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Mueller MG, Ashmore S, Collins S, Lewicky-Gaupp C, Kenton K. Single-Port Robotic Sacrocolpopexy: Description of an Advanced Minimally Invasive Approach and Review of the Relevant Literature. Int Urogynecol J 2024:10.1007/s00192-024-05865-6. [PMID: 39073630 DOI: 10.1007/s00192-024-05865-6] [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: 03/18/2024] [Accepted: 06/18/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Sacrocolpopexy is the gold standard for the surgical management of apical prolapse. Over the years, surgical advancements have transformed the procedure from a laparotomy with a hospital stay of several days to a minimally invasive approach with a much shorter hospital stay. One recent innovation has the potential to transform minimally invasive sacrocolpopexy. METHODS The da Vinci single-port robotic platform has allowed urological procedures to generate improved recovery, pain control, and cosmesis, with no differences in complications rates. RESULTS Although the data with respect to sacrocolpopexy are more limited owing to the novelty of this application, the results appear to be similar to those of urological procedures such as prostatectomy. CONCLUSIONS We present our surgical technique for completing single-port robotic sacrocolpopexy, with and without a hysterectomy, as well as a review of the relevant literature.
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Affiliation(s)
| | - Sarah Ashmore
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Sarah Collins
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Kimberly Kenton
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
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Cao B, Li Y, Liu Y, Chen X, Liu Y, Li Y, Wu Q, Ji F, Shu H. A multi-center study to predict the risk of intraoperative hypothermia in gynecological surgery patients using preoperative variables. Gynecol Oncol 2024; 185:156-164. [PMID: 38428331 DOI: 10.1016/j.ygyno.2024.02.009] [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: 12/16/2023] [Revised: 01/27/2024] [Accepted: 02/07/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVES Hypothermia is highly common in patients undergoing gynecological surgeries under general anesthesia, so the length of hospitalization and even the risk of mortality are substantially increased. Our aim was to develop a simple and practical model to preoperatively identify gynecological surgery patients at risk of intraoperative hypothermia. METHODS In this retrospective study, we collected data from 802 patients who underwent gynecological surgery at three medical centers from June 2022 to August 2023. We further allocated the patients to a training group, an internal validation group, or an external validation group. The preliminary predictive factors for intraoperative hypothermia in gynecological patients were determined using the least absolute shrinkage and selection operator (LASSO) method. The final predictive factors were subsequently identified through multivariate logistic regression analysis, and a nomogram for predicting the occurrence of hypothermia was established. RESULTS A total of 802 patients were included, with 314 patients in the training cohort (mean age 48.5 ± 12.6 years), 130 patients in the internal validation cohort (mean age 49.9 ± 12.5 years), and 358 patients in the external validation cohort (mean age 47.6 ± 14.0 years). LASSO regression and multivariate logistic regression analyses indicated that body mass index, minimally invasive surgery, baseline heart rate, baseline body temperature, history of previous surgery, and aspartate aminotransferase level were associated with intraoperative hypothermia in gynecological surgery patients. This nomogram was constructed based on these six variables, with a C-index of 0.712 for the training cohort. CONCLUSIONS We established a practical predictive model that can be used to preoperatively predict the occurrence of hypothermia in gynecological surgery patients. CLINICAL TRIAL REGISTRATION chictr.org.cn, identifier ChiCTR2300071859.
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Affiliation(s)
- Bingbing Cao
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, PR China
| | - Yongxing Li
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital of Sun Yat-Sen University, Guangzhou 510120, PR China
| | - Yongjian Liu
- Department of Pain Management, Guangdong Second Provincial General Hospital, Guangzhou 510317, PR China
| | - Xiangnan Chen
- Department of Anesthesiology, Guangdong Women and Children Hospital, Guangzhou 510010, PR China
| | - Yong Liu
- Department of Anesthesiology, Third People's Hospital of Shenzhen, Shenzhen 518112, PR China
| | - Yao Li
- Department of Anesthesiology, Shenshan Medical Center, Memorial Hospital of Sun Yat-Sen University, Shanwei 516601, PR China
| | - Qiang Wu
- Department of Anesthesiology, Third People's Hospital of Shenzhen, Shenzhen 518112, PR China
| | - Fengtao Ji
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital of Sun Yat-Sen University, Guangzhou 510120, PR China.
| | - Haihua Shu
- Department of Anesthesiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, PR China; Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, PR China; School of Medicine, South China University of Technology, Guangzhou 510080, PR China.
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Mundhra R, Gupta DK, Bahadur A, Kumar A, Kumar R. Effect of Enhanced Recovery after Surgery (ERAS) protocol on maternal outcomes following emergency caesarean delivery: A randomized controlled trial. Eur J Obstet Gynecol Reprod Biol X 2024; 22:100295. [PMID: 38496380 PMCID: PMC10944090 DOI: 10.1016/j.eurox.2024.100295] [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: 12/07/2023] [Revised: 02/19/2024] [Accepted: 02/28/2024] [Indexed: 03/19/2024] Open
Abstract
Background With ever increasing rates of emergency caesarean deliveries (CD),incorporating the ERAS protocol might provide a perfect window of opportunity to increase maternal comfort during the postsurgical period, but also improve outcomes and facilitate optimal return of physiological function. Objective To determine whether an ERAS pathway at emergency caesarean birth would permit a reduction in postoperative length of stay and improve postoperative patient satisfaction. Material & methods Patients undergoing emergent caesarean delivery at ≥ 34 weeks of gestation were randomized to ERAS or conventional care. The primary outcome was to compare postoperative length of hospital stay. Secondary outcome variables included first oral intake, passage of flatus/defecation, first ambulation, first urination after catheter removal and postoperative pain scores in both groups. Results We randomized 142 women (71 each in ERAS versus Conventional arm) undergoing emergency cesarean delivery. Incorporation of ERAS protocol resulted in shorter length of hospital stay (73.92 ± 8.96 in conventional arm vs 53.87 ± 15.02 in ERAS arm; p value <.0001). Significant difference was seen in visual analogue scoring during initial ambulation and rest on day 0 and day 1 between ERAS and conventional arms with mean scores being lower in ERAS arm compared to Conventional arm (p value <.05). In terms of quality of life, ERAS arm had better quality of life compared to conventional arm. Conclusion Incorporation of ERAS protocol in emergency caesarean definitely improves patient outcome in terms of early resumption of activities with better quality of life.
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Affiliation(s)
- Rajlaxmi Mundhra
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Dipesh Kumar Gupta
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Anupama Bahadur
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Ajit Kumar
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Rakesh Kumar
- Department of Paediatrics, Himalayan Institute of Medical Sciences (HIMS), Dehradun, India
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Akay E, Irmak K, Incebıyık R, Sağlam F, Mutlu EB. Comparing Wound Healing and Infection Risk Between Early and Late Dressing Removal After Abdominal Hysterectomy. Cureus 2024; 16:e62535. [PMID: 39022459 PMCID: PMC11253562 DOI: 10.7759/cureus.62535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION This study evaluates the effects of dressing timing after abdominal hysterectomy on wound healing and infection risk. It highlights the potential for early dressing removal to accelerate healing and underscores the need for clear guidelines in wound care that align with the ERAS (Enhanced Recovery After Surgery) protocol. METHODS Using a prospective, randomized, double-blind design, this research was carried out at Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey. The objective was to investigate the impact of early dressing removal on wound healing and infection rates after elective abdominal hysterectomy. RESULTS Demographic parameters such as age, height, weight, and body mass index (BMI) were found to have no significant impact on wound healing. Patients whose dressings were removed early had shorter hospital stays. No significant differences were observed between the two groups in terms of wound complications and hospital readmission rates. CONCLUSIONS Early dressing removal after abdominal hysterectomy was observed to positively affect wound healing and facilitate earlier hospital discharge. However, no significant differences were found in hospital readmission rates between the two groups. These findings suggest that the dressing timing can be more flexible within the ERAS protocol and does not have a decisive impact on postoperative complications.
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Affiliation(s)
- Emrullah Akay
- Obstetrics and Gynecology, Başakşehir Çam and Sakura City Hospital, Istanbul, TUR
| | - Kübra Irmak
- Obstetrics and Gynecology, Istinye University, Istanbul, TUR
| | - Ravza Incebıyık
- Obstetrics and Gynecology, Başakşehir Çam and Sakura City Hospital, Istanbul, TUR
| | - Fatma Sağlam
- Obstetrics and Gynecology, Başakşehir Çam and Sakura City Hospital, Istanbul, TUR
| | - Enes Burak Mutlu
- Obstetrics and Gynecology, Başakşehir Çam and Sakura City Hospital, Istanbul, TUR
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Richards DC, Dunn BA, Chellappa VR, John CR, Davis WB. Postoperative pain control and opioid use with transversus abdominis plane block and scheduled multimodal pain management in patients undergoing cesarean section. Int J Gynaecol Obstet 2024. [PMID: 38798146 DOI: 10.1002/ijgo.15699] [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: 12/13/2023] [Revised: 04/19/2024] [Accepted: 05/11/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE The impact of a transversus abdominis plane (TAP) block in patients undergoing cesarean section requires further evaluation. The aim of this study was to compare postoperative pain scores and opioid use in cesarean surgery patients undergoing either a TAP block and scheduled multimodal pain management (SMPM) or SMPM alone. METHODS In this retrospective, dual cohort study, cesarean surgery patients underwent neuraxial anesthesia and a TAP block (SMPM/TAP) or SMPM; the TAP block incorporated ropivacaine (20-30 mL) administered bilaterally. The group analyses involved a comparison of postoperative pain scores using the visual analog scale and opioid consumption at 24 and 24-48 h. RESULTS There were 94 (52.8%) patients in the SMPM/TAP group and 84 (47.2%) subjects in the SMPM alone group. At 24 h postoperatively, the SMPM/TAP group exhibited significantly lower pain scores (4.07 vs 4.54) than the SMPM group (P < 0.001) and reduced opioid consumption (2.29 vs 3.28 mg; P < 0.001). However, at 24-48 h, the SMPM group demonstrated lower pain scores (5.46 vs 5.98) compared to the SMPM/TAP group (P < 0.001) and reduced opioid consumption (8.75 vs 10.21 mg; P < 0.001); overall opioid consumption was higher (12.50 vs 12.02 mg) in the SMPM/TAP group (P < 0.001). CONCLUSION The TAP block improved cesarean surgery patients' pain scores and reduced opioid consumption at 24 h postoperatively but the effect of the TAP block was ephemeral as the SMPM/TAP group exhibited inferior pain scores and greater opioid consumption compared to the SMPM group at 24-48 h postoperatively.
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Affiliation(s)
- David C Richards
- Newport Harbor Anesthesia Consultants, Newport Beach, California, USA
| | - Brian A Dunn
- Newport Harbor Anesthesia Consultants, Newport Beach, California, USA
| | - Vivek R Chellappa
- Newport Harbor Anesthesia Consultants, Newport Beach, California, USA
| | - Cameron R John
- Department of Behavioral Sciences, Utah Valley University, Orem, Utah, USA
| | - Warren B Davis
- Newport Harbor Anesthesia Consultants, Newport Beach, California, USA
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Terranova C, Schiavoni L, Ficarola F, Plotti F, De Cicco Nardone C, Montera R, Lotierzo M, Bartolone M, Pascarella G, Mattei A, Costa F, Agrò FE, Angioli R. The Role of TAP/RS Block in Minor Gynecologic Laparoscopic Surgery: A Randomized Clinical Trial. Gynecol Obstet Invest 2024; 89:103-110. [PMID: 38266505 DOI: 10.1159/000535835] [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: 09/14/2023] [Accepted: 12/08/2023] [Indexed: 01/26/2024]
Abstract
OBJECTIVES The aim of the study was to compare, in patients undergoing minor gynecological laparoscopic procedures, the effects of ultrasound (US)-guided transversus abdominis plane (TAP) + rectus sheath (RS) block versus no TAP/RS block in terms of post-surgical pain control using the numeric pain rating scale (NRS) and the degree of patient satisfaction, according to the main goals of Early Recovery After Surgery (ERAS) programs. The primary outcome is to value the postoperative abdominal pain using NRS in both groups. Secondary outcomes are to evaluate blood values, presence of postoperative nausea and vomiting (PONV), postoperative ileus, level of patient expected satisfaction, time of discharge, length of stay (LOS), and the amounts of additional analgesics required. DESIGN In this prospective randomized controlled trial, patients were randomly assigned to loco-regional anesthesia (LRA) group, who received TAP and RS block under US guidance, or no loco-regional anesthesia (N-LRA) group. Enrolled patients were randomized 1:1 to either receive bilateral TAP/RS block with ropivacaine or sham treatment (patches were applied on the abdominal wall of the patients under general anesthesia). PARTICIPANTS All patients aged between 18 and 75 years, with ASA (American Society of Anesthesiologists) physical status 1-2, undergoing laparoscopic minor gynecological surgery, were enrolled. SETTING The study was conducted to the University of Campus Bio-Medico Hospital of Rome. METHODS Half an hour before surgery, all patients received gabapentin 300 mg per os. Once the patient underwent general anesthesia, US-guided bilateral TAP/RS block was performed by the anesthesiology team, while the uterine manipulator was positioned by a gynecology resident (not involved in the study). In the operative room, all patients received the same standardized anesthetic regimen. Postoperative abdominal pain was assessed at rest, after palpation, during movement, and after a cough by evaluating the patient at 6, 12, 18, 24, 36, 48, and 72 h after surgery, using the NRS from 0 to 10 in both groups. The amount of drug used for analgesia in the first 48 h after surgery was recorded. Moreover, hemoglobin, white blood cells, and c-reactive protein levels were recorded at 24, 48, and 72 h. The presence of PONV and the postoperative ileus was recorded throughout convalescence. The expected level of patient satisfaction at discharge and finally the LOS were assessed. LIMITATIONS The major weakness of this study is that 60 mL of 0.5% ropivacaine was administered to each patient, without considering weight differences, yet contemporary literature rarely suggests volume/dose titration in fascial blocks. RESULTS A total of 104 women, undergoing gynecological minor laparoscopic surgery, were enrolled and assigned to LRA group (53 pts) and N-LRA group (51 pts). Postoperative pain was significantly reduced in patients who received TAP/RS block. A reduction in the intake of non-steroidal anti-inflammatory drugs after surgery was registered in LRA group (p < 0.01). Moreover, a significant reduction of LOS (45.97 ± 9.87 vs. 65.08 ± 17.32 h; p < 0.01) and PONV was observed in the LRA group, as well as a better level of patient satisfaction at discharge (9.43 ± 0.94 vs. 8.26 ± 1.19; p < 0.01), compared to the N-LRA group. CONCLUSIONS US-guided TAP and RS block significantly reduces postoperative pain after minor gynecologic laparoscopic surgery and improves patients' post-operative recovery.
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Affiliation(s)
- Corrado Terranova
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Lorenzo Schiavoni
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fernando Ficarola
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Francesco Plotti
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Carlo De Cicco Nardone
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Roberto Montera
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Michela Lotierzo
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Martina Bartolone
- Department of Maternal and Child Health and Urological Sciences, Umberto I Polyclinic Hospital, Sapienza University, Rome, Italy
| | - Giuseppe Pascarella
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Alessia Mattei
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Fabio Costa
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Felice Eugenio Agrò
- Unit of Anesthesia, Intensive Care and Pain Management, Department of Medicine, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Roberto Angioli
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
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Bapodra A, Moy K, Nekola D, Schwartz GS. Neuraxial analgesia, nerve blocks, and special considerations for the parturient. Int Anesthesiol Clin 2024; 62:62-68. [PMID: 38063038 DOI: 10.1097/aia.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Anuj Bapodra
- Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York
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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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Wright KN, Melnyk AI, Emont J, Van Dis J. Sustainability in Obstetrics and Gynecology. Obstet Gynecol 2023; 142:1341-1346. [PMID: 37944151 DOI: 10.1097/aog.0000000000005435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/14/2023] [Indexed: 11/12/2023]
Abstract
Current practices in the U.S. health care industry drive climate change. This review summarizes the vast research on the negative health effects of the climate crisis on patients as relevant to obstetrics and gynecology. We further propose solutions to decarbonize operating rooms, labor and delivery units, and nurseries and neonatal intensive care units through evidence-based reduction in our single-use supply, energy, and water, as well as anesthetic gases and appropriate waste sorting.
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Affiliation(s)
- Kelly N Wright
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California; the Division of Urogynecology and Pelvic Reconstructive Surgery, Department of Obstetrics, Gynecology, and Reproductive Sciences, Pittsburgh, Pennsylvania; and the Department of Obstetrics and Gynecology, Columbia University Medical Center, and NewYork-Presbyterian Hospital, New York, and the Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, New York
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Lee PS, Brunette LL, Sriprasert I, Eloustaz M, Deshpande R, Adams C, Muderspach L, Roman L, Dickerson S, Kim MP. Benefits of the Enhanced Recovery After Surgery (ERAS) Pathway With Quadratus Lumborum Blocks for Minimally Invasive Gynecologic Surgery Patients: A Retrospective Cohort Study. Cureus 2023; 15:e49183. [PMID: 38130508 PMCID: PMC10733622 DOI: 10.7759/cureus.49183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
STUDY OBJECTIVE This study aimed to determine the effect of the implementation of the Enhanced Recovery After Surgery (ERAS) protocol among patients receiving minimally invasive gynecologic surgery. DESIGN AND SETTING This retrospective cohort study was performed in a tertiary care hospital. PATIENTS A total of 328 females who underwent minimally invasive gynecologic surgeries requiring at least one overnight stay at Keck Hospital of University of Southern California (USC), California, USA, from 2016 to 2020 were included in this study. INTERVENTIONS The institutional ERAS protocol was implemented in late 2018. A total of 186 patients from 2016 to 2018 prior to the implementation were compared to 142 patients from 2018 to 2020 after the implementation. Intraoperatively, the ERAS group received a multimodal analgesic regimen (including bilateral quadratus lumborum (QL) blocks) and postoperative care geared toward a satisfactory, safe, and expeditious discharge. MEASUREMENTS AND MAIN RESULTS The two groups were similar in demographics, except for the shorter surgical time noted in the ERAS group. The median opioid use was significantly less among the ERAS patients compared with the non-ERAS patients on postoperative day 1 (7.5 vs. 14.3 mg; p<0.001) and throughout the hospital stay (17.4 vs. 36.2 mg; p<0.001). The ERAS group also had a shorter median hospital length of stay compared to the non-ERAS group (p<0.01). Among patients with a malignant diagnosis, patients in the ERAS group had significantly less postoperative day 1 and total opioid use and a shorter hospital stay (p<0.01). Within the ERAS group, 20% of the patients did not end up receiving a QL block. Opioid use and length of stay were similar between patients who did and did not receive the QL block. CONCLUSIONS The ERAS pathway was associated with a reduction in opioid use postoperatively and a shorter length of hospital stay after minimally invasive gynecologic surgery. There was a more significant decrease in opioid use and hospital length of stay for patients with malignant diagnoses compared to patients with benign diagnoses. Further research can be done to fully delineate the effect of QL blocks in ERAS protocols.
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Affiliation(s)
- Paul S Lee
- Anesthesiology, University of Southern California, Los Angeles, USA
| | - Laurie L Brunette
- Obstetrics and Gynecology, University of Southern California, Los Angeles, USA
| | - Intira Sriprasert
- Obstetrics and Gynecology, Los Angeles County Medical Center and University of Southern California Medical Center, Los Angeles, USA
| | - Mohamed Eloustaz
- Anesthesiology, University of Southern California, Los Angeles, USA
| | - Rasika Deshpande
- Obstetrics and Gynecology, University of Southern California, Los Angeles, USA
| | - Crystal Adams
- Obstetrics and Gynecology, University of Southern California, Los Angeles, USA
| | - Laila Muderspach
- Obstetrics and Gynecology, University of Southern California, Los Angeles, USA
| | - Lynda Roman
- Obstetrics and Gynecology, University of Southern California, Los Angeles, USA
| | - Shane Dickerson
- Anesthesiology, University of Southern California, Los Angeles, USA
| | - Michael P Kim
- Anesthesiology, University of Southern California, Los Angeles, USA
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Cummings S, Scime NV, Brennand EA. Age and postoperative opioid use in women undergoing pelvic organ prolapse surgery. Acta Obstet Gynecol Scand 2023; 102:1371-1377. [PMID: 37587619 PMCID: PMC10540930 DOI: 10.1111/aogs.14638] [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: 04/12/2023] [Revised: 06/08/2023] [Accepted: 06/30/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Our objective was to explore the relation between patient age and postoperative opioid use up to 24 hours following pelvic organ prolapse (POP) surgery. MATERIAL AND METHODS We conducted a prospective cohort study following 335 women ranging in age from 26 to 82 years who underwent surgery for multi-compartment POP at a tertiary center in Alberta, Canada. Patient characteristics were measured using baseline questionnaires. Perioperative data were collected from medical chart review during and up to 24 hours following surgery. We used logistic regression to analyze the odds of being opioid-free and linear regression to analyze mean differences in opioid dose, measured as total morphine equivalent daily dose, exploring for a potential non-linear effect of age. Adjusted models controlled for preoperative pain, surgical characteristics and patient health factors. RESULTS Overall, age was positively associated with greater odds of being opioid-free in the first 24 hours after surgery (adjusted odds ratio per increasing year of age = 1.07, 95% confidence interval [CI] 1.04-1.09, n = 332 women). Among opioid users, age was inversely associated with total opioid dose (adjusted mean difference per increasing year of age = 0.71 mg morphine equivalent daily dose, 95% CI -0.99 to -0.44, n = 204 women). There was no evidence of a non-linear relation between age and postoperative opioid use or dose. CONCLUSIONS In the context of POP surgery, we found that younger women were more likely to use opioids after surgery and to use a higher dose in the first 24 hours when compared with older women. These findings support physicians to consider age when counseling POP patients regarding pain management after surgery, and to direct resources aimed at opioid-free pain control towards younger patients.
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Affiliation(s)
- Shannon Cummings
- Department of Obstetrics and Gynecology, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Natalie V. Scime
- Department of Health and SocietyUniversity of Toronto ScarboroughScarboroughOntarioCanada
| | - Erin A. Brennand
- Department of Obstetrics and Gynecology, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
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Melnyk AI, Niino C, Wright KN. Addressing Sustainability in the Operating Room. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023; 29:719-724. [PMID: 37493260 DOI: 10.1097/spv.0000000000001395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
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13
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Reuter S, Schmalfeldt B, Haas SA, Zapf A, Cevirme S, Prieske K, Wölber L, Müller V, Zöllner C, Jaeger A. Impact of Introducing a PACU24 Concept on the Perioperative Outcome of Patients with Advanced Ovarian Cancer Treated with Cytoreductive Surgery. Geburtshilfe Frauenheilkd 2023; 83:1022-1030. [PMID: 37588253 PMCID: PMC10427201 DOI: 10.1055/a-2055-9349] [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: 12/15/2022] [Accepted: 03/15/2023] [Indexed: 08/18/2023] Open
Abstract
Introduction Patients with ovarian cancer who undergo multivisceral surgery usually require intensive care monitoring postoperatively. In view of the ever-fewer numbers of high-care/intensive care beds and the introduction of fast-track treatment concepts, it is increasingly being suggested that these patients should be cared for postoperatively in 24-h Post Anesthesia Care Units (PACU24). No analyses have been carried out to date to investigate whether such a postoperative care concept might be associated with a potential increase in postoperative complications in this patient cohort. Methods A PACU24 unit was set up in our institution in 2015 and it has become the primary postoperative care pathway for patients with ovarian cancer who have undergone cytoreductive (debulking) surgery. A structured, retrospective analysis of data from patients treated before (control group) and after (PACU group) the introduction of this care concept was carried out, with a particular focus on postoperative complications and secondary admission to an intensive care unit where necessary. Results The data of 42 patients were analyzed for the PACU group and 45 patients for the control group. According to the analysis, the preoperative and surgical data of both groups were comparable (age, ASA, BMI, FIGO stage, duration of surgery, blood loss). The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM score) as a measure for the risk of postoperative complications was higher in the PACU group (11.1% vs. 9.7%, p = 0.001). Patients in the PACU group underwent bowel resection with anastomosis significantly more often (76.3% vs. 33.3%, p < 0.001), although the extent of surgery was otherwise comparable. The total number, type and severity of postoperative complications and the duration of the overall stay in hospital did not differ between the two groups. None of the patients required secondary transfer from the PACU or normal ward to an intensive care unit (ICU). Summary Our data support the assumption that the care concept of transferring patients to a PACU24 represents a safe and cost-saving care pathway for the postoperative care of patients even after complex gynecological-oncological procedures.
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Affiliation(s)
- Susanne Reuter
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Barbara Schmalfeldt
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Sebastian A. Haas
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsmedizin Rostock, Rostock, Germany
| | - Antonia Zapf
- Institut für Medizinische Biometrie und Epidemiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Sinan Cevirme
- Institut für Medizinische Biometrie und Epidemiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Katharina Prieske
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Linn Wölber
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Zöllner
- Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Jaeger
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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Porta-Roda O, Cornet-Cortada A, Font-Vilamitjana A, Huguet-Galofré E, Lleberia-Juanós J, Solà-Arnau I. Vaginal packing after vaginal hysterectomy: systematic review and recommendations. Int Urogynecol J 2023; 34:789-796. [PMID: 36018354 DOI: 10.1007/s00192-022-05331-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/08/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vaginal packing is often used after vaginal hysterectomy to reduce the risk of haemorrhagic and infectious complications, but the procedure may impair spontaneous bladder emptying and necessitate permanent bladder catheterization, which itself increases the risk of urinary infection, patient bother, delayed discharge, and increased costs. This systematic review was aimed at assessing the complications and outcomes associated with vaginal packing after vaginal hysterectomy. METHODS We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, using the Population, Interventions, Comparators, Outcomes, and Study design (PICOS) framework to define eligibility. Following data synthesis and subgroup analyses, we assessed the certainty of evidence according to GRADE guidance and formulated a clinical recommendation. RESULTS The review included four clinical trials (involving 337 participants). These provided no clear evidence that vaginal packing led to clinically meaningful reductions in adverse effects, such as vaginal bleeding, hematoma formation, or postoperative vaginal cuff infection. Overall, the intervention produced no clear benefit regarding the predefined outcomes. CONCLUSIONS Routine vaginal packing after vaginal hysterectomy had no clear benefit on outcomes. We therefore advise against this procedure.
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Affiliation(s)
- Oriol Porta-Roda
- Department of Obstetrics and Gynecology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, Plaça del Dr. Robert, 5, 08221, Barcelona, Terrassa, Spain.
| | | | | | - Eva Huguet-Galofré
- Department of Obstetrics and Gynecology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, Plaça del Dr. Robert, 5, 08221, Barcelona, Terrassa, Spain
| | - Judith Lleberia-Juanós
- Department of Obstetrics and Gynecology, Fundació Hospital de l'Esperit Sant, Santa Coloma de Gramenet, Barcelona, Spain
| | - Ivan Solà-Arnau
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
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Gómez-Hidalgo NR, Pletnev A, Razumova Z, Bizzarri N, Selcuk I, Theofanakis C, Zalewski K, Nikolova T, Lanner M, Kacperczyk-Bartnik J, El Hajj H, Perez-Benavente A, Nelson G, Gil-Moreno A, Fotopoulou C, Sanchez-Iglesias JL. European Enhanced Recovery After Surgery (ERAS) gynecologic oncology survey: Status of ERAS protocol implementation across Europe. Int J Gynaecol Obstet 2023; 160:306-312. [PMID: 35929452 DOI: 10.1002/ijgo.14386] [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: 01/31/2022] [Revised: 07/19/2022] [Accepted: 07/28/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To acquire a comprehensive assessment of the current status of implementation of Enhanced Recovery After Surgery (ERAS) protocols across Europe. METHODS The survey was launched by The European Network of Young Gynecologic Oncologists (ENYGO). A 45-item survey was disseminated online through the European Society of Gynecological Oncology (ESGO) Network database. RESULTS A total of 116 ESGO centers participated in the survey between December 2020 and June 2021. Overall, 80 (70%) centers reported that ERAS was implemented at their institution: 63% reported a length of stay (LOS) for advanced ovarian cancer surgery between 5 and 7 days; 57 (81%) centers reported a LOS between 2 and 4 days in patients who underwent an early-stage gynecologic cancer surgery. The ERAS items with high reported compliance (>75% "normally-always") included deep vein thrombosis prophylaxis (89%), antibiotic prophylaxis (79%), prevention of hypothermia (55%), and early mobilization (55%). The ERAS items that were poorly adhered to (less than 50%) included early removal of urinary catheter (33%), and avoidance of drains (25%). CONCLUSION This survey shows broad implementation of ERAS protocols across Europe; however, a wide variation in adherence to the various ERAS protocol items was reported.
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Affiliation(s)
- Natalia R Gómez-Hidalgo
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
| | - Andrei Pletnev
- Department of Gynecology and Obstetrics, University of Zielona, Góra, Poland
| | - Zoia Razumova
- Department of Women's and Children's Health, Division of Neonatology, Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento per la salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario A Gemelli (IRCCS), Rome, Italy
| | - Ilker Selcuk
- Gynaecological Oncology, Maternity Hospital, Ankara City Hospital, Ankara, Turkey
| | | | - Kamil Zalewski
- Gynecological Oncology, Świętokrzyskie Cancer Center, Kielce, Poland
| | - Tanja Nikolova
- Klinikum Mittelbaden, Academic Teaching Hospital of Heidelberg University, Baden-Baden, Germany
| | - Maximilian Lanner
- Department of Obstetrics and Gynecology, Kardinal Schwarzenberg Klinikum, Schwarzach im Pongau, Austria
| | | | - Houssein El Hajj
- Department of Surgical Oncology, Oscar Lambret Cancer Center, Lille, France
| | - Assumpció Perez-Benavente
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Antonio Gil-Moreno
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Madrid, Spain
| | - Christina Fotopoulou
- West London Gynecological Cancer Centre; Hammersmith Hospital, Imperial College, London, UK
| | - Jose Luis Sanchez-Iglesias
- Center of Gynecologic Oncology, Department of Gynecology, Vall d'Hebron Barcelona Hospital Campus, Autonoma University of Barcelona (UAB), Barcelona, Spain
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Sinha R, Verma N, Bana R, Kalidindi N, Sampurna S, Mohanty GS. Intra- and post-operative outcomes in benign gynaecologic surgeries before and after the implementation of enhanced recovery after surgery protocols: A comparison. J Minim Access Surg 2023; 19:112-119. [PMID: 36722536 PMCID: PMC10034813 DOI: 10.4103/jmas.jmas_42_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 01/20/2023] Open
Abstract
Objective To compare intra- and post-operative outcomes in patients undergoing benign gynaecologic surgery before and after the implementation of enhanced recovery after surgery (ERAS) protocols. Introduction ERAS is a multidisciplinary teamwork with the aim to reduce the body's reaction to surgical stress. The key components of ERAS include pre-operative counselling, avoiding prolonged fasting, standardised analgesic and anaesthetic regimes, early mobilisation and early discharge. Materials and Methods Women undergoing hysterectomy and myomectomy were included in the study. The pre-ERAS group had 100 cases and the ERAS group had 104. Demographic data of both the groups were compared. Duration of surgery, amount of blood loss, intra-abdominal drain, oral feed, catheter removal, ambulation, passage of flatus and length of stay were compared. Results The demographic profiles of both the groups were comparable. Time taken to intake of liquids (P < 0.001), solid food (P < 0.001), passage of flatus (P = 0.001), removal of Foley's catheter (P = 0.023), ambulation (P = 0.007), pain score (P = 0.001) and length of stay in hospital (P < 0.001) were statistically significantly shorter in the ERAS group when compared to the pre-ERAS group. A significant difference was seen in the use of intraperitoneal drains in the ERAS group (81% vs. 23.1%), and if used, drains were removed early in the ERAS group (66.66% vs. 28.39%) within 40 h. Both the groups had similar intra- and immediate post-operative complications. Conclusion ERAS helps in reducing length of stay with early feeding and ambulation, leading to early discharge without increase in intra- and post-operative complications in women undergoing benign gynaecological surgeries.
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Affiliation(s)
- Rooma Sinha
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Neeru Verma
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Rupa Bana
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Nivya Kalidindi
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
| | - Sowmya Sampurna
- Department of Gynecology, Apollo Health City, Hyderabad, Telangana, India
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Kong X, Liu K. The Predictive Value of PCT and Other Infection Indicators in Postoperative Infection of Epithelial Ovarian Cancer. Infect Drug Resist 2023; 16:1521-1536. [PMID: 36960392 PMCID: PMC10029970 DOI: 10.2147/idr.s399666] [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: 11/30/2022] [Accepted: 03/07/2023] [Indexed: 03/18/2023] Open
Abstract
Purpose To study the early predictive value of WBC, CRP and PCT on infectious complications after epithelial ovarian cancer surgery, draw ROC curves, and construct a nomogram prediction model. Patients and Methods The clinical data of patients with epithelial ovarian cancer in Shengjing Hospital from August 2019 to August 2022 were included. The levels of WBC, CRP and PCT were statistically analyzed on the first, third and fifth days after surgery, and the ROC was plotted. Multivariate logistic regression analysis determined independent influencing factors, individualized nomogram model for predicting the occurrence of postoperative infectious complications was constructed, and the correction curve was used for verification. Results A total of 116 patients were enrolled. The postoperative test levels of WBC, CRP and PCT were compared between two groups, and the differences on POD3 and POD5 were statistically significant. The ROC area on POD5 was 0.739, 0.838 and 0.804, respectively, better than that on POD3. Among them, CRP has the greatest value; The predicted value of the combined test of WBC, CRP and PCT on POD5 was greater than that of a single index on POD5. The nomogram model on POD5 was constructed, and the ROC analysis showed that it had a good degree of differentiation. Conclusion WBC, CRP and PCT can effectively predict the occurrence of postoperative infectious complications, among which CRP alone has the greatest diagnostic value on POD5, and the combined test value of the three indicators is higher than that of a single index. The nomogram model constructed by the combined indicators on POD5 can assess the risk individually.
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Affiliation(s)
- Xiangshu Kong
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, People’s Republic of China
| | - Kuiran Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, People’s Republic of China
- Correspondence: Kuiran Liu, Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, 1100001, People’s Republic of China, Tel +86 18940251585, Email
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Patient-Initiated Telephone Calls Before and After Introduction of an Enhanced Recovery After Surgery Protocol for Female Pelvic Reconstructive Surgery. UROGYNECOLOGY (HAGERSTOWN, MD.) 2022; 28:848-854. [PMID: 36409642 DOI: 10.1097/spv.0000000000001237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE An evaluation of Enhanced Recovery After Surgery (ERAS) effect on perioperative patient phone calls. OBJECTIVE The aim of this study was to compare perioperative patient phone calls before and after implementation of ERAS. STUDY DESIGN This is a retrospective chart review of women who underwent surgery by urogynecologists where ERAS was implemented. Patients who underwent surgery were identified before the implementation and compared with the same time period after implementation. Perioperative phone calls were reviewed and categorized by reason for call. Differences between the 2 groups were compared with a Student t test if normally distributed or with a Mann-Whitney U test if not. Categorical outcomes were reported with a percentage and compared with a χ2 test with an α level of 0.05. RESULTS We reviewed 387 records. There was no difference in the percentage of patient calls before and after implementation of ERAS (preoperatively: 19.8% vs 25.1% [ P = 0.21], postoperatively: 64.1% vs 61.5% [ P = 0.61]). Questions about chronic home medications were the most common reasons for calling before surgery (pre-ERAS: 16 [42.1%]; post-ERAS: 12 [28.6%]). Questions related to medications, pain, and bowels were the top reasons people called postoperatively. These remained the top 3 in the post-ERAS time period; however, bowel-related questions switched with medications for the top reason. CONCLUSIONS Despite patient education being an essential component of ERAS with written and verbal instructions provided, our study found no difference in preoperative or postoperative calls with the implementation. By focusing on common concerns, we may be able to improve the patients experience and reduce office phone calls.
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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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Delecourt C, Tourette C, Crochet P, Pivano A, Hamouda I, Agostini A. Benefits of AirSeal® System in Laparoscopic Hysterectomy for Benign Condition: A Randomized Controlled Trial. J Minim Invasive Gynecol 2022; 29:1003-1010. [DOI: 10.1016/j.jmig.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/05/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
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Santiago AE, Filho ALDS, Cândido EB, Ribeiro PA, Silva JCRE, Primo WQSP, Carvalho JP, Podgaec S, Lino CAPC, Quintáiros RDA, Brito LGO. Perioperative management in gynecological surgery based on the ERAS program. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:202-210. [PMID: 35213920 PMCID: PMC9948094 DOI: 10.1055/s-0042-1743401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Sérgio Podgaec
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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22
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Opioid Dispensing After Hysteroscopy in the United States. Obstet Gynecol 2021; 138:888-890. [PMID: 34735387 DOI: 10.1097/aog.0000000000004591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/12/2021] [Indexed: 11/26/2022]
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Surgeon-administered ilio-inguinal and pudendal nerve blocks for major vulval surgery: An observational study with visual analogue pain scoring. Eur J Obstet Gynecol Reprod Biol 2021; 268:87-91. [PMID: 34890844 DOI: 10.1016/j.ejogrb.2021.11.429] [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: 08/04/2021] [Revised: 11/10/2021] [Accepted: 11/21/2021] [Indexed: 11/24/2022]
Abstract
Surgical excision of the groin and vulva is a painful procedure. Traditionally following general or regional anaesthesia, local anaesthetic was infiltrated around the wound. Thedistribution varied and the somatic pain control was not reliable. Inspired by the success of the application of peripheral nerve blocks for postoperative pain control with open abdominal procedures, we introduced blockade of the ilioinguinal nerve (IIN) and pudendal nerve (PN) into our vulval surgery to assess the requirement for parenteral and oral analgesia in the postoperative period. This is an observational study of all patients undergoing major vulval and/or related groin surgery. Sampling biopsies were excluded. Levobipuvicaine 0.25% (2.5 mg/ml) or 0.5% (5 mg/ml) was used for and dosage was calculated based on the patient's weight with no more than 2 mg/kg. For example, using 0.25% of levobupivacaine (2.5 mg/ml) for a 70 kg patient, 56 ml is administered divided into 4, giving 14mls at each site (2 sites abdominally for IIN block and 2 sites for pudendal block). Eighteen women were included in the analysis. Median age was 67 (range 34-81) years and thirteen (72%) were >60 years. Visual analogue scores (VAS) ranged from 0 to 3 for seventeen patients from day 0 to day 1 and fifteen patients from day 2 to day 5. Two patients had pain scores >4 on one or more postoperative days: one had chronic arthralgia and one had received a lower volume of bupivacaine. This observational study demonstrates that ilioinguinal and pudendal nerve LA blocks may be a valuable addition to the multimodal postoperative analgesic pathway for women undergoing major surgical excision in the vulva and groin.
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Efficacy of Different Preemptive Analgesia on Postoperative Analgesia, Oxidative Stress, and Inflammatory Response after Gynecological Laparoscopic Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:4233716. [PMID: 34745282 PMCID: PMC8570873 DOI: 10.1155/2021/4233716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/29/2021] [Indexed: 12/02/2022]
Abstract
Objective To observe and compare the analgesic effects of oxycodone, pentazocine, and ketorolac tromethamine pre-emptive analgesia on gynecological laparoscopic patients after operation and the effects on oxidative stress and inflammatory reaction. Methods A total of 64 patients who underwent elective gynecological laparoscopic surgery in Yiwu Central Hospital from June 2019 to December 2020 were randomly divided into four groups (n = 16). Before anesthesia induction, oxycodone (group A), pentazocine (group B), ketorolac tromethamine (group C), and normal saline (group D) were, respectively, administered. Patients' mean arterial pressure (MAP) and heart rate (HR) changes, visual analogue scale (VAS), Bruggemann comfort scale (BCS), serum tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), C-reactive protein (CRP), blood glucose (CLU), serum cortisol level, postoperative adverse reactions, and additional analgesia were recorded at each time point. Results The MAP levels of T2 (immediate intubation), T3 (immediate catheter removal), and T4 (5 min after catheter removal) in the four groups were higher than those of T1 (quiescent state), and the HR levels T2, T3, and T4 were lower than those of T1 (P < 0.05). The MAP and HR levels of T2, T3, and T4 in patients of groups A, B, and C were lower than those of group D in the same period (P < 0.05). The VAS and BCS scores of groups A, B, and C at 1, 6, 12, and 24 h after operation were better than those of group D at the same time, and the scores of group A at 1 h and 6 h after operation were better than those of groups B and C at the same time (P < 0.05). The levels of serum TNF-α, IL-6, and CRP in the four groups of patients at 6, 12, and 24 h after operation were higher than those before operation, but those in groups A, B, and C were lower than those in group D, and those in group A were higher than those in groups B and C at 12 h and 24 h after operation (P < 0.05). The CLU and serum cortisol levels in the four groups were significantly higher at 6, 12, and 24 h after operation, but those in groups A, B, and C were lower than those in group D, and those in group A were lower than those in groups B and C at 6 and 12 h after operation (P < 0.05). There was no significant difference in the incidence of adverse reactions within 24 h between the four groups (P > 0.05). The incidence of additional analgesia in groups A, B, and C was lower than that in group D (P < 0.05). Conclusion Oxycodone, pentazocine, and ketorolac tromethamine are effective and safe in inhibiting postoperative pain and the generation of inflammatory factors and relieving inflammatory state in gynecological laparoscopic pre-emptive analgesia. Oxycodone has better postoperative analgesic effect because it can effectively alleviate stress reaction.
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Enhanced Recovery Program for Outpatient Female Pelvic Reconstructive Surgery. Female Pelvic Med Reconstr Surg 2021; 27:627-632. [PMID: 34554144 DOI: 10.1097/spv.0000000000001015] [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
OBJECTIVES Enhanced recovery programs (ERPs) are evidence-based perioperative interventions designed to reduce narcotic use, decrease hospital length of stay, decrease medical costs, and improve patient satisfaction. Given the increase in outpatient procedures in female pelvic medicine and reconstructive surgery, we sought to compare patient outcomes before and after implementation of an ERP for women undergoing outpatient pelvic reconstructive surgery. METHODS This was a prospective nonrandomized cohort quality improvement practice initiative. The ERP intervention group included consecutive patients (n = 66) undergoing elective outpatient pelvic reconstructive surgery from March 2016 to October 2016. Historical controls were consecutive patients (n = 124) who had undergone outpatient pelvic reconstructive surgery in the same period a year before ERP implementation. Our primary outcome was opioid use and postoperative pain scores. Secondary outcomes included procedure time, use of intravenous fluids, time to discharge, and total hospital cost. RESULTS There was an observed reduction in opioid use between the ERP patients and historic controls as measured by intraoperative morphine milligram equivalents (MMEs) and total MMEs, with no difference in postoperative pain scores or postoperative MME. In addition, reduction in length of procedure (P = 0.03), intraoperative intravenous fluids (P < 0.0001), and total hospital cost (P ≤ 0.01) was noted between the ERP patients and historic controls. CONCLUSIONS Implementation of an outpatient ERP for female pelvic reconstructive surgery was associated with decreased intraoperative and total MMEs, decreased length of procedure, decreased administration of intravenous fluids, and decreased total hospital cost without changing postoperative pain scores.
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Wright KN, Ronen I, Siedhoff MT, Cass I. Patient Experience and Unplanned Patient Contact After Implementation of an Enhanced Recovery After Surgery Protocol for Laparoscopic Hysterectomy. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kelly N. Wright
- Department of Obstetrics and Gynecology, Cedars–Sinai, Los Angeles, California, USA
| | - Itai Ronen
- Department of Obstetrics and Gynecology, Cedars–Sinai, Los Angeles, California, USA
| | - Matthew T. Siedhoff
- Department of Obstetrics and Gynecology, Cedars–Sinai, Los Angeles, California, USA
| | - Ilana Cass
- Dartmouth–Hitchcock Medical Center, Lebanon, New Hampshire, USA
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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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Sisodia RC, Ellis D, Hidrue M, Linov P, Cavallo E, Bryant AS, Wakamatsu M, del Carmen MG. Cohort study of impact on length of stay of individual enhanced recovery after surgery protocol components. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2021; 3:e000087. [PMID: 35047804 PMCID: PMC8749327 DOI: 10.1136/bmjsit-2021-000087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/09/2021] [Indexed: 11/05/2022] Open
Abstract
Objective The goal of this study was to explore which enhanced recovery after surgery (ERAS) bundle items were most associated with decreased length of stay after surgery, most likely associated with decreased length of stay after surgery. Design A cohort study. Setting Large tertiary academic medical centre. Participants The study included 1318 women undergoing hysterectomy as part of our ERAS pathway between 1 February 2018 and 30 January 2020 and a matched historical cohort of all hysterectomies performed at our institution between 3 October 2016 and 30 January 2018 (n=1063). Intervention The addition of ERAS to perioperative care. This is a cohort study of all patients undergoing hysterectomy at an academic medical centre after ERAS implementation on 1 February 2018. Compliance and outcomes after ERAS roll out were monitored and managed by a centralised team. Descriptive statistics, multivariate regression, interrupted time series analysis were used as indicated. Main outcome measures Impact of ERAS process measure adherence on length of stay. Results After initiation of ERAS pathway, 1318 women underwent hysterectomy. There were more open surgeries after ERAS implementation, but cohorts were otherwise balanced. The impact of process measure adherence on length of stay varied based on surgical approach (minimally invasive vs open). For open surgery, compliance with intraoperative antiemetics (−30%, 95% CI −18% to 40%) and decreased postoperative fluid administration (−12%, 95% CI −1% to 21%) were significantly associated with reduced length of stay. For minimally invasive surgery, ambulation within 8 hours of surgery was associated with reduced length of stay (−53%, 95% CI −55% to 52%). Conclusions While adherence to overall ERAS protocols decreases length of stay, the specific components of the bundle most significantly impacting this outcome remain elusive. Our data identify early ambulation, use of antiemetics and decreasing postoperative fluid administration to be associated with decreased length of stay.
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Affiliation(s)
- Rachel C. Sisodia
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Dan Ellis
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Hidrue
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Pamela Linov
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elena Cavallo
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Allison S. Bryant
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - May Wakamatsu
- Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marcela G. del Carmen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Massachusetts General Hospital Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts, USA
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Curley KL, Richards AE, Zhang N, Lyons MK, Neal MT. Enhanced recovery after posterior cervical fusion surgery: A retrospective case series. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Bahadur A, Kumari P, Mundhra R, Ravi AK, Chawla L, Mahamood M M, Kumari P, Chaturvedi J. Evaluate the Effectiveness of Enhanced Recovery After Surgery Versus Conventional Approach in Benign Gynecological Surgeries: A Randomized Controlled Trial. Cureus 2021; 13:e16527. [PMID: 34430137 PMCID: PMC8378282 DOI: 10.7759/cureus.16527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 01/22/2023] Open
Abstract
Objective This study aimed to evaluate the effectiveness of enhanced recovery after surgery (ERAS) model versus conventional approach in benign gynecological surgeries (incorporating various routes of surgery). Methods This was a randomized controlled trial wherein patients undergoing gynecological surgery for benign indications from January 2019 to July 2020 were recruited and randomized into ERAS and conventional protocol groups using block randomization. The intended primary outcome was to compare the median length of hospital stay in both groups. “Fit for discharge” criteria were used to assess the length of stay as patients who belonged to hilly terrain with limited transportation facilities stayed for a longer duration. Results A total of 180 patients were recruited and 90 each was randomized into ERAS and conventional protocol groups. The difference in length of hospital stay between ERAS (36 hours, range 24-96 hours) and conventional group (72 hours, range: 24-144 hours) was significant (p<0.01). A statistically significant difference was noted in the time for recovery of bowel function and tolerance for diet in the ERAS group. No significant difference in complications and readmission (within 30 days) rate was seen between the two groups. Quality of life as assessed by the World Health Organization Quality of Life Brief Version (WHO-QOL BREF) on the day of discharge and day 30 was higher in the ERAS group in physical and psychological domains, while no difference was seen in environmental and social domains. Conclusion This study as an institutional experience strengthens the existing evidence regarding the efficacy of ERAS in reducing hospital stay and improving quality of life compared to the conventional perioperative management protocol.
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Affiliation(s)
- Anupama Bahadur
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Payal Kumari
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Rajlaxmi Mundhra
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Anoosha K Ravi
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Latika Chawla
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Mahima Mahamood M
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Purvashi Kumari
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
| | - Jaya Chaturvedi
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, IND
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Seaman SJ, Han E, Arora C, Kim JH. Surgical site infections in gynecology: the latest evidence for prevention and management. Curr Opin Obstet Gynecol 2021; 33:296-304. [PMID: 34148977 DOI: 10.1097/gco.0000000000000717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Surgical site infection (SSI) remains one of the most common postoperative surgical complications. Prevention and appropriate treatment remain paramount. RECENT FINDINGS Evidence-based recommendations include recognition and reduction of preoperative risks including hyperglycemia and smoking, treatment of preexisting infections, skin preparation with chlorhexidine gluconate, proper use of preoperative antibiotics, and implementation of prevention bundles. Consideration should be given to the use of dual antibiotic preoperative treatment with cephazolin and metronidazole for all hysterectomies. SUMMARY Despite advancements, SSI in gynecologic surgery remains a major cause of perioperative morbidity and healthcare cost. Modifiable risk factors should be evaluated and patients optimized to the best extent possible prior to surgery. Preoperative risks include obesity, hyperglycemia, smoking, and untreated preexisting infections. Intraoperative risk-reducing strategies include appropriate perioperative antibiotics, correct topical preparation, maintaining normothermia, and minimizing blood loss. Additionally, early recognition and prompt treatment of SSI remain crucial.
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Affiliation(s)
- Sierra J Seaman
- Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, USA
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O'Hanlan KA, Emeney PL, Frank MI, Milanfar LC, Sten MS, Uthman KF. Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients. JSLS 2021; 25:JSLS.2020.00087. [PMID: 34248330 PMCID: PMC8241283 DOI: 10.4293/jsls.2020.00087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective To investigate outcomes and ascertain the safety and efficacy on patients having total laparoscopic hysterectomy (TLH), stratified by body mass index (BMI), focusing on high-BMI patients. Methods This was a retrospective cohort study that reviewed 2,266 patients with benign gynecologic diagnoses, early cervical, endometrial, and ovarian carcinoma from September 1996 to October 2017. BMI was from 14.5 to 74.2 and were classified as normal or underweight (<24.9); overweight (25.0-29.9); class I obese (>30.0-34.9); class II obese (35-39.9); or class III obese (>40.0). All patients underwent TLH. Results Patients' characteristics were similar across all BMI classes except for age, postoperative pathological diagnoses, and whether a cystoscopy was performed. Surgical duration, and estimated blood loss were similar across BMI classes. Overweight and obese class III patients had lower odds of staying >1 day compared to patients of normal BMI (OR = 0.65, P = .015). Obese class II patients had fewer complications compared to normal BMI patients (OR = 0.27, P = .013), but patients from other high BMI categories did not show any difference compared to patients with normal BMI. The rate of unplanned laparotomy was statistically, but not clinically, higher in obese class III patients (1.8% versus .7%, P = 0.011), most often due to large fibroids. The mean reoperation rate was 2.7%, with the lowest rate (.5%) among obese class II patients, and the highest rate (3.9%) among the normal BMI patients. Conclusion TLH is feasible and safe for obese women, regardless of BMI. Obesity is not a contraindication to good outcomes from laparoscopic surgery.
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Affiliation(s)
- Katherine A O'Hanlan
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Pamela L Emeney
- University of California in San Francisco-Fresno, Fresno, CA 93701
| | - Madelyn I Frank
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Leila C Milanfar
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Margaret S Sten
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
| | - Kathryn F Uthman
- Laparoscopic Institute for Gynecology and Oncology; 4370 Alpine Rd, Ste 104, Portola Valley, CA 94028-7927
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Kuniyoshi H, Yamamoto Y, Kimura S, Hiroe T, Terui T, Kase Y. Comparison of the analgesic effects continuous epidural anesthesia and continuous rectus sheath block in patients undergoing gynecological cancer surgery: a non-inferiority randomized control trial. J Anesth 2021; 35:663-670. [PMID: 34268624 DOI: 10.1007/s00540-021-02973-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 07/09/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE We investigated the non-inferiority of continuous rectus sheath block to continuous epidural anesthesia for postoperative analgesia of gynecological cancer patients. METHODS One hundred ASA-PS 1-2 patients via a median incision up to 5 cm above the navel were randomized into a continuous epidural anesthesia (CEA) group and a continuous rectus sheath block (CRSB) group. Following surgery, they have controlled with intravenous patient-controlled analgesia (IV-PCA) as basal postoperative analgesia. For patients in the CEA group were administered 0.25% levobupivacaine at 5 mg/h. Patients in the CRSB group, catheters were inserted on both sides of the posterior rectus sheath after surgery. They received 0.25% levobupivacaine on both sides at 7.5 mg/h. To determine whether CRSB is non-inferior to CEA in postoperative treatment, pain at rest and movement was assessed using the Numerical Rating Scale (NRS). The non-inferiority margin of NRS difference between CRSB and CEA was set at 1.3 difference in means. The primary outcome was non-inferiority comparisons of NRS at rest/at movement after surgery, while the secondary outcome included the frequency of requesting IV-PCA and rescue drugs. RESULTS NRS at rest in the CRSB group was not inferior to that in the CEA group. On the other hand, the NRS at movement at 4, 6, 8, 12 h following surgery in the CRSB group was inferior to CEA. There was no difference in the frequency of requesting IV-PCA and rescue drugs. CONCLUSIONS CRSB showed the non-inferiority to CEA for postoperative analgesia at rest, while CRSB was not non-inferior to CEA at movement in gynecological cancer patients. CRSB would be a substitute when CEA is contraindicated as a component of postoperative multimodal analgesia.
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Affiliation(s)
- Hideki Kuniyoshi
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yu Yamamoto
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Shohei Kimura
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Takanori Hiroe
- Department of Biostatistics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takako Terui
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoichi Kase
- Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan.
- Department of Anesthesiology, Jikei Kashiwa Hospital, 163-1, Kashiwashita, Kashiwa, Chiba, Japan.
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Enhanced Recovery and Same-Day Discharge After Minimally Invasive Sacrocolpopexy. Female Pelvic Med Reconstr Surg 2021; 27:740-745. [PMID: 34261105 DOI: 10.1097/spv.0000000000001043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate whether an enhanced recovery after surgery (ERAS) protocol was associated with a higher rate of same-day discharge after robot-assisted or laparoscopic sacrocolpopexy and to describe the safety and feasibility of same-day discharge after these procedures. METHODS A historical control, retrospective cohort study of women undergoing minimally invasive sacrocolpopexy comparing rates of same-day discharge before and after implementation of an ERAS protocol was conducted. Secondary outcomes were obtained by comparing women discharged the same day with those discharged postoperative day ≥1, including postoperative complications and unplanned postoperative patient encounters within 30 days of surgery. Logistic regression was performed to control for potential confounders. RESULTS Of the 166 women identified (83 before ERAS implementation; 83 after ERAS implementation), 43 underwent same-day discharge versus 123 admitted overnight. The rate of same-day discharge increased 28 percentage points after ERAS implementation (12% vs 40%, P < 0.01). Compared with women admitted overnight, same-day discharge women had shorter procedures (154 vs 173 minutes, P = 0.01), spent longer time in the postanesthesia care unit (130 vs 106 minutes, P = 0.01), and were more likely to be discharged with a Foley catheter (58% vs 28%, P < 0.01). After multivariable logistic regression analysis, ERAS was associated with increased odds of same-day discharge (odds ratio, 4.91; 95% confidence interval, 2.17-11.09). There were no differences in unplanned postoperative patient contacts or postoperative complications within 30 days between same-day discharge and overnight admission groups. CONCLUSIONS Implementation of an ERAS protocol for minimally invasive sacrocolpopexy was associated with a 3-fold increase in same-day discharge.
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Hardman MI, Olsen DA, Amundson AW. Multimodal Analgesia Decreases Postoperative Opioid Consumption in Living Liver Donation. Mayo Clin Proc Innov Qual Outcomes 2021; 5:583-589. [PMID: 34195550 PMCID: PMC8240150 DOI: 10.1016/j.mayocpiqo.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective To evaluate the effects of multimodal analgesia on postoperative opioid consumption and perioperative pain management in patients undergoing living liver donation. Methods A retrospective study was conducted of 129 patients who underwent living liver donation between 2006 and 2015. Patients were separated into 2 cohorts, pre–multimodal analgesia and multimodal analgesia, to allow intergroup analysis. All patients received an intrathecal opioid injection and underwent donor hepatectomy. Primary outcome data compared opioid consumption in oral morphine equivalents for postoperative days (PODs) 0 to 4 between the cohorts. Secondary outcomes compared yearly averaged cumulative opioid consumption on PODs 0 to 4 in oral morphine equivalents; yearly averaged numeric rating scale pain scores; hospital length of stay; and percentage of patients receiving intravenous ketorolac, ketamine, or transversus abdominis plane blocks. Results For PODs 0 to 4, a 50% reduction in overall opioids administered postoperatively (359 mg vs 179 mg; P<.01) was observed in the multimodal analgesia cohort, whereas no significant difference was found in year-to-year average postoperative pain scores (4.5 vs 3.6). The proportion of patients receiving ketorolac increased to more than 90% by 2013. More than 40% of all patients in the multimodal analgesia group received a perioperative regimen of acetaminophen, gabapentin, ketamine, and transverse abdominal plane blocks (0% in pre–multimodal analgesia). Mean hospital length of stay was reduced from 7.7 to 6.6 days (P<.01). Conclusion Implementation of multimodal analgesia to manage perioperative pain in living liver donation resulted in a 50% reduction of postoperative opioid consumption. Clinically satisfactory average pain scores were maintained for PODs 0 to 4.
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Affiliation(s)
| | - David A Olsen
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
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L Laporta M, O Kinney M, R Schroeder D, Sprung J, Weingarten TN. Postoperative respiratory depression after hysterectomy. Bosn J Basic Med Sci 2021; 21:346-351. [PMID: 32937097 PMCID: PMC8112565 DOI: 10.17305/bjbms.2020.5026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/15/2020] [Indexed: 11/16/2022] Open
Abstract
To investigate if sex-specific physiologic characteristics could impact postoperative respiratory depression risks in women, we studied incidence and risk factors associated with postoperative respiratory depression in a gynecologic surgical cohort. Only hysterectomies performed under general anesthesia from 2012 to 2017 were included to minimize interprocedural variability. Respiratory depression was defined as episodes of apnea, hypopnea, hypoxemia, pain-sedation mismatch, unplanned positive airway pressure device application, or naloxone administration in the post-anesthesia care unit. Multivariable logistic regression was used to explore the association with clinical characteristics. From 1,974 hysterectomies, 253 had postoperative respiratory depression, yielding an incidence of 128 (95% confidence interval, 114-144) per 1,000 surgeries. Risk factors associated with respiratory depression were older age (odds ratio 1.22 [95% confidence interval 1.02-1.46] per decade increase, p = 0.03), lower body weight (0.77 [0.62-0.94] per 10 kg/m2, p = 0.01), and higher intraoperative opioid dose (1.05 [1.01-1.09] per 10 mg oral morphine equivalents, p = 0.01); while sugammadex use was associated with a reduced risk (0.48 [0.30-0.75], p = 0.002). Respiratory depression was not associated with increased hospital stay, postoperative complications, or mortality. Postoperative respiratory depression risk in women increased with age, lower weight, and higher intraoperative opioids and decreased with sugammadex use; however, it was not associated with postoperative pulmonary complications.
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Affiliation(s)
- Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle O Kinney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Darrell R Schroeder
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Gillingham A, Kenton K, Geynisman-Tan J, Brown O, Collins SA, Lewicky-Gaupp C, Mueller MG. Does a Hysterectomy Hurt? Comparing Narcotic Requirements and Pain Scores in Patients Undergoing Apical Prolapse Repair With or Without Hysterectomy. Female Pelvic Med Reconstr Surg 2021; 27:356-359. [PMID: 32487885 DOI: 10.1097/spv.0000000000000860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The aim of the study was to compare narcotic requirements with early postoperative pain scores in women undergoing apical prolapse surgery with or without hysterectomy. METHODS All cases of apical prolapse repair at our institution in 2016 were identified. The following was abstracted from the health record: demographics, comorbidities, procedure details, baseline and postoperative care unit (PACU) pain scores, and operating room (OR) and PACU narcotic doses. Doses were converted to morphine milligram equivalents (MME) for analysis. Correlations are reported using Pearson ρ. RESULTS One hundred fifty-six cases were identified. Seventy-eight percent of participants were white and the mean ± SD age was 59 ± 11 years. One hundred seventeen patients (75%) underwent laparoscopic/robotic sacrocolpopexy, 35 (22%) native tissue vaginal repairs, and 4 (3%) open sacrocolpopexy. One hundred twenty-two patients (78%) underwent concomitant hysterectomy: 93 (76%) were laparoscopic, 25 (20%) vaginal, and 4 (4%) abdominal.The groups were similar, with the exception of younger age and longer OR time in the hysterectomy group. Hysterectomy by any route was not associated with increased OR MMEs (29 vs 22, P = 0.22), PACU MMEs (13 vs 13, P = 0.54), 4-hour PACU pain scores (2.5 vs 2.0, P = 0.22), or 6-hour PACU pain scores (2.6 vs 2.3, P = 0.54). After controlling for age and OR time, there remained no differences in these variables. Likewise, when analyzing laparoscopic or vaginal groups separately on multivariate regression, there were no differences in MMEs or postoperative pain scores in patients with and without concomitant hysterectomy. CONCLUSIONS Concomitant hysterectomy at the time of prolapse repair does not increase pain medication requirements or patient-reported postoperative pain scores.
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Affiliation(s)
- Akira Gillingham
- From the Division of Female Pelvic Medicine and Reconstructive Surgery, Northwestern University, Chicago, IL
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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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Björkström LM, Wodlin NB, Nilsson L, Kjølhede P. The Impact of Preoperative Assessment and Planning on the Outcome of Benign Hysterectomy - a Systematic Review. Geburtshilfe Frauenheilkd 2021; 81:200-213. [PMID: 33574624 PMCID: PMC7870288 DOI: 10.1055/a-1263-0811] [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: 04/21/2020] [Accepted: 09/13/2020] [Indexed: 11/28/2022] Open
Abstract
Knowledge concerning the impact of preoperative planning, patient information and patient factors on the outcome of benign hysterectomy is incomplete. This systematic review summarizes the current knowledge on the effect of preoperative planning and of preoperative patient factors on the outcome of benign hysterectomy. The PubMed/PubMed Central/MEDLINE, Scopus, Web of Science, TRIP Medical Database, Prospero and the Cochrane Library databases were searched. Inclusion criteria were prospective trials, hysterectomy for benign disease, systematic preoperative assessment, and article in English. Eighteen articles were included and categorized according to their main aims: use of a preoperative checklist, preoperative decision-making, preoperative information, and the effect on the outcome of surgery of factors that concerns patients preoperatively. Focused and well directed preoperative assessment and thoroughness in the preoperative decision-making was associated with
positive postoperative outcomes. The use of a checklist reduced the overall rate of hysterectomy and increased the use of minimally invasive surgery. Women were often inadequately informed before hysterectomy about the possible side effects after surgery. Preoperative anxiety and preoperative pain were associated with postoperative pain and lower quality of life. The indication for surgery had an impact on the reported quality of life postoperatively. The extent of preoperative planning seemed to affect the outcome of surgery. Preoperative patient factors influenced the postoperative recovery. Prehabilitation measures need further development and should be integrated in the preoperative planning. Prospective studies are warranted to evaluate and improve the preoperative planning in a systematic setting before performing hysterectomy for benign disease.
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Affiliation(s)
- Lollo Makdessi Björkström
- Department of Obstetrics and Gynecology in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ninnie Borendal Wodlin
- Department of Obstetrics and Gynecology in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lena Nilsson
- Department of Anesthesiology and Intensive Care in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping
| | - Preben Kjølhede
- Department of Obstetrics and Gynecology in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Abstract
Enhanced recovery after surgery (ERAS) is a multimodal perioperative strategy originally developed to attenuate the postsurgical stress response in patients after colorectal surgery. Patients undergoing gynecologic surgery who had ERAS had significantly shorter hospital length of stay, reduced hospital-related costs, and acceptable pain management with reduced opioid use, without compromising patient satisfaction. Intrathecal hydromorphone is an effective alternative ERAS protocol analgesia for these patients and will not compromise patient outcomes or healthcare costs.
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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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Evans S, Snook L, Yates T, Bundy H, Abimbola O, Myers EM. Patient experience with enhanced recovery and early discharge after minimally invasive sacrocolpopexy: a qualitative study. Int Urogynecol J 2020; 32:387-394. [PMID: 32681347 DOI: 10.1007/s00192-020-04431-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/03/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aim of this study was to describe patient experiences with an enhanced recovery protocol (ERP) after minimally invasive sacrocolpopexy (SCP). METHODS We conducted 14 semi-structured telephone interviews with women who had undergone SCP and were discharged the day of the surgery (POD#0, n = 7) or spent 1 night at the hospital (POD#1, n = 7). Interviews occurred between 2 and 6 weeks after surgery. We explored the following topics: patient preparedness, preoperative education, physical recovery, emotional recovery, and overall perception of the ERP. Interviewing continued until thematic saturation was achieved. All interviews were recorded, transcribed, and analyzed to identify relevant themes. RESULTS Both POD#0 and POD#1 discharge patients reported largely positive experiences regarding their preparation for surgery, at-home recovery, and access to follow-up care. Yet for some patients, the accelerated pace of the ERP felt rushed and was perceived as an absence of care rather than as an advance in treatment. Patients that elected to stay the night lived farther from ready access to care, had less robust systems of postoperative support, and worried more about the management of their pre-existing conditions. CONCLUSIONS Our research found that despite having consistently positive impressions of the ERP, patients shared common anxieties surrounding their surgeries including worries about access to care and the prospect of going home with a urinary catheter. Furthermore, we found that the therapeutic value of protocol recommendations such as early discharge must be made explicit to patients and often individualized to avoid being interpreted as sub-standard care.
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Affiliation(s)
- Sarah Evans
- Department of Obstetrics and Gynecology, Atrium Health, 2001 Vail Avenue, Suite 360, Charlotte, NC, 28207, USA.
| | - Lindsay Snook
- Department of Obstetrics and Gynecology, Atrium Health, 2001 Vail Avenue, Suite 360, Charlotte, NC, 28207, USA
| | - Traci Yates
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Henry Bundy
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, NC, USA
| | - Obafunbi Abimbola
- School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Erinn M Myers
- Department of Obstetrics and Gynecology, Atrium Health, 2001 Vail Avenue, Suite 360, Charlotte, NC, 28207, USA
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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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Pan J, Hei Z, Li L, Zhu D, Hou H, Wu H, Gong C, Zhou S. The Advantage of Implementation of Enhanced Recovery After Surgery (ERAS) in Acute Pain Management During Elective Cesarean Delivery: A Prospective Randomized Controlled Trial. Ther Clin Risk Manag 2020; 16:369-378. [PMID: 32440135 PMCID: PMC7210449 DOI: 10.2147/tcrm.s244039] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 04/02/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE The aim of this study was to test whether the implementation of an enhanced recovery after surgery (ERAS) protocol for patients undergoing elective cesarean delivery has a positive impact on the postoperative status of the patients in terms of pain management, hospital stay, hospitalization costs, and adverse reactions. METHODS Patients who underwent elective cesarean delivery were randomized into two groups - ERAS group and control group - and the groups were managed with the ERAS protocol and traditional protocol, respectively. RESULTS Compared to the control group, the ERAS group had significantly fewer patients with intraoperative nausea, pain of visual analog scale (VAS) scores, and VAS grade >3 during rest in the first 24 h and during motion in the first 24 and 48 h after surgery. There were no intergroup differences in the requirement of extra analgesics, the incidence of vomiting, shivering, hypotension, postoperative nausea, and pruritus. None of the patients in either group had postoperative vomiting. Patient satisfaction rated as per the VAS was significantly higher in the ERAS group than in the control group. The total length of stay, postoperative length of stay, and the cost of anesthesia in both groups were comparable. Further, the average daily hospitalization cost was significantly lower in the ERAS group than in the control group. CONCLUSION The ERAS protocol shows promise and appears to be worthwhile for widespread implementation among patients undergoing elective cesarean delivery; it was found to be beneficial in reducing the postoperative pain, incidence of intraoperative nausea, and average cost of hospitalization and also improved patient satisfaction.
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Affiliation(s)
- Jingru Pan
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Ziqing Hei
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Liping Li
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Dan Zhu
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Hongying Hou
- Department of Obstetrics, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Huizhen Wu
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Chulian Gong
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
| | - Shaoli Zhou
- Department of Anesthesiology, Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People’s Republic of China
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Weston E, Noel M, Douglas K, Terrones K, Grumbine F, Stone R, Levinson K. The impact of an enhanced recovery after minimally invasive surgery program on opioid use in gynecologic oncology patients undergoing hysterectomy. Gynecol Oncol 2020; 157:469-475. [DOI: 10.1016/j.ygyno.2020.01.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/31/2020] [Indexed: 01/01/2023]
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Netter A, Jauffret C, Brun C, Sabiani L, Blache G, Houvenaeghel G, Lambaudie E. Choosing the most appropriate minimally invasive approach to treat gynecologic cancers in the context of an enhanced recovery program: Insights from a comprehensive cancer center. PLoS One 2020; 15:e0231793. [PMID: 32324762 PMCID: PMC7179891 DOI: 10.1371/journal.pone.0231793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/31/2020] [Indexed: 02/06/2023] Open
Abstract
Objective The aim of the study was to compare the characteristics of procedures for gynecologic cancers conducted with conventional laparoscopy (CL) or robotically assisted laparoscopy (RAL) in the context of an enhanced recovery program (ERP). Methods This is a secondary analysis of prospectively collected data from a cohort study conducted between 2016 (when the ERP was first implemented at the Institut Paoli-Calmettes, a comprehensive cancer center in France) and 2018. We included patients who had undergone minimally invasive surgery for gynecological cancers and followed our ERP. The endpoints were the analysis of postoperative complications, the length of postoperative hospitalization (LPO), and the proportion of combined procedures depending on the approach (RAL or CL). Combined procedures were defined by the association of at least two of the following operative items: hysterectomy, pelvic lymphadenectomy, and para-aortic lymphadenectomy. Results A total of 362 women underwent either CL (n = 187) or RAL (n = 175) for gynecologic cancers and followed our ERP. The proportion of combined procedures performed by RAL was significantly higher (85/175 [48.6%]) than that performed by CL (23/187 [12.3%]; p < 0.001). The proportions of postoperative complications were similar between the two groups (19.4% versus 17.1%; p = 0.59). Logistic regression analysis revealed a statistically insignificant trend in the association of RAL with a reduced likelihood of an LPO > 3 days after adjusting for predictors of prolonged hospitalization (adjusted OR = 0.573 [0.236–1.388]; p = 0.217). Conclusion Experts from our cancer center preferentially choose RAL to perform gynecologic oncological procedures that present elements of complexity. More studies are needed to determine whether this strategy is efficient in managing complex procedures in the framework of an ERP.
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Affiliation(s)
- Antoine Netter
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
- Department of Obstetrics and Gynecology, Assistance Publique Hôpitaux de Marseille, La Conception Hospital, Aix Marseille University, Marseille, France
- Institut Méditerranéen de Biodiversité et d'Écologie marine et continentale (IMBE), Aix Marseille University, CNRS, IRD, Avignon University, Marseille, France
- * E-mail: (AN); (EL)
| | - Camille Jauffret
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Clément Brun
- Département d'Anesthésie Réanimation, Institut Paoli Calmettes et CRCM, Marseille, France
| | - Laura Sabiani
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Guillaume Blache
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Gilles Houvenaeghel
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
| | - Eric Lambaudie
- Department of Surgical Oncology, Aix-Marseille Univ, CNRS, INSERM, Institut Paoli-Calmettes, CRCM, Marseille, France
- * E-mail: (AN); (EL)
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Rosenbaum AJ, Moore KJ, Louie M, Schiff LD, Carey ET. Postanesthesia Care Unit Stay and Complications After Same-Day Discharge Laparoscopic Hysterectomy. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Alan J. Rosenbaum
- Division of Global Women's Health, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristin J. Moore
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michelle Louie
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lauren D. Schiff
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erin T. Carey
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Abstract
The robotic-assisted laparoscopic surgical approach has improved complex gynecologic surgeries. It has the advantages of excellent visualization through the high-resolution 3-dimensional view, a wrist-like motion of the robotic arms and improved ergonomics. Similar to conventional laparoscopic surgeries, it is associated with a decrease in long-term surgical morbidity, early recovery and return to work, and improved esthetics. We discuss preoperative planning, surgical techniques, and some of the latest clinical results of robotic-assisted laparoscopic gynecologic surgery.
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Affiliation(s)
- Ashley S Moon
- Department of Obstetrics, Gynecology and Reproductive Biology, Danbury Hospital, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, USA.
| | - John Garofalo
- Department of Obstetrics, Gynecology and Reproductive Biology, Norwalk Hospital, Nuvance Health, 30 Stevens Street, Norwalk, CT 06850, USA
| | - Pratistha Koirala
- Department of Obstetrics, Gynecology and Reproductive Biology, Danbury Hospital, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, USA
| | - Mai-Linh T Vu
- Complete Women Care, 3711 Long Beach Boulevard, Suite 110, Long Beach, CA 90807, USA
| | - Linus Chuang
- Department of Obstetrics, Gynecology and Reproductive Biology, Danbury Hospital, Nuvance Health, 24 Hospital Avenue, Danbury, CT 06810, USA
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Kay AH, Venn M, Urban R, Gray HJ, Goff B. Postoperative narcotic use in patients with ovarian cancer on an Enhanced Recovery After Surgery (ERAS) pathway. Gynecol Oncol 2019; 156:624-628. [PMID: 31882241 DOI: 10.1016/j.ygyno.2019.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine the impact of an ERAS pathway on post-discharge narcotic use for patients with ovarian cancer undergoing open surgery. METHODS This was a retrospective cohort study of women who underwent open ovarian cancer surgeries in 2014 prior to ERAS ("pre-ERAS") and in 2016/2018 after ERAS was instituted ("ERAS"). Patients taking chronic narcotics were excluded. A statewide prescription monitoring program was used to identify narcotic prescriptions filled in the three months after surgery. Quantity of narcotic medication is referenced in morphine milligram equivalents (MME). RESULTS 42 pre-ERAS and 94 ERAS patients were included. The groups were similar in age, BMI, diabetes, tobacco use, mean number of prior abdominal/pelvic surgeries, and advanced stage disease. ERAS patients had a shorter hospital stay (6.7 days pre-ERAS vs 4.2 days ERAS, p = 0.003), used less narcotic in the 24 h prior to discharge (74.0 MME pre-ERAS vs 25.8 MME ERAS, p = 0.002), and filled prescriptions at time of discharge for less narcotic (519.9 MME pre-ERAS vs 339.7 MME ERAS, p = 0.011). After hospital discharge, ERAS patients filled fewer additional prescriptions (52.4% pre-ERAS, vs 29.4% ERAS, p = 0.012). In total, ERAS patients filled prescriptions for 55% fewer narcotics in the three months after surgery than the pre-ERAS group (1101.4 MME pre-ERAS vs 492.1 MME ERAS, p < 0.001). CONCLUSIONS Institution of an ERAS protocol appears to decrease the narcotic needs of patients in the three months after ovarian cancer surgery.
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Affiliation(s)
- Allison H Kay
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, United States of America.
| | - Monica Venn
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, United States of America
| | - Renata Urban
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, United States of America
| | - Heidi J Gray
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, United States of America
| | - Barbara Goff
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA 98195, United States of America
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Gong R, Hu Q, Liu D, Zu J, Wu Y, Xia Z. Enhanced recovery after surgery versus traditional care in total pelvic floor reconstruction surgery with transvaginal mesh. Int J Gynaecol Obstet 2019; 148:107-112. [PMID: 31591718 DOI: 10.1002/ijgo.12991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 08/04/2019] [Accepted: 10/04/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the impact of enhanced recovery after surgery (ERAS) on perioperative outcomes after total pelvic floor reconstruction surgery with transvaginal mesh. METHODS A single-center, retrospective observational cohort study involved 177 patients who underwent total pelvic floor reconstruction surgery with transvaginal mesh between August 2015 and November 2017. Eighty-five patients treated according to a traditional protocol formed the control group and 92 patients treated using the ERAS pathway were assigned to the ERAS group. Registered outcomes included demographic characteristics, intraoperative and postoperative data (first assisted walking time, first intestinal exhaust time, length of stay, hospital costs), and complications. RESULTS The first assisted walking time (40.6 ± 1.48 vs 23.56 ± 3.26 hours, P<0.001) and the first intestinal exhaust time (27.65 ± 11.63 vs 18.65 ± 10.68 hours, P<0.001) were earlier in the ERAS group. The implementation of the ERAS pathway was associated with shorter length of stay (121.35 vs 70.25 hours, P<0.001) and lower hospital costs (46 838.65 ± 2584.08 vs 42 793.57 ± 2560.3 RMB, P<0.001). There was no difference in surgical outcomes or postoperative complications between the two groups. CONCLUSION ERAS is safe, economical, and reliable after total pelvic floor reconstruction surgery and promotes perioperative recovery without increasing complication rates.
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Affiliation(s)
- Runqi Gong
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Qing Hu
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Dan Liu
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Jianyu Zu
- Anesthesia Department, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Ying Wu
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
| | - Zhijun Xia
- Department of Obstetrics and Gynecology, Pelvic Floor Disease Diagnosis and Treatment Center, Shengjing Hospital of China Medical University, Shenyang City, Liaoning Province, China
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