Changes to Perioperative Care Improve Outcomes

Use of an enhanced recovery pathway (ERP) for complex gynecological surgery can lead to significant reductions in length of hospital stay, narcotic use, and cost, according to a new study conducted at the Mayo Clinic.¹

Developed by gynecologic oncologists, urogynecologists, and anesthesiologists, the ERP was designed to reduce the recovery period for women undergoing gynecological surgery. Before the ERP was implemented, standard preoperative procedures included extensive bowel preparations, caloric restrictions, and intravenous fluids. Also, postoperative care involved bed rest, high rates of intravenous opioids, and the liberal use of drains and catheters, explained the study authors.

Under the ERP, prolonged preoperative fasting and bowel cleansing were eliminated, as was the routine use of drains and nasogastric tubes. To avoid hypervolemia, fluids were restricted. The ERP also called for early ambulation and oral nutrition after surgery as well as the limited use of intravenous narcotics. In addition, urinary catheters were removed promptly after 24 hours.

The ERP was tested in a group of 241 consecutive patients undergoing cytoreduction (n=81), surgical staging (n=84), or pelvic organ prolapse surgery (n=76), and preselected outcomes were compared with those of 235 consecutive historical controls. Cytoreduction involved extensive, complex surgeries for ovarian cancer. Surgical staging involved abdominal surgery for hysterectomy or lymph node dissection for ovarian or endometrial cancer. Lastly, pelvic organ prolapse surgery involved complicated vaginal surgeries for pelvic floor dysfunction.

Use of the ERP resulted in dramatic improvements in the recovery period for all surgical groups. However, patients who underwent cytoreduction benefited most. The usual hospital stay for cytoreduction is 10 days, reported the study authors. Using the ERP, the hospital stay was reduced by 4 days, and the readmission rates remained stable at 25.9% in the ERP group and 17.9% in the control group. Opioid use decreased by 80% overall in the first 48 hours with no subsequent change in pain scores. The use of patient-controlled narcotics decreased from 98.7% to 33.3%. Complication rates and severity were similar between study groups. Use of the ERP resulted in a 30-day per-patient cost savings of 18.8%, or about $7600. Patient satisfaction with perioperative care was high, with more than 95% of all patients rating their care as excellent or very good.

Although the main goal of a quicker recovery was achieved, the study authors highlighted an additional benefit of EFT: it allows patients with cancer to receive other recommended therapies, such as chemotherapy or radiation, sooner.

Pertinent Points:
- The enhanced recovery pathway (ERP) eliminates preoperative bowel preps and prolonged fasting, the routine use of drains and nasogastric tubes, and preoperative intravenous fluids and supports early postoperative ambulation and oral nutrition.
- Use of the ERP for complex gynecological surgeries is associated with decreased narcotic use, earlier discharge, stable readmission rates, cost savings, and satisfied patients.

References:

1. Kalogera E, Bakkum-Gamez JN, Jankowski CJ, et al. Enhanced recovery in gynecologic surgery. Obstet Gynecol. 2013;122(pt 1):319-328.