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de Groot JJA, Ament SMC, Maessen JMC, Dejong CHC, Kleijnen JMP, Slangen BFM. Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2015; 95:382-95. [PMID: 26613531 DOI: 10.1111/aogs.12831] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 11/16/2015] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Jeanny J A de Groot
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Stephanie M C Ament
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
| | - José M C Maessen
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Department of Patient & Integrated Care, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,NUTRIM, School for Nutrition, Toxicology, and Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jos M P Kleijnen
- Department of Family Medicine, CAPHRI, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands.,Kleijnen Systematic Reviews Ltd, York, UK
| | - Brigitte F M Slangen
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands.,GROW, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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Miller EC, McIsaac DI, Chaput A, Antrobus J, Shenassa H, Lui A. Increased postoperative day one discharges after implementation of a hysterectomy enhanced recovery pathway: a retrospective cohort study. Can J Anaesth 2015; 62:451-60. [PMID: 25724789 DOI: 10.1007/s12630-015-0347-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 02/13/2015] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Elizabeth C Miller
- Department of Anesthesia, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada,
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Carter J. Fast-track surgery in gynaecology and gynaecologic oncology: a review of a rolling clinical audit. ISRN SURGERY 2012; 2012:368014. [PMID: 23320193 PMCID: PMC3540771 DOI: 10.5402/2012/368014] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 11/01/2012] [Indexed: 01/26/2023]
Abstract
Clinical audit is the process by which clinicians are able to demonstrate to themselves, their patients, hospital administrators, and healthcare financial providers the outcome and safety of their clinical practice. It is a process by which the public can be assured of safety and outcomes. A fast-track surgery program was initiated in January 2008, and this paper represents a rolling clinical audit of the outcomes of that program until the end of June 2012. Three hundred and eighty-nine patients underwent fast track surgical management after having a laparotomy for suspected or confirmed gynaecological cancer. There were no exclusions and the data presented represents the practice and outcomes of all patients referred to a single gynaecological oncologist. The majority of patients were deemed to have complex surgical procedures performed usually through a vertical midline incision. One third of patients had a nonzero performance status, median weight was 68 kilograms, and median BMI was 26.5 with 31% being classified as obese. Median operating time was 2.25 hours, and the median estimated blood loss was 175 mL. Overall the median length of stay (LOS) was 3 days with 95% of patients tolerating early oral feeding. Four percent of patients required readmission, and 0.5% were required to return to the operating room. Whilst the wound infection rate was 2.6%, there were no ureteric, bowel or neurovascular injuries. Overall there were 2 bladder injuries (0.5%), and the incidence of venous thromboembolism was 1%. Subset analysis was also undertaken. Whilst a number of variables were associated with reduced LOS, on multivariate analysis, benign pathology, shorter operating time, and the ability to tolerate early oral feeding were found to be significant. The data and experience presented is the largest and most extensive reported in the literature relating to fast-track surgery in gynaecology and gynaecologic oncology. The public can be reassured of the safety and improved outcomes that can be achieved after the introduction of such a program.
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Affiliation(s)
- Jonathan Carter
- The University of Sydney, Sydney, NSW 2006, Australia
- Sydney Gynaecological Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia
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Brand A, Sidhu VS, Lancaster L, Elliott D. Re: Reimplementation and audit of ‘Fast Track Surgery’ in gynaecological oncology surgery. Aust N Z J Obstet Gynaecol 2012. [DOI: 10.1111/ajo.12005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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