ROCHESTER, Minn. — Patients who had complex gynecologic surgery managed by an enhanced recovery pathway (ERP) resulted in decreased narcotic use, earlier discharge, stable readmission rates, excellent patient satisfaction and cost savings, according to a Mayo Clinic study. The findings are published in the journal Obstetrics & Gynecology.
A team of gynecologic oncologists, urogynecologists and anesthesiologists developed an enhanced recovery pathway for patients undergoing gynecologic surgery to recover more quickly. Prior to the ERP for gynecologic surgery, patients had extensive bowel preparations, caloric restriction, received more intravenous fluids, bed rest, high rates of intravenous opioid use, and drains and catheters were used liberally. The ERP standardized postoperative management to avoid prolonged preoperative fasting and eliminated bowel cleansing. Patients are eating, drinking and ambulating shortly after surgery. In addition, drains and nasogastric tubes are not routinely used and urinary catheters are promptly removed after 24 hours. Patients receive limited IV narcotics and their fluid is restricted to avoid fluid overload.
"Patients are much happier when we are able to eliminate the use of unproven and unpleasant interventions such as bowel preparations, caloric restriction, sedating medications and the use of surgical drains," says Sean Dowdy, M.D., a Mayo Clinic gynecologic surgeon and lead study author. "We show that patients undergoing the most complex and invasive operations have the most to gain from this recovery pathway."
In a retrospective study, the researchers studied the outcomes of 241 women who followed the ERP during a six-month period and compared them to 235 women who did not follow the ERP during a nine-month period. The patients were divided into three cohorts: patients with complicated vaginal surgeries due to pelvic floor dysfunction; surgery through the abdomen for hysterectomy and lymph node dissection for ovarian or endometrial cancer; and extensive, complex surgeries for patients with ovarian cancer.
Though all three groups had dramatic improvements, the researchers found that patients who underwent surgery for ovarian cancer had the most significant improvement in recovery. These patients need extensive surgery that can last 4 to 8 hours and their average hospital stay is about 10 days. For this group, intravenous narcotic use decreased from 98.7 percent to 33.3 percent; overall narcotic use decreased by 80 percent within the first 48 hours after surgery; patients had a four-day reduction in hospital stay and cost of care was reduced 18.8 percent due to the shorter hospital stay.
"Our goal after surgery is for patients to recover as quickly as possible in order for them to return home to their families and get back to normal activities as soon as possible," Dr. Dowdy says.
The use of the ERP allows patients to have a more rapid recovery with faster return of bowel function, stable pain scores despite reduced narcotic use, excellent patient satisfaction and stable complication and readmission rates.
"There is accumulating evidence that patients who receive chemotherapy sooner rather than later for example, patients with ovarian cancer, have improved outcomes," Dr. Dowdy says. "Thus, the quicker recovery made possible by this pathway may allow patients to receive other recommended therapies, such as chemotherapy, sooner." The researchers conclude that the enhanced recovery pathway substantially improves the outcome and the quality of care for patients undergoing complex and extensive gynecologic surgeries.
Other study co-authors are Eleftheria Kalogera, M.D.; Jamie Bakkum-Gamez, M.D.; Christopher Jankowski, M.D.; Emanuel Trabuco, M.D.; Jenna Lovely; Pamela Grubbs; Amy Weaver; Lindsey Haas; Bijan Borah, Ph.D.; April Bursiek; Michael Walsh, M.D.; and William Cliby, M.D., all of Mayo Clinic.