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Bai S, Wu Q, Wu W, Song L. Discussion on the influence of optimizing the perioperative management on the recovery after laparoscopic hysterectomy. Medicine (Baltimore) 2023; 102:e36396. [PMID: 38115304 PMCID: PMC10727684 DOI: 10.1097/md.0000000000036396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/21/2023] Open
Abstract
The concept of enhanced recovery after surgery (ERAS) was first proposed by Professor Kehlet from the University of Copenhagen in Denmark in 1997. The aim is to optimize multiple perioperative management measures, promote rapid postoperative recovery, shorten hospital stay, and reduce surgical related costs, this article explores the effect of optimizing perioperative bowel preparation and diet management under the strategy of ERAS on the postoperative recovery of patients undergoing laparoscopic hysterectomy for benign gynecological diseases. We selected 90 patients who underwent laparoscopic total hysterectomy for benign gynecological diseases at Hebei General Hospital from June 2018 to June 2019, these patients are between the ages of 40 and 65. Divide these 90 patients into an experimental group and a control group using a random number table method (n = 45). The experimental group of patients applied the concept of accelerated rehabilitation surgery for perioperative intestinal preparation and dietary management. The control group patients received routine perioperative management. Compare the first postoperative exhaust time, first postoperative defecation time, incision healing status 7 days after surgery, and pelvic infection status 1 month after surgery between 2 groups of patients. The first postoperative exhaust time and first postoperative bowel movement time of the experimental group patients were shorter than those of the control group (P < .05), and the difference was statistically significant; The incidence of poor incision healing 7 days after surgery was lower than that of the control group (P < .05), and the difference was statistically significant; There was no statistically significant difference in the incidence of postoperative pelvic infection between the experimental group and the control group (P > .05). Perioperative intestinal preparation and dietary management under the concept of accelerated rehabilitation surgery can promote postoperative recovery of patients undergoing laparoscopic total hysterectomy, promote incision healing, and have good safety.
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Affiliation(s)
- Suning Bai
- Department of Gynecology, Hebei General Hospital, Shijiazhuang, China
| | - Qi Wu
- Department of Gynecology, Hebei General Hospital, Shijiazhuang, China
| | - Wenfei Wu
- Department of Gynecology, Hebei General Hospital, Shijiazhuang, China
| | - Liyun Song
- Department of Gynecology, Hebei General Hospital, Shijiazhuang, China
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Fan S, Liu H, Zhu Y, Zheng Z, Cui Q. Effect of fast-track surgery on postoperative wound pain in patients with prostate cancer: A meta-analysis. Int Wound J 2023; 21:e14417. [PMID: 37737032 PMCID: PMC10824699 DOI: 10.1111/iwj.14417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 09/23/2023] Open
Abstract
Fast track surgery (FTS) is widely used in many procedures and has been shown to reduce complications and accelerate recovery. However, no studies have been conducted to assess their effectiveness in treating wounds after radical prostatectomy (RP). The objective of this study was to evaluate the impact of FTS on RP. We went through 4 major databases. A study was conducted by PubMed, the Cochrane Library, Embase, and the Web of Science to determine the effect of comparison of FTS versus conventional surgery in RP on postoperative wound complications as of 1 July 2023. Based on the review of literature, data extraction and literature quality assessment, we conducted meta-analyses with RevMan 5.3. In the course of the study, the researchers selected 6 of the 404 studies to be analysed according to exclusion criteria. Data analysis showed that the FTS method reduced the postoperative pain associated with VAS and also decreased the rate of postoperative complications in post-surgical patients. However, there was no significant difference between FTS and conventional surgery in terms of blood loss, operation time, and postoperative infection rate. Therefore, generally speaking, FTS has less impact on postoperative complications in patients with minimal invasive prostatic cancer, but it does reduce postoperative pain and total postoperative complications.
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Affiliation(s)
- Shicheng Fan
- Department of UrologyThe Third People's Hospital of Yunnan ProvinceKunmingChina
| | - Haolin Liu
- Department of UrologyInstitute of Urology, West China Hospital, Sichuan UniversityChengduChina
| | - Yuanquan Zhu
- Department of UrologyThe Third People's Hospital of Yunnan ProvinceKunmingChina
| | - Zhiqiang Zheng
- Department of UrologyThe Third People's Hospital of Yunnan ProvinceKunmingChina
| | - Qingpeng Cui
- Department of UrologyThe Third People's Hospital of Yunnan ProvinceKunmingChina
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Enhanced Recovery Protocols in Urogynecologic and Pelvic Floor Reconstructive Surgery: A Systematic Review and Meta-Analysis. UROGYNECOLOGY (HAGERSTOWN, MD.) 2023; 29:21-32. [PMID: 36548102 DOI: 10.1097/spv.0000000000001261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE The implementation of Enhanced Recovery After Surgery (ERAS) protocols may optimize the clinical outcome of surgical patients, by reducing the length of hospital stay (LOS) and improving the quality of recovery. OBJECTIVE This study aims to evaluate the impact of ERAS protocols in the intraoperative and postoperative course of patients undergoing pelvic floor reconstructive surgery. METHODS A systematic search of PubMed/MEDLINE, Embase, and the Cochrane Library was conducted up to January 2022, using the Systematic Reviews and Meta-analyses guidelines. Search terms, such as ERAS, urogynecology, sacrocolpopexy were tailored to each database as necessary. Statistical analysis was performed using the RevMan 5.4 software. Confidence intervals (CI) were set at 95%. Mean difference and risk ratio were used in the analysis, and the results were calculated using the random effect model. RESULTS Six studies that reported outcomes of 1,153 women were included. The ERAS protocols were implemented in 553 women, whereas the remaining 600 received standard perioperative care. A significantly shorter LOS (mean difference, -16.17 hours; 95% CI, -24.07 to -8.26 hours; P < 0.0001) and a higher proportion of patients discharged within 24 hours postoperatively was observed in ERAS patients compared with non-ERAS controls (risk ratio, 3.08; 95% CI, 2.00-4.75; P < 0.00001). Operative time, estimated blood loss, complications, and readmission rates did not differ between the 2 groups. CONCLUSIONS Our analysis showed that ERAS protocols have a favorable impact on the perioperative course of urogynecologic populations. More research is required to determine those key components of ERAS protocols, specifically applicable and more beneficial to women with pelvic floor disorders.
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ERAS implementation in an urban patient population undergoing gynecologic surgery. Best Pract Res Clin Obstet Gynaecol 2022; 85:1-11. [PMID: 36031533 DOI: 10.1016/j.bpobgyn.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols improve outcomes. We investigated ERAS implementation in a population with comorbid conditions, inadequate insurance, and barriers to healthcare undergoing gynecologic surgery. OBJECTIVE To investigate ERAS implementation in publicly insured/uninsured patients undergoing gynecologic surgery on hospital length of stay (LOS), 30-day hospital readmission rates, opioid administration, and pain scores. STUDY DESIGN Data were obtained pre- and post-ERAS implementation. Patients undergoing gynecologic surgery with private insurance, public insurance, and uninsured were included (N = 589). LOS, readmission <30 days, opioid administration, and pain scores were assessed. RESULTS Implementation of ERAS led to shorter LOS 1.75 vs. 1.49 days (p = 0.008). Average pain scores decreased from 3.07 pre-ERAS vs. 2.47 post-ERAS (p = <0.001). Opioid use decreased for ERAS patients (67.22 vs. 33.18, p = <0.001). Hospital readmission rates were unchanged from 8.2% pre-ERAS vs. 10.3% post-ERAS (p = 0.392). CONCLUSIONS ERAS decreased pain scores and opioid use without increasing LOS or readmissions.
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Enhanced Recovery After Surgery in Minimally Invasive Gynecologic Surgery. Obstet Gynecol Clin North Am 2022; 49:381-395. [DOI: 10.1016/j.ogc.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Fu CY, Wan L, Shen PY, Wang LZ. Feasibility of immediate removal of urinary catheter after laparoscopic gynecological surgery for benign diseases: A meta-analysis of randomized controlled trials. Int J Gynaecol Obstet 2022; 159:622-629. [PMID: 35616374 DOI: 10.1002/ijgo.14283] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/09/2022] [Accepted: 05/10/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The proper time for removing the urinary catheter after gynecologic laparoscopy is unclear. OBJECTIVES To assess the feasibility of immediate catheter removal after benign gynecologic laparoscopy. SEARCH STRATEGY PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and Wanfang Data were searched from inception to November 30, 2021. SELECTION CRITERIA Only randomized controlled trials published in English or Chinese comparing immediate versus delayed catheter removal after gynecologic laparoscopy for benign diseases were included. DATA COLLECTION AND ANALYSIS The primary outcome was the incidence of postoperative urinary retention (PUR). A random effects model was used to calculate pooled relative risk (RR) and 95% confidence interval (CI). MAIN RESULTS Six studies were included in this meta-analysis. There was no significant difference in PUR between immediate and delayed catheter removal (RR 1.51, 95% CI 0.37-6.18), but the evidence was of very low quality. Subgroup analysis according to the type of surgery showed a higher rate of PUR with immediate removal after hysterectomy than after other surgeries. Immediate removal was associated a lower incidence of urinary tract infection and a shorter time to mobilization compared with delayed removal. CONCLUSIONS Immediate removal of the urinary catheter is feasible and beneficial after benign gynecologic laparoscopy.
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Affiliation(s)
- Chun-Yan Fu
- Department of Gynecologic Nursing, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital, Jiaxing University, Jiaxing, Zhejiang, China
| | - Li Wan
- Department of Gynecologic Nursing, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital, Jiaxing University, Jiaxing, Zhejiang, China
| | - Pei-Ying Shen
- Department of Gynecologic Nursing, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital, Jiaxing University, Jiaxing, Zhejiang, China
| | - Li-Zhong Wang
- Department of Anesthesiology, Jiaxing Maternity and Children Health Care Hospital, Affiliated Women and Children Hospital, Jiaxing University, Jiaxing, Zhejiang, China
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Historical and Forecasted Changes in Utilization of Same-Day Discharge Following Minimally Invasive Hysterectomy. J Minim Invasive Gynecol 2022; 29:855-861.e1. [PMID: 35321849 DOI: 10.1016/j.jmig.2022.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVES To describe changes in length of stay and same-day discharges (SDD) following minimally invasive hysterectomy (MIH) over the last decade and forecast anticipated utilization over the subsequent decade. DESIGN Cross-sectional analysis SETTING: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. PATIENTS All benign MIH excluding joint cases with concomitant non-gynecologic surgery in the 2011-2019 NSQIP datasets, identified by current procedural terminology code. INTERVENTIONS A descriptive analysis of changes in the estimated length of stay and utilization of SDD from 2011-2019. Multivariable negative binomial regression assessed for individual-level risk factors for prolonged hospital stay and autoregressive linear forecasting estimated the growth of SDD through 2029. MEASUREMENTS AND MAIN RESULTS 239,220 MIH were identified. Over the 9-year period, SDD increased by 10.7% across all MIH. However, in 2019, SDD represented only 29.8% of total MIH discharges and utilization varied by surgical approach (laparoscopic hysterectomy: 35.4%; vaginal hysterectomy: 18.6%; laparoscopic-assisted vaginal hysterectomy: 19.6%) as well as a surgical indication of pelvic organ prolapse (32.7% without and 13.9% with prolapse). Multivariable models controlling for patient characteristics showed independent associations of route and indication for MIH and length of stay (adjusted relative rate 1.30, 95% CI 1.29,1.32 for vaginal hysterectomy and aRR 1.12, 95% CI 1.11, 1.14 for prolapse), however, these individual-level factors provided limited information explaining variation in the length of stay (model pseudo-R2 0.054). Forecasting models suggest that utilization of SDD will grow to 48.5% (95% CI 38.7-58.4) by the end of 2029. CONCLUSION While the estimated length of stay is decreasing among MIH over time, the utilization of SDD remained low in 2019, and was not explained by patient factors. If current trends hold, SDD utilization is not forecast to exceed 50% through 2029. Additional efforts focused on the provider and institution level are needed to encourage SDD as the standard of care for MIH.
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Lambat Emery S, Brossard P, Petignat P, Boulvain M, Pluchino N, Dällenbach P, Wenger JM, Savoldelli GL, Rehberg-Klug B, Dubuisson J. Fast-Track in Minimally Invasive Gynecology: A Randomized Trial Comparing Costs and Clinical Outcomes. Front Surg 2021; 8:773653. [PMID: 34859043 PMCID: PMC8632235 DOI: 10.3389/fsurg.2021.773653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/07/2021] [Indexed: 12/04/2022] Open
Abstract
Study Objective: Evaluate the effects of a fast-track (FT) protocol on costs and post-operative recovery. Methods: One hundred and seventy women undergoing total laparoscopic hysterectomy for a benign indication were randomized in a FT protocol or a usual care protocol. A FT protocol included the combination of minimally invasive surgery, analgesia optimization, early oral refeeding and rapid mobilization of patients was compared to a usual care protocol. Primary outcome was costs. Secondary outcomes were length of stay, post-operative morbidity and patient satisfaction. Main Results: The mean total cost in the FT group was 13,070 ± 4,321 Euros (EUR) per patient, and that in the usual care group was 3.5% higher at 13,527 ± 3,925 EUR (p = 0.49). The FT group had lower inpatient surgical costs but higher total ambulatory costs during the first post-operative month. The mean hospital stay in the FT group was 52.7 ± 26.8 h, and that in the usual care group was 20% higher at 65.8 ± 33.7 h (p = 0.006). Morbidity during the first post-operative month was not significantly different between the two groups. On their day of discharge, the proportion of patients satisfied with pain management was similar in both groups [83% in FT and 78% in the usual care group (p = 0.57)]. Satisfaction with medical follow-up 1 month after surgery was also similar [91% in FT and 88% in the usual care group (p = 0.69)]. Conclusion: Implementation of a FT protocol in laparoscopic hysterectomy for benign indications has minimal non-significant effects on costs but significantly reduces hospital stay without increasing post-operative morbidity nor decreasing patient satisfaction. Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04839263.
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Affiliation(s)
- Shahzia Lambat Emery
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Philippe Brossard
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Patrick Petignat
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Nicola Pluchino
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Patrick Dällenbach
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Jean-Marie Wenger
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | - Georges L Savoldelli
- Department of Anesthesiology, Division of Anesthesiology Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benno Rehberg-Klug
- Department of Anesthesiology, Division of Anesthesiology Clinical Pharmacology, Intensive Care and Emergency Medicine, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean Dubuisson
- Department of Pediatrics, Gynecology, and Obstetrics, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
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Effect of Enhanced Recovery Protocol on Opioid Use in Pelvic Organ Prolapse Surgery. Female Pelvic Med Reconstr Surg 2021; 27:e705-e709. [PMID: 34807884 DOI: 10.1097/spv.0000000000001114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Our primary objective was to compare the total opioid use by patients undergoing apical pelvic organ prolapse surgery before and after implementation of an enhanced recovery protocol (ERP). METHODS Participants of this ambispective cohort study included a "pre-ERP" retrospective cohort and an "ERP" cohort of patients prospectively enrolled after the full implementation of the ERP in January 2019. Demographic and clinical data were collected from the electronic record. Descriptive statistics were used for demographic variables. Total opioid use was calculated for each participant using morphine milligram equivalents (MMEs) and compared between cohorts using the Student t test. RESULTS Study participants (n = 65) were similar between cohorts and had a mean (SD) age of 62.4 (9.7) years and body mass index of 28.9 (4.8), and had a median parity of 3 (interquartile range, 2-4). Comorbid conditions, assessed with the Charlson Comorbidity Index, were also similar, with a mean (SD) of 2 (2.9). Hysterectomy approach and apical procedures did not differ between groups. After ERP implementation, mean (SD) intraoperative and postoperative MMEs decreased significantly (59.4 [31.6] vs 36.9 [20.5], P < 0.01). Total MMEs prescribed at discharge also decreased (392.3 [88.4] vs 94.6 [61.3], P < 0.01). Total anesthesia time and surgical time were similar, whereas mean total admission time decreased (27.3 [10.8] vs 18 [8.6] hours, P < 0.01). Telephone calls within 30 days increased from mean 1 (1.0) to 2.2 (1.9) (P < 0.01), whereas clinic visits and 30-day readmissions did not differ. CONCLUSIONS Women undergoing apical pelvic organ prolapse surgery at an academic medical center received significantly fewer opioids after implementation of an ERP without a change in postoperative pain scores.
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Retrograde Bladder Filling After Outpatient Gynecologic Surgery: A Systematic Review and Meta-analysis. Obstet Gynecol 2021; 138:647-654. [PMID: 34623077 DOI: 10.1097/aog.0000000000004541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/03/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To systematically review and meta-analyze randomized controlled trials (RCTs) comparing postoperative bladder retrofilling to passive filling after outpatient gynecologic surgery to evaluate effects on postoperative outcomes. DATA SOURCES We searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and ClinicalTrials.gov from 1947 to August 2020. METHODS OF STUDY SELECTION Two reviewers screened 1,465 articles. We included RCTs that compared postoperative bladder retrofilling to passive filling in patients who underwent outpatient gynecologic surgery by any approach. The primary outcome was the time to first void. Secondary outcomes included time to discharge, postoperative urinary retention, urinary tract infection, and patient satisfaction. Mean differences and relative risks (RRs) were calculated for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias Tool. TABULATION, INTEGRATION, AND RESULTS We included eight studies with 1,173 patients. Bladder retrofilling in the operating room resulted in a significant decrease in the time to first void (mean difference -33.5 minutes; 95% CI -49.1 to -17.9, 4 studies, 403 patients) and time to discharge (mean difference -32.0 minutes; 95% CI -51.5 to -12.6, eight studies, 1,164 patients). Bladder retrofilling did not shorten time to discharge when performed in the postanesthetic care unit (mean difference -14.8 min; 95% CI -62.6 to 32.9, three studies, 258 patients) or after laparoscopic hysterectomy (mean difference -26.0 min; 95% CI -56.5 to 4.5, five studies, 657 patients). There were no differences in postoperative urinary retention (RR 0.77; 95% CI 0.45-1.30, five studies, 910 patients) or risk of urinary tract infection between the retrofill and passive fill groups (RR 0.50; 95% CI 0.14-1.77, four studies, 387 patients). Patient satisfaction was comparable between groups. CONCLUSION Retrofilling the bladder in the operating room after outpatient gynecologic surgery modestly reduces the time to first void and discharge with no increase in adverse events. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42020203692.
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Marchand GJ, Coriell C, Taher A, King A, Ruther S, Brazil G, Cieminski K, Calteux N, Ulibarri H, Parise J, Arroyo A, Sainz K. Systematic review of the effect of implementing enhanced recovery after surgery on selected attributes of surgical recovery in gynecology. Turk J Obstet Gynecol 2021; 18:245-257. [PMID: 34580992 PMCID: PMC8480214 DOI: 10.4274/tjod.galenos.2021.47717] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This study aimed to systematically review the available literature on enhanced recovery after surgery (ERAS) following gynecologic procedures performed either as an open surgery or as a minimally invasive gynecological surgery (MIGS) in terms of outcomes. This review revealed the results of published literature and assessed the benefits and diverse outcomes of ERAS implementation in patients undergoing MIGS or other gynecologic surgeries. In this review, we sought to examine the efficacy of entire ERAS protocols, faithfully performed, to determine whether they were successful in improving individual attributes of surgical recovery. Electronic databases of PubMed, Cochrane, Web of Science, Scopus, MEDLINE, and ClinicalTrials.gov were systematically searched in January 2021 for relevant studies. Data were extracted from eligible studies including LOS, change in the quality-of-life and recovery over time, postoperative complications including nausea and vomiting, opioid or anesthesia use, hospital cost, patient satisfaction, postoperative pain, and readmission rate as outcomes. Many of the included studies reported a significant reduction in the LOS as well as in readmission rates, hospital cost, and occurrence of nausea and vomiting postoperatively. Moreover, a clinically significant increase was noted in patient satisfaction in studies that have used tools that measure patient satisfaction. No studies have reported a significant increase in the overall quality of recovery using appropriately validated tools. Following ERAS implementation, patients’ postoperative rehabilitation, including postoperative discomfort, readmission rates, and satisfaction, showed a clinically significant improvement.
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Affiliation(s)
- Greg J Marchand
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Catherine Coriell
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Ahmed Taher
- Fayoum University Faculty of Medicine, Fayoum, Egypt
| | - Alexa King
- International University of Health Sciences, Basseterre, St. Kitts
| | - Stacy Ruther
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Giovanna Brazil
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | | | - Nicolas Calteux
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Hollie Ulibarri
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Julia Parise
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Amanda Arroyo
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
| | - Katelyn Sainz
- Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona, USA
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Enhanced Recovery After Urogynecologic Surgery. Female Pelvic Med Reconstr Surg 2021; 28:225-232. [DOI: 10.1097/spv.0000000000001110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Enhanced Recovery Protocol Enhances Postdischarge Recovery After Laparoscopic Sacrocolpopexy. Female Pelvic Med Reconstr Surg 2021; 27:667-671. [PMID: 34171879 DOI: 10.1097/spv.0000000000001042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study is to determine if an ERAS (enhanced recovery after surgery) protocol enhanced the patient-perceived postdischarge recovery after laparoscopic sacrocolpopexy. METHODS In this prospective cohort study, patients exposed to an ERAS protocol completed a preoperative survey that included established predictors of postdischarge recovery. Postoperatively, they completed the validated Postdischarge Surgical Recovery 13 (PSR-13) scale at 7, 14, and 42 days. A historical cohort of non-ERAS patients who completed similar surveys were included for comparisons. Characteristics between the 2 cohorts were analyzed using the χ2 test, Student t tests, and Mann-Whitney U tests where appropriate. A mixed-design analysis of variance model was constructed to determine if our ERAS protocol affected recovery as measured by the PSR-13 scale. RESULTS Eighty-nine ERAS patients were compared with 169 non-ERAS controls. There were no differences in established predictors of recovery between the groups. Length of hospital stay was shorter in the ERAS cohort (33±13.1 hours vs 44.2±25.9 hours; mean difference, 11.2; 95% confidence interval [CI], 6.44-16.0). Postdischarge recovery significantly improved with time (7 days: 52.7; 95% CI, 50.1-55.2; 14 days: 63.4; 95% CI, 60.9-65.8; 42 days: 80.1, 95% CI, 78.1-82.1). The ERAS cohort reported greater postdischarge recovery than the non-ERAS cohort (as measured by the PSR-13 scale) at postoperative days 7, 14, and 42 days (68.4 vs 62.3; mean difference, 6.1; 95% CI, 2.04-10.16). CONCLUSIONS Enhanced recovery after surgery protocols reduce length of hospital stay and enhance patient-perceived postdischarge recovery.
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Smith MJ, Lee J, Brodsky AL, Figueroa MA, Stamm MH, Giard A, Luker N, Friedman S, Huncke T, Jain SK, Pothuri B. Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway. J Minim Invasive Gynecol 2021; 28:2052-2059.e3. [PMID: 34139329 DOI: 10.1016/j.jmig.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/24/2021] [Accepted: 06/09/2021] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVE Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m2 undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP. DESIGN A retrospective cohort study. SETTING An academic teaching hospital. PATIENTS A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m2) undergoing robotic hysterectomy. INTERVENTIONS The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls. MEASUREMENTS AND MAIN RESULTS Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room). CONCLUSION The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.
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Affiliation(s)
- Maria J Smith
- Department of Obstetrics and Gynecology, NYU Langone Health (Dr. Smith), New York, NY
| | - Jessica Lee
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Texas Southwestern Medical Center (Drs. Lee), Dallas, TX
| | - Allison L Brodsky
- Department of Obstetrics and Gynecology, University of California San Diego (Drs. Brodsky), San Diego, CA
| | - Melissa A Figueroa
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Matthew H Stamm
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Audra Giard
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Nadia Luker
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Steven Friedman
- Department of Population Health, NYU Langone Health (Mr. Friedman)
| | - Tessa Huncke
- Department of Anesthesiology, NYU Langone Health (Drs. Huncke and Jain), New York, NY
| | - Sudheer K Jain
- Department of Anesthesiology, NYU Langone Health (Drs. Huncke and Jain), New York, NY
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, NYU Langone Health (Dr. Pothuri).
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15
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Shen W, Wu Z, Wang Y, Sun Y, Wu A. Impact of Enhanced Recovery After Surgery (ERAS) protocol versus standard of care on postoperative Acute Kidney Injury (AKI): A meta-analysis. PLoS One 2021; 16:e0251476. [PMID: 34015002 PMCID: PMC8136724 DOI: 10.1371/journal.pone.0251476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/27/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common postoperative complication with an incidence of nearly 15%. Relatively balanced fluid management, flexible use of vasoactive drugs, multimodal analgesia containing non-steroidal anti-inflammatory drugs are fundamental to ERAS protocols. However, these basic tenants may lead to an increased incidence of postoperative AKI. METHODS A search was done in the PubMed, Embase, Cochrane Library and reference lists to identify relevant studies from inception until May 2020 to be included in this study. Effects were summarized using pooled risk ratios (RRs), mean differences (MDs) and corresponding 95% confidence intervals (Cls) with random effect model. Heterogeneity assessment, sensitivity analysis, and publication bias were performed. RESULTS A systematic review of nineteen cohort studies covering 17,205 patients, comparing impact of ERAS with conventional care on postoperative AKI was performed. Notably, the ERAS regimen did not increase the incidence of postoperative AKI compared with standard care (RR: 1.21; 95% CI: 0.96 to 1.52; I2 = 53%). Both goal-directed fluid therapy (RR: 1.26; 95% CI: 0.99-1.61; I2 = 55%) and restrictive fluid management (RR: 1.06; 95% CI: 0.57-1.98; I2 = 60%) had no significant effect on the incidence of postoperative AKI. There was no significant statistical difference between different AKI diagnostic criteria (P = 0.43; I2 = 0%). ERAS group had significantly shorter hospital stay (MD: -1.54; 95% CI: -1.91 to -1.17; I2 = 66%). There was no statistical difference in 30-day readmission rate (RR: 0.98; 95% CI: 0.80 to 1.20; I2 = 42%), 30-day reoperation rate (RR: 0.98; 95% CI: 0.71 to 1.34; I2 = 42%) and mortality (RR: 0.81; 95% CI: 0.59 to 1.11; I2 = 0%) between the two groups. CONCLUSIONS This meta-analysis suggests that ERAS protocols do not increase readmission or reoperation rates and mortality while significantly reducing LOS. Most importantly, the ERAS protocol was shown to have no promoting effect on the incidence of postoperative AKI. Even GDFT and restrictive fluid management cannot avoid the occurrence of postoperative AKI, and the ERAS protocol is still worth recommending and its safety is further confirmed.
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Affiliation(s)
- Whenzhen Shen
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Zehao Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yunlu Wang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yi Sun
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Anshi Wu
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
- * E-mail:
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16
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Altman AD, Robert M, Armbrust R, Fawcett WJ, Nihira M, Jones CN, Tamussino K, Sehouli J, Dowdy SC, Nelson G. Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations. Am J Obstet Gynecol 2020; 223:475-485. [PMID: 32717257 DOI: 10.1016/j.ajog.2020.07.039] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023]
Abstract
This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.
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Affiliation(s)
- Alon D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Magali Robert
- Department of Obstetrics and Gynecology, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Robert Armbrust
- Department of Gynecology with Center for Oncological Surgery, Charité University Medicine of Berlin, European Competence Center for Ovarian Cancer, Berlin, Germany
| | - William J Fawcett
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
| | - Mikio Nihira
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of California, Riverside, Riverside, CA
| | - Chris N Jones
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, Surrey, United Kingdom
| | - Karl Tamussino
- Division of Gynecology, Medical University of Graz, Graz, Austria
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Charité University Medicine of Berlin, European Competence Center for Ovarian Cancer, Berlin, Germany
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
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17
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Xie N, Hu Z, Ye Z, Xu Q, Chen J, Lin Y. A systematic review comparing early with late removal of indwelling urinary catheters after pelvic organ prolapse surgery. Int Urogynecol J 2020; 32:1361-1372. [PMID: 32886172 DOI: 10.1007/s00192-020-04522-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND An indwelling catheter is routinely used after pelvic organ prolapse surgery to prevent urinary retention. However, the timing of catheter removal remains controversial. OBJECTIVES To investigate the optimal timing of catheter removal following prolapse surgery. METHODS Electronic databases including the Cochrane Center Controlled Test Center, Embase, CINAHL, MEDLINE, PubMed, Web of Science and CNKI were searched up to January 2010. Randomized controlled trials (RCTs) comparing different timings of catheter removal after prolapse surgery were eligible. Results from RCTs comparing early versus late removal were pooled, and different durations of catheterization were divided into three sub-comparisons (≤ 2 days versus > 2 days; ≤ 1 day versus 2 days; < 1 day versus 1 day). Primary outcomes were urinary tract infection (UTI) and re-catheterization. Secondary outcomes were the length of hospital stay and patient-reported outcomes. RESULTS Seven RCTs with 964 women were involved in the analysis. Early catheter removal was associated with a reduced incidence of UTI (RR 0.46, 95% CI 0.24 to 0.9) but an increased risk of re-catheterization (RR 2.67, 95% CI 1.6 to 4.48). Significant differences in primary outcomes were found in the sub-comparison of ≤ 2 days versus > 2 days. Three of six trials found a significantly shorter length of hospital stay in the early removal group. The results for postoperative pain were mixed. CONCLUSION Among patients following pelvic organ prolapse surgery, early catheter removal is preferred. Moreover, the timing for removal is preferably within 2 days postoperatively.
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Affiliation(s)
- Nansha Xie
- Department of Urogynecology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Zeyin Hu
- Department of Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zengjie Ye
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiong Xu
- Department of Urogynecology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Jie Chen
- Department of Pediatric Intensive Care Unit, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Yan Lin
- Department of Nursing Administrative Office, Guangzhou Women and Children's Medical Center, Guangzhou, China.
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18
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Peters A, Siripong N, Wang L, Donnellan NM. Enhanced recovery after surgery outcomes in minimally invasive nonhysterectomy gynecologic procedures. Am J Obstet Gynecol 2020; 223:234.e1-234.e8. [PMID: 32087147 PMCID: PMC7395891 DOI: 10.1016/j.ajog.2020.02.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/15/2019] [Accepted: 02/03/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Improved patient outcomes and satisfaction associated with enhanced recovery after surgery protocols have increasingly replaced traditional perioperative anesthesia care. Fast-track surgery pathways have been extensively validated in patients undergoing hysterectomies, yet the impact on fertility-sparing laparoscopic gynecologic operations, particularly those addressing chronic pain conditions, has not been examined. OBJECTIVE The objective of the study was to determine the effects of enhanced recovery after surgery pathway implementation compared with conventional perioperative care in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures. STUDY DESIGN We conducted a retrospective cohort study of women undergoing uterine-sparing laparoscopic gynecologic procedures for benign conditions (tubal/adnexal pathology, endometriosis, or leiomyomas) during a 24 month period before and after enhanced recovery after surgery implementation at a tertiary care center. We compared immediate perioperative outcomes and 30 day complications. The primary outcome was same-day discharge rates. Factors influencing unplanned admissions, postoperative pain, sedation, nausea, and vomiting represented secondary analyses. RESULTS A total of 410 women (enhanced recovery after surgery, n = 196; conventional perioperative care, n = 214) met inclusion criteria. Following enhanced recovery after surgery implementation, same-day discharge rates increased by 9.4% (P = .001). Reductions in postoperative pain and nausea/vomiting represented the primary driving factor behind lower unplanned admissions. Higher preoperative antiemetic medication administration in the enhanced recovery after surgery group resulted in a 57% reduction in postanesthesia care unit antiemetics (P < .001). Total perioperative narcotic medication use was also significantly reduced by 64% (P < .001), and the enhanced recovery after surgery cohort still demonstrated significantly lower postanesthesia unit care pain scores at hours 2 and 3 (P < .001). A 19 minute shorter postanesthesia care unit stay was noted in the enhanced recovery after surgery cohort (P = .036). Increased same-day discharge did not lead to higher postoperative complications or changes in 30 day emergency department visits or readmissions in patients with enhanced recovery after surgery. CONCLUSION Enhanced recovery after surgery implementation resulted in increased same-day discharge rates and improved perioperative outcomes without affecting 30 day morbidity in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.
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Affiliation(s)
- Ann Peters
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nalyn Siripong
- Clinical and Translational Science Institute, Office of Clinical Research, University of Pittsburgh, Pittsburgh, PA
| | - Li Wang
- Clinical and Translational Science Institute, Office of Clinical Research, University of Pittsburgh, Pittsburgh, PA
| | - Nicole M Donnellan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA.
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19
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Smith AE, Heiss K, Childress KJ. Enhanced Recovery After Surgery in Pediatric and Adolescent Gynecology: A Pilot Study. J Pediatr Adolesc Gynecol 2020; 33:403-409. [PMID: 32061749 DOI: 10.1016/j.jpag.2020.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in adult gynecology as well as adult and pediatric colorectal and urologic surgery with reduction in narcotic use, complications, return to the system (RTS), length of stay (LOS), and improved patient satisfaction. There are no studies evaluating the use of ERAS in pediatric and adolescent gynecology (PAG). The goals of this study are to present initial patient outcomes using ERAS in PAG patients undergoing intra-abdominal gynecologic surgery to prove efficacy, patient satisfaction, and decreased narcotic use. DESIGN As a quality improvement measure in perioperative care, an ERAS protocol including preoperative, intraoperative, and postoperative components and a follow-up patient telephone call for pain assessment was implemented for all intra-abdominal gynecologic procedures. A retrospective study on implementation of ERAS components, outcomes, and patient satisfaction was then performed in participants meeting inclusion criteria. SETTING Large academic children's hospital. PARTICIPANTS Patients <25 years of age who underwent laparoscopic (LSC) or open abdominal (XLAP) gynecologic surgery using an ERAS protocol by the PAG service over a 12-month period. INTERVENTIONS An ERAS protocol including preoperative, intraoperative, and postoperative components and follow-up patient telephone call for pain assessment was implemented for all major gynecologic surgeries performed by the PAG service. MAIN OUTCOME MEASURES Patient satisfaction with the perioperative ERAS protocol along with components including pain management, narcotic use, LOS, RTS, and postoperative complications for various intra-abdominal gynecologic procedures. RESULTS A total of 40 participants met inclusion criteria for the study. Thirty-four (85%) participants underwent LSC procedures and six (15%) underwent XLAP. Of the LSC patients, 95% were discharged on postoperative day 0, and all XLAP patients and one LSC patient were discharged on postoperative day 1. In all, 95% of patients were discharged from the hospital requiring only non-narcotic ERAS medications. There were no readmissions or postoperative complications. All patients were satisfied with their postoperative pain control at their follow-up telephone call and clinic visit. CONCLUSION Implementation of a pediatric-specific ERAS protocol in children and adolescents undergoing gynecologic surgery is feasible and safe, and leads to less narcotic use without an increase in complications or decrease in patient satisfaction.
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Affiliation(s)
| | - Kurt Heiss
- Division of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, GA; Department of Surgery, Emory University, Atlanta, GA
| | - Krista J Childress
- Division of Pediatric Surgery, Children's Healthcare of Atlanta, Atlanta, GA; Division of Gynecologic Specialties, Department of Gynecology and Obstetrics, Emory University, Atlanta, GA.
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20
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Ramirez-Caban L, Kannan A, Goggins ER, Shockley ME, Haddad LB, Chahine EB. Factors that Lengthen Patient Hospitalizations Following Laparoscopic Hysterectomy. JSLS 2020; 24:JSLS.2020.00029. [PMID: 32714003 PMCID: PMC7362931 DOI: 10.4293/jsls.2020.00029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To establish descriptive observations associated with prolonged hospitalization after laparoscopic hysterectomy prior to the implementation of a department-wide Enhanced Recovery After Surgery protocol. Methods A retrospective cohort study at three academic affiliated hospitals in the southeastern United States was conducted evaluating length of hospitalization by patient, surgical, and physician factors for 384 patients who underwent total laparoscopic hysterectomy, laparoscopic assisted vaginal hysterectomy, and robotic assisted total laparoscopic hysterectomy for benign conditions by general and subspecialized gynecologists from 2010 to 2015. Results Among 384 patients, 19.5% experienced prolonged hospitalization, defined as greater than one day. After adjusting for covariates, robotic assisted total laparoscopic hysterectomy (aOR 3.13), dietary restrictions on postoperative day 1 (aOR 4.42), postoperative nausea or vomiting (aOR 2.01), and postoperative complications (aOR 3.58) were associated with prolonged hospitalization. Conclusion Data from this study were collected prior to implementation of department-wide enhanced recovery after surgery protocols and highlights areas for improvement. Implementation of specific aspects of these protocols, including aggressive prevention of postoperative nausea and vomiting and early feeding, are easily made changes which may help to effectively decrease length of stay after laparoscopic hysterectomy. Patient and provider education on enhanced recovery protocols is also key to reducing length of stay.
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21
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Foley CE, Ryan E, Huang JQ. Less is more: clinical impact of decreasing pneumoperitoneum pressures during robotic surgery. J Robot Surg 2020; 15:299-307. [PMID: 32572753 DOI: 10.1007/s11701-020-01104-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/09/2020] [Indexed: 01/01/2023]
Abstract
The objective of this study was to investigate the effects of decreasing insufflation pressure during robotic gynecologic surgery. The primary outcomes were patient-reported postoperative pain scores and length of stay. Secondary outcomes include surgical time, blood loss, and intraoperative respiratory parameters. This is a retrospective cohort study of patients undergoing robotic surgery for benign gynecologic conditions by a single minimally invasive surgeon at an academic hospital between 2014 and 2017. Patients were categorized by the maximum insufflation pressure reached during the surgery as either 15, 12, 10, or 8 mmHg. Continuous variables were compared using analysis of variance and χ2 test was used for categorical variables. 598 patients were included in this study with no differences in age, BMI, race, prior abdominal surgeries, or specimen weight between the four cohorts. When comparing cohorts, each decrease in insufflation pressure correlated with a significant decrease in initial pain scores (5.9 vs 5.4 vs 4.4 vs. 3.8, p ≤ 0.001), and hospital length of stay (449 vs 467 vs 351 vs. 317 min, p ≤ 0.001). There were no differences in duration of surgery (p = 0.31) or blood loss (p = 0.09). Lower operating pressures were correlated with significantly lower peak inspiratory pressures (p < 0.001) and tidal volumes (p < 0.001). Surgery performed at lower-pressure pneumoperitoneum (≤ 10 mmHg) is associated with lower postoperative pain scores, shorter length of stay, and improved intraoperative respiratory parameters without increased duration of surgery or blood loss. Operating at lower insufflation pressures is a low-cost, reversible intervention that should be implemented during robotic surgery as it results in the improved pain scores and shorter hospital stays.
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Affiliation(s)
- Christine E Foley
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA. .,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Magee-Womens Hospital, 300 Halket Street, Suite 2300, Pittsburgh, PA, 15213, USA.
| | - Erika Ryan
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - Jian Qun Huang
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
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22
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Enhanced recovery after surgery in minimally invasive gynecologic surgery surgical patients: one size fits all? Curr Opin Obstet Gynecol 2020; 32:248-254. [DOI: 10.1097/gco.0000000000000634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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23
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Lee NH, Ryu K, Song T. Postoperative analgesic efficacy of continuous wound infusion with local anesthetics after laparoscopy (PAIN): a randomized, double-blind, placebo-controlled trial. Surg Endosc 2020; 35:562-568. [PMID: 32055994 DOI: 10.1007/s00464-020-07416-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND To investigate the efficacy of continuous wound infusion (CWI) with local anesthetics for reducing postoperative pain compared with placebo in patients undergoing benign gynecologic laparoscopy. METHODS In this double-blind trial, 66 patients were randomly assigned to receive either ropivacaine or normal saline though a multi-orifice catheter placed into the umbilical surgical wound for 50 h postoperatively. The primary outcome measure was the severity of postoperative pain 1, 6, 12, 24, and 48 h after surgery. The secondary outcome measure was the number of rescue analgesics requested. RESULTS Baseline characteristics did not statistically differ between the ropivacaine and placebo groups. The intensity of postoperative pain was significantly lower in the ropivacaine group than in the placebo group 1, 6, 12, 24, and 48 h after surgery (all P < 0.05). The number of rescue analgesics requested was also significantly lower in the ropivacaine group than in the placebo group. There were no significant differences between the two groups regarding other surgical outcomes. CONCLUSION CWI with local anesthetics after laparoscopic surgery provides good analgesia and reduces rescue analgesics consumption.
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Affiliation(s)
- Nae Hyun Lee
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, Republic of Korea
| | - Kyoungho Ryu
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Taejong Song
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, Republic of Korea.
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24
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Gynecologic Surgical Outcomes Through the Patient's Eyes: Are Physicians Looking in the Same Direction? Obstet Gynecol Surv 2019; 74:351-361. [PMID: 31216044 DOI: 10.1097/ogx.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Patient-centered care integrates the highest clinical standards with patient preferences surrounding their treatment. Increasing focus is being placed on the identification of patient-centered outcomes to optimize the impact of medical treatments on patient quality of life, as defined by patients themselves. Objective This article will review the central concepts of patient-centered outcomes in benign gynecologic surgery. This expert review will serve as a practical guide for surgeons to incorporate patient preferences into shared surgical decision making. Evidence Acquisition The current literature is examined, defining those outcomes identified by women undergoing gynecologic procedures as the most important factors in their decision making. Available literature on these patient-identified priorities is then reviewed with respect to gynecologic surgery in the preoperative, intraoperative, and postoperative periods. Results Each section of the article concludes with Clinical Pearls, where practical tools and key elements are summarized to assist providers with incorporating these concepts into practice. Conclusions and Relevance Many key outcomes have been identified by women undergoing benign gynecologic surgery in their decision-making process. Patient counseling should address clinically appropriate treatment modalities and include an exploration of patient expectations and preferences around nonclinical outcomes as well. This shared decision-making model will result in improved satisfaction with outcomes.
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Schwenk W, Freys SM. Perioperative medicine - a vital but neglected part of success in surgery. Innov Surg Sci 2019; 4:121-122. [PMID: 33977120 PMCID: PMC8059347 DOI: 10.1515/iss-2019-2036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Wolfgang Schwenk
- Professor of Surgery, Chairman, Department of General-, Visceral- and Vascular Surgery, Städtisches Klinikum Solingen gGmbH, Gotenstrasse 1, D-42653 Solingen, Germany
| | - Stephan M Freys
- Department of Surgery, DIAKO Evangelisches Diakonie-Krankenhaus gGmbH, Bremen, Gemany
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Slakey DP, Silver DS, Chazin SM, Katoozian PY, Sikora KS, Ruther MM. Making enhanced recovery the norm not the exception. Am J Surg 2019; 219:472-476. [PMID: 31551144 DOI: 10.1016/j.amjsurg.2019.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/12/2019] [Accepted: 09/17/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery ("STAAR" in our system) is multimodal care focused on the reduction of physiological and psychological stress. While enhanced recovery is well established in colorectal surgery, and there is evidence for effectiveness in other surgical disciplines, to date widespread use is limited. METHOD We implemented a Lean process that, within 12 months, expanded STAAR to 13 surgical services lines involving >130 surgeons, and impacting the care of >6000 surgical patients/year. RESULTS Implementation involved educational and administrative meetings (279 in the first 6 months) and rounding. Use of STAAR was defined as >60% compliance. LOS was reduced up to 40%, mortality index and transfusion decreased 67% and 23% respectively. Case mix index increased 17%. Readmission rates, infections, ER visits were not increased. CONCLUSION Using a Lean process focused on value, STAAR protocols became the standard rather than the exception. Time investment by senior surgical leadership was extensive.
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Affiliation(s)
| | - D S Silver
- University of Pittsburgh Department of Surgery, United States
| | - S M Chazin
- Tulane University School of Medicine, United States
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Lecompte P, Benitez D, Moyano J, Garzon CQ. Defining trajectories of acute pain in surgical patients short title: acute pain follow-up. ACTA ACUST UNITED AC 2019; 65:825-829. [PMID: 31340311 DOI: 10.1590/1806-9282.65.6.825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 01/09/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Assessment of acute postoperative pain is mandatory for effective treatments. Pain trajectories may help professionals improve treatments. It has been suggested that uncontrolled pain in the immediate postoperative period generates higher pain intensities on the following days of hospital stay. OBJECTIVE To determine the relationship between pain during the first postoperative hour and the first 24 postoperative hours. METHODS Setting: a general university hospital. Study design: a prospective observational, analytical study of patients undergoing surgical procedures under general anesthesia and hospitalized for at least 24 hours. Five assessments of pain were carried out during the first hour in the recovery room followed by three assessments during the first 24 hours. The slopes of pain trajectories were calculated, and the relationship between them was analyzed. RESULTS 234 patients were recruited, 31.3% had uncontrolled pain on arrival at the recovery room; at the end of the first 24 hours after surgery, 5.5% of the patients had uncontrolled pain. The first pain intensity score in the recovery room correlated negatively with the slope for the first hour (P1): rS = -0.657 (p = 0.000). Similarly, the first pain intensity score had a negative association with the pain trajectory slope during the hospital stay (P2): rS = -0.141 (p = 0.032). When comparing the two slopes, a nonsignificant negative correlation was found: rS = -0.126. CONCLUSIONS the trajectory of pain during the first hour does not predict the behavior of the trajectory during the first day after surgery.
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Affiliation(s)
- Paola Lecompte
- Department of Anaesthesia University Hospital Fundación SantaFe de Bogota, Colombia
| | - Daniel Benitez
- Department of Anaesthesia University Hospital Fundación SantaFe de Bogota, Colombia
| | - Jairo Moyano
- Department of Anaesthesia University Hospital Fundación SantaFe de Bogota, Colombia
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Moon A, Tangada A, Andikyan V, Chuang L. Enhanced Recovery after Surgery (ERAS) in Gynecologic Surgery—A Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2018. [DOI: 10.1007/s13669-018-0247-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Comparison of Fast-Track Versus Conventional Surgery Protocol for Patients Undergoing Robot-Assisted Laparoscopic Radical Prostatectomy: A Chinese Experience. Sci Rep 2018; 8:8017. [PMID: 29789672 PMCID: PMC5964157 DOI: 10.1038/s41598-018-26372-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/11/2018] [Indexed: 12/11/2022] Open
Abstract
Fast-track surgery (FTS), which includes a series of evidence-based adjustments, is expected to reduce complications, relieve surgical stress reaction, accelerate recovery, and shorten hospitalization, as well as improve safety. The aim of this study was to critically evaluate the safety and effectiveness of FTS in Chinese prostate cancer (Pca) patients who underwent robot-assisted laparoscopic prostatectomy (RALP). A retrospective analysis was performed on 73 consecutive Chinese Pca patients who underwent RALP and who were divided into two groups: conventional surgery (CS) and FTS. Preoperative clinical data, intraoperative characteristics, postoperative outcomes and incidence of complications were compared between the two groups. No significant differences in preoperative parameters were observed between the two groups. Compared with the CS group, the FTS group showed a significantly shorter time to first flatus, time to regular diet, postoperative hospitalization time, lower incidence of complications, and lower reactions of postoperative stress and pain. Our study demonstrates that FTS is feasible and safe for Chinese Pca patients undergoing RALP and that it accelerates recovery, attenuates surgical stress response, and reduces morbidity compared to CS.
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Enhanced Recovery After Minimally Invasive Surgery (ERAmiS) for Gynecology. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2018. [DOI: 10.1007/s13669-018-0234-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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