Enhanced Recovery after Surgery (ERAS) for Minimally Invasive Gynecologic Oncology Surgery: A Review
Round 1
Reviewer 1 Report
General Comments:
The manuscript provides a comprehensive review of the impacts of ERAS in patients undergoing minimally invasive gynecologic oncology surgery. The focus on specific benefits such as decreased length of hospital stay, cost savings, reduced opioid use, and patient satisfaction is commendable. The authors systematically extracted data from the existing literature to provide evidence-based insights. The paper is generally well-structured, coherent, and well-written.
Specific Comments:
1. Introduction
The introduction succinctly presents the evolution and significance of ERAS across surgical disciplines, specifically gynecologic oncology surgery. It might be beneficial to provide brief insights into the principles or key elements of ERAS to give readers unfamiliar with the concept a clearer understanding.
2. Materials and Methods
The methodology employed is clearly laid out, providing a transparent view of the search strategy and inclusion criteria. The only recommendation would be to clarify the exact exclusion criteria or any biases that might be present in the study selection.
3. Results
The results are thorough and detailed. The sub-sectioning of the results into specific outcomes (like SDD rates, cost savings, opioid use, and patient satisfaction) is useful for clarity. The repeated mention of specific study findings may make this section slightly verbose. Perhaps summarizing similar findings could enhance the readability without compromising the information's richness.
4. Additional Recommendation on Visual Presentation:
Inclusion of a Flowchart or Table for ERAS Process: I recommend the inclusion of a visual representation, preferably a flowchart or a simplified table, to illustrate the ERAS process for minimally invasive gynecologic oncology surgery. This can assist readers in quickly understanding the fundamental steps and critical considerations of the ERAS protocol.
The flowchart could visually break down:
- Preoperative preparations - such as patient education, nutritional optimization, and psychological support.
- Intraoperative practices - detailing anesthesia protocols, surgical techniques, and fluid management.
- Postoperative care - highlighting early mobilization, dietary resumption, and pain management strategies.
This kind of visual breakdown would provide a concise snapshot of the ERAS journey, making the process more digestible for readers.
5. Additional Visual Recommendation:
- Bar Graph or Pie Chart for Results: To better present the data on the benefits of ERAS in MIS gynecologic oncology surgery, consider including a bar graph or pie chart. This could visually showcase the percentages of patients benefiting from reduced hospital stays, reduced opioid use, and other benefits of the ERAS protocol. For instance, a bar graph showing the percentage of patients discharged on the same day pre-ERAS and post-ERAS would vividly illustrate the protocol's impact.
- Infographic on Opioid Reduction: Given the significance of reduced opioid use in the current healthcare climate, a dedicated infographic highlighting the percentage decrease in opioid use, the alternatives employed, and the benefits to patients (like reduced pain scores) would be valuable.
Incorporating these visuals will not only enrich the presentation of your findings but also cater to a broader audience who might find visual data more accessible and engaging.
Author Response
Reply to reviewer 1
Introduction:
-A summary statement of the components of an ERAS program has been added for additional clarity
Materials and Methods:
-Exclusion criteria have been added
Results:
-Given the word recommendations, we have elected to keep the discussion length the same as further making it succinct will drastically decrease the word count.
Additional Recommendation on Visual Presentation:
-We have added an infographic on opioid reduction within ERAS MIS in gynecologic oncology. Due to the nature of this review we felt that an overview of the ERAS program would detract from the main point of the study, which is not to review ERAS but rather to increase awareness of the benefits of ERAS within this population
Reviewer 2 Report
Appreciate Authors ; well written manuscript .
Comments
1: In Table 1 primary outcome column is empty for Levytska et al (2022).
2: While it is a comprehensive review of enhanced recovery practices, well-known for their benefits in Western countries, it is essential to note that from the perspective of a gynaecologist or gynecologic oncologist, there is a noticeable gap in disease-specific evidence regarding the feasibility of ERAS protocols, especially for patients with advanced disease
I had anticipated that the authors might provide additional insights, particularly concerning more advanced cases. This expectation stems from the awareness that studies reporting on the clinical advantages of Enhanced Recovery After Surgery (ERAS) in ovarian cancer patients exhibit significant heterogeneity and variations in quality.
I would like to propose the inclusion of an additional column in Table 1, where the authors could delve into:
- Details regarding the type of minimally invasive surgery performed (e.g., Robotic vs. Total Laparoscopic Hysterectomy, Uterine cancer vs. ovarian cancer vs. lymphadenectomies etc.).
Suggestion AND /OR: Can also Write a paragraph about ERAS effectiveness for advanced diseases like ovarian cancers / additional procedures like lymphadenectomies etc
Quality is good
Author Response
1:
-the table formatting has been fixed
2:
-The studies included were heterogenous in what was included, most all included both robotic and laparoscopic procedures, and majority of studies did not comment on the extent of surgical procedures completed.
the majority of diagnosis in the studies were uterine carcinoma, and generalizable information has been added to the results section, 1st paragraph. We feel due to how heterogeneous the studies were in this regard, that inclusion of these specifics would detract from the main message of the paper.
Round 2
Reviewer 1 Report
I appreciate the efforts made to address the feedback. The revisions have enhanced the manuscript and its contribution to the field.
Reviewer 2 Report
Still In Table 1 primary outcome column is empty for Levytska et al (2022). Add primary outcome for this study
Good
