Systematic Reviews
Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

https://doi.org/10.1016/j.ajog.2018.07.014Get rights and content

Background

The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Armstrong Institute at Johns Hopkins, developed the Safety Program for Improving Surgical Care and Recovery, which integrates principles of implementation science into adoption of enhanced recovery pathways and promotes evidence-based perioperative care.

Objective

The objective of this study is to review the enhanced recovery pathways literature in gynecologic surgery and provide the framework for an Improving Surgical Care and Recovery pathway for gynecologic surgery.

Study Design

We searched PubMed and Cochrane Central Register of Controlled Trials databases from 1990 through October 2017. Studies were included in hierarchical and chronological order: meta-analyses, systematic reviews, randomized controlled trials, and interventional and observational studies. Enhanced recovery pathways components relevant to gynecologic surgery were identified through review of existing pathways. A PubMed search for each component was performed in gynecologic surgery and expanded to include colorectal surgery as needed to have sufficient evidence to support or deter a process. This review focuses on surgical components; anesthesiology components are reported separately in a companion article in the anesthesiology literature.

Results

Fifteen surgical components were identified: patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization, early postoperative feeding, early intravenous fluid discontinuation, early removal of urinary catheters, use of laxatives, chewing gum, peripheral mu antagonists, surgical site infection reduction bundle, glucose management, and preoperative and postoperative venous thromboembolism prophylaxis. In addition, 14 components previously identified in the colorectal Improving Surgical Care and Recovery pathway review were included in the final pathway.

Conclusion

Evidence and existing guidelines support 29 protocol elements for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery in gynecologic surgery.

Introduction

A multistakeholder partnership among the Agency for Healthcare Research and Quality (AHRQ) (funder), the American College of Surgeons (ACS), and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality has developed the Safety Program for Improving Surgical Care and Recovery (ISCR), a national effort to assist hospitals in implementing pathways for surgical patients that incorporates evidence-based practices to >750 hospitals across multiple surgical procedures over the next 5 years. This program will cover 5 surgical areas including colorectal surgery (CRS), orthopedics, gynecology, bariatrics, and emergency general surgery. This expansive project aims to assist hospitals in improving perioperative care through implementation of evidence-based enhanced recovery pathways (ERP).

AJOG at a Glance

  • To review the literature on enhanced recovery pathways in gynecologic surgery and identify the evidence-based components that will comprise the pathway for gynecologic surgery within the Safety Program for Improving Surgical Care and Recovery.

  • Evidence and existing guidelines support 29 protocol elements for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery in gynecologic surgery.

  • This study provides a detailed evidence-based enhanced recovery pathway specifically focused on gynecologic surgery that will serve as the reference pathway during the Agency for Healthcare Research and Quality national effort to assist hospitals in implementing evidence-based pathways for surgical patients to >750 hospitals across multiple surgical procedures including gynecologic surgery over the next 5 years.

ERP have reduced complications, shortened length of stay, improved patient satisfaction, and reduced costs for a variety of operations across specialties, including gynecology. The effectiveness of these programs is directly related to a hospitals’ ability to promote high compliance with each pathway process. Adherence to these pathways appears to have a dose-response effect on clinical outcomes.1 Successful and sustainable implementation goes beyond protocol development, requiring integration across patient units, timely feedback of performance data sharing, senior executive support, as well as ongoing educational sessions.2 As such, the Safety Program for ISCR will provide extensive resources beyond the ERP including access to outcome registries, performance benchmarking, educational materials, leadership training, and contemporary implementation science tools.

The objective of this article is to systematically review the literature supporting the individual components that most commonly comprise the ERP in gynecologic surgery and develop a comprehensive AHRQ Safety Program for ISCR pathway tailored to gynecologic surgery for widespread dissemination and implementation.

Section snippets

Materials and Methods

This study was conducted in parallel with the AHRQ Safety Program for ISCR review in CRS and adhered to the methodology originally developed for the CRS review with minor modifications to accommodate special circumstances in gynecologic surgery.3 Two subject-matter experts reviewed existing ERP in gynecologic surgery and developed a list of the individual interventions that were most commonly adopted. Considering that evidence for implementation of individual components in gynecologic surgery

Patient education

Rationale: Preoperative education may improve patient outcomes through expectation setting and adherence to postoperative protocols.

Evidence: We identified 2 RCT that met inclusion criteria. One RCT compared written vs verbal preoperative information in patients undergoing hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer.5 Patients who received written information had significantly lower length of stay (3.47 vs 4.36, P = .03), lower mean visual analog scale value for

Comment

A growing body of literature demonstrates that ERP are safe and effective in accelerating postoperative recovery following gynecologic surgery. Dissemination, however, is still lagging in the United States with a marked lack of uniformity among implemented pathways. This study is published in conjunction with the AHRQ Safety Program for ISCR reviews in CRS and anesthesiology and examines the most current evidence supporting 16 individual interventions sentinel to the ERP in gynecologic surgery.

References (96)

  • C.C. Shen et al.

    A prospective, randomized study of closed-suction drainage after laparoscopic-assisted vaginal hysterectomy

    J Am Assoc Gynecol Laparosc

    (2002)
  • A. Obermair et al.

    Nutrition interventions in patients with gynecological cancers requiring surgery

    Gynecol Oncol

    (2017)
  • M.R. Ahmed et al.

    Timing of urinary catheter removal after uncomplicated total abdominal hysterectomy: a prospective randomized trial

    Eur J Obstet Gynecol Reprod Biol

    (2014)
  • C.T. Hansen et al.

    Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study

    Am J Obstet Gynecol

    (2007)
  • M. Patel et al.

    The use of senna with docusate for postoperative constipation after pelvic reconstructive surgery: a randomized, double-blind, placebo-controlled trial

    Am J Obstet Gynecol

    (2010)
  • J. Fanning et al.

    Prospective trial of aggressive postoperative bowel stimulation following radical hysterectomy

    Gynecol Oncol

    (1999)
  • K. Kraus et al.

    Prospective trial of early feeding and bowel stimulation after radical hysterectomy

    Am J Obstet Gynecol

    (2000)
  • I.E. Ertas et al.

    Influence of gum chewing on postoperative bowel activity after complete staging surgery for gynecological malignancies: a randomized controlled trial

    Gynecol Oncol

    (2013)
  • A.M. Jernigan et al.

    A randomized trial of chewing gum to prevent postoperative ileus after laparotomy for benign gynecologic surgery

    Int J Gynaecol Obstet

    (2014)
  • J.N. Bakkum-Gamez et al.

    Accelerating gastrointestinal recovery in women undergoing ovarian cancer debulking: a randomized, double-blind, placebo-controlled trial

    Gynecol Oncol

    (2016)
  • T.J. Herzog et al.

    A double-blind, randomized, placebo-controlled phase III study of the safety of alvimopan in patients who undergo simple total abdominal hysterectomy

    Am J Obstet Gynecol

    (2006)
  • D.N. Lobo et al.

    Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomized controlled trial

    Lancet

    (2002)
  • M.B. Schiavone et al.

    Surgical site infection reduction bundle in patients with gynecologic cancer undergoing colon surgery

    Gynecol Oncol

    (2017)
  • P.J. Culligan et al.

    A randomized trial that compared povidone iodine and chlorhexidine as antiseptics for vaginal hysterectomy

    Am J Obstet Gynecol

    (2005)
  • A.G. Lake et al.

    Surgical site infection after hysterectomy

    Am J Obstet Gynecol

    (2013)
  • H.L. Steiner et al.

    Surgical-site infection in gynecologic surgery: pathophysiology and prevention

    Am J Obstet Gynecol

    (2017)
  • A.N. Al-Niaimi et al.

    Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients

    Gynecol Oncol

    (2015)
  • L. Hopkins et al.

    Implementation of a referral to discharge glycemic control initiative for reduction of surgical site infections in gynecologic oncology patients

    Gynecol Oncol

    (2017)
  • S. Kumar et al.

    Risk of postoperative venous thromboembolism after minimally invasive surgery for endometrial and cervical cancer is low: a multi-institutional study

    Gynecol Oncol

    (2013)
  • B.R. Corr et al.

    Effectiveness and safety of expanded perioperative thromboprophylaxis in complex gynecologic surgery

    Gynecol Oncol

    (2015)
  • M.H. Einstein et al.

    Venous thromboembolism prevention in gynecologic cancer surgery: a systematic review

    Gynecol Oncol

    (2007)
  • K.M. Schmeler et al.

    Venous thromboembolism (VTE) rates following the implementation of extended duration prophylaxis for patients undergoing surgery for gynecologic malignancies

    Gynecol Oncol

    (2013)
  • G. Nelson 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)
  • G. Nelson et al.

    Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery after Surgery (ERAS®) Society recommendations–part II

    Gynecol Oncol

    (2016)
  • K.A. Ban et al.

    American College of Surgeons and Surgical Infection Society: surgical site infection guidelines, 2016 update

    J Am Coll Surg

    (2017)
  • M. Mandala et al.

    Management of venous thromboembolism (VTE) in cancer patients: ESMO clinical practice guidelines

    Ann Oncol

    (2011)
  • The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry

    Ann Surg

    (2015)
  • A. Abeles et al.

    Enhanced recovery after surgery: current research insights and future direction

    World J Gastrointest Surg

    (2017)
  • G.H. Guyatt et al.

    GRADE: an emerging consensus on rating quality of evidence and strength of recommendations

    BMJ

    (2008)
  • S.L. Oetker-Black et al.

    Preoperative teaching and hysterectomy outcomes

    AORN J

    (2003)
  • H. Huang et al.

    Is mechanical bowel preparation still necessary for gynecologic laparoscopic surgery? A meta-analysis

    Asian J Endosc Surg

    (2015)
  • J. Zhang et al.

    Is mechanical bowel preparation necessary for gynecologic surgery? A systematic review and meta-analysis

    Gynecol Obstet Invest

    (2015)
  • B. Mulayim et al.

    Do we need mechanical bowel preparation before benign gynecologic laparoscopic surgeries? A randomized, single-blind, controlled trial

    Gynecol Obstet Invest

    (2018)
  • N.A. Ryan et al.

    Evaluating mechanical bowel preparation prior to total laparoscopic hysterectomy

    JSLS

    (2015)
  • W. Suadee et al.

    Appropriate bowel preparation for laparotomy gynecologic surgery: a prospective, surgeon-blinded randomized study

    Gynecol Obstet Invest

    (2017)
  • M.H. Lippitt et al.

    Outcomes associated with a five-point surgical site infection prevention bundle in women undergoing surgery for ovarian cancer

    Obstet Gynecol

    (2017)
  • E. Kalogera et al.

    Enhanced recovery in gynecologic surgery

    Obstet Gynecol

    (2013)
  • M.P. Johnson et al.

    Using bundled interventions to reduce surgical site infection after major gynecologic cancer surgery

    Obstet Gynecol

    (2016)
  • Cited by (0)

    Two study authors (Drs Liu and Hu) received salary support from the Agency for Healthcare Research and Quality (AHRQ) (HHSP23337004T) for their participation in the completion of this review. Dr Wick's (Armstrong Institute for Patient Safety and Quality, Johns Hopkins University) and Drs Liu's and Hu's Institutions (Division of Research and Optimal Patient Care, American College of Surgeons) received support from the AHRQ (HHSP23337004T) for this review. The opinions expressed in this document are those of the authors and do not reflect the official position of AHRQ or the US Department of Health and Human Services.

    The authors report no conflict of interest.

    View full text