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An enhanced recovery pathway decreases length of hospital stay in gynecologic oncology patients undergoing minimally invasive surgery
186
Abstracts / Gynecologic Oncology 139 (2015) 178–207
of the robot group. Both SILS and robotic surgery appeared to have a similar learning curve with consistent improvement in operative time across the study period. Conclusion: SILS has statistically significant shorter operative time than robotic surgery, and similar length of hospital stay, blood loss, operative and post-operative complications, conversion rates, and yield of lymph node counts. Patient in the SILS groups had a lower BMI and lower grade of their endometrial cancer indicating that with adequate patient selection, this technique could be successfully incorporated for the management of patients with endometrial cancer at a tertiary care center. Learning objective: Learners will be able to better identify characteristics of suitable patients for consideration of single incision laparo-endoscopic surgery in the treatment of gynecologic cancers. Additionally this will allow learners to elucidate the benefits of the SILS procedure when counseling patients and implementing this procedure into their practice. doi:10.1016/j.ygyno.2015.07.038
An enhanced recovery pathway decreases length of hospital stay in gynecologic oncology patients undergoing minimally invasive surgery J.S. Chapman, E. Roddy, L.L. Chen, G. Westhoff, R. Brooks, S. Ueda, L. Chen. University of California San Francisco, San Francisco, CA, USA Objectives: Enhanced recovery pathways (ERPs) are multimodal strategies to accelerate post-operative recovery and shorten hospital stays. ERPs have been successfully implemented in select surgical populations but their benefit in minimally invasive gynecologic oncology surgery is unknown. This study sought to determine if an ERP would decrease post-operative length of stay (LOS) in gynecologic oncology patients undergoing minimally invasive surgery. Methods: In the academic year beginning July 2014 we initiated a multi-disciplinary ERP for gynecologic oncology patients undergoing minimally invasive surgery. Our ERP involved pre-operative patient education, oral feeding until 2 h prior to surgery, elimination of preoperative bowel preparation, multimodal pain medication administration, early ambulation, early feeding and streamlining of postoperative day one nursing goals. Consecutive patients undergoing minimally invasive surgery from July–September 2014 were enrolled on our ERP and matched in a 1:2 fashion by age and American Society of Anesthesiologists (ASA) status with historical controls from July 2013–June 2014. Our outcome of interest was postoperative LOS. Results: Our first 28 patients eligible for the ERP were matched with 56 historical controls. Median age at the time of surgery was 61 years (range 40–83). Half of our 28 cases and no controls received transversus abdominus plexus (TAP) blocks peri-operatively. There was no significant difference in recovery room or post-operative day one pain scores between cases and controls (median scores 2.15 vs. 1.94, p = 0.77). While mean length of surgery was not different (216 vs. 203 min, p = 0.54), post-operative LOS was significantly reduced in ERP cases when compared to controls (21.9 vs. 32.2 h, p b 0.01). There were no re-admissions in ERP cases and two readmissions in historical controls (p = NS). Conclusion: Post-operative LOS is reduced in ERP patients undergoing minimally invasive surgery without evidence of increased readmission rates. We are currently adding to our patient cohort, and investigating patient satisfaction metrics to present at the annual meeting. doi:10.1016/j.ygyno.2015.07.039
The role of extended prophylaxis for venous thromboembolism in patients undergoing minimally invasive surgery for endometrial cancer ME Tenneya, S.A. Hamb, N.K. Leea, T. Febbraroa, R. Steppacherc, S.D. Yamadaa. aThe University of Chicago Medicine, Chicago IL Department of Obstetrics and Gynecology, Section of Gynecologic Oncology, USA, b Center for Health and the Social Sciences (CHeSS), USA, cDepartment of General Surgery, Section of Vascular and Endovascular Surgery, USA Objectives: The objectives of this study are to evaluate the role of extended prophylaxis (EP) for venous thromboembolism (VTE) in women undergoing minimally invasive surgery (MIS) for endometrial cancer (EC) and to examine the frequency of EP use and VTE in this population using a healthcare claims database. Methods: Data was extracted from the Truven Health MarketScan™ Commercial Claims and Encounters (CCAE) and The Medicare Supplemental and Coordination of Benefits (MDCR) Databases of healthcare claims from 2003–2013 which includes 66 million covered employees and dependents in 2013. Patients were identified through ICD-9 codes for endometrial cancer and procedures were identified by CPT and ICD9 codes. Exclusion criteria included history of VTE, those with prescriptions for anticoagulants in the prior year or inadequate prescription coverage during the study period. Filling a new outpatient prescription for anticoagulation within 5 days of the date of discharge up to day prior to date of subsequent VTE was used to define EP. VTE events were defined as the new diagnosis of deep vein thrombosis or pulmonary embolism as defined by CMS Core Measures. Results: A total of 146,213 women with EC were identified and 50,093 (34.2%) of these women underwent hysterectomy during this time. 29,211 (58.3%) had an open/abdominal procedure and 20,882 (41.7%) underwent MIS. After applying exclusion criteria, 10,225 were included in the analysis. EP was prescribed in 767 (7.5%) women. The 30-day VTE rate for all women undergoing MIS was 0.71%. Thirteen women had VTE prior to hospital discharge and in the remaining 10,212 women the use of EP was not associated with lower rates of 30-day postoperative VTE (0.78% for EP vs. 0.57% [p = 0.46] for no EP). In multivariate analysis, length of stay N1 day (OR = 3.00 [CI 1.27–4.14]; p = 0.0004) and secondary malignancy (OR = 2.76 [CI 1.64–4.63]; p = 0.0001) were found to be significantly associated with higher VTE rates while age, lymph node dissection, obesity, robotic vs. laparoscopic procedure and other medical comorbidities were not. The use of EP did not significantly alter this association. Conclusion: This is the largest study to evaluate the role of EP for VTE in MIS for EC. The baseline rate of VTE in these women is low and the use of EP does not significantly alter this rate. It appears to be safe to withhold EP in the majority of women, however those with prolonged hospital stay or secondary malignancy may benefit from EP.
1 2 3 4 5
1 2 3 4 5
Age
BMI
Histology
Grade
Stage
Length of surgery (min)
LND?
Length of stay
59 73 81 60 77
38 35 22 49 47
Endometrioid Endometrioid Endometrioid Endometrioid Endometrioid
1 1 2 1 2
1 2 1 1 1
461 485 203 243 154
Pelvic None Pelvic None Pelvic
1 5 3 5 3
EP? (yes/no)
Days of VTE prophylaxis (including day of surgery)
Type of VTE
Timing of VTE
No Yes Yes N/A N/A
1 13 9 2 2
PE PE DVT PE DVT
b 30 days b 30 days b 30 days POD 1 POD 1
doi:10.1016/j.ygyno.2015.07.040
Abstracts / Gynecologic Oncology 139 (2015) 178–207
of the robot group. Both SILS and robotic surgery appeared to have a similar learning curve with consistent improvement in operative time across the study period. Conclusion: SILS has statistically significant shorter operative time than robotic surgery, and similar length of hospital stay, blood loss, operative and post-operative complications, conversion rates, and yield of lymph node counts. Patient in the SILS groups had a lower BMI and lower grade of their endometrial cancer indicating that with adequate patient selection, this technique could be successfully incorporated for the management of patients with endometrial cancer at a tertiary care center. Learning objective: Learners will be able to better identify characteristics of suitable patients for consideration of single incision laparo-endoscopic surgery in the treatment of gynecologic cancers. Additionally this will allow learners to elucidate the benefits of the SILS procedure when counseling patients and implementing this procedure into their practice. doi:10.1016/j.ygyno.2015.07.038
An enhanced recovery pathway decreases length of hospital stay in gynecologic oncology patients undergoing minimally invasive surgery J.S. Chapman, E. Roddy, L.L. Chen, G. Westhoff, R. Brooks, S. Ueda, L. Chen. University of California San Francisco, San Francisco, CA, USA Objectives: Enhanced recovery pathways (ERPs) are multimodal strategies to accelerate post-operative recovery and shorten hospital stays. ERPs have been successfully implemented in select surgical populations but their benefit in minimally invasive gynecologic oncology surgery is unknown. This study sought to determine if an ERP would decrease post-operative length of stay (LOS) in gynecologic oncology patients undergoing minimally invasive surgery. Methods: In the academic year beginning July 2014 we initiated a multi-disciplinary ERP for gynecologic oncology patients undergoing minimally invasive surgery. Our ERP involved pre-operative patient education, oral feeding until 2 h prior to surgery, elimination of preoperative bowel preparation, multimodal pain medication administration, early ambulation, early feeding and streamlining of postoperative day one nursing goals. Consecutive patients undergoing minimally invasive surgery from July–September 2014 were enrolled on our ERP and matched in a 1:2 fashion by age and American Society of Anesthesiologists (ASA) status with historical controls from July 2013–June 2014. Our outcome of interest was postoperative LOS. Results: Our first 28 patients eligible for the ERP were matched with 56 historical controls. Median age at the time of surgery was 61 years (range 40–83). Half of our 28 cases and no controls received transversus abdominus plexus (TAP) blocks peri-operatively. There was no significant difference in recovery room or post-operative day one pain scores between cases and controls (median scores 2.15 vs. 1.94, p = 0.77). While mean length of surgery was not different (216 vs. 203 min, p = 0.54), post-operative LOS was significantly reduced in ERP cases when compared to controls (21.9 vs. 32.2 h, p b 0.01). There were no re-admissions in ERP cases and two readmissions in historical controls (p = NS). Conclusion: Post-operative LOS is reduced in ERP patients undergoing minimally invasive surgery without evidence of increased readmission rates. We are currently adding to our patient cohort, and investigating patient satisfaction metrics to present at the annual meeting. doi:10.1016/j.ygyno.2015.07.039
The role of extended prophylaxis for venous thromboembolism in patients undergoing minimally invasive surgery for endometrial cancer ME Tenneya, S.A. Hamb, N.K. Leea, T. Febbraroa, R. Steppacherc, S.D. Yamadaa. aThe University of Chicago Medicine, Chicago IL Department of Obstetrics and Gynecology, Section of Gynecologic Oncology, USA, b Center for Health and the Social Sciences (CHeSS), USA, cDepartment of General Surgery, Section of Vascular and Endovascular Surgery, USA Objectives: The objectives of this study are to evaluate the role of extended prophylaxis (EP) for venous thromboembolism (VTE) in women undergoing minimally invasive surgery (MIS) for endometrial cancer (EC) and to examine the frequency of EP use and VTE in this population using a healthcare claims database. Methods: Data was extracted from the Truven Health MarketScan™ Commercial Claims and Encounters (CCAE) and The Medicare Supplemental and Coordination of Benefits (MDCR) Databases of healthcare claims from 2003–2013 which includes 66 million covered employees and dependents in 2013. Patients were identified through ICD-9 codes for endometrial cancer and procedures were identified by CPT and ICD9 codes. Exclusion criteria included history of VTE, those with prescriptions for anticoagulants in the prior year or inadequate prescription coverage during the study period. Filling a new outpatient prescription for anticoagulation within 5 days of the date of discharge up to day prior to date of subsequent VTE was used to define EP. VTE events were defined as the new diagnosis of deep vein thrombosis or pulmonary embolism as defined by CMS Core Measures. Results: A total of 146,213 women with EC were identified and 50,093 (34.2%) of these women underwent hysterectomy during this time. 29,211 (58.3%) had an open/abdominal procedure and 20,882 (41.7%) underwent MIS. After applying exclusion criteria, 10,225 were included in the analysis. EP was prescribed in 767 (7.5%) women. The 30-day VTE rate for all women undergoing MIS was 0.71%. Thirteen women had VTE prior to hospital discharge and in the remaining 10,212 women the use of EP was not associated with lower rates of 30-day postoperative VTE (0.78% for EP vs. 0.57% [p = 0.46] for no EP). In multivariate analysis, length of stay N1 day (OR = 3.00 [CI 1.27–4.14]; p = 0.0004) and secondary malignancy (OR = 2.76 [CI 1.64–4.63]; p = 0.0001) were found to be significantly associated with higher VTE rates while age, lymph node dissection, obesity, robotic vs. laparoscopic procedure and other medical comorbidities were not. The use of EP did not significantly alter this association. Conclusion: This is the largest study to evaluate the role of EP for VTE in MIS for EC. The baseline rate of VTE in these women is low and the use of EP does not significantly alter this rate. It appears to be safe to withhold EP in the majority of women, however those with prolonged hospital stay or secondary malignancy may benefit from EP.
1 2 3 4 5
1 2 3 4 5
Age
BMI
Histology
Grade
Stage
Length of surgery (min)
LND?
Length of stay
59 73 81 60 77
38 35 22 49 47
Endometrioid Endometrioid Endometrioid Endometrioid Endometrioid
1 1 2 1 2
1 2 1 1 1
461 485 203 243 154
Pelvic None Pelvic None Pelvic
1 5 3 5 3
EP? (yes/no)
Days of VTE prophylaxis (including day of surgery)
Type of VTE
Timing of VTE
No Yes Yes N/A N/A
1 13 9 2 2
PE PE DVT PE DVT
b 30 days b 30 days b 30 days POD 1 POD 1
doi:10.1016/j.ygyno.2015.07.040