The results of this study might indicate that the implementation of the abbreviation of preoperative fasting with clear liquid containing carbohydrate and protein, oral and early refeeding, early mobilization and thromboprophylaxis according to the recommendations of the ERAS protocol are plausible, reproducible in medical practice In addition, that practical recommendations minimize negative outcomes and favor postoperative recovery on urogynecological surgeries.
These results from the application of the ERAS protocol in urogynecological practice are in line with the results of numerous studies of application of the same recommendations in surgeries in other areas, such as gynecological, gastrointestinal, oncological, orthopedic and even pediatric surgeries [1–9].
Recent guidelines of medical societies recommend that the use of preoperative carbohydrate-rich beverages should be encouraged with the purpose to attenuate insulin resistance induced by surgery and starvation after colon, rectal surgical procedures and gynecological surgeries [12, 19]. Years of success using ERAS in colorectal surgery have helped to establish a body of evidence through a number of randomized controlled trials that encourage application of these pathways in other surgical specialties [12, 19–21].
Robust analysis included 27 trials involving 1,976 participants to assess the effects of preoperative carbohydrate treatment, compared with placebo or preoperative fasting, on postoperative recovery and insulin resistance in adult patients undergoing other elective surgeries [21]. The authors reported improved postoperative outcomes, including decreased insulin resistance or increased postoperative peripheral insulin sensitivity [21]. Those trials were conducted in Europe, China, Brazil, Canada, and New Zealand and involved patients undergoing elective abdominal surgery, orthopedic surgery, cardiac surgery, thyroidectomy and on gynecological surgeries [20].
Aguilar-Nascimento et al. [15] reported that prolonged fasting negatively affected elective surgery patients, increasing insulin resistance, incidence of nausea and vomiting, and length of hospital stay. Meta-analyses of randomized controlled trials on preoperative oral carbohydrate treatment in elective surgery confirmed the safety and physiological benefits of preoperative carbohydrate [12, 22, 23].
Given the current recommendations on perioperative care, the traditional rules of preoperative fasting subjectively compromise the comfort of the surgical patient, who wants the safe liberalization of these rules [13, 24–26]. Efforts to reduce postoperative symptoms, such as pain, anxiety, and preoperative tension, as well as to value perioperative satisfaction, are highlighted in this study. These measures may provide a positive impact on the quality of perioperative care from the perspective of the surgical patient [13, 24, 27].
In a recent systematic review of satisfaction predictors, patient’s perception in relation to a good pain management has been the most consistent factor associated with high satisfaction [11, 13, 27], which has also favored early mobilization and discharge and, consequently, greater well-being [13, 27]. Thus, the implementation of recovery acceleration has been associated with less pain, reduction of hospital stay, and postoperative morbidity, good satisfaction, and cost reduction [13, 27].
Among all the possible complications resulting from the mistaken practice of absolute bed rest in the postoperative period, the most fearful is Venous Thromboembolism (VTE). Despite significant advances in the prevention and treatment of VTE, pulmonary embolism remains the leading cause of preventable death in the hospital environment. In the practice of urogynecologists, gynecologists or urologists, there are medical and mechanical methods that can be used to prevent VTE [15–18].
According to ERAS protocol, early mobilization was recommended for all patients of this study. This practice can prevent or minimize the occurrence of various complications during the surgical patient's evolution. It is up to the urogynecologist to inform the patient of the need to walk early and get out of bed on the same day and in the days following the procedure. In a didactic way, it was possible to exemplify the stay out of bed on walks through the hospital, or in areas intended for walking for 2 hours on the day of surgery, and 6 hours on the following days at home [1, 15–18].
Current ERAS protocols indicate the use of the Caprini model. Therefore, according to ERAS protocol, the practice of this study in urogynecological surgeries, was at least ultra-early mobilization with or without compression stockings (very low and low risk) and the use of drug prophylaxis are recommended (moderate and high risk)[1, 15–18]. The outcomes of that practice indicate that there was no patient with VTE.
4.1. Strengths and limitations
The positive point of this study is that it aligns with the ERAS protocols of main gynecological and urogynecological societies such as IUGA, AUGS, ACOG, ESPEN, ERAS Society and others which focus on nutritional therapies and perioperative care. According to the cited societies, the basic principles of ERAS include attention to the following: preoperative counseling and nutritional strategies, including communication with the pre-admission patient, avoidance of prolonged perioerative fasting, encourage early postoperative oral nutrition, prevent nausea and vomiting, avoid excess fluid in the perioperative period, focus on regional anesthetic and nonopioid analgesic approaches, fluid balance, and maintenance of normothermia; and promotion of postoperative recovery strategies, including early mobilization and appropriate thromboprophylaxis [1–9]. Practically, all recommendations work as a fit where one measure favors the other. In this sense, the abbreviation of preoperative fasting and prevention of thrombosis may be the starting point to favor the other measures.
The main limitation of this guideline lies in the fact that it is a non-randomized clinical trial. As this is a recommended protocol with benefits for the patient, a randomized control group without receiving the benefits would be ethically inadvisable. In addition, the objetive of this study was to evaluate in urogynecological practice the application of the main ERAS recommendations. There are still few publications on the implementation of the ERAS protocol in urogynecology, although there are numerous randomized studies that prove the benefits of abbreviation of fasting with clear liquid enriched with carbohydrates and proteins in the medical literature. Furthermore, the authors report the challenge of establishing general recommendations for the adequacy of practical applicability for each hospital service in different countries.
Finally, the success of program implementation of ERAS protocols in Urogynecology can be dependent on collaboration, communication among a multidisciplinary team including urogynecologists, physical therapists, dieticians, social workers, such other areas, as well as the center of innovation: the urogynecological patient.