Background
Improved patient outcomes and satisfaction associated with enhanced recovery after surgery protocols have increasingly replaced traditional perioperative anesthesia care. Fast-track surgery pathways have been extensively validated in patients undergoing hysterectomies, yet the impact on fertility-sparing laparoscopic gynecologic operations, particularly those addressing chronic pain conditions, has not been examined.
Objective
The objective of the study was to determine the effects of enhanced recovery after surgery pathway implementation compared with conventional perioperative care in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.
Study Design
We conducted a retrospective cohort study of women undergoing uterine-sparing laparoscopic gynecologic procedures for benign conditions (tubal/adnexal pathology, endometriosis, or leiomyomas) during a 24 month period before and after enhanced recovery after surgery implementation at a tertiary care center. We compared immediate perioperative outcomes and 30 day complications. The primary outcome was same-day discharge rates. Factors influencing unplanned admissions, postoperative pain, sedation, nausea, and vomiting represented secondary analyses.
Results
A total of 410 women (enhanced recovery after surgery, n = 196; conventional perioperative care, n = 214) met inclusion criteria. Following enhanced recovery after surgery implementation, same-day discharge rates increased by 9.4% ( P = .001). Reductions in postoperative pain and nausea/vomiting represented the primary driving factor behind lower unplanned admissions. Higher preoperative antiemetic medication administration in the enhanced recovery after surgery group resulted in a 57% reduction in postanesthesia care unit antiemetics ( P < .001). Total perioperative narcotic medication use was also significantly reduced by 64% ( P < .001), and the enhanced recovery after surgery cohort still demonstrated significantly lower postanesthesia unit care pain scores at hours 2 and 3 ( P < .001). A 19 minute shorter postanesthesia care unit stay was noted in the enhanced recovery after surgery cohort ( P = .036). Increased same-day discharge did not lead to higher postoperative complications or changes in 30 day emergency department visits or readmissions in patients with enhanced recovery after surgery.
Conclusion
Enhanced recovery after surgery implementation resulted in increased same-day discharge rates and improved perioperative outcomes without affecting 30 day morbidity in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.
Enhanced recovery after surgery (ERAS) is a multidisciplinary care team approach aimed to improve perioperative patient outcomes, recovery, and satisfaction. Evidence supporting decreased hospital length of stay, complications, health care cost, and expedited recovery with faster return of bowel function reduced pain and postoperative nausea and vomiting (PONV) has challenged conventional perioperative care (CPC). ,
Why was the study conducted?
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To investigate the advantages of enhanced recovery after surgery in women undergoing fertility-sparing minimally invasive gynecologic procedures.
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To explore perioperative care outcomes using enhanced recovery after surgery protocols with an emphasis on women with chronic pelvic pain conditions.
Key findings
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Enhanced recovery after surgery implementation increases same-day discharge rates without affecting 30 day morbidity in nonhysterectomy procedures.
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Our enhanced recovery after surgery protocol resulted in a 64% and 57% reduction in opioid medication requirements and antiemetics, respectively.
What does this add to what is known?
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Enhanced recovery after surgery protocols should be implemented for all gynecologic laparoscopic procedures and not reserved for laparoscopic/robotic hysterectomies alone.
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Enhanced recovery after surgery administration prevents unplanned postanesthesia care unit admissions by primarily targeting pain management in women undergoing extensive endometriosis surgery.
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Health care costs could significantly be curbed with universal enhanced recovery after surgery initiatives.
ERAS protocols have now widely been adapted and modified throughout most surgical specialties including gynecologic care. , , Although first introduced in open gynecologic oncology procedures, urogynecologic and minimally invasive gynecologic surgeons have increasingly integrated ERAS care into standard perioperative patient care for pelvic organ prolapse and hysterectomies. , However, to date, no studies exist that specifically address outcomes in women undergoing minimally invasive gynecologic procedures treating chronic pelvic pain conditions such as endometriosis, fibroids, or tubal and adnexal pathology.
Moreover, the true impact of ERAS protocols on outcome parameters such as length of stay or same-day discharge (SDD) rates is difficult to determine, given that extensive institutional practice shifts, patient education, and perioperative care team attitudes toward outpatient major gynecologic surgery have primarily been credited for the success of fast-track surgery care. Hence, studying ERAS implementation in patients undergoing uterine-sparing gynecologic operations may provide insight into whether universal implementation of ERAS protocols for all gynecologic surgeries is effective.
In contrast to the traditional 24 hour observation period that until recently was considered standard of care following major gynecologic procedures, nonhysterectomy operations have long been accepted as outpatient surgeries and thus may overcome study limitations and inherent bias associated with ERAS implementation.
The objective of this study was to determine whether ERAS implementation improved SDD rates among women undergoing minimally invasive nonhysterectomy gynecologic surgery for endometriosis, fibroids, or adnexal pathology as compared with CPC. Immediate perioperative outcomes, factors influencing postoperative admission, pain, and PONV management as well as 30 day outcomes were also examined.
Material and Methods
We performed a retrospective, observational cohort study of women undergoing minimally invasive nonhysterectomy gynecologic procedure at Magee-Womens Hospital of the University of Pittsburgh Medical Center before and after ERAS pathway implementation. Details of our institution specific minimally invasive gynecologic ERAS protocol have previously been published.
Surgical cases were identified using surgical service calendars. Eligibility criteria included ages 18–100 and laparoscopic, nonrobotic gynecologic surgeries for tubal/adnexal pathology, endometriosis and other pelvic pain conditions, or leiomyoma removal by 1 of 4 minimally invasive gynecologic fellowship-trained surgeons during a 24 month period before (July 2015 through 2016) and after (February 2017 through 2018) ERAS implementation.
The surgeons remained constant throughout the study period. Caseloads did not change significantly before and after ERAS implementation nor did the case types performed by each surgeon. Surgeries were performed at only 1 hospital. A 6 month time interval between the CPC and ERAS group was omitted because ongoing modifications occurred to the ultimately final ERAS protocol used in this study. Other exclusion criteria included study subjects aged <18 years, known gynecologic malignancy, hysterectomy, or urogynecologic procedures.
Data collection occurred retrospectively using electronic medical data from outpatient clinic notes and operative and anesthesia records as well as emergency and inpatient documentation up to 30 days postoperatively. Patient demographics collected were comprised of age, gravidity, parity, body mass index, previous surgical history, and medical comorbidities including coronary artery disease, congestive heart failure, obstructive sleep apnea, chronic obstructive pulmonary disease, diabetes, hypertension, asthma, venous thromboembolism, and liver disease.
Preoperative pain scores (scale 1–10) when available were recorded. Surgical and perioperative care outcomes included primary indication for the procedure and estimated blood loss as well as pre-, intra-, postoperative and postanesthesia care unit (PACU) times. PONV and pain outcomes were analyzed utilizing medication records for antiemetics as well as narcotic and nonnarcotic pain medications.
For standardization, all narcotic administrations were converted to oral morphine equivalent dosing. Thirty day emergency room presentations and readmissions rates were characterized by evaluation for pain, wound, venous thromboembolism, cardiac/chest pain, small bowel obstruction, ileus, constipation, PONV, gastrointestinal injury, urinary tract injury, voiding dysfunction, or ovarian torsion.
We hypothesized that ERAS implementation would significantly increase the SDD rates, and hence, this variable was selected as our primary outcome. A multivariate analysis adjusting for patient demographics, surgeon, and surgery type was performed to ensure that these factors did not modify the primary outcome. Secondary outcomes analyzed included changes in perioperative times, PONV, and pain management as well as 30 day complication rates.
Because SDD rates with CPC for nonhysterectomy minimally invasive gynecologic surgeries were not available from our institution prior to our analysis, sample size calculations were performed using data extrapolation from a similar patient population undergoing minimally invasive myomectomies with reports of outpatient procedure rates of 88%.
We estimated that 102 women in each cohort were required to detect a 10% increase in SDD rates with 80% power at a 2-sided alpha of 0.05. This increase in SDD was predicted based on the observed increase of same-day hysterectomy discharges following ERAS rollout at our institution. However, given potential institutional and procedural variances, data collection was extended to include all patients in a 1 year period before and after ERAS implementation to ensure statistical robustness.
Both patient cohorts were characterized through descriptive statistics. Continuous variables were presented as means with standard deviations. Categorical variables were presented as frequencies in percentages. For comparisons between CPC and ERAS groups, Student t tests were used for continuous variables, and χ 2 or Fisher exact test was utilized for categorical variables.
A mixed-effects linear regression model adjusted for patient demographics, surgeon, and surgery type was applied to analyze PACU pain (scale 1–10) and sedation (scale 0–3) scores at various time intervals of recovery and calculate the difference in score changes between CPC and ERAS at hours 1–3. A sensitivity analysis was performed using only people with complete data in the first 3 hours to confirm that missing values did not have an impact on the results and their statistical accuracy. STATA version 15 (State Corp, College Station, TX) was used for all analyses. Values of P < .05 were considered statistically significant. The University of Pittsburgh Institutional Review Board approved this study.
Results
During the 24 month study period, 410 women met inclusion criteria (CPC, n = 214; ERAS, n = 196). Demographic characteristics were similar in both groups ( Table 1 ). Chronic pelvic pain was the primary indication for surgery in 64.9% of all patients with no difference in the remaining operative interventions ( Table 2 ). Preoperative pain scores were available in 55.9% of patients (CPC: 5.16 ± 0.2 vs ERAS: 4.60 ± 0.24, P = .071). Patient cohorts underwent comparable rates of myomectomies, adnexal surgery including ovarian cystectomies or salpingo-oophorectomies, and excision of endometriosis with or without concurrent adnexal or bowel surgery ( Table 3 ).
| Demographic characteristic | CPC (n = 214) | ERAS (n = 196) | P value |
|---|---|---|---|
| Age | 33.6 ± 10.2 | 35.1 ± 11.3 | .154 |
| Gravidity | 1.4 ± 1.8 | 1.2 ± 1.6 | .433 |
| Parity | 0.9 ± 1.3 | 0.8 ± 1.1 | .134 |
| BMI | 28.0 ± 7.5 | 28.2 ± 7.8 | .743 |
| Previous pelvic surgery | 132 (61.7) | 111 (56.6) | .299 |
| Previous abdominal surgery | 61 (28.5) | 71 (36.2) | .095 |
| Medical comorbidities | 65 (30.4) | 64 (32.7) | .620 |
| Indication | CPC (n = 214) | ERAS (n = 196) | P value |
|---|---|---|---|
| Pelvic pain, endometriosis | 104 (48.6) | 97 (49.5) | .857 |
| Pelvic pain, nonendometriosis | 47 (22.0) | 18 (9.2) | < .001 |
| Fibroids | 6 (2.8) | 17 (8.7) | .010 |
| Infertility | 2 (0.9) | 2 (1.0) | > .999 |
| Sterilization | 6 (2.8) | 6 (3.0) | .877 |
| Adnexal cyst/mass | 43 (20.1) | 47 (24.0) | .342 |
| Foreign body | 1 (0.5) | 0 (0.0) | .338 |
| Prophylactic/breast cancer | 5 (2.3) | 9 (4.6) | .209 |
| Surgery type a | CPC (n = 214) | ERAS (n = 196) |
|---|---|---|
| Adnexal/tubal | 75 (35.0) | 62 (31.6) |
| Endometriosis plus adnexal PSN | 26 (12.2) | 34 (17.4) |
| Endometriosis PSN | 78 (36.5) | 64 (32.7) |
| Endometriosis plus bowel adnexal PSN | 8 (3.7) | 3 (1.5) |
| Myomectomy | 9 (4.2) | 20 (10.2) |
| Other | 18 (8.4) | 13 (6.6) |
a P value is .073, noting no difference in distribution between CPC and ERAS across any surgery types.
ERAS implementation significantly increased SDD by 9.4% ( Table 4 ). ERAS remained superior, with 96.9% of patients discharged on postoperative day 0 ( P = .005) after excluding planned postoperative admissions because of medical comorbidities or complex surgical interventions such as bowel surgery. While planned admission rates did not vary, unplanned admissions occurred more frequently in the CPC group because of unanticipated PACU complications (CPC: 43.3% vs ERAS: 33.3%, P = .021).
