gap by evaluating the clinical efficacy of ERAS protocols in this context. By examining various dimensions of patient care, ranging from preoperative preparation to postoperative recovery, the current study provides a comprehensive analysis and insights for the implementation of ERAS in laparoscopic surgeries for patients with cervical cancer.
The present study retrospectively analyzed 230 patients with cervical cancer who received standard (non-ERAS; n=127) or ERAS (n=103) care between April 2020 and April 2022. This study was approved by the ethics committee of Guilin Maternity and Child Healthcare Hospital (approval no. 2019-04; Guilin, China). Written informed consent was obtained from all the participants.
The inclusion criteria were as follows: i) No prior treatment for cervical cancer; ii) disease classification as clinical stage I or II according to the revised 2008 International Federation of Gynecology and Obstetrics staging system (
ERAS adoption involved a series of pre-operative, intra-operative and postoperative care enhancements or improvements, as detailed in
The evaluated outcomes included the length of hospital stay as the primary outcome, along with a range of secondary outcomes. Postoperative pain intensity was measured using the 11-point Numeric Rating Scale (NRS; 0=no pain, 10=worst imaginable pain) at 24, 48 and 72 h after surgery. These secondary outcomes included the following 30-day outcomes: i) The total rate of surgical site infections (superficial, deep or organ space infections); ii) development of urinary tract infections; iii) pneumonia; iv) sepsis; v) or septic shock; vi) wound dehiscence; vii) venous thromboembolism (VTE); viii) myocardial infarction or myocardial injury following non-cardiac surgery (MINS); ix) necessity for intra- or postoperative blood transfusions; x) returns to the operating room (any unplanned re-operation that occurs within the 30-day postoperative period); and xi) readmission to hospital; xii) or death. Outcome definitions strictly followed NSQIP program guidelines, without any gradation (
All statistical analyses were conducted using SPSS software (version 17.0; SPSS, Inc.). Continuous variables are presented as mean ± standard deviation (SD) when normally distributed or as median (interquartile range, IQR) when skewed. Categorical variables are expressed as number (percentage). Patient demographics, comorbidities, baseline health indicators and clinical outcomes between the ERAS and non-ERAS groups were compared (non-ERAS n=127; ERAS n=103). Comparisons were made using the independent (unpaired) student's t-test for continuous and the χ2 test for categorical variables. For continuous data, the method depended on its distribution: The independent (unpaired) Student's t-test was applied for normally distributed data, whereas the Mann-Whitney U-test was used for non-normally distributed data. Normality of each continuous variable was assessed using the Shapiro-Wilk test. Pain scores between groups at each postoperative time point were compared using the Mann-Whitney U-test, and longitudinal changes were analyzed with a mixed-effects linear model accounting for repeated measures (group x time interaction). In cases where the variances between the ERAS and non-ERAS groups were unequal, as determined using the F-test, the Satterthwaite two-sample t-test was used instead of the standard two-sample t-test. P<0.05 was considered to indicate a statistically significant difference (
The key variables assessed included demographic information [age; body mass index (BMI)], medical history [diabetes; smoking status; severe chronic obstructive pulmonary disease (COPD; defined as GOLD stage III-IV or requiring long-term oxygen therapy); American Society of Anesthesiologists (ASA) physical status classification 3-4; chronic steroid use (defined as systemic corticosteroid therapy for ≥30 consecutive days within the 6 months preceding surgery); significant weight loss >10%; and preoperative hypoalbuminemia], functional status (categorized as independent, partially dependent, or totally dependent according to NSQIP criteria) and length of surgery. Statistical analysis revealed no significant differences between the ERAS and non-ERAS groups in terms of age, BMI, prevalence of diabetes, smoking status, severe COPD, ASA classification 3-4, chronic steroid use, significant weight loss, preoperative hypoalbuminemia and independent functional status.
By contrast, a significant increase in the median length of surgery was observed in the ERAS cohort compared to the non-ERAS cohort (142.00 vs. 125.37 min; P<0.001) (
This study further explored the outcome of patients undergoing laparoscopic surgery for cervical cancer, comparing results before and after the implementation of the ERAS protocol. A significant reduction in the mean length of hospital stay was observed in the ERAS group (4.1±3.1 vs. 5.7±3.9; P=0.0005), indicating improved recovery associated with ERAS protocols.
Although the overall incidence of complications decreased from 24.41 to 16.50% (ERAS vs. non-ERAS), this reduction was not statistically significant (P=0.192). Similarly, no significant differences were found between the two groups in specific postoperative infections, including total surgical site infections, superficial incisional infections, deep incisional infections, organ/space infections, and urinary tract infections, pneumonia and sepsis/septic shock. This suggests that although there was a trend towards reduced complications and infections, these differences were not statistically significant in the present study (
Other outcome measures such as wound dehiscence, VTE (including deep venous thrombosis and pulmonary embolism), myocardial infarction/minor ischemic necrosis, intra/postoperative transfusion, return to the operating room, readmission and death showed no significant differences between the non-ERAS and ERAS groups. These findings suggest that the implementation of the ERAS protocols did not adversely affect specific outcome measures.
Next, unadjusted and adjusted 30-day postoperative outcomes, including complications, infections and other notable events were evaluated. A significant reduction in hospital stay duration was demonstrated with ERAS implementation, showing an unadjusted OR of 0.46 (95% CI, 0.27-0.79; P=0.0049) and an adjusted OR of 0.43 (95% CI, 0.25-0.75; P=0.0032). However, for other outcomes, such as complications, postoperative infections and readmission rates, the differences between the non-ERAS and ERAS periods were not statistically significant (
Pain levels were assessed using a numerical analog scale over 3 days post-surgery. The initial findings revealed a significant reduction in severe pain and improved management of moderate pain in the ERAS group compared to the non-ERAS group on the first day post-operation. This trend continued on the second day, with fewer patients reporting severe pain and more reporting mild pain in the ERAS group. By the third day, 69.9% of the ERAS patients reported mild pain, a substantial improvement compared to the non-ERAS group, where only 16% of patients reported mild pain (
This study comprehensively evaluated the effects of the ERAS protocols on laparoscopic cervical cancer surgery. Our findings demonstrated significant improvements in various aspects of surgical care, from preoperative preparation to postoperative recovery. ERAS protocols not only improved clinical outcomes but also overall patient outcomes.
ERAS is a multidisciplinary and patient-centered approach that aims to reduce surgical stress and facilitate quicker recovery. It emphasizes patient education on ERAS principles, perioperative nutrition, pain management, early mobilization and postoperative self-care, and reduces preoperative fasting and stress, and reduces preoperative fasting and stress. The introduction of carbohydrate-rich drinks optimizes nutritional status, enhances surgical readiness and improves post-surgery recovery (
A retrospective analysis of long-term outcomes in elderly patients with colorectal cancer has demonstrated the lasting effectiveness of ERAS protocols (
The increase in surgery length with ERAS may be due to more meticulous surgical techniques or additional steps within the ERAS framework. A previous study found that ERAS increased surgical time in gynecological oncology undergoing laparotomy (
A study on laparoscopic bariatric surgery with ERAS protocols found significant reductions in hospital stay and complications compared with conventional care (
In conclusion, ERAS protocols significantly improved patient outcomes in laparoscopic cervical cancer surgeries, including reduced hospital stay, fewer complications and enhanced recovery. These findings highlight the importance of ERAS in optimizing surgical care and patient recovery. Our comparison of standard care with ERAS demonstrated a significant reduction in the length of hospital stay. The incidence of overall complications and postoperative infections showed a trend of reduction. Numerous studies have reported similar outcomes (
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In summary, the present study substantiated the effectiveness of ERAS protocols in laparoscopic cervical cancer surgery and demonstrated significant improvement in patient outcomes. The findings highlight the protocols' ability to accelerate recovery but also improve the overall patient experience and potentially curtail the healthcare costs associated with extended hospital stays. In essence, our research reinforces the importance of ERAS protocols in evolving surgical care, promoting a paradigm shift towards evidence-based, patient-centered practices that aim for surgical excellence, increased patient satisfaction and optimal utilization of healthcare resources.
Not applicable.
The data generated in the present study may be requested from the corresponding author.
XJL conceived and designed the study. WH, TL, CQ, SL, LM, HT, XY and XLL collected the data. WH and CQ confirm the authenticity of all the raw data. WH, SL, LM, HT, XY and QL analyzed and interpretated the results. WH, TL, CQ and XJL prepared the draft manuscript. All authors read and approved the final version of the manuscript.
The study was approved by the ethical committee of Guilin Maternity and Child Healthcare Hospital (2019-04, Guilin, China). Informed consent was provided by all participating individuals.
Not applicable.
The authors declare that they have no competing interests.
ERAS elements.
| Phase | ERAS | Non-ERAS |
|---|---|---|
| Preoperative | Pre-admission education. | N/A |
| No bowel preparation unless an anterior resection is planned or likely. | Routine mechanical bowel preparation. | |
| Reducing preoperative fasting (solid food: 8 h, clear fluids: 3 h). | Fasting from midnight before surgery. | |
| Preoperative oral carbohydrate loading with carbohydrate-rich meals the evening before and a clear fluid carbohydrate drink (50 g) on the morning of surgery. | N/A | |
| Preoperative analgesia includes Acetaminophen, NSAIDs and Gabapentin. | No specific preoperative oral analgesia protocol. | |
| Preoperative body warming system. | N/A | |
| Intraoperative | Antibiotic prophylaxis before the incision with appropriate weight-adjusted dosing and repeated every 4 h. | Standard antibiotic prophylaxis before incision. |
| Goal-directed fluid therapy focused on avoiding fluid overload. | More liberal fluid administration at the discretion of the anesthesiologist. | |
| Avoidance of resection-site drainage. | More frequent use of resection-site drainage. | |
| Postoperative | Prompt termination of intravenous fluid and urinary drainage. | Continued intravenous fluid infusion into late postoperative day 1 or 2; delayed urinary drainage termination. |
| Minimization of systemic opioids, favoring narcotic-sparing oral analgesia | More liberal use of opioids for pain management. | |
| Encouraging mobilization on the day of surgery. | Mobilization typically starting on postoperative day 1. | |
| Starting oral intake on the day of surgery. | Oral intake typically beginning on postoperative day 1. | |
| Continued mechanical VTE prophylaxis with the addition of extended postoperative chemoprophylaxis using low-molecular-weight heparin for 28 days. | No extended VTE prophylaxis protocol. | |
| Scheduled bowel regimens from postoperative day 1. | Bowel regimens administered as needed. | |
| Routine administration of antiemetics. | Antiemetics provided as needed. |
ERAS, enhanced recovery after surgery; N/A, not applicable; NSAIDs, nonsteroidal anti-inflammatory drugs; VTE, venous thromboembolism. 1, Use of analgesia were determined a visual analog scale (VAS). VAS<4, no analgesia; VAS 4-6, oral acetaminophen, non-steroidal anti-inflammatory drug, or gabapentin; VAS ≥7, opioid.
Clinical characteristics of patients undergoing laparoscopic cervical cancer surgery.
| Characteristics | Non-ERAS (n=127) | ERAS (n=103) | P-value |
|---|---|---|---|
| Age, years, mean (SD) | 61.66 (9.84) | 60.30 (8.95) | 0.277 |
| BMI, mean (SD) | 24.39 (3.97) | 24.75 (3.75) | 0.477 |
| Diabetes, n (%) | 16 (12.60) | 13 (12.62) | 1.0 |
| Smoker, n (%) | 22 (17.32) | 18 (17.48) | 1.0 |
| Severe COPD, n (%) | 4 (3.15) | 2 (1.94) | 0.694 |
| ASA 3-4, n (%) | 118 (92.91) | 98 (95.15) | 0.670 |
| Chronic steroid use, n (%) | 3 (2.36) | 1 (0.97) | 0.630 |
| Weight loss >10%, n (%) | 5 (3.94) | 2 (1.94) | 0.464 |
| Preoperative hypoalbuminemia, n (%) | 76 (59.84) | 55 (53.40) | 0.397 |
| Independent functional status, n (%) | 124 (97.64) | 103 (100.00) | 0.255 |
| Length of surgery, median (IQR) | 125.37 (70.74) | 142.00 (83.58) | <0.001 |
ERAS, enhanced recovery after surgery; SD, standard deviation; BMI, body mass index; COPD, chronic obstructive pulmonary disease; ASA, American Society of Anesthesiologists; IQR, Interquartile range.
Outcome measures in patients with or without enhanced recovery after surgery.
| 30-day outcomes | Non-ERAS (n=127) | ERAS (n=103) | P-value |
|---|---|---|---|
| Length of hospital stay, days (mean ± SD) | 5.7±3.9 | 4.1±3.1 | 0.001 |
| Complications | 31 (24.41%) | 17 (16.50%) | 0.192 |
| Postoperative infections | 19 (14.96%) | 11 (10.68%) | 0.446 |
| Total surgical site infection | 14 (11.02%) | 9 (8.74%) | 0.677 |
| Superficial incisional infection | 8 (6.30%) | 6 (5.83%) | >0.999 |
| Deep incisional infection | 2 (1.57%) | 0 (0%) | 0.503 |
| Organ/Space infection | 4 (3.15%) | 3 (2.91%) | >0.999 |
| Urinary tract infection | 5 (3.94%) | 1 (0.97%) | 0.228 |
| Pneumonia | 3 (2.36%) | 1 (0.97%) | 0.630 |
| Sepsis/septic shock | 5 (3.94%) | 1 (0.97%) | 0.228 |
| Wound dehiscence | 2 (1.57%) | 2 (1.94%) | >0.999 |
| Venous thromboembolism | 4 (3.14%) | 3 (2.91%) | >0.999 |
| Deep venous thrombosis | 1 (0.79%) | 1 (0.97%) | >0.999 |
| Pulmonary embolism | 3 (2.36%) | 2 (1.94%) | >0.999 |
| Myocardial infarction/MINS | 10 (7.87%) | 3 (2.91%) | 0.151 |
| Intra- or post-operative transfusion | 30 (23.62%) | 22 (21.36%) | 0.803 |
| Return to the operating room | 4 (3.15%) | 3 (2.91%) | >0.999 |
| Readmission | 9 (7.09%) | 5 (4.85%) | 0.670 |
| Death | 1 (0.79%) | 0 (0%) | >0.999 |
ERAS, Enhanced Recovery After Surgery; SD, standard deviation; MINS, myocardial injury after noncardiac surgery.
Multivariable regression analysis of 30-day outcomes in patients with or without ERAS implementation.
| Outcome | Unadjusted OR (95% CI) | P-value | Adjusted OR (95% CI) | P-value |
|---|---|---|---|---|
| Length of hospital stay (days) | 0.46 (0.27, 0.79) | 0.005 | 0.43 (0.25, 0.75) | 0.003 |
| Complications | 0.61 (0.32, 1.18) | 0.138 | 0.62 (0.32-1.19) | 0.154 |
| Postoperative infections | 0.68 (0.31, 1.50) | 0.338 | 0.69 (0.32-1.51) | 0.349 |
| Total surgical site infection | 0.74 (0.29, 1.86) | 0.525 | 0.75 (0.31-1.86) | 0.529 |
| Superficial incisional infection | 0.92 (0.31, 2.74) | 0.881 | 0.94 (0.33-2.69) | 0.908 |
| Deep incisional infection | 0.24 (0.01, 5.11) | 0.370 | 0.24 (0.01-5.11) | 0.370 |
| Organ/space infection | 0.92 (0.20, 4.22) | 0.915 | 0.96 (0.23-3.96) | 0.955 |
| Urinary tract infection | 0.24 (0.03, 2.08) | 0.187 | 0.33 (0.05-2.02) | 0.240 |
| Pneumonia | 0.41 (0.04, 3.96) | 0.447 | 0.52 (0.08-3.59) | 0.500 |
| Sepsis/septic shock | 0.24 (0.03, 2.08) | 0.187 | 0.33 (0.05-2.02) | 0.240 |
| Wound dehiscence | 1.24 (0.17, 8.94) | 0.831 | 1.24 (0.21-7.28) | 0.812 |
| Venous thromboembolism | 1.24 (0.24, 6.28) | 0.796 | 1.24 (0.28-5.58) | 0.778 |
| Deep venous thrombosis | 1.24 (0.08, 20.00) | 0.879 | 1.23 (0.13-12.04) | 0.858 |
| Pulmonary embolism | 0.82 (0.13, 4.99) | 0.831 | 0.88 (0.17-4.54) | 0.879 |
| Myocardial infarction/MINS | 0.35 (0.09, 1.31) | 0.124 | 0.39 (0.11-1.34) | 0.140 |
| Intra-/postoperative blood transfusion | 0.88 (0.47, 1.64) | 0.688 | 0.88 (0.48-1.64) | 0.683 |
| Return to the operating room | 0.92 (0.20, 4.22) | 0.915 | 0.96 (0.23-3.96) | 0.955 |
| Readmission | 0.67 (0.22, 2.06) | 0.483 | 0.70 (0.24-2.06) | 0.515 |
| Death | 0.41 (0.02, 10.11) | 0.575 | 0.41 (0.02-10.11) | 0.575 |
ERAS, Enhanced Recovery After Surgery; OR, Odds ratio; CI, confidence interval; MINS, myocardial injury after non-cardiac surgery.
Analysis of postoperative pain (numerical analog scale).
| Pain rating | ERAS, n (%) | Non-ERAS, n (%) | χ2 | P-value |
|---|---|---|---|---|
| 1st postoperative day | 4.96 | 0.026 | ||
| Moderate (4-6) | 49 (47.6) | 41 (32.3) | ||
| Severe (7-10) | 54 (52.4) | 86 (67.7) | ||
| Pain score (Mean ± SD) | 5.57±1.50 | 6.03±1.40 | ||
| 2nd postoperative day | 42.46 | <0.001 | ||
| Mild (1-3) | 15 (14.6) | 0 (0) | ||
| Moderate (4-6) | 77 (74.8) | 72 (56.7) | ||
| Severe (7-10) | 11 (10.7) | 55 (43.4) | ||
| Pain score (Mean ± SD) | 4.03±1.24 | 5.30±1.49 | ||
| 3rd postoperative day | 69.88 | <0.013 | ||
| Mild (1-3) | 72 (69.9) | 21 (16.5) | ||
| Moderate (4-6) | 31 (30.1) | 98 (77.2) | ||
| Severe (7-10) | 0 (0.0) | 9 (7.1) | ||
| Pain score (Mean ± SD) | 2.60±0.92 | 3.88±1.13 |
ERAS, Enhanced Recovery After Surgery; SD, standard deviation.