Early discharge after major gynaecological surgery: advantages of fast track surgery

Abstract

Introduction: Fast Track Surgery (FTS) programs have been adopted by many specialties with documented improved patient outcomes and reduced length of stay (LOS). Methods: We initiated a FTS program in January 2008 and present our experience up to and including November 2010 on patients whose LOS was 2 days. Results: During the study period 242 patients had a laparotomy performed. Overall 54 (22.3%) patients were discharged on day 2. In the first year of initiating our FTS program 10% were discharged on day 2, 25% in year 2 and 31% in year 3. Twenty-two patients (41%) had malignant pathology and of these, 16 (73%) had local or regional spread and 6 (27%) had distant spread. Forty patients (74%) had vertical midline incisions (VMI) performed. Surgery was classified as complex in 40 cases (74%) and 6 (11%) patients underwent staging lymph node dissection. Average patient BMI was 26.1 with 44% of patients considered overweight or obese. There were no intraoperative complications recorded. When compared to 188 patients whose LOS was greater than 2 days, the early discharge cohort were more likely to have benign pathology, more likely to be younger, to have a transverse incision, to have received COX II inhibitors, to have a lower net haemoglobin (Hb) change and to tolerate early oral feeding. Conclusions: Increased clinical experience with FTS enables over 31% patients undergoing laparotomy to be safely discharged on day 2 without an increase in the readmission rate or morbidity.

Fast-Track Surgery in Gynaecology and Gynaecologic Oncology: A Review of a Rolling Clinical Audit

“…We have previously reported that with experience, 1 in 3 patients undergoing a laparotomy for gynaecological surgery can be discharged on day 2 post surgery, without an increased morbidity or readmission rate [17, 94, 104]. …”

“…Whilst much of the evidence supporting FTS has been published in the colorectal literature [9, 10], there are increasing reports in the gynaecological literature attesting to the safety and improved outcomes [11–17]; however, prospective randomized controlled studies are lacking [18]. Despite Victorian Department of Health, Cochrane and Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIP-S) reviews, the concept and principles have been slow to be adopted in Australia [18, 19].…”

Increased postoperative day one discharges after implementation of a hysterectomy enhanced recovery pathway: a retrospective cohort study

“…[16][17][18][19] Studies of enhanced recovery in gynecology have focused on laparoscopic surgery or featured a mix of benign and malignant surgical indications. 15,16 We describe a pathway oriented specifically at an open surgical approach for treating benign disease that allows practitioners to identify patients appropriate for HER pathway application. Over the study period, the only institutional change at TOH was implementation of the HER pathway.…”

“…11 The few multifaceted enhanced recovery pathways currently described in the literature enrolled fewer than 100 patients, 12,13 were specific to minimally invasive procedures, 12,14 or mixed benign and malignant diagnoses. 15,16 Some investigations did not compare their pathway to a previous standard of care. 17 To guide the development of our pathway, we performed a structured review of the literature using PubMed, Google Scholar, and Embase databases to identify evidence-based interventions associated with improved pain control and functional recovery, decreased nausea and vomiting, or decreased LOS after gynecologic surgery.…”

Development and Extended Experience with a Fast Track Surgery Program in a Gynaecological Oncology Service

“…With increasing experience we have been able to increase the percentage of patients discharged on day 2 from 10% in the first year of the program to 25% in the second year and 31% in the third year after initiating a FTS program. These outcomes were not restricted to "low risk cases" as 24 (44%) patients discharged on day 2 were considered overweight or obese, 40 (74%) had complex procedures performed and 40 (74%) had vertical midline incisions [12].…”