Enhanced recovery after surgery program following focused ultrasound ablation surgery for uterine fibroids

An ERAS protocol can help patients who receive focused ultrasound ablation surgery (FUAS) for uterine fibroids recover faster, lessen the need for opioids, and cut costs, according to a study published in the International Journal of Hyperthermia.

Guowei Sang, from the State Key Laboratory of Ultrasound in Medicine and Engineering at the College of Biomedical Engineering at Chongqing Medical University in Chongqing, China, and colleagues emphasized the need for a specific ERAS protocol for FUAS.

ERAS has special procedural and recovery requirements, the authors explained. Researchers stated that current ERAS protocols for laparoscopy are insufficient for FUAS because these patients require proper pain management while keeping them awake to avoid nerve injury.

They said that after FUAS treatment, patients need to be moved from the traditional prone position to a more comfortable position, and also need different postoperative health education. In addition, Sang and colleagues noted that because patients need an MRI to locate tumors prior to the procedure, FUAS treatment costs more than uterine artery embolization.

Researchers conducted a retrospective data analysis of measured clinical outcomes at Chongqing HAIFU gynecological teaching hospital, which in addition to treatment and rehabilitation, conducts scientific research.

Sang and colleagues recorded data prior to the implementation of an ERAS protocol at Chongqing HAIFU for FUAS from September- December 2019 (pre-ERAS, 224 patients), during implementation from April-July 2020 (interim-ERAS, 179 patients), and after a program had been introduced from August-November 2020 (post-ERAS, 224 patients).

Researchers reported that patients were of similar diagnosis, maximum diameter of myoma, location of myoma, preoperative anemia, age, and BMI in all 3 groups.

In April for the interim-ERAS group, researchers implemented postoperative comfortable position, preoperative education, prevention of venous thromboembolism preoperative blood, and preoperative glucose control.

In May, they added individualized diet preparation and mannitol lubrication instead of an enema. In June, preoperative energy intake was calculated by body weight. Patients unable to eat were given IV nutrition, and all patients were given chronic disease management assistance via the internet. In July, patients received multimodal postoperative pain medication and had improved pain assessment. The ERAS program was considered complete after these additions.

Researchers said that following the ERAS implementation, the median total length of stay (LOS) was reduced by a full day, from 3.0 days to 2.0 (IQR = 1.00); the median postoperative stay was 1.0 days, lower than the length of hospital stay before ERAS had been implemented [total LOS of pre-ERAS 3.00 (1.00) days, p=.000] and postoperative LOS for pre-ERAS [1.00 (0–4) day, p=.003].¹

Researchers also reported reduced costs, from a pre-ERAS median of 23694.35¥ (IQR=3358.32) to a post-ERAS 22612.51¥ (IQR= 3189.23). The interim ERAS median cost was reported as 23229.78¥ (IQR= 2836.42).¹

Researchers said that regular medications such as NSAIDs and tramadol were used during the pre-ERAS and interim-ERAS periods. They reported a single dose of 40mg phloroglucinol was given to 6 patients in the interim-ERAS group. While more patients in the post-ERAS group (21.08%, 47/223) received NSAIDS than those in the pre-ERAS group (4.91%/11/224), fewer patients in the interim-ERAS group received tramadol (4.47%, 8/179) than the pre-ERAS group (10.27%, 23/224).¹

Sang and colleagues also noted less use of hydromorphone in the post-ERAS group before leaving the operating room. This suggests that ERAS reduced opioid use, researchers wrote.

ERAS also resulted in a reduction of postoperative nausea and vomiting, with 6.8% (48/179) patients in the interim-ERAS group compared to 16.6% (37/223) patients in the post-ERAS group (p=.013).¹

Sang and colleagues noted several limitations to their study. “Real-world data, clinical practice, and some variables were not collected regularly during the practice,” they wrote, including data such as post-operative limb pain and pain score records.

They added that more studies are needed to examine ERAS programs for uterine fibroid patients. They also noted that only one hospital was used in the study, and confirmation is needed by repeating the study in more hospitals.

After evaluating the protocol at Chongqing HAIFU, researchers concluded that “implementation of the ERAS program improves patient comfort during treatment and reduces the postoperative pain level, the number of postoperative complications, the hospital stay duration, and treatment costs, all of which contribute to increased overall hospital productivity.”¹

Reference

1. Sang G, Zhang X, Fan H, Ao X, Chen Y, Shi Q. Implementation of an enhanced recovery after surgery program in the treatment of uterine fibroids with focused ultrasound ablation surgery. Int J Hyperthermia. 2022;39(1):414-420. doi:10.1080/02656736.2022.2037740