Fast track hysterectomy

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH).

OBJECTIVES

To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

SEARCH METHODS

We searched the following databases (from their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

MAIN RESULTS

We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies.

AUTHORS' CONCLUSIONS

Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.

Predictive factors of return to work after hysterectomy: a retrospective study

PURPOSE

Although hysterectomy is one of the most frequently performed gynaecological surgeries, there is a dearth of evidence on perioperative care. The aim of the current study was to identify sociodemographic, surgical-related and work-related predictors of recovery following different approaches of hysterectomy.

METHODS

Eligible patients for this retrospective cohort study were women who underwent vaginal, abdominal or laparoscopic hysterectomy for both benign and malignant gynaecological disease in 2014 in Máxima Medical Centre in the Netherlands. The main outcome measure was full return to work (RTW). Data were collected using a patient survey. Potential prognostic factors for time to RTW were examined in univariate Cox regression analyses. The strongest prognostic factors were combined in a multivariable model.

RESULTS

In total 83 women were included. Median time to full return to work was 8 weeks (interquartile range [IQR] 6-12). The multivariable analysis showed that higher age (hazard ratio [HR] 1.053, 95% confidence interval [CI] 1.012-1.095) and same day removal of indwelling catheter (HR 0.122, 95% CI 0.028-0.539) were predictors of shorter duration until full RTW after hysterectomy.

CONCLUSIONS

This study provided insight in the predictors of recovery after hysterectomy. By identifying patient specific factors, pre-operative counselling can be individualized, changes can be made in perioperative care and effective interventions can be designed to target those factors.

The impact of Enhanced Recovery after Surgery (ERAS) pathways with regard to perioperative outcome in patients with ovarian cancer

Purpose

Major surgery for ovarian cancer is associated with significant morbidity. Recently, guidelines for perioperative care in gynecologic oncology with a structured “Enhanced Recovery after Surgery (ERAS)” program were presented. Our aim was to evaluate if implementation of ERAS reduces postoperative complications in patients undergoing extensive cytoreductive surgery for ovarian cancer.

Methods

134 patients with ovarian cancer (FIGO I-IV) were included. 47 patients were prospectively studied after implementation of a mandatory ERAS protocol (ERAS group) and compared to 87 patients that were treated before implementation (pre-ERAS group). Primary endpoints of this study were the effects of the ERAS protocol on postoperative complications and length of stay in hospital.

Results

Preoperative and surgical data were comparable in both groups. Only the POSSUM score was higher in the ERAS group (11.8% vs. 9.3%, p < 0.001), indicating a higher surgical risk in the ERAS group. Total number of postoperative complications (ERAS: 29.8% vs. pre-ERAS: 52.8%, p = 0.011), and length of hospital stay (ERAS: 11 (6–23) vs pre-ERAS: 13 (6–50) days; p < 0.001) differed significantly. A lower fraction of patients of the ERAS group (87.2%) needed postoperative admission to the ICU compared to the pre-ERAS group (97.7%), p = 0.022). Mortality within the ERAS group was 0% vs. 3.4% (p = 0.552) in the pre-ERAS group.

Conclusion

The implementation of a mandatory ERAS protocol was associated with a lower rate of postoperative complications and a reduced length of stay in hospital. If ERAS has influence on long-term outcome needs to be further evaluated.

One shot to control Pain: Decreasing postoperative opioid use in gynecologic oncology patients with intrathecal opioid injection

•

- ITO administration was associated with significantly lower IV opioid requirement for the first 12 h following surgery.

•

- Pain scores were similar between the patients in the ITO and non-ITO groups.

•

- Patients in the ITO group had increased length of stay of 1 day, compared with the non-ITO group.

•

- The total overall postoperative opioid requirements were similar in the ITO and non-ITO groups.

Objectives

To determine whether regional anesthesia with single-shot intrathecal opioid injections (ITO) reduce postoperative pain and intravenous (IV) opioid use after exploratory laparotomy in major gynecologic surgeries.

Methods

A retrospective chart review of 315 consecutive cases of patients who underwent an exploratory laparotomy on the gynecologic oncology service from July 2015 to January 2018 was conducted. Single-shot ITO was offered to all patients undergoing open abdominal surgery. The primary outcomes of interest were IV opioid use in morphine equivalents during the first 48 hours after surgery. Univariate analyses were performed to estimate the effect of ITO on IV opioid use at 0, 6, 12, 24 and 48 hours after surgery. Longitudinal regression analyses were performed to estimate the effect of ITO on changes in outcomes of interest over time, adjusting for potential confounders.

Results

35% (110/315) received ITO preoperatively. There were no differences in patient age, BMI, previous number of abdominal surgeries, history of opioid dependence, type of gynecologic surgery, or total EBL between the ITO and control groups. Preoperative ITO was associated with a significantly lower IV opioid requirement between 0 and 6 hours after surgery (9.7 ± 8.1 vs 14.3 ± 11.5, p < 0.0001) and between 6 and 12 hours after surgery (2.7 ± 3.8 vs 5.4 ± 9.5, p = 0.0054). There was no statistically significant difference in total hospital stay opioid requirement but median length of stay was increased by 1 day.

Conclusions

Preoperative administration of ITO reduced IV opioid requirement in the first 12 hours postoperatively but was associated with median 1 day increase in hospital stay.

Safety and efficacy of laxatives after major abdominal surgery: systematic review and meta-analysis

Background

Recovery of gastrointestinal function is often delayed after major abdominal surgery, leading to postoperative ileus (POI). Enhanced recovery protocols recommend laxatives to reduce the duration of POI, but evidence is unclear. This systematic review aimed to assess the safety and efficacy of laxative use after major abdominal surgery.

Methods

Ovid MEDLINE, Embase, Cochrane Library and PubMed databases were searched from inception to May 2019 to identify eligible RCTs focused on elective open or minimally invasive major abdominal surgery. The primary outcome was time taken to passage of stool. Secondary outcomes were time taken to tolerance of diet, time taken to flatus, length of hospital stay, postoperative complications and readmission to hospital.

Results

Five RCTs with a total of 416 patients were included. Laxatives reduced the time to passage of stool (mean difference (MD) −0·83 (95 per cent c.i. −1·39 to −0·26) days; P = 0·004), but there was significant heterogeneity between studies for this outcome measure. There was no difference in time to passage of flatus (MD −0·17 (−0·59 to 0·25) days; P = 0·432), time to tolerance of diet (MD −0·01 (−0·12 to 0·10) days; P = 0·865) or length of hospital stay (MD 0·01(−1·36 to 1·38) days; P = 0·992). There were insufficient data available on postoperative complications for meta‐analysis.

Conclusion

Routine postoperative laxative use after major abdominal surgery may result in earlier passage of stool but does not influence other postoperative recovery parameters. Better data are required for postoperative complications and validated outcome measures.

Reduced Complications Following Implementation of Laparoscopic Hysterectomy: A Danish Population-based Cohort Study of Minimally Invasive Benign Gynecologic Surgery between 2004 and 2018

STUDY OBJECTIVE

To monitor and report nationwide changes in the rates of and complications after different methods for benign hysterectomy, operative hysteroscopy, myomectomy, and embolization in Denmark. To report the national mortality after benign hysterectomy DESIGN: National prospective, observational cohort study.

SETTING

The Danish Hysterectomy and Hysteroscopy Database.

PATIENTS

Women undergoing surgery for benign gynecologic diseases: 64 818 hysterectomies, 84 175 hysteroscopies, 4016 myomectomies, and 1209 embolizations in Denmark between 2004 and 2018.

INTERVENTIONS

National meetings with representatives from all departments, annual working reports of institutional complication rates, workshops, and national guideline initiative to improve minimally invasive surgical methods.

MEASUREMENTS AND MAIN RESULTS

Rates of the different methods and complications after each method with follow-up to 5 years as recorded by the database directly in the National Patient Registry. Nationwide, a decline in the use of hysterectomy, myomectomy, embolizations, and endometrial ablation. The total short-term complications were 9.8%, 7.5%, 8.9%, and 2.7% respectively, however, with a persistent risk of approximately 20% for recurrent operations within 5 years after endometrial ablation. Initially, we urged for increased use of vaginal hysterectomy, but only reached 36%. From 2010, we urged for reducing abdominal hysterectomies by implementing laparoscopic hysterectomy and reached 72% laparoscopic and robotic procedures. Since 2015, we used coring or contained morcellation for removal of large uterus at laparoscopic hysterectomy. The major and minor complication rates (modified Clavien-Dindo classification) were reduced significantly from 8.1% to 4.1% and 9.9% to 5.7% respectively. Mortality after benign hysterectomy was 0.27‰. The odds ratio for major complications after abdominal hysterectomy was 1.66 (1.52-1.81) compared to minimally invasive hysterectomy independent of the length of stay, high-volume departments, indications, comorbidity, age, and calendar year.

CONCLUSION

Fifteen years with a national database has resulted in a marked quality improvement. Denmark has 85% minimally invasive hysterectomies and has reduced the number of major complications by 50%.

Decreasing postoperative narcotics in reconstructive pelvic surgery: a randomized controlled trial

BACKGROUND

Postoperative pain control is crucial to any successful recovery plan. Many currently used medication regimens are narcotic-focused.

OBJECTIVE

The objective of our study was to evaluate the efficacy of a multimodal pain regimen after pelvic reconstructive surgery.

STUDY DESIGN

The primary outcome measure was narcotic use. Secondary outcomes included pain, nausea, and constipation. Patients were randomized to either usual care postoperative treatment or multimodal pain regimen. Usual care included no specific preoperative or intraoperative medications, and postoperative narcotics with ibuprofen. Multimodal pain regimen included preoperative and postoperative celecoxib, gabapentin, intraoperative and postoperative intravenous and oral acetaminophen and ibuprofen, and narcotics as needed. All narcotics were converted to milligram equivalents of oral morphine for standardization according to Centers for Disease Control and Prevention guidelines where conversion factors for oral hydrocodone = 1, oral oxycodone = 1.5, and oral hydromorphone = 4. Patients were given the validated Brief Pain Inventory survey preoperatively (baseline), at postoperative day 1, and 1 week postoperatively. At 1 week, bowel function and narcotics usage was assessed.

RESULTS

Seventy patients were randomized to the usual care arm and 68 to the multimodal pain regimen arm. Patients in the multimodal pain regimen arm used significantly fewer intravenous narcotics in the operating room (90.7 ± 39.1 mg vs 104.6 ± 33.5 mg; P = .026) and while in the hospital (10.8 ± 15.1 mg vs 31.2 ± 29.6 mg; P < .001) and were more likely to use 0 oral narcotics after discharge to home (34.8% of patients vs 10.6%; P = .001). Of the patients who did use oral narcotics after discharge to home, there was no difference in amount used between groups (121.3 ± 103.7 mg in the multimodal pain regimen arm vs 153.0 ± 113.8 mg in the usual care arm; P = .139). Total narcotic usage (operating room + hospital + home) was significantly less in the multimodal pain regimen arm of the study (195.5 ± 147.2 mg vs 304.0 ± 162.1 mg; P < .001). There were no significant differences in pain scores between the 2 arms of the study on either postoperative time point. There were no significant differences in antiemetic use while in hospital, consistency of first bowel movement, length of stay, or number of telephone calls to nurses in first 3 weeks postoperatively.

CONCLUSION

A multimodal pain regimen in pelvic reconstructive surgery was found to decrease postoperative opioid requirements, while providing equivalent pain control.

Effects of multimodal fast-track surgery on liver transplantation outcomes

BACKGROUND

Fast-track surgery and enhanced recovery after surgery have been applied to many surgical procedures; however, data on fast-track surgery and enhanced recovery after surgery following liver transplantation is limited. This study aimed to conduct a prospective study to determine the effects of fast-track surgery on prognosis after liver transplantation.

METHODS

This was a prospective, single-blinded, randomized study. One hundred twenty-eight patients undergoing liver transplantation were selected for the fast-track (FT group, n=54) or conventional process (NFT group, n=74). The primary endpoints were intensive care unit (ICU) stay and hospital stay. The secondary endpoints were as follows: operative time, anhepatic phase time, intraoperative blood loss, intraoperative blood transfusion volume, postoperative complications, readmission rate, and postoperative mortality.

RESULTS

There was no significant difference in preoperative demographics between the two groups. The median ICU stay was 2 days (range 1-7 days) in the FT group and 5 days (range 3-12 days) in the NFT group (P<0.01). Furthermore, the hospital stay was also significantly reduced in the FT group (P<0.01). The operative time, anhepatic phase time, intraoperative blood loss, and intraoperative blood transfusion volume were decreased in the FT group compared with the NFT group (P<0.05). Based on Spearman correlation analysis, the ICU stay and hospital stay may be positively correlated with operative time, anhepatic phase time and intraoperative blood loss. There were no differences in the incidence of postoperative complications, readmissions, and postoperative mortality between the two groups.

CONCLUSION

Fast-track procedures effectively reduce the ICU stay and hospital stay without adversely affecting prognosis. This study demonstrated that fast-track protocols are safe and feasible in liver transplantation.

Enhanced Recovery Program and Length of Stay After Laparotomy on a Gynecologic Oncology Service: A Randomized Controlled Trial

OBJECTIVE

To estimate whether a rapid recovery program would reduce length of stay among patients undergoing laparotomy on a gynecologic oncology service.

METHODS

We conducted a prospective, randomized, controlled trial comparing an enhanced recovery after surgery protocol with routine postoperative care among women undergoing laparotomy on the gynecologic oncology service. Protocol elements included: preoperative counseling, regional anesthesia, intraoperative fluid restriction, and early postoperative ambulation and feeding. A sample size of 50 per group (N=100) was planned to achieve 80% power to detect a two-day difference in our primary outcome, length of hospital stay; secondary outcomes included: total daily narcotics used, time to postoperative milestones, and complications.

RESULTS

A total of 112 women were enrolled between 2013 and 2015. Nine patients did not undergo laparotomy and were excluded, leaving 52 and 51 patients in the control and intervention groups, respectively. There was no difference in length of stay between the two groups (median 3.0 in both groups; P=.36). Enhanced recovery after surgery patients used less narcotics on day 0 (10.0 compared with 5.5 morphine equivalents in the control and intervention arms, respectively, P=.09) and day 2 (10.0 compared with 7.5 morphine equivalents, respectively; P=.05); however, there was no statistically significant difference between groups in any of the secondary outcomes. Post hoc analysis based on actual anesthesia received also failed to demonstrate a difference in time to discharge.

CONCLUSION

When compared with usual care, introducing a formal enhanced recovery after surgery protocol did not significantly reduce length of stay.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT01705288.

Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis

INTRODUCTION

Enhanced recovery pathways have been widely accepted and implemented for different types of surgery. Their overall effect in abdominal gynecologic surgery is still underdetermined. A systematic review and meta-analysis were performed to provide an overview of current evidence and to examine their effect on postoperative outcomes in women undergoing open gynecologic surgery.

MATERIAL AND METHODS

Searches were conducted using Embase, Medline, CINAHL, and the Cochrane Library up to 27 June 2014. Reference lists were screened to identify additional studies. Studies were included if at least four individual items of an enhanced recovery pathway were described. Outcomes included length of hospital stay, complication rates, readmissions, and mortality. Quantitative analysis was limited to comparative studies. Effect sizes were presented as relative risks or as mean differences (MD) with 95% confidence intervals (CI).

RESULTS

Thirty-one records, involving 16 observational studies, were included. Diversity in reported elements within studies was observed. Preoperative education, early oral intake, and early mobilization were included in all pathways. Five studies, with a high risk of bias, were eligible for quantitative analysis. Enhanced recovery pathways reduced primary (MD -1.57 days, 95% CI CI -2.94 to -0.20) and total (MD -3.05 days, 95% CI -4.87 to -1.23) length of hospital stay compared with traditional perioperative care, without an increase in complications, mortality or readmission rates.

CONCLUSION

The available evidence based on a broad range of non-randomized studies at high risk of bias suggests that enhanced recovery pathways may reduce length of postoperative hospital stay in abdominal gynecologic surgery.

[Urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery on the Fallopian tube: Guidelines]

OBJECTIVES

To provide clinical practice guidelines from the French College of Obstetrics and Gynecology (CNGOF) based on the best evidence available, concerning the urinary, infectious and digestive adverse events related to benign hysterectomy and the associated surgery including opportunistic salpingectomy and adnexectomy.

MATERIAL AND METHOD

Review of literature using following keywords: benign hysterectomy; urinary injury; bladder injury; ureteral injury; vesicovaginal fistula; infection; bowel injury; salpingectomy.

RESULTS

Urinary catheter should be removed before 24h following uncomplicated hysterectomy (grade B). In case of urinary catheter during hysterectomy, immediate postoperative removal is possible (grade C). No hemostasis technics can be recommended to avoid urinary injury (grade C). There is not any evidence to recommend to perform a window in the broad ligament or an ureterolysis, to put ureteral stent or a uterine manipulator in order to avoid ureteral injury. An antibiotic prophylaxis by a cephalosporin is always recommended (grade B). Mechanical bowel preparation before hysterectomy is not recommended (grade B). If there is no ovarian cyst/disease and no familial or personal history of ovarian/breast cancer, ovarian conservation is recommended in premenopausal women (grade B). In postmenopausal women, informed consent and surgical approach should be taken in account to perform a salpingo-oophorectomy. Since the association salpingectomy and hysterectomy is not assessed in the prevention of ovarian cancer, systematic bilateral salpingectomy is not recommended (expert consensus).

CONCLUSIONS

Practical application of these guidelines should decrease the prevalence of visceral complications associated with benign hysterectomy.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH).

OBJECTIVES

To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions.

SEARCH METHODS

We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction).

MAIN RESULTS

We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies.

AUTHORS' CONCLUSIONS

Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.

Perioperative enhanced recovery programmes for gynaecological cancer patients

BACKGROUND

Gynaecological malignancies contribute to 10% to 15% of cancers in women internationally. In recent years, a trend towards new perioperative care strategies has been documented as 'Fast Track (FT) surgery', or 'Enhanced Recovery Programmes' to replace some traditional approaches in surgical care. The FT multimodal programmes may enhance the postoperative recovery by means of reducing surgical stress. This systematic review aims to assess fully the beneficial and harmful effects of FT programmes in gynaecological cancer care.

OBJECTIVES

To evaluate the beneficial and harmful effects of FT programmes in gynaecological cancer care.

SEARCH METHODS

We searched the following databases, The Cochrane Gynaecological Cancer Review Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 4, 2009, MEDLINE and EMBASE to November 2009. In addition, all reference lists of included trials were searched and experts in the gynaecological oncology community were contacted in an attempt to locate trials. This search was updated and re-run in May 2012 and November 2014.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing any type of FT programmes for surgery in gynaecological cancer to conventional recovery strategies were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. Since no RCTs were identified, data collection and analysis could not be performed.

MAIN RESULTS

No studies were identified that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We currently have no evidence from high-quality studies to support or refute the use of perioperative enhanced recovery programmes for gynaecological cancer patients. Further well-designed RCTs with standard FT programmes are needed. This review has been updated in 2012 and 2014. The results of the original review published in 2010 remain unchanged.

Increased postoperative day one discharges after implementation of a hysterectomy enhanced recovery pathway: a retrospective cohort study

PURPOSE

In 2011, the hysterectomy enhanced recovery (HER) pathway, a multi-disciplinary, evidence-based care plan designed to improve recovery after open gynecologic surgery for non-malignant lesions, was introduced at The Ottawa Hospital (TOH). This before-and-after study examined the impact of the HER pathway on postoperative day (POD) 1 hospital discharge.

METHODS

Ethical approval was obtained. This retrospective cohort study included patients who had undergone open abdominal gynecologic surgery for non-malignant lesions at TOH Civic Campus between July 2010 and September 2012 (the year before and year after HER implementation). Patients were analyzed in either a pre-HER or post-HER group depending on their surgery date. Patients with chronic pain and emergent surgery were excluded. Data were obtained via medical chart review. Our primary outcome was the percentage of POD 1 discharges before and after HER implementation. Secondary outcomes included return to hospital within 30 days of discharge, median length of stay (LOS), clinician compliance with HER, and an exploratory analysis with multivariable modelling to evaluate which aspects of the HER independently predicted POD 1 discharge. Variables used included American Society of Anesthesiologists physical status (≥ II), prior abdominal surgery, body mass index, use of transversus abdominis plane blocks, and anesthetic type.

RESULTS

Among the 223 patients, significantly more POD 1 discharges occurred for post-HER compared to pre-HER patients (34% vs 7%, respectively; adjusted odds ratio [OR] = 7.33; 95% confidence interval [CI] = 3.05 to 17.62). Rates of return to hospital at 30 days were similar between the groups (10% post-HER and 13% pre-HER; adjusted OR = 0.74; 95% CI = 0.32 to 1.74). The median length of stay was two days in the post-HER group and three days in the pre-HER group (P < 0.0001). Only inhalational general anesthesia was independently associated with decreased odds of POD 1 discharge (adjusted OR = 0.16, 95% CI = 0.04 to 0.65).

CONCLUSION

For patients undergoing abdominal hysterectomy, implementation of a HER pathway is associated with a higher POD 1 discharge rate, with no increase in the early return to hospital rate.

The Decreasing Length of Hospital Stay following Vaginal Hysterectomy: 2011-2012 vs. 1996-1997 vs. 1995-1996

Background/Definition of the Problem: In recent years, postoperative management has changed towards rapid mobilisation, early oral feeding and rapid rehabilitation (known as Fast-Track or Enhanced Recovery Concepts). This study analysed the postoperative length of stay after vaginal hysterectomy in 3 different periods of time. Material and Methods: In the period October 2011 - September 2012, 75 patients underwent vaginal hysterectomies (± adnexectomy); another 114 vaginal or laparoscopic hysterectomies with additional operations (e.g. prolapse surgery and incontinence surgery) and malignancies were not included. The time periods August 1995 - July 1996 (n = 50) and October 1996 - September 1997 (n = 96) served as a comparison. Reducing the length of stay was not an explicit goal. Results: The median postoperative stay was shortened from 7 (5-9) to 5 (3-15) or 3 (0-5) days (p < 0.001). The recovery rate remained unchanged at 2.7 % (n = 2), cf. 2 % (n = 1) and 3.1 % (n = 3). In 40/75 cases (53.3 %), the surgery took place on the day of admission. Conclusion: The length of hospital stay after vaginal hysterectomy has more than halved since 1995/1996 and continues to decline. This development occurred without a shortened stay being an explicit goal of the clinic. The shortened length of stay does not appear to have a negative impact on postoperative complications and recovery rate.

Implementing a structured Enhanced Recovery After Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy

OBJECTIVE

To study the effects of introducing an Enhanced Recovery After Surgery (ERAS) protocol, modified for gynecological surgery, on length of stay and complications following abdominal hysterectomy.

DESIGN

Observational study.

SETTING

Department of Obstetrics and Gynecology, Örebro University Hospital, Sweden.

POPULATION

Eighty-five patients undergoing abdominal hysterectomy for benign or malignant indications between January and December 2012, with or without salpingo-oophorectomy. Outcomes were compared with all consecutive patients who had undergone the same surgery from January to December 2011, immediately before establishing the ERAS protocol (n = 120).

METHODS

The ERAS protocol was initiated in January 2012 as part of a targeted implementation program. Data were extracted from patient records and from a specific database.

MAIN OUTCOME MEASURES

Length of stay and the proportion of patients achieving target length of stay (2 days).

RESULTS

Length of stay was significantly reduced in the study population after introducing the ERAS protocol from a mean of 2.6 (SD 1.1) days to a mean of 2.3 (SD 1.2) days (p = 0.011). The proportion of patients discharged at 2 days was significantly increased from 56% pre-ERAS to 73% after ERAS (p = 0.012). No differences were found in complications (5% vs. 3.5% in primary stay, 12% vs. 15% within 30 days after discharge), reoperations (2% vs. 1%) or readmission (4% vs. 4%).

CONCLUSIONS

Introducing the ERAS protocol for abdominal hysterectomy reduced length of stay without increasing complications or readmissions.

Enhanced recovery in gynecologic surgery

OBJECTIVE

To investigate the effects of enhanced recovery (a multimodal perioperative care enhancement protocol) in patients undergoing gynecologic surgery.

METHODS

Consecutive patients managed under an enhanced recovery pathway and undergoing cytoreduction, surgical staging, or pelvic organ prolapse surgery between June 20, 2011, and December 20, 2011, were compared with consecutive historical controls (March to December 2010) matched by procedure. Wilcoxon rank-sum, χ, and Fisher's exact tests were used for comparisons. Direct medical costs incurred in the first 30 days were obtained from the Olmsted County Healthcare Expenditure and Utilization Database and standardized to 2011 Medicare dollars.

RESULTS

A total of 241 enhanced recovery women in the case group (81 cytoreduction, 84 staging, and 76 vaginal surgery) were compared with women in the control groups. In the cytoreductive group, patient-controlled anesthesia use decreased from 98.7% to 33.3% and overall opioid use decreased by 80% in the first 48 hours with no change in pain scores. Enhanced recovery resulted in a 4-day reduction in hospital stay with stable readmission rates (25.9% of women in the case group compared with 17.9% of women in the control group) and 30-day cost savings of more than $7,600 per patient (18.8% reduction). No differences were observed in rate (63% compared with 71.8%) or severity of postoperative complications (grade 3 or more: 21% compared with 20.5%). Similar, albeit less dramatic, improvements were observed in the other two cohorts. Ninety-five percent of patients rated satisfaction with perioperative care as excellent or very good.

CONCLUSIONS

Implementation of enhanced recovery was associated with acceptable pain management with reduced opioids, reduced length of stay with stable readmission and morbidity rates, good patient satisfaction, and substantial cost reductions.

LEVEL OF EVIDENCE

II.

Direct hospital costs of total laparoscopic hysterectomy compared with fast-track open hysterectomy at a tertiary hospital: a retrospective case-controlled study

AIMS

To assess the direct intraoperative and postoperative costs in women undergoing total laparoscopic hysterectomy and fast-track open hysterectomy.

METHODS

A retrospective review of the direct hospital-related costs in a matched cohort of women undergoing total laparoscopic hysterectomy (TLH) and fast-track open hysterectomy (FTOH) at a tertiary hospital. All costs were calculated, including the cost of advanced high-energy laparoscopic devices. The effect of the learning curve on cost in laparoscopic hysterectomy was also assessed, as was the hospital case-weighted cost, which was compared with the actual cost.

RESULTS

Fifty women were included in each arm of the study. TLH had a higher intraoperative cost, but a lower postoperative cost than FTOH (AUD$3877 vs AUD$2776 P < 0.001, AUD$3965 vs AUD$6233 P < 0.001). The total cost of TLH was not different from FTOH (AUD$7842 vs AUD$9009 P = 0.068) and after a learning curve; TLH cost less than FTOH (AUD$6797 vs AUD$8647, P < 0.001). The use of high-energy devices did not impact on the cost benefit of TLH, and hospital case-weight-based funding correlated poorly with actual cost.

CONCLUSION

Despite the use of fast-track recovery protocols, the cost of TLH is no different to FTOH and after a learning curve is cheaper than open hysterectomy. Judicious use of advanced energy devices does not impact on the cost, and hospital case-weight-based funding model in our hospital is inaccurate when compared to directly calculated hospital costs.

Perioperative enhanced recovery programmes for gynaecological cancer patients

BACKGROUND

Gynaecological malignancies contribute to 10% to 15% of cancers in women internationally. In recent years, a trend towards new perioperative care strategies has been documented as 'Fast Track (FT) surgery', or 'Enhanced Recovery Programmes' to replace some traditional approaches in surgical care. The FT multimodal programmes may enhance the postoperative recovery by means of reducing surgical stress. This systematic review aims to assess fully the beneficial and harmful effects of FT programmes in gynaecological cancer care.

OBJECTIVES

To evaluate the beneficial and harmful effects of FT programmes in gynaecological cancer care.

SEARCH METHODS

We searched the following databases, The Cochrane Gynaecological Cancer Review Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 4, 2009, MEDLINE and EMBASE to November 2009. In addition, all reference lists of included trials were searched and experts in the gynaecological oncology community were contacted in an attempt to locate trials. This search was updated and re-run to 1 May 2012, for this update.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing any type of FT programmes for surgery in gynaecological cancer to conventional recovery strategies were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. Since no RCTs were identified, data collection and analysis could not be performed.

MAIN RESULTS

No studies were identified that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We currently have no evidence from high-quality studies to support or refute the use of perioperative enhanced recovery programmes for gynaecological cancer patients. Further well-designed RCTs with standard FT programmes are needed. This review has been updated in 2012. The results of the original review published in 2010 remain unchanged.

The development of fast-track principles in gynecological surgery

Fast-track is a multimodal strategy aimed at reducing the physiological burden of surgery to achieve an enhanced postoperative recovery. The strategy combines unimodal evidence-based interventions in the areas of preoperative preparation, anesthesia, surgical factors and postoperative care. The advantages of fast-track most likely extend to gynecology, although so far have scarcely been reported. This review summarizes current evidence concerning use of fast-track in general and in gynecological surgery. The main findings of this review are that there are benefits within elective gynecological surgery, but studies of quality of life, patient satisfaction and health economics in elective surgery are needed. Studies of fast-track within the field of non-elective gynecological surgery are lacking. Widespread education is needed to improve the rate of implementation of fast-track. Close involvement of the entire surgical team is imperative to ensure a structured perioperative care aiming for enhanced postoperative recovery.

Risk factors for postoperative complications after fast-track abdominal hysterectomy

BACKGROUND

Fast-track regimen has been shown to reduce postoperative complications in gastrointestinal surgery.

AIMS

We investigated the incidence and type of postoperative complications and associated risk factors after benign abdominal hysterectomy undertaken in a fast-track program.

METHODS

A prospective longitudinal cohort study. In five Swedish hospitals, a cohort of 162 women, ASA 1-2, undergoing abdominal hysterectomy in a fast-track program was prospectively studied. Surgery was performed under spinal or general anaesthesia. The fast-track concept was standardised with discharge criteria and a restricted intravenous fluid regimen. Complications were systematically registered during the five-week follow-up period. Risk factors for complications were analysed using multiple logistic regression models.

RESULTS

Forty-one (25.3%) developed postoperative complications, mainly infection and wound healing complications. The majority of the complications developed after discharge and were treated in the outpatient clinics. Four women (2.5%) were readmitted to hospital. Substantial risk factors for postoperative complications were obesity (OR 8.83), prior laparotomy (OR 2.92) and relative increase in body weight on the first postoperative day (OR 1.52).

CONCLUSIONS

Minor infection and wound healing complications seem to be common in healthy women undergoing abdominal hysterectomy in a fast-track program. Obesity is an important risk factor also in fast-track abdominal hysterectomy. A modest increase in postoperative relative weight gain during the first postoperative day seemed to increase the risk of postoperative complications. This factor merits further study. Randomised studies are necessary to determine the impact of fast-track program and perioperative fluid regimens on postoperative complications.

Results of introducing a rapid recovery program for total abdominal hysterectomy

OBJECTIVE

To review the impact of implementing a rapid recovery protocol (RRP) for patients undergoing abdominal hysterectomy.

SETTING

Metropolitan teaching hospital.

POPULATION

Women undergoing abdominal hysterectomy for non-malignant indications.

METHODS

We conducted a retrospective review of consecutive cases performed during study periods before and after the introduction of an elective rapid recovery program emphasizing regional anesthesia. To control for universal improvements in medical practice, charts from a comparable local hospital without an RRP were also reviewed.

RESULTS

400 charts were reviewed and 366 cases met inclusion criteria and had sufficient information. Patients were well matched for demographic and medical variables between the study periods and between the institutions. The median length of stay (LOS) fell dramatically from 3 (range 1-12) days prior to RRP introduction to 1 (range 1-17) day after RRP (p < 0.001). LOS among patients at the 'control' institution remained unchanged at 3 days during the same time frame, indicating that external pressures contributed minimally to the observed changes. There were no significant differences in estimated blood loss, duration of surgery, or complication rate between the groups in either time period.

CONCLUSIONS

Introducing a rapid recovery program was associated with shorter hospitalization and did not appear to compromise surgical outcome.

Cost-effectiveness of general anesthesia vs spinal anesthesia in fast-track abdominal benign hysterectomy

OBJECTIVE

The study objective was to compare total costs for hospital stay and postoperative recovery for 2 groups of women who underwent fast-track abdominal benign hysterectomy: 1 group under general anesthesia; 1 group under spinal anesthesia. Costs were evaluated in relation to health-related quality of life.

STUDY DESIGN

Costs of treatment were analyzed retrospectively with data from a randomized multicenter study at 5 hospitals in Sweden. Of 180 women who were scheduled for benign abdominal hysterectomy, 162 women were assigned randomly for the study: 80 women allocated to general anesthesia and 82 women to spinal anesthesia.

RESULTS

Total costs (hospital costs plus cost-reduced productivity costs) were lower for the spinal anesthesia group. Women who had spinal anesthesia had a faster recovery that was measured by health-related quality of life and quality adjusted life-years gained in postoperative month 1.

CONCLUSION

The use of spinal anesthesia for fast-track benign abdominal hysterectomy was more cost-effective than general anesthesia.

Multidisciplinary convalescence recommendations after gynaecological surgery: a modified Delphi method among experts

OBJECTIVE

To generate structured detailed uniform convalescence recommendations after gynaecological surgery by a modified Delphi method amongst experts and a representative group of physicians.

DESIGN

Modified Delphi study.

SETTING

Expert physicians recruited by their respective medical boards and employed at different hospitals, doctor's surgeries and healthcare services.

POPULATION

Twelve experts (five gynaecologists, two general practitioners [GPs] and five occupational physicians [OPs]) and a representative sample of 63 medical doctors.

METHODS

Multidisciplinary detailed recommendations for graded resumption of relevant activities after uncomplicated hysterectomy (laparoscopic supracervical, total laparoscopic/laparoscopic-assisted, vaginal and abdominal hysterectomies) and laparoscopic adnexal surgery were developed. Recommendations were based on a literature review and a modified Delphi procedure among 12 experts, recruited in collaboration with the participating medical boards of gynaecologists, GPs and OPs.

MAIN OUTCOME MEASURES

A multidisciplinary consensus of at least 67% on the relevant detailed convalescence recommendations in relation to hysterectomy and laparoscopic adnexal surgery.

RESULTS

Out of initially 65 activities, the expert panel judged 38 activities relevant for convalescence recommendations. Consensus for all activities was achieved after four Delphi rounds and two group discussions. The recommendations were judged as feasible by a representative sample of 26 gynaecologists, 19 GPs and 18 OPs.

CONCLUSIONS

Consensus between gynaecologists, GPs and OPs was achieved on all relevant convalescence recommendations regarding hysterectomy (abdominal, vaginal and laparoscopic) and laparoscopic adnexal surgery.

Multicentre trial of a perioperative protocol to reduce mortality in patients with peptic ulcer perforation

BACKGROUND

Morbidity and mortality rates in patients with perforated peptic ulcer (PPU) remain substantial. The aim of the present study was to evaluate the effect of a multimodal and multidisciplinary perioperative care protocol on mortality in patients with PPU.

METHODS

This was an externally controlled multicentre trial set in seven gastrointestinal departments in Denmark. Consecutive patients who underwent surgery for gastric or duodenal PPU between 1 January 2008 and 31 December 2009 were treated according to a multimodal and multidisciplinary evidence-based perioperative care protocol. The 30-day mortality rate in this group was compared with rates in historical and concurrent national controls.

RESULTS

The 30-day mortality rate following PPU was 17·1 per cent in the intervention group, compared with 27·0 per cent in the three control groups (P = 0·005). This corresponded to a relative risk of 0·63 (95 per cent confidence interval 0·41 to 0·97), a relative risk reduction of 37 (5 to 58) per cent and a number needed to treat of 10 (6 to 38).

CONCLUSION

The 30-day mortality rate in patients with PPU was reduced by more than one-third after the implementation of a multimodal and multidisciplinary perioperative care protocol, compared with conventional treatment.

REGISTRATION NUMBER

NCT00624169 (http://www.clinicaltrials.gov).

Health-related quality of life and postoperative recovery in fast-track hysterectomy

OBJECTIVE

To determine whether health-related quality of life (HRQoL) and postoperative recovery of women who undergo abdominal hysterectomy in a fast-track program under general anesthesia (GA) differ from women who receive spinal anesthesia with intrathecal morphine (SA).

DESIGN

Secondary analysis from an open randomized controlled multicenter study.

SETTING

Five hospitals in south-east Sweden.

POPULATION

One hundred and eighty women admitted for abdominal hysterectomy for benign disease were randomized; 162 completed the study, 80 with GA and 82 with SA.

METHODS

The HRQoL was measured preoperatively using the EuroQoL EQ-5D and the Short-Form-36 health survey (SF-36) questionnaires. The EQ-5D was used daily for 1 week; thereafter, once weekly for 4 weeks and again 6 months after operation. The SF-36 was completed at 5 weeks and 6 months. Dates of commencing and ending sick leave were registered.

MAIN OUTCOME MEASURES

Changes in HRQoL; duration of sick leave.

RESULTS

The HRQoL improved significantly faster in women after SA than after GA. Sick leave was significantly shorter after SA than after GA (median 22.5 vs. 28 days). Recovery of HRQoL and duration of sick leave were negatively influenced by postoperative complications. In particular, the mental component of HRQoL was negatively affected by minor complications, even 6 months after the operation.

CONCLUSIONS

Spinal anesthesia with intrathecal morphine provided substantial advantages in fast-track abdominal hysterectomy for benign gynecological disorders by providing faster recovery and shorter sick leave compared with general anesthesia.

Mode of anesthesia and postoperative symptoms following abdominal hysterectomy in a fast-track setting

OBJECTIVE

To determine whether postoperative symptoms differ between women who undergo abdominal benign hysterectomy in a fast-track model under general anesthesia or spinal anesthesia with intrathecal morphine.

DESIGN

Secondary analysis from a randomized, open, multicenter study.

SETTING

Five hospitals in south-east Sweden.

POPULATION

One-hundred and eighty women scheduled for benign hysterectomy were randomized; 162 completed the study; 82 were allocated to spinal and 80 to general anesthesia.

METHODS

The Swedish Postoperative Symptoms Questionnaire, completed daily for 1 week and thereafter once a week until 5 weeks postoperatively.

MAIN OUTCOME MEASURES

Occurrence, intensity and duration of postoperative symptoms.

RESULTS

Women who had hysterectomy under spinal anesthesia with intrathecal morphine experienced significantly less discomfort postoperatively compared with those who had the operation under general anesthesia. Spinal anesthesia reduced the need for opioids postoperatively. The most common symptoms were pain, nausea and vomiting, itching, drowsiness and fatigue. Abdominal pain, drowsiness and fatigue occurred significantly less often and with lower intensity among the spinal anesthesia group. Although postoperative nausea and vomiting was reported equally in the two groups, vomiting episodes were reported significantly more often during the first day after surgery in the spinal anesthesia group. Spinal anesthesia was associated with a higher prevalence of postoperative itching.

CONCLUSIONS

Spinal anesthesia with intrathecal morphine carries advantages regarding postoperative symptoms and recovery following fast-track abdominal hysterectomy.

Fast track surgery: a clinical audit

BACKGROUND

Fast track surgery is a concept that utilises a variety of techniques to reduce the surgical stress response, allowing a shortened length of stay, improved outcomes and decreased time to full recovery.

AIMS

To evaluate a peri-operative Fast Track Surgical Protocol (FTSP) in patients referred for abdominal surgery.

METHODS

All patients undergoing a laparotomy over a 12-month period were entered prospectively on a clinical database. Data were retrospectively analysed.

RESULTS

Over the study period, 72 patients underwent a laparotomy. Average patient age was 54 years and average weight and BMI were 67.2 kg and 26 respectively. Sixty three (88%) patients had a vertical midline incision (VMI). There were no intraoperative blood transfusions. The median length of stay (LOS) was 3.0 days. Thirty eight patients (53%) were discharged on or before post op day 3, seven (10%) of whom were discharged on postoperative day 2. On stepwise regression analysis, the following were found to be independently associated with reduced LOS: able to tolerate early enteral nutrition, good performance status, use of COX inhibitor and transverse incision. In comparison with colleagues at the SGOG not undertaking FTS for their patients, the authors' LOS was lower and the RANZCOG modified Quality Indicators (QI's) did not demonstrate excess morbidity.

CONCLUSIONS

Patients undergoing fast track surgery can be discharged from hospital with a reduced LOS, without an increased readmission rate and with comparative outcomes to non-fast tracked patients.

Perioperative enhanced recovery programmes for gynaecological cancer patients

BACKGROUND

Gynaecological malignancies contribute to 10 to 15% of cancers in women internationally. In recent years, a trend towards new perioperative care strategies has been documented as "Fast Track (FT) surgery", or "Enhanced Recovery Programmes" to replace some traditional approaches in surgical care. The FT multimodal programmes may enhance the postoperative recovery by means of reducing surgical stress. This systematic review aims to fully assess the beneficial and harmful effects of FT programmes in gynaecological cancer care.

OBJECTIVES

To evaluate the beneficial and harmful effects of FT programmes in gynaecological cancer care.

SEARCH STRATEGY

We searched the following databases, The Cochrane Gynaecological Cancer Collaborative Review Group's Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 4, 2009, MEDLINE and EMBASE to November 2009. In addition, all reference lists of included trials were searched and experts in the gynaecological oncology community were contacted in an attempt to locate trials.

SELECTION CRITERIA

All randomised controlled trials (RCTs) comparing any type of FT programmes for surgery in gynaecological cancer to conventional recovery strategies were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion. Since no RCTs were identified, data collection and analysis could not be performed.

MAIN RESULTS

No studies were found that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We currently have no evidence from high quality studies to support or refute the use of perioperative enhanced recovery programmes for gynaecological cancer patients. Further well-designed RCTs with standard FT programmes are needed.

Fast-track hysterectomy: a randomised, controlled study

OBJECTIVE

To investigate if intrathecally administered morphine combined with a low-dose mode of total intravenous anaesthesia (TIVA) accelerates recovery after abdominal surgery as compared, to patient-controlled analgesia (PCA) combined with anaesthesia, based on volatile anaesthetics.

STUDY DESIGN

Fifty-three patients who were hysterectomised abdominally were randomised to TIVA or PCA. Their per- and post-operative course was strictly monitored and their pain score was evaluated with a visual analogue scale at repeated time intervals.

RESULTS

Patients with TIVA had a significantly shorter stay on the post-operative ward, 180 (105-330)min, compared with the PCA group, 237 (120-1140)min (p<0.01). The start of peroral fluid also differed significantly between groups, 4h (2-6) for TIVA versus 5h (2-24) for the PCA group (p<0.01). The removal of the indwelling catheter took place significantly earlier in the TIVA group, 9h (5-23) versus 22h (17-24) in the PCA group (p<0.0001). There was significantly less post-operative nausea in the TIVA group compared with the PCA group on the first post-operative day (p<0.01). The length of stay was shorter, 2 days (1-3) compared with 3 days (1-6) for the TIVA group versus PCA (p<0.001). There was no difference in complications between groups. One patient in each group was re-admitted to hospital because of a vaginal cuff infection.

CONCLUSION

The TIVA per- and post-operative care was an advantage over PCA in most respects.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically.

OBJECTIVES

To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists.

SELECTION CRITERIA

Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included.

DATA COLLECTION AND ANALYSIS

Independent selection of trials and data extraction were employed following Cochrane guidelines.

MAIN RESULTS

There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures.

AUTHORS' CONCLUSIONS

Because of equal or significantly better outcomes on all parameters, VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH however the length of the surgery increases as the extent of the surgery performed laparoscopically increases. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.

A clinical pathway for postoperative management and early patient discharge: does it work in gynecologic oncology?

OBJECTIVE

This study evaluates a postoperative clinical pathway among gynecologic oncology patients.

STUDY DESIGN

880 surgical admissions were retrospectively reviewed at an institution which used a clinical pathway consisting of early feeding and ambulation as well as prompt discontinuation of intravenous fluids with conversion to oral analgesics. Readmission, mortality, and complication rates were calculated. Patient proportions were compared by using the chi(2), Mann-Whitney, and t tests.

RESULTS

40% of the surgeries were radical and/or staging procedures and 100% underwent open laparotomies. The median length of hospital stay was 2 days. Only 5% required readmission. The median time to readmission was 4 days. Those patients with a longer initial length of hospital stay and higher mean blood loss were more likely to be readmitted (P < .01). The most common diagnosis was endometrial carcinoma (n = 188). This subgroup also had a median length of hospital stay of 2 days and the readmission rate was 3.6%. The perioperative mortality rate was low in the group as a whole with only 1 death (0.2%). There were no reoperations for hemoperitoneum or urinary or intestinal fistulas.

CONCLUSION

This management approach resulted in a length of hospital stay of 2 days without increasing morbidity or mortality after laparotomy for suspected gynecologic malignancy.