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Enhanced Recovery in Gynecologic Surgery

Kalogera, Eleftheria MD; Bakkum-Gamez, Jamie N. MD; Jankowski, Christopher J. MD; Trabuco, Emanuel MD; Lovely, Jenna K. DrPH; Dhanorker, Sarah; Grubbs, Pamela L. RN, CNS; Weaver, Amy L.; Haas, Lindsey R.; Borah, Bijan J. PhD; Bursiek, April A. RN; Walsh, Michael T. MD; Cliby, William A. MD; Dowdy, Sean C. MD

doi: 10.1097/AOG.0b013e31829aa780
Original Research

OBJECTIVE: To investigate the effects of enhanced recovery (a multimodal perioperative care enhancement protocol) in patients undergoing gynecologic surgery.

METHODS: Consecutive patients managed under an enhanced recovery pathway and undergoing cytoreduction, surgical staging, or pelvic organ prolapse surgery between June 20, 2011, and December 20, 2011, were compared with consecutive historical controls (March to December 2010) matched by procedure. Wilcoxon rank-sum, χ2, and Fisher’s exact tests were used for comparisons. Direct medical costs incurred in the first 30 days were obtained from the Olmsted County Healthcare Expenditure and Utilization Database and standardized to 2011 Medicare dollars.

RESULTS: A total of 241 enhanced recovery women in the case group (81 cytoreduction, 84 staging, and 76 vaginal surgery) were compared with women in the control groups. In the cytoreductive group, patient-controlled anesthesia use decreased from 98.7% to 33.3% and overall opioid use decreased by 80% in the first 48 hours with no change in pain scores. Enhanced recovery resulted in a 4-day reduction in hospital stay with stable readmission rates (25.9% of women in the case group compared with 17.9% of women in the control group) and 30-day cost savings of more than $7,600 per patient (18.8% reduction). No differences were observed in rate (63% compared with 71.8%) or severity of postoperative complications (grade 3 or more: 21% compared with 20.5%). Similar, albeit less dramatic, improvements were observed in the other two cohorts. Ninety-five percent of patients rated satisfaction with perioperative care as excellent or very good.

CONCLUSIONS: Implementation of enhanced recovery was associated with acceptable pain management with reduced opioids, reduced length of stay with stable readmission and morbidity rates, good patient satisfaction, and substantial cost reductions.


Supplemental Digital Content is Available in the Text.Enhanced recovery after gynecologic surgery results in improved pain management with fewer narcotics, reduced hospital stay, reduced costs, excellent patient satisfaction, and stable readmission rates.

Division of Gynecologic Surgery, the Department of Anesthesiology, Hospital Pharmacy Services, the Department of Nursing, the Division of Biomedical Statistics and Informatics, and the Department of Health Sciences, Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota.

Corresponding author: Sean C. Dowdy, MD, 200 1st Street SW, Rochester, MN 55905; e-mail:

Supported in part by the Mayo Clinic Comprehensive Cancer Center (P30 CA 15083; S.C.D.) and the Office of Women's Health Research Building Interdisciplinary Careers in Women's Health (BIRCWH award K12 HD065987; J.N.B.-G.).

Financial Disclosure The authors did not report any potential conflicts of interest.

The authors thank Drs. David Larson and Robert Cima from Colorectal Surgery who pioneered enhanced recovery at the Mayo Clinic, Rochester and served as important consultants throughout this project.

Presented at the 14th Biennial meeting of the International Gynecologic Cancer Society, October 13-16, 2012, Vancouver, Canada.

© 2013 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.