E nhanced recovery after surgery (ERAS) is an evidencebased and multidisciplinary perioperative care pathway and a surgical quality improvement initiative, which has been shown to promote patient mobilization, reduce complication rates after surgery, decrease hospital length of stay and reduce costs, if carefully implemented. There is an increasing interest across Canada to implement enhanced recovery after surgery recommendations. 1 Several Canadian institutions have succeeded in implementing an official ERAS protocol. However, it can be challenging to start such a program 2 because it requires multidisciplinary effort and the buy-in of many stakeholders. Because the ERAS approach has been shown to decrease the stress of surgery 3 through its objective to maintain patients' normal physiology as far as possible, any patient undergoing surgery could benefit from the approach. "Enhanced recovery" started with the initial work of Henrik Kehlet, a Danish colorectal surgeon, who in the early 2000s began to challenge many of the traditional surgical practices that were not supported by high-level evidence. 4 The Enhanced Recovery After Surgery Society (www.erassociety.org), an international, multidisciplinary, not-for-profit organization comprising surgeons, anesthesiologists, nurses and allied health professionals, delivers the ERAS program, and has made recommendations and developed guidelines for colorectal surgeries, 3,5 gynecologic surgeries, 6,7 pancreaticoduodenectomy, 8 hepatectomy, 9 gastrectomy, 10 urologic surgery 11 and esophagectomy, 12 all of which have been implemented with good results. 13 The ERAS approach can be broken down into 3 main components: preoperative, intraoperative and postoperative (Box 1). However, enhanced recovery begins with optimizing a patient's physical status before surgery. Therefore, primary care physicians can support successful implementation of enhanced recovery and help to improve patient outcomes by offering preoperative education and counselling. It is also important to remember that ERAS is a multifaceted approach that should be used for all surgical patients; in other words, anyone receiving a surgical intervention should have an enhanced recovery. We review evidence (Box 2) that supports the elements of the ERAS approach and discuss requirements for and barriers to implementation of an ERAS protocol.

Background: Methods: Results: Conclusions:

High-grade ovarian cancer (HGOC) is the leading cause of mortality from gynecological malignancies, due to diagnosis at a metastatic stage. Current screening options fail to improve mortality due to the absence of early-stage-specific biomarkers. We postulated that a liquid biopsy, such as utero-tubal lavage (UtL), may identify localized lesions better than systemic approaches of serum/plasma analysis. Furthermore, while mutation-based assays are challenged by the rarity of tumor DNA within non-mutated DNA, analyzing the proteomic profile, is expected to enable earlier detection, as it reveals perturbations in both the tumor as well as in its microenvironment. To attain deep proteomic coverage and overcome the high dynamic range of this body fluid, we applied our method for microvesicle proteomics to the UtL samples. Liquid biopsies from HGOC patients (n=49) and controls (n=127) were divided into a discovery and validation sets. Data-dependent analysis of the samples on the Q-Exactive mass spectrometer provided depth of 8,578 UtL proteins in total, and on average ~3,000 proteins per sample. We used support vector machine algorithms for sample classification, and crossed three feature-selection algorithms, to construct and validate a 9-protein classifier with 70% sensitivity and 76.2% specificity. The signature correctly identified all Stage I lesions. These results demonstrate the potential power of microvesicle-based proteomic biomarkers for early cancer diagnosis.