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Huepenbecker SP, Soliman PT, Meyer LA, Iniesta MD, Chisholm GB, Taylor JS, Wilke RN, Fleming ND. Perioperative outcomes in gynecologic pelvic exenteration before and after implementation of an enhanced recovery after surgery program. Gynecol Oncol 2024; 189:80-87. [PMID: 39042957 DOI: 10.1016/j.ygyno.2024.07.674] [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: 06/25/2024] [Accepted: 07/18/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVES To compare perioperative outcomes in patients undergoing pelvic exenteration for gynecologic malignancies before and after implementation of Enhanced Recovery After Surgery (ERAS) protocols. METHODS We performed an institutional retrospective cohort study of patients undergoing pelvic exenteration for gynecologic malignancies before (1/1/2006-12/30/2014) and after (1/1/2015-6/30/2023) ERAS implementation. We described ERAS compliance rates. We compared outcomes up to 60 days post-exenteration. Complication grades were defined by the Clavien-Dindo system. RESULTS Overall, 105 women underwent pelvic exenteration; 74 (70.4%) in the pre-ERAS and 31 (29.5%) in the ERAS cohorts. There were no differences between cohorts in age, body mass index, race, primary disease site, type of exenteration, urinary diversion, or vaginal reconstruction. All patients had complications, with at least one grade II+ complication in 94.6% of pre-ERAS and 90.3% of ERAS patients. The ERAS cohort had more grade I-II gastrointestinal (61.3% vs 21.6%, p < 0.001) and hematologic (61.3% vs 36.5%, p = 0.030) and grade III-IV renal (29.0% vs 12.2%, p = 0.048) and wound (45.2% vs 18.9%, p = 0.008) complications compared to the pre-ERAS cohort. ERAS patients had a higher rate of ileus (38.7% vs 10.8%, p = 0.002), urinary leak (22.6% vs 5.4%, p = 0.014), pelvic abscess (35.5% vs 10.8%, p = 0.005), postoperative bleeding requiring intervention (61.3% vs 28.4%, p = 0.002), and readmission (71.4% vs 46.5%, p = 0.025). Median ERAS compliance was 60%. CONCLUSIONS Pelvic exenteration remains a morbid procedure, and complications were more common in ERAS compared to pre-ERAS cohorts. ERAS protocols should be optimized and tailored to the complexity of pelvic exenteration compared to standard gynecologic oncology ERAS pathways.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pamela T Soliman
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gary B Chisholm
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Roni Nitecki Wilke
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicole D Fleming
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Casas-Puig V, Paraiso MFR, Park AJ, Ferrando CA. Same-day Discharge Following Vaginal Hysterectomy and Native-tissue Apical Repair for Uterovaginal Prolapse: A Prospective Cohort Study. Int Urogynecol J 2024; 35:1421-1433. [PMID: 38814468 DOI: 10.1007/s00192-024-05803-6] [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: 12/21/2023] [Accepted: 04/06/2024] [Indexed: 05/31/2024]
Abstract
INTRODUCTION AND HYPOTHESIS The safety and feasibility of same-day discharge (SDD) has been consistently reported across the benign and gynecologic oncology literature. However, outcomes of SDD in the urogynecology population are sparse. The objectives of this study were to describe the success of SDD following vaginal hysterectomy and native-tissue colpopexy, and to compare the incidence of postoperative adverse events in patients discharged same-day versus postoperative day 1 (POD1). Further objectives were to compare pain, quality of recovery (QoR), and satisfaction between the groups. METHODS This was a single-center, prospective cohort study of patients with planned SDD. A standardized ERAS protocol was utilized. The QoR-40 questionnaire was administered at baseline, POD2, and the 6-week postoperative visit. Pain scores were captured similarly, and a satisfaction survey was administered at 6 weeks. The primary outcome was composite adverse events defined as any postoperative adverse event and/or health care utilization, excluding telephone calls, and urinary tract infection. RESULTS A total of 101 patients were enrolled in the study; the primary outcome was available for 99. SDD was achieved for 76 patients (77.0%); 23 patients stayed overnight (23.2%). The overall incidence of composite adverse events was 20.2% (95% CI, 13.5-29.2), and was not different between the groups (26.1% vs 18.4%, p = 0.42). Additionally, there were no differences in the QoR-40 or pain scores on POD2 and at 6 weeks. Patient satisfaction was high and similar between the groups. CONCLUSIONS Successful SDD was achieved in 77.0% of the patients. SDD following vaginal hysterectomy and native-tissue colpopexy appears to be safe, feasible, and associated with good QoR and a high degree of patient satisfaction.
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Affiliation(s)
- Viviana Casas-Puig
- Urogynecology, Advent Health, 960 Rinehart Road, Suite 2020, Lake Mary, FL, 32746, USA.
| | - Marie Fidela R Paraiso
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy J Park
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Cecile A Ferrando
- Center for Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Allanson E, Hari A, Ndaboine E, Cohen PA, Bristow R. Medicolegal, infrastructural, and financial aspects in gynecologic cancer surgery and their implications in decision making processes: Quo Vadis? Int J Gynecol Cancer 2024; 34:451-458. [PMID: 38438180 DOI: 10.1136/ijgc-2023-004585] [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] [Indexed: 03/06/2024] Open
Abstract
Surgical decision making is complex and involves a combination of analytic, intuitive, and cognitive processes. Medicolegal, infrastructural, and financial factors may influence these processes depending on the context and setting, but to what extent can they influence surgical decision making in gynecologic oncology? This scoping review evaluates existing literature related to medicolegal, infrastructural, and financial aspects of gynecologic cancer surgery and their implications in surgical decision making. Our objective was to summarize the findings and limitations of published research, identify gaps in the literature, and make recommendations for future research to inform policy.
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Affiliation(s)
- Emma Allanson
- Division of Obstetrics and Gynaecology, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Anjali Hari
- Division of Gynecologic Oncology, University of California Irvine, Orange, California, USA
| | - Edgard Ndaboine
- Department of Obstetrics & Gynecology, Catholic University of Health and Allied Sciences, Mwanza, Mwanza, Tanzania
| | - Paul A Cohen
- Division of Obstetrics and Gynaecology, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Robert Bristow
- Division of Gynecologic Oncology, University of California Irvine, Orange, California, USA
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Huepenbecker SP, Iniesta MD, Wang XS, Cain KE, Zorrilla-Vaca A, Shen SE, Basabe MS, Suki T, Garcia Lopez JE, Mena GE, Lasala JD, Williams LA, Ramirez PT, Meyer LA. Longitudinal perioperative patient-reported outcomes in open compared with minimally invasive hysterectomy. Am J Obstet Gynecol 2024; 230:241.e1-241.e18. [PMID: 37827271 DOI: 10.1016/j.ajog.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND There are few prospective studies in the gynecologic surgical literature that compared patient-reported outcomes between open and minimally invasive hysterectomies within enhanced recovery after surgery pathways. OBJECTIVE This study aimed to compare prospectively collected perioperative patient-reported symptom burden and interference measures in open compared with minimally invasive hysterectomy cohorts within enhanced recovery after surgery pathways. STUDY DESIGN We compared patient-reported symptom burden and functional interference in 646 patients who underwent a hysterectomy (254 underwent open surgery and 392 underwent minimally invasive surgery) for benign and malignant indications under enhanced recovery after surgery protocols. Outcomes were prospectively measured using the validated MD Anderson Symptom Inventory, which was administered perioperatively up to 8 weeks after surgery. Cohorts were compared using Fisher exact and chi-squared tests, adjusted longitudinal generalized linear mixed modeling, and Kaplan Meier curves to model return to no or mild symptoms. RESULTS The open cohort had significantly worse preoperative physical functional interference (P=.001). At the time of hospital discharge postoperatively, the open cohort reported significantly higher mean symptom severity scores and more moderate or severe scores for overall (P<.001) and abdominal pain (P<.001), fatigue (P=.001), lack of appetite (P<.001), bloating (P=.041), and constipation (P<.001) when compared with the minimally invasive cohort. The open cohort also had significantly higher interference in physical functioning (score 5.0 vs 2.7; P<.001) than the minimally invasive cohort at the time of discharge with no differences in affective interference between the 2 groups. In mixed modeling analysis of the first 7 postoperative days, both cohorts reported improved symptom burden and functional interference over time with generally slower recovery in the open cohort. From 1 to 8 postoperative weeks, the open cohort had worse mean scores for all evaluated symptoms and interference measures except for pain with urination, although scores indicated mild symptomatic burden and interference in both cohorts. The time to return to no or mild symptoms was significantly longer in the open cohort for overall pain (14 vs 4 days; P<.001), fatigue (8 vs 4 days; P<.001), disturbed sleep (2 vs 2 days; P<.001), and appetite (1.5 vs 1 days; P<.001) but was significantly longer in the minimally invasive cohort for abdominal pain (42 vs 28 days; P<.001) and bloating (42 vs 8 days; P<.001). The median time to return to no or mild functional interference was longer in the open than in the minimally invasive hysterectomy cohort for physical functioning (36 vs 32 days; P<.001) with no difference in compositive affective functioning (5 vs 5 days; P=.07) between the groups. CONCLUSION Open hysterectomy was associated with increased symptom burden in the immediate postoperative period and longer time to return to no or mild symptom burden and interference with physical functioning. However, all patient-reported measures improved within days to weeks of both open and minimally invasive surgery and differences were not always clinically significant.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xin S Wang
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katherine E Cain
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shu-En Shen
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Sol Basabe
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tina Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Juan E Garcia Lopez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Loretta A Williams
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges. METHODS Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
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O'Neill AM, Calpin GG, Norris L, Beirne JP. The impact of enhanced recovery after gynaecological surgery: A systematic review and meta-analysis. Gynecol Oncol 2023; 168:8-16. [PMID: 36356373 DOI: 10.1016/j.ygyno.2022.10.019] [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: 09/15/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery programs have become the gold standard of care in many surgical specialities. OBJECTIVES This updated systematic review and meta-analysis aims to evaluate how an ERAS program can impact outcomes across both benign and oncological gynaecological surgery to inform standard surgical practice. SEARCH STRATEGY An electronic search of the SCOPUS, Embase and PubMed Medline databases was performed for relevant studies assessing the use of ERAS in patients undergoing gynaecological surgery compared with those without ERAS. SELECTION CRITERIA The studies included were all trials using ERAS programs in gynaecological surgery with a clearly outlined protocol which included at least four items from the most recent guidelines and recorded one primary outcome. DATA COLLECTION AND ANALYSIS Meta-analysis was performed on two primary endpoints; post-operative length of stay and readmission rate and one secondary endpoint; rates of ileus. Further subgroup analyses was performed to compare benign and oncological surgeries. MAIN RESULTS Forty studies (7885 patients) were included in the meta-analysis; 15 randomised controlled trials and 25 cohort studies. 21 studies (4333 patients) were included in meta-analyses of length of stay. Patients in the ERAS group (2351 patients) had a shortened length of stay by 1.22 days (95% CI: -1.59 - -0.86, P < 0.00001) compared to those in the control group (1982 patients). Evaluation of 27 studies (6051 patients) in meta-analysis of readmission rate demonstrated a 20% reduction in readmission rate (OR: 0.80, 95% CI: 0.65-0.97). Analysis of our secondary outcome, demonstrated a 47% reduction in rate of ileus compared to the control group. CONCLUSIONS ERAS pathways significantly reduce length of stay without increasing readmission rates or rates of ileus across benign and oncological gynaecological surgery.
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Affiliation(s)
- Alice M O'Neill
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Gavin G Calpin
- Department of Surgery, University Hospital Galway, Newcastle Road, Galway, Ireland
| | - Lucy Norris
- Department of Obstetrics and Gynaecology, Trinity St. James' Cancer Institute, Trinity Centre for Health Sciences, St. James' Hospital, Dublin 8, Ireland
| | - James P Beirne
- Department of Gynaecological Oncology, Trinity St. James' Cancer Institute, St. James' Hospital, Dublin 8, Ireland
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Hayek J, Zorrilla-Vaca A, Meyer LA, Mena G, Lasala J, Iniesta MD, Suki T, Huepenbecker S, Cain K, Garcia-Lopez J, Ramirez PT. Patient outcomes and adherence to an enhanced recovery pathway for open gynecologic surgery: a 6-year single-center experience. Int J Gynecol Cancer 2022; 32:ijgc-2022-003840. [PMID: 36202425 DOI: 10.1136/ijgc-2022-003840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To evaluate compliance with an Enhanced Recovery After Surgery (ERAS) protocol for open gynecologic surgery at a tertiary center and the relationship between levels of compliance and peri-operative outcomes. METHODS This retrospective cohort study was conducted between November 2014 and December 2020. Two groups were defined based on compliance level (<80% vs ≥80%). The primary outcome was to analyze overall compliance since implementation of the ERAS protocol. The secondary endpoint was to assess the relationship between compliance and 30-day re-admission, length of stay, re-operation, opioid-free rates, and post-operative complications. We also assessed compliance with each ERAS element over three time periods (P1: 2014-2016, P2: 2017-2018, P3: 2019-2020), categorizing patients according to the date of surgery. Values were compared between P1 and P3. RESULTS A total of 1879 patients were included. Overall compliance over the period of 6 years was 74% (95% CI 71.9% to 78.2%). Mean overall compliance increased from 69.7% to 75.8% between P1 and P3. Compliance with ERAS ≥80% was associated with lower Clavien-Dindo complication rates (grades III (OR 0.55; 95% CI 0.33 to 0.93) and V (OR 0.08, 95% CI 0.01 to 0.60)), 30-day re-admission rates (OR 0.61; 95% CI 0.43 to 0.88), and length of stay (OR 0.59; 95% CI 0.47 to 0.75). No difference in opioid consumption was seen. Pre-operatively, there was increased adherence to counseling by 50% (p=0.01), optimization by 21% (p=0.02), and carbohydrate loading by 74% (p=0.02). Intra-operatively, compliance with use of short-acting anesthetics increased by 37% (p=0.01) and avoidance of abdominal drainage increased by 7% (p=0.04). Use of goal-directed fluid therapy decreased by 16% (p=0.04). Post-operatively, there was increased compliance with avoiding salt and water overload (8%, p=0.02) and multimodal analgesia (5%, p=0.02). CONCLUSIONS Over the time period of the study, overall compliance increased from 69.7% to 75.8%. Compliance (≥80%) with ERAS is associated with lower complication rates, fewer 30-day re-admissions, and shorter length of stay without impacting re-operation rates and post-operative opioid use.
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Affiliation(s)
- Judy Hayek
- Gynecologic Oncology, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Andres Zorrilla-Vaca
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tina Suki
- Gynecology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sarah Huepenbecker
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan Garcia-Lopez
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Chau JPC, Liu X, Lo SHS, Chien WT, Hui SK, Choi KC, Zhao J. Perioperative enhanced recovery programmes for women with gynaecological cancers. Cochrane Database Syst Rev 2022; 3:CD008239. [PMID: 35289396 PMCID: PMC8922407 DOI: 10.1002/14651858.cd008239.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gynaecological cancers account for 15% of newly diagnosed cancer cases in women worldwide. In recent years, increasing evidence demonstrates that traditional approaches in perioperative care practice may be unnecessary or even harmful. The enhanced recovery after surgery (ERAS) programme has therefore been gradually introduced to replace traditional approaches in perioperative care. There is an emerging body of evidence outside of gynaecological cancer which has identified that perioperative ERAS programmes decrease length of postoperative hospital stay and reduce medical expenditure without increasing complication rates, mortality, and readmission rates. However, evidence-based decisions on perioperative care practice for major surgery in gynaecological cancer are limited. This is an updated version of the original Cochrane Review published in Issue 3, 2015. OBJECTIVES To evaluate the beneficial and harmful effects of perioperative enhanced recovery after surgery (ERAS) programmes in gynaecological cancer care on length of postoperative hospital stay, postoperative complications, mortality, readmission, bowel functions, quality of life, participant satisfaction, and economic outcomes. SEARCH METHODS We searched the following electronic databases for the literature published from inception until October 2020: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PubMed, AMED (Allied and Complementary Medicine), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and four Chinese databases including the China Biomedical Literature Database (CBM), WanFang Data, China National Knowledge Infrastructure (CNKI), and Weipu Database. We also searched four trial registration platforms and grey literature databases for ongoing and unpublished trials, and handsearched the reference lists of included trials and accessible reviews for relevant references. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared ERAS programmes for perioperative care in women with gynaecological cancer to traditional care strategies. DATA COLLECTION AND ANALYSIS Two review authors independently screened studies for inclusion, extracted the data and assessed methodological quality for each included study using the Cochrane risk of bias tool 2 (RoB 2) for RCTs. Using Review Manager 5.4, we pooled the data and calculated the measures of treatment effect with the mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with a 95% confidence interval (CI) to reflect the summary estimates and uncertainty. MAIN RESULTS We included seven RCTs with 747 participants. All studies compared ERAS programmes with traditional care strategies for women with gynaecological cancer. We had substantial concerns regarding the methodological quality of the included studies since the included RCTs had moderate to high risk of bias in domains including randomisation process, deviations from intended interventions, and measurement of outcomes. ERAS programmes may reduce length of postoperative hospital stay (MD -1.71 days, 95% CI -2.59 to -0.84; I2 = 86%; 6 studies, 638 participants; low-certainty evidence). ERAS programmes may result in no difference in overall complication rates (RR 0.71, 95% CI 0.48 to 1.05; I2 = 42%; 5 studies, 537 participants; low-certainty evidence). The certainty of evidence was very low regarding the effect of ERAS programmes on all-cause mortality within 30 days of discharge (RR 0.98, 95% CI 0.14 to 6.68; 1 study, 99 participants). ERAS programmes may reduce readmission rates within 30 days of operation (RR 0.45, 95% CI 0.22 to 0.90; I2 = 0%; 3 studies, 385 participants; low-certainty evidence). ERAS programmes may reduce the time to first flatus (MD -0.82 days, 95% CI -1.00 to -0.63; I2 = 35%; 4 studies, 432 participants; low-certainty evidence) and the time to first defaecation (MD -0.96 days, 95% CI -1.47 to -0.44; I2 = 0%; 2 studies, 228 participants; low-certainty evidence). The studies did not report the effects of ERAS programmes on quality of life. The evidence on the effects of ERAS programmes on participant satisfaction was very uncertain due to the limited number of studies. The adoption of ERAS strategies may not increase medical expenditure, though the evidence was of very low certainty (SMD -0.22, 95% CI -0.68 to 0.25; I2 = 54%; 2 studies, 167 participants). AUTHORS' CONCLUSIONS Low-certainty evidence suggests that ERAS programmes may shorten length of postoperative hospital stay, reduce readmissions, and facilitate postoperative bowel function recovery without compromising participant safety. Further well-conducted studies are required in order to validate the certainty of these findings.
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Affiliation(s)
- Janita Pak Chun Chau
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Xu Liu
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Suzanne Hoi Shan Lo
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Wai Tong Chien
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Sze Ki Hui
- Department of Obstetrics and Gynaecology, Princess Margaret Hospital, Hong Kong, China
| | - Kai Chow Choi
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Jie Zhao
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Agusti N, Zorrilla Vaca A, Segarra-Vidal B, Iniesta MD, Mena G, Pareja R, Dos Reis R, Ramirez PT. Outcomes of open radical hysterectomy following implementation of an enhanced recovery after surgery program. Int J Gynecol Cancer 2022; 32:480-485. [PMID: 35264404 DOI: 10.1136/ijgc-2021-003244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Open surgery has become the standard approach for radical hysterectomy in early stage cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2018 IA1 with lymphovascular space invasion-IIA1). Our primary objective was to compare the length of stay in patients undergoing open radical hysterectomy before and after implementation of an enhanced recovery after surgery (ERAS) program. METHODS This was a single center, retrospective, before-and-after intervention study including patients who underwent open radical hysterectomy for cervical cancer from January 2009 to December 2020. Two groups were identified based on the time of ERAS implementation: pre-ERAS group included patients who were operated on between January 2009 and October 2014; post-ERAS group included patients who underwent surgery between November 2014 and December 2020. RESULTS A total of 81 patients were included, of whom 29 patients were in the pre-ERAS group and 52 patients in the post-ERAS group. Both groups had similar clinical characteristics with no differences in terms of median age (42 years (interquartile range (IQR) 35-53) in pre-ERAS group vs 41 years (IQR 35-49) in post-ERAS group; p=0.47) and body mass index (26.1 kg/m2 (IQR 24.6-29.7) in pre-ERAS group vs 27.1 kg/m2 (IQR 23.5-33.5) in post-ERAS group; p=0.44). Patients in the post-ERAS group were discharged from the hospital earlier compared with those in the pre-ERAS group (median 3 days (IQR 2-3) vs 4 (IQR 3-4), p<0.01). The proportion of patients discharged within 48 hours was significantly higher in the post-ERAS group (47.3% vs 17.3%, p=0.013). There were no differences regarding either overall complications (44.8% pre-ERAS vs 38.5% post-ERAS; p=0.57) or readmission rates within 30 days (20.7% pre-ERAS group vs 17.3% ERAS group; p=0.40). Adherence to the ERAS pathway since its implementation in 2014 has remained stable with a median of 70% (IQR 65%-75%). CONCLUSIONS Patients undergoing open radical hysterectomy on an ERAS pathway have a shorter length of hospital stay without increasing overall complications or readmissions rates.
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Affiliation(s)
- Nuria Agusti
- Department of Gynecologic Oncology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Andrés Zorrilla Vaca
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rene Pareja
- Gynecologic Oncology, Clinica ASTORGA, Medellin, and Instituto Nacional de Cancerología, Medellin, Colombia
| | - Ricardo Dos Reis
- Department of Gynecologic Oncology, Hospital de Cancer de Barretos, Barretos, Brazil
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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10
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Zorrilla-Vaca A, Lasala JD, Mena GE. Updates in Enhanced Recovery Pathways for Gynecologic Surgery. Anesthesiol Clin 2022; 40:157-174. [PMID: 35236578 DOI: 10.1016/j.anclin.2021.11.008] [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] [Indexed: 06/14/2023]
Abstract
Gynecologic surgery encompasses over a quarter of inpatient surgical procedures for US women, and current projections estimate an increase of the US female population by nearly 50% in 2050. Over the last decade, US hospitals have embraced enhanced recovery pathways in many specialties. They have increasingly been used in multiple institutions worldwide, becoming the standard of care for patient optimization. According to the last updated enhanced recovery after surgery (ERAS) guideline published in 2019, there are several new considerations behind each practice in ERAS protocols. This article discusses the most updated evidence regarding ERAS programs for gynecologic surgery.
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Affiliation(s)
- Andres Zorrilla-Vaca
- Department of Anesthesiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 409 13th floor, Houston, TX 77030, USA
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 409 13th floor, Houston, TX 77030, USA.
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11
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Faulkner HR, Coopey SB, Sisodia R, Kelly BN, Maurer LR, Ellis D. Does An ERAS Protocol Reduce Postoperative Opiate Prescribing in Plastic Surgery? JPRAS Open 2021; 31:22-28. [PMID: 34869817 PMCID: PMC8626793 DOI: 10.1016/j.jpra.2021.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background Enhanced recovery after surgery (ERAS) protocols are effective at reducing inpatient opiate use. There is a paucity of studies on the effects of an ERAS protocol on outpatient opiate prescriptions. The aim of this study was to determine whether an ERAS protocol for plastic and reconstructive surgery would reduce opiate use in the outpatient postoperative setting. Methods A statewide (Massachusetts, USA) controlled substance prescription monitoring database was retrospectively reviewed to assess the prescribing patterns of a single academic plastic surgeon performing common plastic surgical outpatient operations. The time period prior to implementation of the ERAS protocol was then compared with the time period following protocol implementation. An additional three months of post-implementation data were then compared with those of each of the previous time periods to investigate whether the results were sustained. Results A comparison of opiate prescriptions in pre-ERAS, immediate post-ERAS procedures, and follow-up ERAS implementation procedures revealed a statistically significant decrease in opiate prescriptions after ERAS protocol implementation. This decrease in the quantity of opiates prescribed was sustained over time. Conclusions ERAS protocols are effective at reducing outpatient opiate prescriptions after a variety of plastic surgery operations. Appropriate patient and physician education is paramount for success.
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Affiliation(s)
- Heather R Faulkner
- Division of Plastic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Suzanne B Coopey
- Division of Surgical Oncology, Allegheny Health Network, Wexford, Pennsylvania, USA
| | - Rachel Sisodia
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Bridget N Kelly
- Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Lydia R Maurer
- Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Dan Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Huepenbecker SP, Iniesta MD, Zorrilla-Vaca A, Ramirez PT, Cain KE, Vaughn M, Cata JP, Mena GE, Lasala J, Meyer LA. Incidence of acute kidney injury after open gynecologic surgery in an enhanced recovery after surgery pathway. Gynecol Oncol 2021; 163:191-198. [PMID: 34400005 DOI: 10.1016/j.ygyno.2021.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To determine the incidence of postoperative AKI after open gynecologic surgery within ERAS, compare AKI in pre-ERAS and ERAS cohorts, and identify factors associated with AKI. METHODS We compared postoperative AKI in patients who underwent open gynecologic surgery at one institution before and after ERAS implementation. AKI was defined as acute risk, injury, or failure by RIFLE criteria. Pre-ERAS and ERAS cohorts were matched using propensity score analysis in a 1:1 fashion using the nearest neighbor technique. Chi-squared, Fisher's Exact, and Wilcoxon rank-sum tests were used. RESULTS Among 1334 ERAS and 191 pre-ERAS patients, postoperative AKI incidence was higher in the ERAS cohort (13.1% vs 5.8%, p = .004). In 166 matched pairs, ERAS patients had higher incidence (16.9% vs 5.4%, p < .001) and odds (OR 3.54, 95% CI 1.61-7.76) of AKI. Within ERAS, AKI was associated with older age (median age 65 vs 57, p < .001), Charlson Comorbidity Index score ≥ 3 (71.4% vs 57.9%, p < .001), and higher intraoperative estimated blood loss (400 vs 225 mL, p < .001), fluid administration (net fluid balance +1535 vs 1261 mL, p < .001), and hypotension lasting >5 min (41.7% vs 30.7%, p < .001). ERAS patients with AKI had longer hospital stays (median 4 vs 3 days, p < .001) and more readmissions (19% vs. 10%, p < .001) and grade 3+ complications (26% vs. 7%, p < .001). CONCLUSIONS The incidence and odds of postoperative AKI was higher after gynecologic surgery within ERAS, and patients with AKI were more likely to have complications. Potential strategies to prevent postoperative AKI include perioperative fluid and blood pressure optimization.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrés Zorrilla-Vaca
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katherine E Cain
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Micah Vaughn
- The University of Texas Medical Branch, Galveston, TX, USA
| | - Juan P Cata
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriel E Mena
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Javier Lasala
- Department of Anesthesia and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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13
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Gong J, Luo L, Liu H, Li C, Tang Y, Zhou Y. How Much Benefit Can Patients Acquire from Enhanced Recovery After Surgery Protocols with Percutaneous Endoscopic Lumbar Interbody Fusion? Int J Gen Med 2021; 14:3125-3132. [PMID: 34239321 PMCID: PMC8260044 DOI: 10.2147/ijgm.s318876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/16/2021] [Indexed: 12/29/2022] Open
Abstract
Purpose We aimed to explore the role of enhanced recovery after surgery (ERAS) in patients who underwent percutaneous endoscopic lumbar interbody fusion (PELIF). Patients and Methods We performed a retrospective, observational, cohort study on 91 patients who underwent PELIF for degenerative disc disease. The primary outcomes were postoperative opioid consumption, hospital length of stay (LOS), and hospital cost. Results Forty-six patients comprised the ERAS group, and 45 patients comprised the pre-ERAS group (control group). The groups had comparable demographic characteristics. Good compliance with the ERAS pathway was observed in the ERAS group. Patients in the ERAS group used significantly fewer morphine equivalents compared with the pre-ERAS group (25.0 vs 33.3, respectively; p = 0.017). Hospital LOS did not decrease significantly in the ERAS group compared with the pre-ERAS group (3.1days vs 3.4 days, respectively; p = 0.096). Likewise, there was no significant difference in hospital cost between the pre-ERAS group and the ERAS group ($10,598.60 vs $10,384.50, respectively; p = 0.468). Conclusion In the present study, the benefit of ERAS in the context of PELIF was limited. Although a multidisciplinary ERAS protocol can improve analgesia and decrease opioid consumption, no significant reduction in hospital LOS and cost was observed.
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Affiliation(s)
- Junfeng Gong
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Liwen Luo
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Huan Liu
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Changqing Li
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Yu Tang
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
| | - Yue Zhou
- Department of Orthopedics, The Second Affiliated Xinqiao Hospital of Army Military Medical University, Chongqing, People's Republic of China
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14
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Chen Q, Mariano ER, Lu AC. Enhanced recovery pathways and patient-reported outcome measures in gynaecological oncology. Anaesthesia 2021; 76 Suppl 4:131-138. [PMID: 33682089 DOI: 10.1111/anae.15422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 12/14/2022]
Abstract
Comprehensive peri-operative care for women with gynaecological malignancy is essential to ensure optimal clinical outcomes and maximise patient experience through the continuum of care. Implementation of peri-operative enhanced recovery pathways in gynaecological oncology have been repeatedly shown to improve postoperative recovery, decrease complications and reduce healthcare costs. With increasing emphasis being placed on patient-centred care in the current healthcare environment, incorporation of patient-reported outcome data collection and analysis within the enhanced recovery pathway as part of quality measurement is not only useful, but necessary. Inclusion of patient-reported outcome enhanced recovery pathway evaluation enables clinicians to capture authentic patient-reported parameters such as subtle symptoms, changes in function and multiple dimensions of well-being, directly from the source. These data guide the treatment course by encouraging shared decision-making between the patient and clinicians and provide the necessary foundation for ongoing peri-operative quality improvement efforts. Elements of the gynaecological oncology enhanced recovery pathway are divided into five phases of care: pre-admission; pre-operative; intra-operative; postoperative; and post-discharge. The development process starts with detailing each step of the patient's journey in all five phases, then identifying stakeholder groups responsible for care at each of these phases and assembling a multidisciplinary team including: gynaecologists; anaesthetists; nurses; nutritionists; physical therapists; and others, to provide input into the institutional pathway. To practically integrate patient-reported outcomes into an enhanced recovery pathway, a validated measurement tool should be incorporated into the peri-operative workflow. The ideal tool should be concise to facilitate longitudinal assessments by the clinical staff.
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Affiliation(s)
- Q Chen
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - E R Mariano
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Peri-operative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - A C Lu
- Department of Anesthesiology, Peri-operative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Quality, Safety and Clinical Effectiveness, Stanford Health Care, Stanford, CA, USA
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15
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Ellis DB, Agarwala A, Cavallo E, Linov P, Hidrue MK, Del Carmen MG, Sisodia R. Implementing ERAS: how we achieved success within an anesthesia department. BMC Anesthesiol 2021; 21:36. [PMID: 33546602 PMCID: PMC7863438 DOI: 10.1186/s12871-021-01260-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background The Massachusetts General Hospital is a large, quaternary care institution with 58 operating rooms, 164 anesthesiologists, 76 certified nurse anesthetists (CRNAs), an anesthesiology residency program that admits 25 residents annually, and 35 surgeons who perform laparoscopic, vaginal, and open hysterectomies. In March of 2018, our institution launched an Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing hysterectomy. To implement the anesthesia bundle of this pathway, an intensive 14-month educational endeavor was created and put into effect. There were no subsequent additional educational interventions. Methods We retrospectively reviewed records of 2570 patients who underwent hysterectomy between October 2016 and March 2020 to determine adherence to the anesthesia bundle of the ERAS Hysterectomy pathway. RESULTS: Increased adherence to the four elements of the anesthesia bundle (p < 0.001) was achieved during the intervention period. Compliance with the pathway was sustained in the post-intervention period despite no additional actions. Conclusions Implementing the anesthesia bundle of an ERAS pathway in a large anesthesia group with diverse providers successfully occurred using implementation science-based approach of intense interventions, and these results were maintained after the intervention ceased.
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Affiliation(s)
- Dan B Ellis
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Aalok Agarwala
- Department of Anesthesia, Massachusetts Eye and Ear Infirmary, Boston, USA.,Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Elena Cavallo
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Pam Linov
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts, 02114, USA
| | - Marcela G Del Carmen
- Department of Gynecology Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Rachel Sisodia
- Department of Gynecology Oncology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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16
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Outcomes of enhanced recovery after surgery (ERAS) in gynecologic oncology - A systematic review and meta-analysis. Gynecol Oncol 2020; 161:46-55. [PMID: 33388155 DOI: 10.1016/j.ygyno.2020.12.035] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/22/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the benefit of Enhanced Recovery After Surgery (ERAS) on length of stay (LOS), postoperative complications, 30-day readmission, and cost in gynecologic oncology. METHODS A systematic literature search was performed in MEDLINE, EMBASE, Cochrane Register of Controlled Trials, and Web of Science for all peer-reviewed cohort studies and controlled trials on ERAS involving gynecologic oncology patients. Abstracts, commentaries, non-controlled studies, and studies without specific data on gynecologic oncology patients were excluded. Meta-analysis was performed on the primary endpoint of LOS. Subgroup analyses were performed based on risk of bias of the studies included, number of ERAS elements, and ERAS compliance. Secondary endpoints were readmission rate, complications, and cost. RESULTS A total of 31 studies (6703 patients) were included: 5 randomized controlled trials, and 26 cohort studies. Meta-analysis of 27 studies (6345 patients) demonstrated a decrease in LOS of 1.6 days (95% confidence interval, CI 1.2-2.1) with ERAS implementation. Meta-analysis of 21 studies (4974 patients) demonstrated a 32% reduction in complications (OR 0.68, 95% CI 0.55-0.83) and a 20% reduction in readmission (OR 0.80, 95% CI 0.64-0.99) for ERAS patients. There was no difference in 30-day postoperative mortality (OR 0.61, 95% CI 0.23-1.6) for ERAS patients compared to controls. No difference in the odds of complications or reduction in LOS was observed based on number of included ERAS elements or reported compliance with ERAS interventions. The mean cost savings for ERAS patients was $2129 USD (95% CI $712 - $3544). CONCLUSIONS ERAS protocols decrease LOS, complications, and cost without increasing rates of readmission or mortality in gynecologic oncology surgery. This evidence supports implementation of ERAS as standard of care in gynecologic oncology.
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Bernard L, McGinnis JM, Su J, Alyafi M, Palmer D, Potts L, Nancekivell KL, Thomas H, Kokus H, Eiriksson LR, Elit LM, Jimenez WGF, Reade CJ, Helpman L. Thirty-day outcomes after gynecologic oncology surgery: A single-center experience of enhanced recovery after surgery pathways. Acta Obstet Gynecol Scand 2020; 100:353-361. [PMID: 33000463 DOI: 10.1111/aogs.14009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/16/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The purpose of the study is to evaluate the impact of an enhanced recovery after surgery (ERAS) program implemented in a Gynecologic Oncology population undergoing a laparotomy at a Canadian tertiary care center. MATERIAL AND METHODS Prospectively collected data, using the American College of Surgeons' National Surgical Quality Improvement Program dataset (ACS NSQIP), was used to compare 30-day postoperative outcomes of gynecologic oncology patients undergoing a laparotomy before and after the 2018 implementation of an ERAS program in a Canadian regional cancer center. Patient demographics, surgical variables and postoperative outcomes of 187 patients undergoing surgery in 2019 were compared with those of 441 patients undergoing surgery between January 2016 and December 2017. Student's t, Mann-Whitney U and Chi-square tests, as well as multivariate linear and logistic regressions were used to evaluate baseline characteristics and 30-day postoperative complications. RESULTS Length of stay was significantly shortened in the study population after introducing the ERAS protocol, from a mean of 4.7 (SD = 3.8) days to a mean of 3.8 (SD = 3.2) days (P = .0001). The overall complication rate decreased from 24.3% to 16% (P = .02). Significant decreases in the rates of postoperative infections (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.31-0.99) and cardiovascular complications (adjusted OR 0.27, 95% CI 0.09-0.79) were noted, without a significant increase in readmission rate (adjusted OR 0.50, 95% CI 0.21-1.07). CONCLUSIONS Introducing an ERAS program for gynecologic oncology patients undergoing laparotomy was effective in shortening length of stay and the overall complication rate without a significant increase in readmission. Advocacy for broader implementation of ERAS among gynecologic oncology services and ongoing discussion on challenges and opportunities in the implementation process are warranted to improve patient outcomes and experiences.
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Affiliation(s)
- Laurence Bernard
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Justin M McGinnis
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jane Su
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mohammad Alyafi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Delia Palmer
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Leonard Potts
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Kelly-Lynn Nancekivell
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Heidi Thomas
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Heather Kokus
- Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Lua R Eiriksson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Lorraine M Elit
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Waldo G F Jimenez
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Clare J Reade
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Limor Helpman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada.,Juravinski Hospital & Cancer Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
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18
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Street AD, Elia JM, McBroom MM, Hamilton AJ, Grundt JE, Blackwell JMN, Romito BT. The impact of implementation of a hysterectomy enhanced recovery pathway on anesthetic medication costs. J Comp Eff Res 2020; 9:1067-1077. [PMID: 33052053 DOI: 10.2217/cer-2020-0142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Aim: To evaluate the effect of implementation of a hysterectomy Enhanced Recovery After Surgery (ERAS) protocol on perioperative anesthetic medication costs. Patients & methods: Historical cohort study of 84 adult patients who underwent a hysterectomy. Forty-two patients who underwent surgery before protocol implementation comprised the pre-ERAS group. Forty-two patients who underwent surgery after protocol implementation comprised the post-ERAS group. Data on anesthetic medication costs and outcomes were analyzed. Results: Compared with the pre-ERAS group, the post-ERAS group's total medication cost was significantly lower (median: 325.20 USD; interquartile range [IQR]: 256.12-430.65 USD vs median: 273.10 USD; IQR: 220.63-370.59 USD, median difference: -40.76, 95% CI: -130.39, 16.99, p = 0.047). Length of stay was significantly longer in pre-ERAS when compared with post-ERAS groups (median: 5.0 days; IQR: 4.0-7.0 days vs median: 3.0 days; IQR: 3.0-4.0 days, median difference: -2.0 days, 95% CI: -2.5581, -1.4419, p < 0.0001). Conclusion: ERAS protocols may reduce perioperative medication costs.
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Affiliation(s)
- Austin D Street
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Jennifer M Elia
- Department of Anesthesiology & Perioperative Care, University of California - Irvine, 333 City Boulevard W #2150, Orange, CA 92868, USA
| | - Mandy M McBroom
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Allan J Hamilton
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Jessica E Grundt
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - James-Michael N Blackwell
- Department of Population & Data Sciences, Division of Behavioral & Communication Sciences, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9066, USA
| | - Bryan T Romito
- Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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19
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Harrison R, Iniesta MD, Pitcher B, Ramirez PT, Cain K, Siverand AM, Mena G, Lasala J, Meyer LA. Enhanced recovery for obese patients undergoing gynecologic cancer surgery. Int J Gynecol Cancer 2020; 30:1595-1602. [PMID: 32848023 DOI: 10.1136/ijgc-2020-001663] [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: 05/26/2020] [Revised: 07/23/2020] [Accepted: 08/03/2020] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To compare post-operative length of stay and complication rates of matched obese and non-obese patients in an enhanced recovery (ERAS) program after open gynecologic cancer surgery. METHODS We performed an observational cohort study of patients (n=1225) undergoing open surgery from November 2014 to November 2018 at a tertiary cancer center. Patients undergoing multidisciplinary procedures, non-oncologic surgery, or procedures in addition to abdominal surgery were excluded (n=190). Obese and non-obese patients were matched by date, age, disease status, and surgical complexity. The primary outcome was post-operative length of stay. Secondary outcomes included 30-day peri-operative complications, re-operation, re-admission, opioid use, and program compliance. RESULTS After matching, 696 patients (348 obese, 348 non-obese) with median age of 57 years (IQR 48-66) were analyzed. Obese patients had a longer median procedure time (218 min vs 192.5 min, p<0.001) and greater median estimated blood loss (300 mL vs 200 mL, p<0.001). Median (IQR) post-operative length of stay was the same for obese and non-obese patients: 3 days (IQR 2-4). Obese and non-obese patients had similar rates of grade III-IV complications (10.9% and 6.6%, respectively, p=0.06), re-operation (2.3% and 1.4%, respectively, p=0.58), and re-admission (11.8% and 8.0%, respectively, p=0.13). Grade I-II complications were more common among obese patients (62.4% vs 48.3%, p<0.001) because they had more wound complications (17.8% vs 4.9%, p<0.001). Obese patients received more opioids both during surgery (morphine equivalent dose 57.25 mg (IQR 35-72.5) vs 50 mg (IQR 25-622.5), p=0.003) and after surgery (morphine equivalent daily dose 45 mg/day (IQR 10-96.2) vs 29.37 mg/day (IQR 7.5-70), p=0.01). Obese and non-obese patients had similar ERAS program compliance (70.1% and 69.8%, respectively, p=0.32). CONCLUSIONS Neither post-operative length of stay nor the rate of serious complications differed significantly despite longer surgeries, greater blood loss, and more opioid use among obese patients. An ERAS program was safe, effective, and feasible for obese patients with suspected gynecologic cancer.
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Affiliation(s)
- Ross Harrison
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria D Iniesta
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brandelyn Pitcher
- Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katherine Cain
- Clinical Pharmacy Services, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ashley M Siverand
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Larissa A Meyer
- Gynecologic Oncology and Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Gynäkologische Operationen: Modernes perioperatives Management spart Kosten. Geburtshilfe Frauenheilkd 2020. [DOI: 10.1055/a-1091-0782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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