Advertisement

International Urogynecology Journal

, Volume 30, Issue 2, pp 313–321 | Cite as

Enhanced recovery program for minimally invasive and vaginal urogynecologic surgery

  • Elisa Rodriguez TrowbridgeEmail author
  • Sarah L. Evans
  • Bethany M. Sarosiek
  • Susan C. Modesitt
  • Dana L. Redick
  • Mohamed Tiouririne
  • Robert H. Thiele
  • Traci L. Hedrick
  • Kathie L. Hullfish
Original Article

Abstract

Introduction and hypothesis

Enhanced recovery protocols (ERPs) are evidenced-based interventions designed to standardize perioperative care and expedite recovery to baseline functional status after surgery. There remains a paucity of data addressing the effect of ERPs on pelvic reconstructive surgery patients.

Methods

An ERP was implemented at our institution including: patient counseling, carbohydrate loading, avoidance of opioids, goal-directed fluid resuscitation, immediate postoperative feeding and early ambulation. Patients undergoing elective pelvic reconstructive surgery before and after implementation of the ERP were identified in this cohort study.

Results

One hundred eighteen patients underwent pelvic reconstructive surgery within the ERP compared with 76 historic controls. Reductions were seen in length of hospital stay (29.9 vs. 27.9 h, p = 0.04), total morphine equivalents (37.4 vs. 19.4 mg, p < 0.01) and total intravenous fluids administered (2.7 l vs. 1.5 l, p < 0.0001). Hospital discharges before noon doubled (32.9 vs. 60.2%, p < 0.01). More patients in the ERP group ambulated on the day of surgery (17.1 vs. 73.7%, p < 0.01) and ambulated at least two times the day following surgery (34.2 vs. 72.9%, p < 0.01). No differences were seen in average pain scores (highest pain score 7.39 vs. 7.37, p = 0.95), hospital readmissions (3.9 vs. 3.4%, p = 0.84), or postoperative complications (6.58 vs. 8.47%, p = 0.79). Patient satisfaction significantly improved. ERP was not associated with an increase in 30-day total hospital costs.

Conclusions

Implementation of ERP for pelvic reconstructive surgery patients was associated with a reduced length of hospital stay, improved patient satisfaction, and decreased administration of intravenous fluids and opioids without an increase in complications, readmissions, or hospital costs.

Keywords

ERP Vaginal hysterectomy Vaginal reconstruction Fast track recovery 

Notes

Compliance with ethical standards

Conflicts of interest

None.

References

  1. 1.
    ACOG Committee Opinion 444. Choosing the route of hysterectomy for benign disease. The American College of Obstetricians and Gynecologists. 2011;444.Google Scholar
  2. 2.
    Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–17.CrossRefGoogle Scholar
  3. 3.
    Thiele R, Rea K, Turrentine F, Friel C, Hassinger T, Goudreau B, et al. Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220(4):430–43.CrossRefGoogle Scholar
  4. 4.
    Yoong W, Sivashanmugarajan V, Relph S, Bell A, Fajemirokun E, Davies T, et al. Can enhanced recovery pathways improve outcomes of vaginal hysterectomy? Cohort control study. J Minim Invasive Gynecol. 2014;21(1):83–9.CrossRefGoogle Scholar
  5. 5.
    Kroon U, Radstrom M, Hielte C, Dahlin C, Kroon L. Fast-track hysterectomy: a randomised, controlled study. Eur J Obstet Gynecol Reprod Biol. 2010;151:203–7.CrossRefGoogle Scholar
  6. 6.
    Meyer L, Lasala J, Iniesta M, Nick A, Munsell M, Shi Q, et al. Effect of an enhanced recovery after surgery program on opioid use and patient-reported outcomes. Obstet Gynecol. 2018;132(2):281–90.CrossRefGoogle Scholar
  7. 7.
    Nelson G, Altman A, Nick A, Meyer L, Ramirez P, Achtari C, et al. Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: enhanced recovery after surgery (ERAS®) society recommendations — part I. Gynecol Oncol. 2016;140:313–22.CrossRefGoogle Scholar
  8. 8.
    Sjetne S, Krogstad U, Ødegård S, Engh M. Improving quality by introducing enhanced recovery after surgery in a gynaecological department: consequences for ward nursing practice. Qual Saf Health Care. 2009;18:236–40.CrossRefGoogle Scholar
  9. 9.
    Wijk L, Franzen K, Ljungqvist O, Nilsson K. Implementing a structured enhanced recovery after surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy. Acta Obstet Gynecol Scand. 2014;93:749–59.CrossRefGoogle Scholar
  10. 10.
    de Groot J, van Es L, Maessen J, Dejong C, Kruitwagen R, Slangen B. Diffusion of enhanced recovery principles in gynecologic oncology surgery: is active implementation still necessary? Gynecol Oncol. 2014;134:570–5.CrossRefGoogle Scholar
  11. 11.
    Modesitt SC, Sarosiek BM, Trowbridge ER, Redick DL, Shah PM, Thiele RH, et al. Enhanced recovery implementation in major gynecologic surgeries: effect of care standardization. Obstet Gynecol. 2016;128(3):457–66.CrossRefGoogle Scholar
  12. 12.
    Chapman J, Roddy E, Ueda S, Brooks R, Chen L, Chen L. Enhanced recovery pathways for improving outcomes after minimally invasive gynecologic oncology surgery. Obstet Gynecol. 2016;128(1):138–44.CrossRefGoogle Scholar
  13. 13.
    Wu JM, Kawasaki A, Hundley AF, Dieter AA, Myers ER, Sung VW. Predicting the number of women who will undergo incontinence and prolapse surgery, 2010 to 2050. Am J Obstet Gynecol. 2011;205(3):230.e1–5.CrossRefGoogle Scholar
  14. 14.
    Hughes S, Leary A, Zweizig S, Cain J. Surgery in elderly people: preoperative, operative and postoperative care to assist healing. Best Pract Res Clin Obstet Gynaecol. 2013;27:753–65.CrossRefGoogle Scholar
  15. 15.
    Cook DJ, Rooke GA. Priorities in perioperative geriatrics. Anesth Analg. 2003;96(6):1823–36.CrossRefGoogle Scholar
  16. 16.
    Schmocker RK, Stafford LMC, Siy AB, Leverson GE, Winslow ER. Understanding the determinants of patient satisfaction with surgical care using the consumer assessment of healthcare providers and systems surgical care survey (S-CAHPS). Surgery. 2015;6(1724):158.Google Scholar
  17. 17.
    Bradshaw BG, Liu SS, Thirlby RC. Standardized perioperative care protocols and reduced length of stay after colon surgery. J Am Coll Surg. 1997;186(5):501–6.CrossRefGoogle Scholar
  18. 18.
    NadlerA PEA, Victor JC, Aarts MA, Okrainec A, McLeod RS. Understanding surgical residents’ postoperative practices and barriers and enablers to the implementation of an enhanced recovery after surgery (ERAS) guideline. J Surg Educ. 2014;71(4):632–8.CrossRefGoogle Scholar

Copyright information

© The International Urogynecological Association 2018

Authors and Affiliations

  • Elisa Rodriguez Trowbridge
    • 1
    • 2
    Email author
  • Sarah L. Evans
    • 1
  • Bethany M. Sarosiek
    • 3
  • Susan C. Modesitt
    • 1
  • Dana L. Redick
    • 1
  • Mohamed Tiouririne
    • 4
  • Robert H. Thiele
    • 4
  • Traci L. Hedrick
    • 3
  • Kathie L. Hullfish
    • 1
  1. 1.Department of Obstetrics and GynecologyUniversity of Virginia Health SystemCharlottesvilleUSA
  2. 2.University of Virginia Health SystemCharlottesvilleUSA
  3. 3.Department of General SurgeryUniversity of Virginia Health SystemCharlottesvilleUSA
  4. 4.Department of AnesthesiaUniversity of Virginia Health SystemCharlottesvilleUSA

Personalised recommendations