Factors Associated with Same Day Discharge after Laparoscopic Surgery in Gynecologic Oncology

Abstract

To identify factors associated with same day discharge (SDD) after laparoscopic surgery in gynecologic oncology. Design: Retrospective cohort. Setting: Teaching hospital. Patients: Total of 800 patients having minimally invasive surgery in the division of gynecologic oncology during a 20month period. Intervention: Minimally invasive surgery cases were reviewed for determinants of SDD to identify factors that could improve the SDD rate. Measurements and Main Results: During the study period, 800 minimally invasive procedures were performed with a 43.0% SDD rate. Patients who had SDD were younger (52.3 years vs 58.0 years; p <.001), had a lower body mass index (31.1 kg/m 2 vs 33.7 kg/m 2 ; p <.001), were less likely to have a malignancy (28.2% vs 55.5%; p <.001), had a lower estimated blood loss (36 vs 72 mL; p <.001), and were more likely to have received an enhanced recovery after surgery protocol (49.8% vs 39.3%; p <.003). Total surgical time was shorter in women with SDD (156 minutes vs 208 minutes) as was total narcotic use in morphine equivalents (MEq) (milligram intravenous MEq, 23.1 mg MEq vs 28.8 mg MEq). SDD was also associated with earlier start time (p <.001). Laparoscopic cases were most likely to have SDD (51.4%) as compared with robotic assisted surgery (16.1%) or minilaparotomy (10.5%). There was a wide range of SDD among surgeons ranging from 19.8% to 56.2% (p <.001). In a multivariate analysis, the factors predicting SDD in order of predictive factors were surgical time (p <.001), recovery time (p <.001), start time (p <.001), surgeon (p <.001), age (p <.001), estimated blood loss (p <.001), and type of surgery (p = .005). Conclusion: Multiple factors affect SDD. Modifiable factors for SDD include the start time, surgeon preference, and patient expectations for SDD. Given these data, centers should prioritize surgical order by which patients are more likely to go home, and surgeons should analyze their own data with respect to achieving higher SDD rates.

Enhanced recovery after surgery (ERAS) protocol is associated with lower post-operative opioid use and a reduced office burden after minimally invasive surgery

“…Overall, there were no significant differences in patient age, BMI, tobacco use, or alcohol use between groups. Further patient characteristics for this study population have been previously reported [14,17]. There were no differences between the type of minimally invasive approach between the two groups or the need for mini-laparotomy (5.2% vs 4.3%, p = 0.78).…”

Enhanced Recovery after Surgery (ERAS) for Minimally Invasive Gynecologic Oncology Surgery: A Review

“…They predicted SDD rates to improve only to 48.5% by 2029 unless focused SDD improvement measures were instituted [6]. In our review of the literature, we found that an ERAS MIS protocol in gynecologic oncology improved the rates of SDD from a baseline of approximately 30% to 50-70%, depending on the extent of measures in place (patient education, standardized orders, prioritizing surgery earlier in the day, early Foley removal, reduction of opioids, and prophylactic anti-emetics) [9,15,17]. There remain barriers to SDD, and surgeon preference has been shown to be a major contributor, which is why it is imperative to develop robust eligibility criteria, based on safety data to determine those who are most able likely to benefit [4,9].…”

“…Subsequently, a number of studies have reported similar outcomes to enhance SDD rates with ERAS implementation in MIS gynecologic oncology surgery patients. Brancazio et al, in a pre/post-ERAS MIS implementation study of 800 patients, 351 of whom were in the post-intervention arm, found that the standardized ERAS protocol alone increased the rates of SDD from 39.3% to 48.9% [9]. The safety and feasibility of SDD in ERAS MIS gynecologic oncology surgery was investigated in a retrospective cohort study by Wield et al, where 1124 patients were evaluated.…”

Assessment of the feasibility of same-day discharge following minimally invasive hysterectomy in the elderly population

“…Forty percent of hysterectomies are now completed via a minimally invasive approach, which has increased significantly over the past 20 years ( ACOG Committee, 2018 , Bixel et al, 2022 ). Most women who undergo surgery for endometrial cancer undergo a minimally invasive hysterectomy (MIH), and the oncologic outcomes of this approach are comparable to laparotomy ( Bishop et al, 2018 , Brancazio et al, 2021 , Hospital, 2022 ). Additionally, compared to open surgery, MIH is associated with numerous benefits, including lower rates of peri -operative complications, faster recovery time, and decreased length of hospital stay ( Di Donato et al, 2021 , Farhat et al, 2012 , Fountain and Havrilesky, 2017 , Gallotta et al, 2018 ).…”