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An enhanced recovery protocol decreases complication rates in high-risk gynecologic oncology patients undergoing non-emergent laparotomy
  1. Teresa K.L. Boitano1,
  2. Haller J. Smith1,
  3. Alexander C. Cohen2,
  4. Allison Todd2,
  5. Charles A. Leath III1 and
  6. J. Michael Straughn Jr.1
  1. 1Division of Gynecologic Oncology, Obstetrics and Gynecology, University of Alabama at Birmingham HCOP, Birmingham, Alabama, USA
  2. 2Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
  1. Correspondence to Dr Teresa K.L. Boitano, Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL 35294-2172, USA; tlboitano{at}


Objective Enhanced recovery protocols are now established as the standard of care leading to improved perioperative outcomes and associated cost-benefits. The objective of this study was to evaluate the impact of an enhanced recovery program on complication rates in high-risk gynecologic oncology patients undergoing surgery.

Methods This retrospective cohort study included gynecologic oncology patients with pathology-proven malignancy undergoing non-emergent laparotomy from October 2016 to December 2018 managed on an enhanced recovery protocol, and a control group from October 2015 through September 2016 prior to enhanced recovery protocol implementation. The primary outcome was complication rates in a high-risk population pre- and post-enhanced recovery protocol. High-risk patients were defined as those with obesity (body mass index >30 kg/m2) and/or age ≥65 years. Analysis was performed using Statistical Package for Social Sciences (SPSS) v.24.

Results A total of 363 patients met the inclusion criteria: 104 in the control group and 259 in the enhanced recovery protocol group. Patient demographics, including age, body mass index, diagnosis, and performance status, were similar. Overall complication rates were less in the enhanced recovery protocol group (29% vs 53.8%; p<0.0001). The enhanced recovery protocol group had a shorter length-of-stay compared with control (3.3 vs 4.2 days; p<0.0001). The 30-day readmission rates were similar between the groups (9.6% vs 13.5%; p=0.19). In the enhanced recovery protocol group compared with control, complication rates were less in obese patients (29.4% vs 57.8%; p<0.0001), morbidly obese patients (20.9% vs 76.2%; p<0.0001), and age ≥65 (36.1% vs 57.1%; p<0.0001). The most common complications in the enhanced recovery protocol group were ileus (9.7%), pulmonary complications (2.7%), and blood transfusions (10.8%).

Conclusions Implementation of an enhanced recovery protocol decreases complication rates and length-of-stay in morbidly obese and geriatric patients with gynecologic malignancy without an increase in readmission rates.

  • gynecologic surgical procedures
  • laparotomy
  • preoperative care
  • postoperative complications
  • postoperative care

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  • Presented at Oral Presentation at the American College of Surgeons 106th Annual Clinical Congress, Virtual Scientific Forum, October 2020.

  • Contributors TKB was involved with study design development, data collection, and statistical analysis. TKB wrote the manuscript. AC helped with data collection and reviewing the manuscript. AT, MSN, RN were part of the data collection set up, assisting with the study design, and reviewing the manuscript. HJS and CL were integral to the design and initiation of the ERP at UAB and also critically reviewed the paper. CL was supported in part by the UG1 CA23330 and P50 CA098252. JMS was involved in the initial study design development, supervised the project, and critically edited the manuscript.

  • 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 None declared.

  • Patient consent for publication Not required.

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

  • Data availability statement Data are available upon reasonable request.