A group of European surgeons founded the Enhanced Recovery after Surgery (ERAS) Society in the early 2000s with the goal of enhancing recovery via audit, research, education, and the implementation of evidence-based practice (ERAS Society standards). In 2003, Marx and associates illustrated this idea in gynecologic oncology, whereas earlier studies primarily focused on colorectal surgery. [1] Today, ERAS is a globally recognized surgical quality improvement program that provides both clinical and economic benefit to the healthcare system. [2] The primary goal of the ERAS is to reduce length of hospital stay by promoting early return to daily activities following surgery, thereby decreasing postoperative complications and overall health care costs. The ERAS approach focuses on minimizing perioperative surgical stress, early mobilization, accelerating the return of gastrointestinal function, and ensuring effective multimodal pain management. [3, 4] Gynecologic surgery is one of the surgical specialties that has successfully integrated ERAS protocols. [5] Moreover, the use of this pathway in gynecologic oncology has been promoted by randomized controlled trials. The ERAS perioperative pathway consist of three stages: The guidelines emphasize the value of preoperative patient education and counseling throughout the preoperative phase, as well as patient optimization before surgery. Preoperative optimization is accomplished by promoting a decrease in alcohol and tobacco use, unnecessary preoperative fasting and dehydration. key components of perioperative ERAS protocol include prophylactic antiemetics, antimicrobial prophylaxis, thromboembolism prophylaxis, and multimodal analgesia to minimize opioid use and prevent complications. Intraoperative ERAS guidelines aims to minimize use of unnecessary tubes and drains while maintaining normovolemia and normothermia. [6] Postoperatively, the focus remains on restoring normal physiology by encouraging early oral intake, optimizing nutrition and promptly removing intravenous lines and urinary catheters. The use of multimodal non-narcotic analgesia, gut stimulation, and early mobilization all contribute to the prevention of ileus. [7] Enhanced recovery protocols include: 1) Comprehensive patient surgical expectations and goals ; 2) a significantly shorter preoperative fasting period and active use of oral electrolyte and carbohydrate fluids until surgery; 3) a multimodal pain management regimen that includes regional anesthesia and non-opioid analgesics to reduce opioid use; and 4)Early resumption of normal diet and physical activity. These methods have been tested in a wide range of surgical situations and have consistently given result of shorter hospital stays and better surgical outcomes. [8, 9]. Despite substantial supporting evidence adherence to ERAS guidelines are suboptimal due to various implementation barriers.  Thus, this study aims to evaluate the effectiveness of ERAS protocols in minimizing postoperative stress responses and enhancing recovery in a tertiary care setting.

Study design: Randomized controlled trial.

Place of study: Rajendra Institute of Medical Sciences, Ranchi, Jharkhand.

Period of study: 1 year (1st June 2023 to 31st mat 2024)

Sample size: 220 female patients undergoing gynecological surgeries ERAS Group (n = 110) and Conventional Group (n = 110)

Inclusion Criteria

• Female patients aged >18 years
• Undergoing elective gynecological surgeries as mentioned above
• Willing to participate and provide consent

Exclusion Criteria

• Female patients aged <18 years
• Body Mass Index (BMI) >30 kg/m²
• Patients with diabetes mellitus
• Patients unwilling or unable to comply with the ERAS protocol

Study Parameter:

• Age
• Day of mobilization
• Day of oral feeding
• Pain score with Visual Analog Scale
• I/V Fluids (IN ML)
• Post-operative quality of recovery Score (QOR-15)
• Length Of Hospital Stay (In Days)
• Day Of Passage Of Stool
• Wound status (e.g. Presence of infection, discharge)

Study Protocol

Eligible patients were randomly allocated into ERAS and conventional care groups. The ERAS group was managed according to ERAS protocols in preoperative and postoperative periods while the conventional group received standard perioperative care.

Statistical Analysis:-

Data were initially entered into a Microsoft Excel and analyzed using SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism (version 5).Two sample t test were used to compare independent groups while paired t test accounted for correlations in paired data. Chi- square tests were used for categorical data comparisons. P-values ≤ 0.05 were considered statistically significant.

Table 1: Comparison of day of mobilization and oral feeding in both groups

Table 2: Comparison of pain score, of I/V FLUIDS (in ml), post-operative QOR-15 score and length of hospital stay (days) in both groups

Table 3: Comparison of day of passage of stool in both groups

Table 4: Comparison of wound status in both groups

Table 5: Comparison of Tramadol Use in both groups

There is no discernible difference in the mean age of the ERAS (Enhanced Recovery after Surgery) and conventional groups. With 109 participants, the conventional group's mean age was 46.183 years (SD = 10.165, SEM = 0.974), while the ERAS group's mean age was 44.423 years (SD = 11.887, SEM = 1.128). These results suggest that there is no statistically significant difference in the mean ages of the two groups. With 109 participants, the conventional group's mean weight was 57.46 kg (SD = 6.89, SEM = 0.66), while the ERAS group's mean weight was 57.69 kg (SD = 6.94, SEM = 0.66). These results suggest that there is no statistically significant difference in the mean weights of the two groups. There is no discernible difference between the two groups' surgical recovery times. Out of 220 patients, 111 (50.5%) were mobilized on Day 0 (all from the ERAS group), and 109 (49.5%) were mobilized on Day 2 (all from the Conventional group), according to the overall distribution. This implies that, in comparison to the Conventional procedure, the ERAS protocol considerably speeds up patient mobilization. One patient (0.5%) started oral feeding on Day 2 (from the Conventional group), 108 patients (49.1%) started on Day 1 (all from the Conventional group), and 111 patients (50.5%) started on Day 0 (all from the ERAS group). There is a highly significant difference (p < 0.001) between the two groups with respect to the day of oral feeding, as indicated by the chi-square value of 220 and the p-value being less than 0.001. This indicates that, in contrast to the Conventional protocol, the ERAS protocol considerably encourages early oral feeding. With a standard deviation (SD) of 0.88 and a mean pain score of 7.35, the Conventional Group exhibits somewhat variable and comparatively high pain levels. With a similar standard deviation (SD) of 0.86 and a substantially lower mean pain score of 3.16, the ERAS group exhibits comparable variability to the Conventional group despite having lower pain levels. This outcome shows that, in comparison to patients in the Conventional group, individuals in the ERAS group have noticeably less discomfort. I/V fluids in the Conventional Group have a mean volume of 4454.86 ml and a standard deviation (SD) of 332.22 ml, which indicates considerable variability. With a mean volume of I/V fluids of 2230.99 ml and a standard deviation (SD) of 156.99 ml, the ERAS Group exhibits less variability than the Conventional group. This outcome shows that, in comparison to patients in the Conventional group, individuals in the ERAS group receive noticeably less intravenous fluid. With a mean post-operative QOR-15 score of 116.73 and a standard deviation (SD) of 5.53, the ERAS Group exhibits much less variability than the Conventional group. In comparison to patients in the Conventional group, this finding shows that patients in the ERAS group had considerably higher post-operative QOR-15 ratings, indicating a greater quality of recovery. There is some heterogeneity in the conventional group's mean length of hospital stay, which is 5.17 days with a standard deviation (SD) of 1.38 days. With a somewhat larger standard deviation (SD) of 1.55 days and a much shorter mean length of hospital stay of 4.26 days, the ERAS Group exhibits greater variability than the Conventional group. This outcome shows that, in comparison to patients in the Conventional group, individuals in the ERAS group have a noticeably shorter hospital stay. In our research Of the 220 patients, 96 (43.6%) had passage of stool on the first day, 17 (7.7%) on the second, 67 (30.5%) on the third, and 40 (18.2%) on the fourth. Regarding the day of stool transit, there is a highly significant difference (p < 0.001) between the two groups, as indicated by the chi-square value of 212.941 and the p-value of less than 0.001. This implies that, as comparison to the Conventional procedure, the ERAS protocol considerably results in early return of bowel function. There were 22 patients (10.0%) with unhealthy wounds in the Conventional and ERAS groups, with 11 individuals (10.1% and 9.9%, respectively) in each group. There is no significant difference (p > 0.05) in the wound status of the two groups, as indicated by the chi-square value of 0.002 and the p-value of 0.964. This implies that in terms of wound health, the Conventional and ERAS treatments produce comparable results. The mean total costs for patients with healthy wounds differ significantly from those with unhealthy wounds when comparing the traditional and ERAS (Enhanced Recovery After Surgery) groups based on wound status. The average overall cost for patients with healthy wound s was $3,197.04 (SD=181.56, SEM=18.34) in the traditional group (N=98), but it was much lower in the ERAS group (N=100) at $2,374.25 (SD=226.65, SEM=22.66). There was a highly significant difference favoring the ERAS group in terms of cost reduction, as indicated by the comparison's t-statistic of 28.158 and p-value of less than 0.001.  In contrast, the mean total cost for patients with unhealthy wounds was 11,447.45 (SD=15,933.52, SEM=4,804.14) in the ERAS group (N=11) and $7,394.27 (SD=2,214.64, SEM=667.74) in the conventional group (N=11). With a p-value of 0.413 and a t- statistic of -0.836, there was no discernible difference between the two groups. Accordingly, the study demonstrates that the length of hospital stay and wound condition also affect ERAS cost reduction. A total of 220 patients were analyzed, with 109 in the Conventional group and 111 in the ERAS group. The use of tramadol was significantly higher in the Conventional group, where 99 patients (90.8%) required tramadol compared to only 3 patients (2.7%) in the ERAS group. Conversely, only 10 patients (9.2%) in the Conventional group did not receive tramadol, while 108 patients (97.3%) in the ERAS group did not require it. The difference between the groups was statistically significant (Chi-square = 171.739; p < 0.001).

The purpose of this study was to ascertain how ERAS procedures affected patients having major gynecologic surgery in terms of their postoperative recovery. One of the most fascinating advancements in perioperative care surgery in recent years is the creation of structured multimodal therapy programs, or ERAS protocols. By reducing the metabolic stress caused by surgery and combining it with therapies that encourage the reversal of functions that, in traditional care, slow down the healing process, ERAS programs aim to accelerate the patient's recovery. There is no discernible difference in the mean age of the conventional and ERAS (Enhanced Recovery after Surgery) groups in our study. This is in line with the Goswami et al. [10] study, which found that patients between the ages of 41 and 50 made up the largest group, followed by those between the ages of 31 and 40. There were no appreciable variations between the two groups' patient demographics, according to a research by Gulseren Yilmaz et al. [11]. There is no discernible difference in the mean weight of the ERAS (Enhanced Recovery after Surgery) and standard groups. According to the study by Bahadur A et al., there is no appreciable variation in mean weight between the conventional and ERAS (Enhanced Recovery after Surgery) groups. [12]. Out of 220 patients, 111 (50.5%) were mobilized on Day 0 (all from the ERAS group), and 109 (49.5%) were mobilized on Day 2 (all from the Conventional group), according to the overall distribution. This implies that, in comparison to the Conventional procedure, the ERAS protocol considerably speeds up patient mobilization. The ERAS group ambulated earlier than the conventional care group (20.3 ±1.5 h vs. 23.9 ±3.3 h, p = 0.008), according to a research by Yilmaz et al. [13]. When compared to the conventional procedure, the ERAS protocol in this study considerably encourages early oral feeding. The ERAS group needed less time to consume solid meals than the traditional care group, P < 0.001, according to research by Yilmaz et al. [13] (13.9 ±4.2 h vs. 18.7 ±5.1 h). According to Gulseren Yilmaz et al. [11], the ERAS group had a significantly shorter time to eating solid meals (p < 0.001). Patients in the ERAS group report substantially less pain than those in the Conventional group, according to the mean pain score. Weston E et al. found that the pain scores of the ERAS MIS cohort were 0.56 points lower (p = 0.013) [14]. Despite this, Chapman et al. showed a 30% decrease in opioid use (31 mg vs. 44 mg IV morphine equivalents, p < 0.01) and reported lower postoperative pain scores of 2.6 vs. 3.12 (p = 0.03). [15]. In our study, the ERAS protocol considerably lowers the need for Tramadol as compared to the Conventional treatment. The ERAS group experienced a decrease in opioid use during the perioperative and postoperative periods, according to C. Aubrey et al. [16]. After ERAS was implemented for major gynecologic surgery, Modesitt et al. published an ERAS "light" regimen for MIS surgery that showed decreased opioid use in the intraoperative and postoperative contexts. [17]

The study's findings indicated that, in comparison to the conventional protocol, the ERAS treatment considerably speeds up the passing of feces.  This is in line with the Goswami et al.

[10] study, which shown that the ERAS group experienced a quicker recovery in gastrointestinal function. In a double-blind, randomized controlled trial of patients after abdominal hysterectomy, Hansen et al. discovered that the ERAS group had a 24-hour head start in time to defecation in comparison to the controls. [18] The outcome also shows that, in comparison to patients in the Conventional group, those in the ERAS group receive noticeably less intravenous fluid. Gulseren Yilmaz et al. found that the ERAS group had significantly fewer intravenous fluids given during and after surgery (p < 0.001). [11] According to Won-Ji Kim et al., the ERAS group received significantly fewer intravenous fluids both during and after surgery. [19] According to the study's findings, patients in the ERAS group recovered more effectively than those in the Conventional group, as evidenced by their significantly higher post -operative QoR- 15 ratings. According to Shen Y et al. [20], the QoR-15 ratings of the two groups on the day before the procedure did not differ significantly. Three of the five QoR-15 dimensions—pain (P

<0.05), physical independence (P <0.05), and physical comfort (P <0.05)—showed superiority for the ERAS groups. According to Ren Yet al., the ERAS group recovered faster and more efficiently than the control group, as indicated by the QoR-15 scale. [21] Those in the ERAS group in our study stay in the hospital for a much shorter period of time than those in the Conventional group. The results of an observational research by Wijk et al. demonstrated that the percentage of patients who are discharged from the hospital two days after surgery is considerably increased when the ERAS method is used. [22] Similarly, Mukhopadhyay found that patients undergoing open hysterectomies experienced a shorter length of stay (LOS) of three days instead of five days when ERAS protocols were used. [23] The mean total costs for patients with healthy wounds differ significantly from those with unhealthy wounds when comparing the traditional and ERAS (Enhanced Recovery After Surgery) groups based on wound status. Pache B et al. discovered significant cost reductions from the use of ERAS in gynecologic surgery. [24] Cost-efficiency was demonstrated by Bell A et al., who claimed a 15% cost decrease for single gynecological procedures, such as benign vaginal hysterectomy. [25]

The present study demonstrated a markedly reduced requirement of tramadol in the ERAS group compared to the Conventional group, highlighting the effectiveness of ERAS protocols in minimizing postoperative opioid consumption. These findings are consistent with the study by Liang et al. (2018), [26] which reported significantly lower opioid use in patients managed under ERAS protocols following abdominal surgery. Similarly, Lv et al. (2020) [27] observed reduced postoperative analgesic requirements and faster recovery among ERAS patients undergoing colorectal surgery. The reduced need for tramadol in the ERAS group in our study supports the growing body of evidence that ERAS pathways, through multimodal analgesia and optimized perioperative care, can effectively decrease opioid consumption while maintaining adequate pain control.

The effectiveness of ERAS lies in its ability to minimize the physiological stress response while preserving normal body functions throughout the perioperative period. Early ambulation and early initiation of oral feeding are key components that contribute to reduced hospital stays. Patients in the ERAS group recovered their gastrointestinal functions earlier and had better food tolerance on the first postoperative day. The new study contributes to the growing body of evidence suggesting that a well implemented ERAS program facilitates faster, early discharge, and improves patient and quality of life.

1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630–641. doi:10.1016/S0002-9610(02)00866-8
2. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg. 2017;152(3):292–298. doi:10.1001/jamasurg.2016.4952
3. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Gynecol Oncol. 2016;140(2):313–322. doi:10.1016/j.ygyno.2015.11.015
4. Nygren J, Thacker J, Carli F, Fearon KC, Norderval S, Lobo DN, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr. 2012;31(6):801–816. doi:10.1016/j.clnu.2012.08.012
5. Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, et al. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Gynecol Oncol. 2019;153(1):114–121. doi:10.1016/j.ygyno.2018.12.023
6. Feldheiser A, Aziz O, Baldini G, Cox BP, Fearon K, Feldman LS, et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anesthesia practice. Acta Anaesthesiol Scand.
7. Ljungqvist O, Hubner M, Francis N, Ichikawa J, Kurz A, Mythen M, et al. Enhanced Recovery After Surgery Society Recommendations for Implementation of Enhanced Recovery Pathways: An International Consensus. World J Surg.
8. Lv F, Song J, He Y, Lin J, Wang G. Enhanced recovery after surgery (ERAS) versus conventional perioperative care in laparoscopic gynecological surgery: a meta-analysis. Arch Gynecol Obstet. 2021;303(1):11–23. doi:10.1007/s00404-020-05769-8
9. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ, et al. Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220(4):430–443. doi:10.1016/j.jamcollsurg.2014.12.042
10. Goswami S, Singh A, Goel S, et al. Impact of enhanced recovery after surgery protocol on postoperative outcomes in gynecological oncology. J Obstet Gynaecol India. 2017;67(5):347–351.
11. Yilmaz G, Uyar O, Oztekin MK, et al. The effect of enhanced recovery after surgery protocol on recovery in gynecologic oncology patients: a prospective cohort study. J Gynecol Oncol. 2018;29(4):e89.
12. Bahadur A, Wadhwa R, Anand S, et al. Enhanced recovery after surgery (ERAS) versus conventional care in radical hysterectomy: a randomized controlled trial. Int J Gynecol Cancer. 2019;29(4):673–678.
13. Yilmaz G, Uyar O, Oztekin MK, et al. Enhanced recovery after surgery in gynecologic oncology: effect on postoperative outcomes and hospital stay. J Obstet Gynaecol Res. 2018;44(10):1869–1875.
14. Weston E, Holbert C, Jorgensen S, et al. Enhanced recovery after minimally invasive gynecologic surgery: effect on pain and opioid use. J Minim Invasive Gynecol. 2020;27(2):420–425.
15. Chapman JS, Roddy E, Ueda S, et al. Enhanced recovery pathways reduce opioid use and length of stay after open gynecologic surgery. Gynecol Oncol. 2016;141(3):555–559.
16. Aubrey C, Gillis C, Thorpe KE, et al. Impact of enhanced recovery protocols on opioid consumption after gynecologic surgery. Am J Obstet Gynecol. 2018;219(5):459.e1–459.e7.
17. Modesitt SC, Sarosiek BM, Trowbridge ER, et al. Enhanced recovery implementation in major gynecologic surgeries: effect on length of stay and narcotic use. Am J Obstet Gynecol. 2016;214(3):364.e1–364.e7.
18. Hansen CT, Møller C, Daugbjerg SB, et al. Fast-track abdominal hysterectomy. A randomized, clinical trial. Acta Obstet Gynecol Scand. 2008;87(3):345–351.
19. Kim WJ, Kim KH, Lee SH, et al. The effect of enhanced recovery after surgery program on perioperative fluid management in gynecologic surgery. J Obstet Gynaecol Res. 2019;45(3):547–554.
20. Shen Y, Wang W, Yu X, et al. Effect of enhanced recovery after surgery (ERAS) on quality of recovery in patients undergoing laparoscopic gynecological surgery: a randomized controlled trial. Medicine (Baltimore). 2018;97(24):e11181.
21. Ren Y, Wang Y, Chen X, et al. Enhanced recovery after surgery (ERAS) pathway improves postoperative recovery in laparoscopic myomectomy: a randomized controlled trial. Medicine (Baltimore). 2019;98(32):e16619.
22. van Wijk L, van der Plas WY, Prins HA, et al. The enhanced recovery after surgery (ERAS) program in gynecologic oncology: a systematic review and meta-analysis. Gynecol Oncol. 2020;159(3):780–790.
23. Mukhopadhyay S, Twomey A, Naughton F, et al. Enhanced recovery after surgery in benign gynecological procedures: a prospective observational study. J Obstet Gynaecol. 2016;36(7):853–857.
24. Pache B, Grass F, Demartines N, et al. Cost-analysis of enhanced recovery after surgery (ERAS) programs in colorectal surgery. World J Surg. 2017;41(3):586–592.
25. Bell A, Taylor M, Althausen P, et al. Cost savings associated with an enhanced recovery protocol for benign gynecologic surgery. J Minim Invasive Gynecol. 2019;26(3):457–462.
26. Liang X, Ying H, Wang H, et al. Enhanced recovery after surgery programs versus traditional care in laparoscopic colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum. 2018;61(5):650–662.
27. Lv F, Wang B, Meng Y, et al. Effect of enhanced recovery after surgery on postoperative recovery in colorectal cancer patients. Medicine (Baltimore). 2020;99(18):e20060.