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  • Enhanced Recovery After Surgery protocol implementation was associated with decreased narcotic use, lower maximum pain scores, and expedited return of baseline functions among medically complex gynecologic oncology patients

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Original Article
Enhanced Recovery After Surgery protocol implementation was associated with decreased narcotic use, lower maximum pain scores, and expedited return of baseline functions among medically complex gynecologic oncology patients
  1. Amanda Rae Schwartz1,
  2. Stephanie Lim1,
  3. Gloria Broadwater2,
  4. Lauren Cobb3,
  5. Fidel Valea4,
  6. Julie Marosky Thacker1,
  7. Ashraf Habib5 and
  8. Laura Havrilesky1
  1. 1Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
  2. 2Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC, USA
  3. 3Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
  4. 4Department of Obstetrics and Gynecology, Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, VA, USA
  5. 5Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
  1. Correspondence to Dr Amanda Rae Schwartz, Obstetrics and Gynecology, Duke University Medical Center, Durham, NC 27708, USA; amanda.rae.schwartz{at}gmail.com

Abstract

Objective Enhanced Recovery After Surgery (ERAS) protocols are designed to mitigate the physiologic stress response created by surgery, to decrease the time to resumption of daily activities, and to improve overall recovery. This study aims to investigate postoperative recovery outcomes following gynecologic surgery before and after implementation of an ERAS protocol.

Methods A retrospective chart review was performed of patients undergoing elective laparotomy at a major academic center following implementation of an ERAS protocol (11/4/2014–7/27/2016) with comparison to a historical cohort (6/23/2013–9/30/2014). The primary outcome was length of hospital stay. Secondary outcomes included surgical variables, time to recovery of baseline function, opioid usage, pain scores, and complication rates. Statistical analyses were performed using Wilcoxon rank sum, Fisher’s exact, and chi squared tests.

Results One hundred and thirty-three women on the ERAS protocol who underwent elective laparotomy were compared with 121 historical controls. There was no difference in length of stay between cohorts (median 4 days; P = 0.71). ERAS participants had lower intraoperative (45 vs 75 oral morphine equivalents; P < 0.0001) and postoperative (45 vs 154 oral morphine equivalents; P < 0.0001) opioid use. ERAS patients reported lower maximum pain scores in the post-anesthesia care unit (three vs six; P < 0.0001) and on postoperative day 1 (four vs six; P = 0.002). There was no statistically significant difference in complication or readmission rates.

Conclusions ERAS protocol implementation was associated with decreased intraoperative and postoperative opioid use and improved pain scores without significant changes in length of stay or complication rates.

  • genital neoplasms, female
  • laparotomy
  • postoperative care
  • opioid-related disorders

https://doi.org/10.1136/ijgc-2018-000131

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    Footnotes

    • Contributors LH, FV, JMT, and AH played an active role in the design and implementation of the Division of Gynecologic Oncology Enhanced Recovery After Surgery Protocol. JMT was integral in the creation of an Enhanced Recovery After Surgery patient database from which the ERAS cohort for this study was selected. LH, AH, LC, and ARS were involved in the study design. The Institutional Review Board protocol was written by LC and LH. With guidance from GB, the RedCap database was created by SL and ARS. Data collection was performed by SL and ARS. Statistical analysis was performed by GB. The research manuscript was drafted by ARS and edited by all listed authors.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

    • Competing interests GB reports grants from National Institutes of Health, during the conduct of the study. FV reports personal fees from American Board of Obstetrics and Gynecology, personal fees from Elsevier, outside the submitted work. JMT reports other from Merck Advisory Council, other from Ethicon Advisory Council, other from Medtronic, other from Edwards LifeScience, outside the submitted work. LH reports grants from Astra Zeneca, grants from Tesaro, other from Bioventus, outside the submitted work.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.