Is enhanced recovery after surgery essential?

The enhanced recovery after surgery (ERAS) method is designed for the patient to recover quickly, have less pain and have a more comfortable period after the surgery; that includes preoperative, intra and postoperative processes. ERAS has been started to be applied in cesarean section surgeries as the patients need to recover quickly. In the literature, there is no study about the results of ERAS in cesarean section about pain scores and complications.


INTRODUCTION
The enhanced recovery after surgery (ERAS) method is now a method that is applied in the perioperative period in most colorectal, urologic, gynecologic, and hepatobiliary surgeries, aiming for the rapid recovery of the patient. 1,2The aim of this rapid recovery is to reduce the length of hospital stay, minimize complications, and prevent readmissions. 2ith 18.5 million operations per year, cesarean section has become the most frequently performed major surgery in the world.The ERAS method is also used in cesarean section surgery.Unlike other major surgeries, ERAS is also planned for cesarean section operations, as it is aimed to return the mother and the baby to daily life as soon as possible.While using the ERAS method in cesarean section surgery, there are applications performed before, during, and after the surgery.
Preoperative procedures are done 30-60 min before cesarean section.The preoperative ERAS method is valid for both planned and unplanned/emergency cesarean sections. 3Cervical dilatation for uterine drainage in the preoperative period, drainage to the wound site for infection prevention, or preoperative oxygen administration to the mother is not recommended. 4Although the use of sedating drugs such as fentanyl and midazolam before cesarean section is controversial, it is not recommended in premedication as it will prevent skin-to-skin contact with the baby or cause a loose baby. 5In a prospective study with preoperative carbohydrate loading, no benefit was found compared to fasting pregnant women. 6Preoperative bowel preparation is not recommended.
Maternal hypotension due to regional anesthesia during surgery is the most common cause of nausea and vomiting, and to prevent it, colloid or crystalloid preloading, the intravenous administration of ephedrine or phenylephrine, and lower limb compression (by bandages, stockings, or inflatable boots) can be performed. 7n ERAS, early nutrition, early mobilization, early withdrawal of the urinary catheter after 6 h, adequate analgesia and thromboembolism prophylaxis are performed in the postoperative period.
Preoperative/intraoperative and postoperative procedures to be performed in the ERAS method are as follows.
Preoperative As you can see, the ERAS protocol includes very detailed steps and things to do.In our study, we aimed to evaluate the complications, recovery, and pain scores by dividing the patients into groups, especially by performing some of the procedures to be performed in the postoperative period and not performing some of them.It is aimed to compare the results of cesarean section patients using the ERAS method completely in patients who have had cesarean section without meeting some of the postoperative conditions of the ERAS criteria.

METHOD
As of 2023, patients who had non-emergent and emergent cesarean section by regional anesthesia at Şanlıurfa Training and Research Hospital will be prospectively divided into four groups: Group 1: The ERAS protocol was fully applied, postoperative enema-metoclopramide of the ERAS protocol and opioids were used for pain control.
Group 2: ERAS protocol was fully applied, postoperative enema-metoclopramide belonging to ERAS protocol was used.
Group 3: ERAS protocol was fully applied, metoclopramide belonging to the ERAS protocol was used postoperatively.
Group 4: ERAS protocol was completely applied, nothing of the ERAS protocol was used postoperatively (no enema, metoclopramide, and opioid).
In this prospective study; patients' age, number of cesarean sections, presence of additional disease, birth weight of their babies, time to discharge after surgery, degree of postoperative pain, presence of postoperative complications will be compared between groups.
All patients who met the preoperative and intraoperative conditions of the ERAS criteria were included in the study.For all groups, ERAS's latest guidelines for antenatal and preoperative care in cesarean delivery criteria applied to all groups of patients.Afterwards, in the postoperative evaluation, the patient groups were separated according to the treatments applied.Patients with incomplete patient data were not included in the study.
Visual analog scale (VAS) scoring is the pain recognition method where the patient scores out of 10 for pain, where 0 is no pain, and its pain is the strongest. 8The highest VAS score value was taken as data in our study by looking at the VAS scores at the postoperative early (first hour) and mobilization (sixth hour) hours of the patients.
The data were evaluated in the SPSS 26.0 statistics program, and the percentages were calculated for the mean, standard deviations, and categorical data.The normal distribution of values was examined using visual (histogram and probability graphs) and analytical methods (Kolmogorov-Smirnov test).Student's T test was used for the variables with normal distribution to evaluate the statistical significance between the two independent groups.While the t test was used to compare means between groups, the chi-square test was used for categorical data.If the values were not normally distributed, nonparametric tests were used.Comparison of more than two group averages: single way analysis of variance was used.Correlation analysis was performed for the significant means.For the level of significance, p < 0.05 was accepted.
Permission was obtained from the Harran University Ethics Committee for the study (HRU/23.09.08).It conforms to the provisions of the Declaration of Helsinki.

RESULTS
The results of a total of 800 patients were evaluated by taking 200 patients in each group.
Group 1: The ERAS protocol was fully applied, postoperative enema-metoclopramide of the ERAS protocol and opioids were used for pain control.
Group 2: ERAS protocol was fully applied, postoperative enema-metoclopramide belonging to ERAS protocol was used.
Group 3: ERAS protocol was fully applied, metoclopramide belonging to the ERAS protocol was used postoperatively.
Group 4: ERAS protocol was completely applied, nothing of the ERAS protocol was used postoperatively (no enema, no metoclopramide, and no opioid).
The table showing the demographic characteristics of each group is as follows (Table 1).
According to age, parity, and birth weight there were no statistically difference between groups ( p > 0.05).In the first group, the week of birth was statistically significantly less than the other groups.
Robson classification according to study groups and detailed cesarean section indications are shown in Figure 1.Robson 1 classification is nulliparous, singleton, head presentation, ≥37 weeks pregnant, who started labor spontaneously.According to groups; Robson 1 rates were 2.5; 4.5; 1% and 0% respectively.In Robson 2 classification, there are nulliparous, single head presentation, ≥37 weeks, induced pregnant women.According to groups; Robson 2 rates were 3; 4; 6; 5% respectively.Robson 4, on the other hand, are multiparous (not previous cesarean section), single head presentation, ≥37 weeks, induced pregnant women.Rates were 24; 24, 34.5; 23% respectively according to the groups.Robson 5, on the other hand, includes pregnant women with previous cesarean section and single head presentation at ≥37 weeks.Rates were 66; 63.F I G U R E 1 Cesarean indications according to study groups.
pregnancies (including repeated cesarean deliveries).Rates were 3.5; 3; 4.5; 0% respectively.Robson 10 includes all preterm births.Rates were 1% all in groups.There were no patients as Robson 3, 7 and 9 classification.According to the chi-square test, Robson 4 patients in group 3 were statistically significantly higher than the other groups and Robson 5 patients were less than the other groups ( p: 0.005).There was no difference between the groups according to other Robson classifications ( p > 0.05).
The detailed state of the cesarean section indications according to the groups is shown in Table 2.
When examined between the groups, it was statistically significant that repeated cesarean sections were less in group 3 compared to the other groups and more cesarean section was performed due to fetal distress and overweight fetus (p: 0.000).
There was no statistically significant difference between the groups in terms of baby's gender and live/ stillbirth (p > 0.05).Mean discharge time was 36.2 ± 2.5 h and there was no difference among groups ( p > 0.05).There were 13 wound infections in total and they recovered completely with oral antibiotic treatment.There was no difference between the groups in terms of wound infection ( p > 0.05).There were no other complications in total.
Mean VAS score of all groups was 5 ± 1.72 (2-10).When the VAS scoring was examined according to the groups, the group with the highest pain score was group 1 (enema + metoclopramide + opioid), and group 3 (metoclopramide only) with the lowest VAS score.Detailed VAS scores of the groups are given in Figure 2.
Metoclopramide groups' (group 3) mean VAS score was lower than other groups (p: 0.00) (analysis of variance test result).Considering the VAS scores between group 1 (enema + metoclopramide and opioid) group and group 4, by independent t test, group 1's (which was given nothing) VAS scores, which are pain scores, were found to be lower ( p: 0.000).But the group with the least pain is in still group 3.

DISCUSSION
Our hospital is the hospital with the highest number of births in Turkey and the annual number of births is 27 000 and 6798 of them are cesarean section.In our hospital, the primary cesarean section rate is 11% and cesarean sections are also performed in patients who have had a high numbers of cesarean sections such as the 8th or 9th.Although ERAS is not routinely applied, preoperative and intraoperative recommendations are made; F I G U R E 2 Mean visual analog scale (VAS) scores according to study groups.
however, there is no consistency in postoperative recommendations in our hospital.Appropriate antibiotics, venous thromboembolism prophylaxis, early mobilization and early withdrawal of the urinary catheter and early feeding are always done, while the use of enemas, antiemetics and opioids is limited to the physician's own preference.Therefore, by aiming this study, we wanted to see the effect on the results.In the study by Wrench et al., 9 it was revealed that cesarean section patients who underwent ERAS were discharged earlier than those who did not.In our study, while the patients were discharged in roughly 36 h in general, there was no significant difference in the time of discharge between the groups that underwent ERAS (group 1) and other groups with some changes, and group 4, which did not receive postoperative enemas, opioids, and metoclopramide.
In the ERAS approach, appropriate postoperative antibiotic use, venous thromboembolism prophylaxis, antiemetic use, early mobilization, urinary catheter withdrawal, and use of painkillers are recommended. 10In the literature, there is no study in which the use of ERAS in cesarean section and postoperative recommendations are examined one by one and postoperative results are examined.In our study, both the ERAS results were examined and it is being investigated whether there is a need for such a detailed postoperative drug use.There is no publication on how the results might change without postoperative opioid or routine enema or metoclopramide.
Although it is seen in the literature that patients who underwent ERAS in both colorectal and cesarean operations are discharged earlier, 9 there is no difference in terms of discharge time in our patients.In our patients, this may have been achieved by complying with all preoperative and intraoperative criteria and some of the postoperative criteria.This may indicate that there is no need for enema, metoclopramide, and routine opioids.
According to age, parity and birth weight there were no statistically difference between groups ( p > 0.05).In the first group, the week of birth was earlier than other groups, which is still in the term, the VAS was not the highest in this group higher either.
Considering in detail, Robson 4 is the group of those who have had a cesarean section for the first time and Robson 5 is the group of those who have had a repeat cesarean section.Considering that in group 3, patients with Robson 4 were the most, and patients with Robson 5 were the most, it is confusing whether the reason for the pain in group 3 to be significantly least is that there are fewer patients with recurrent cesarean section or whether the first cesarean section is less painful.There was no difference between the groups according to other Robson classifications (p > 0.05).
In fact, the high number of primary cesarean sections in group 3 patients indicates that there are patients with pain who have undergone labor, although VAS scores are the lowest.
Although the group with the lowest VAS score average was the third group, metoclopramide was additionally administered postoperatively in the third group.Although enema + metoclopramide + opioid was applied in the first group, the VAS score was higher.It has been routinely performed without considering opioid pain, and it has shown that non-steroidal antiinflammatory drugs can be chosen instead of opioids, although it is observed to be ineffective in the VAS score.Group 3 has metoclopramide and group 2 has extra enema.VAS score increased significantly in group 2 compared to group 3 when enema was added.
While VAS score indicates pain, pain is recorded according to the information obtained from the patient, that is, it is a subjective finding.Although the perception of pain varies according to the individual, there is no difference between the groups in terms of hospital discharge time, complications and wound infection.
The successful aspects of our study are that we received both elective and emergency cesarean sections, and we could evaluate 200 patients in each group.Our limitations are that pain is a subjective criterion and our study is a single-center study.
Despite this, it was found that ERAS provides benefits to the patient in the postoperative period with early mobilization, early nutrition, venous thromboembolism prophylaxis and early urinary catheter removal, but routine application of opioids, enemas, and metoclopramide is not necessary.Instead of opioids, it has been observed that the patient's pain can be minimized by giving routine non-steroidal anti-inflammatory drugs and metoclopramide.It has been found that patients can get through this process without any complications and early discharge without giving anything extra under all conditions.
In our study, ERAS is not essential and there is a need for randomized controlled studies that can evaluate all stages of ERAS individually.

T A B L E 2
Detailed indications of cesarean section according to study groups.Values were in percentages.
5; 53; 70.5% respectively.Robson 6 covers all nulliparous breech fetuses.Although there were no patients with Robson 6 in group 1, 2 and 3, 0.5% of patients in group 4 were in the Robson 6 classification.Robson 8 includes all multiple T A B L E 1 Demographic characteristics of groups.
Note: Values were written in mean ± standard deviation.Abbreviation: n, number of groups.