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.
Similar content being viewed by others
References
ACOG Committee Opinion 444. Choosing the route of hysterectomy for benign disease. The American College of Obstetricians and Gynecologists. 2011;444.
Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–17.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Cook DJ, Rooke GA. Priorities in perioperative geriatrics. Anesth Analg. 2003;96(6):1823–36.
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.
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.
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.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None.
Rights and permissions
About this article
Cite this article
Trowbridge, E.R., Evans, S.L., Sarosiek, B.M. et al. Enhanced recovery program for minimally invasive and vaginal urogynecologic surgery. Int Urogynecol J 30, 313–321 (2019). https://doi.org/10.1007/s00192-018-3794-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00192-018-3794-0