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Enhanced Recovery After Hysterectomy
Örebro University, School of Medical Sciences.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Objectives: To study recovery after hysterectomy under Enhanced Recovery After Surgery (ERAS) care, and in relation to different operation techniques.

Materials and Methods: An observational study was conducted comparing 85 patients undergoing hysterectomy with ERAS care to 120 patients immediately before establishing ERAS. In a prospective cohort study of 121 consecutive patients undergoing hysterectomy, the outcome was compared for patients with malignant versus benign indications. The main outcome measure was length of stay (LOS). A randomised controlled trial (RCT) of 20 women scheduled for hysterectomy compared robot-assisted laparoscopic with abdominal hysterectomy in terms of the development of insulin resistance, inflammatory reactions, and clinical recovery, and examined the relation to hormonal status. All studies were conducted in 2011--2015, at the Department of Obstetrics and Gynaecology, Örebro University Hospital, Sweden.

Results: Implementation of a structured ERAS protocol significantly reduced LOS compared to non-ERAS care. The effect was similar between patients with malignant and benign indications for surgery. No difference in complications was found. There was no difference in development of insulin resistance between robotic and abdominal technique, but clinical outcomes and inflammatory responses significantly favoured robot-assisted hysterectomy. Female sex hormone status was associated with the development of insulin resistance.

Conclusions: Recovery after hysterectomy can be influenced. ERAS care seems to be effective and safe. Clinical outcome can also be influenced by operational technique. Hysterectomy triggers a stress reaction in both the metabolic and the inflammatory system. It remains unclear why the reduced inflammatory reaction and favourable clinical outcome in robotic surgery were not mirrored by less insulin resistance. This could not be explained by female sex hormone status.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2017. , 73 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 164
Keyword [en]
Hysterectomy, ERAS, Insulin Resistance, Female Sex hormones
National Category
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-58057ISBN: 978-91-7529-203-8 (print)OAI: oai:DiVA.org:oru-58057DiVA: diva2:1110045
Public defence
2017-09-22, Örebro universitet, Campus USÖ, hörsal C2, Södra Grev Rosengatan 32, Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2017-06-15 Created: 2017-06-15 Last updated: 2017-10-18Bibliographically approved
List of papers
1. Implementing a structured Enhanced Recovery After Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy
Open this publication in new window or tab >>Implementing a structured Enhanced Recovery After Surgery (ERAS) protocol reduces length of stay after abdominal hysterectomy
2014 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 93, no 8, 749-756 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To study the effects of introducing an Enhanced Recovery After Surgery (ERAS) protocol, modified for gynecological surgery, on length of stay and complications following abdominal hysterectomy.

Design: Observational study.

Setting: Department of Obstetrics and Gynecology, Orebro University Hospital, Sweden.

Population: Eighty-five patients undergoing abdominal hysterectomy for benign or malignant indications between January and December 2012, with or without salpingo-oophorectomy. Outcomes were compared with all consecutive patients who had undergone the same surgery from January to December 2011, immediately before establishing the ERAS protocol (n = 120).

Methods: The ERAS protocol was initiated in January 2012 as part of a targeted implementation program. Data were extracted from patient records and from a specific database.

Main outcome measures: Length of stay and the proportion of patients achieving target length of stay (2 days).

Results: Length of stay was significantly reduced in the study population after introducing the ERAS protocol from a mean of 2.6 (SD 1.1) days to a mean of 2.3 (SD 1.2) days (p = 0.011). The proportion of patients discharged at 2 days was significantly increased from 56% pre-ERAS to 73% after ERAS (p = 0.012). No differences were found in complications (5% vs. 3.5% in primary stay, 12% vs. 15% within 30 days after discharge), reoperations (2% vs. 1%) or readmission (4% vs. 4%).

Conclusions: Introducing the ERAS protocol for abdominal hysterectomy reduced length of stay without increasing complications or readmissions.

Keyword
Fast track, hysterectomy, length of stay, perioperative care, perioperative period
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:oru:diva-36157 (URN)10.1111/aogs.12423 (DOI)000339616100004 ()24828471 (PubMedID)2-s2.0-84904260752 (Scopus ID)
Note

Funding Agency:

Research Committee of Örebro County Council

Available from: 2014-09-03 Created: 2014-08-28 Last updated: 2017-10-18Bibliographically approved
2. Enhanced Recovery after Surgery Protocol in Abdominal Hysterectomies for Malignant versus Benign Disease
Open this publication in new window or tab >>Enhanced Recovery after Surgery Protocol in Abdominal Hysterectomies for Malignant versus Benign Disease
2016 (English)In: Gynecologic and Obstetric Investigation, ISSN 0378-7346, E-ISSN 1423-002X, Vol. 81, no 5, 461-467 p.Article in journal (Refereed) Published
Abstract [en]

Background: The enhanced recovery after surgery (ERAS) protocol combines unimodal evidence-based interventions aiming to enhance recovery after surgery and reduce length of stay (LOS). We introduced an ERAS protocol in gynecological surgery and compared outcomes after hysterectomies performed for malignant vs. benign indications.

Methods: This prospective cohort study was conducted at the Department of Obstetrics and Gynecology, Örebro University Hospital, Sweden, among 121 consecutive patients undergoing abdominal hysterectomy and salpingo-oophorectomy for malignant (n = 40) or benign (n = 81) indications between 2012 and 2014. Clinical data were prospectively collected and extracted from the patient records and from a specific database. The primary outcomes were LOS and proportion of patients achieving target LOS (2 days).

Results: Patients operated for malignant vs. benign disease did not differ significantly in terms of LOS (2 (1-5) vs. 2 (1-11) days; p = 0.505), proportion discharged at target LOS (62 vs. 69%; p = 0.465; OR 0.74, 95% CI 0.3-1.6), complications (2 vs. 7% in primary stay, 8 vs. 11% within 30 days after discharge), re operations (0 vs. 2%), or readmissions (2 vs. 1%).

Conclusion: The ERAS protocol may be equally applicable to patients undergoing hysterectomy either for a malignant or for a benign disease.

Place, publisher, year, edition, pages
Basel: S. Karger, 2016
Keyword
ERAS, Fast-track, Hysterectomy, Length of stay, Perioperative care
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:oru:diva-53181 (URN)10.1159/000443396 (DOI)000384034700012 ()26799328 (PubMedID)2-s2.0-84955604181 (Scopus ID)
Note

Funding Agencies:

Research Committee of Örebro County Council

Nyckelfonden, Örebro, Sweden

Available from: 2016-10-24 Created: 2016-10-24 Last updated: 2017-10-18Bibliographically approved
3. Metabolic and inflammatory responses and subsequent recovery in robotic versus abdominal hysterectomy: A randomised controlled study
Open this publication in new window or tab >>Metabolic and inflammatory responses and subsequent recovery in robotic versus abdominal hysterectomy: A randomised controlled study
2016 (English)In: Clinical Nutrition, ISSN 0261-5614, E-ISSN 1532-1983, S0261-5614(16)31356-5Article in journal (Refereed) Epub ahead of print
Abstract [en]

BACKGROUND & AIMS: Surgery causes inflammatory and metabolic responses in the body. The aim of the study was to investigate whether robotic-assisted total laparoscopic hysterectomy induces less insulin resistance than abdominal hysterectomy, and to compare inflammatory response and clinical recovery between the two techniques.

METHODS: A randomised controlled study at the Department of Obstetrics and Gynaecology, Örebro University Hospital, Sweden. Twenty women scheduled for a planned total hysterectomy with or without salpingo-oophorectomy between October 2014 and May 2015, were randomly allocated to robotic-assisted total laparoscopic hysterectomy or abdominal hysterectomy. Insulin resistance after surgery was measured by the hyperinsulinemic normoglycaemic clamp method, inflammatory response measured in blood samples, and clinical recovery outcomes registered.

RESULTS: There were no differences in development of insulin resistance between the robotic group and the abdominal group (mean ± SD: 39% ± 22 vs. 40% ± 19; p = 0.948). The robotic group had a significantly shorter hospital stay (median 1 vs. 2 days; p = 0.005). Inflammatory reaction differed; in comparison to the robotic group, the abdominal group showed significantly higher increases in serum interleukin 6 levels, white blood cell count and cortisol from preoperative values to postoperative peak values.

CONCLUSIONS: Robotic laparoscopic surgery reduced inflammatory responses and recovery time, but these changes were not accompanied by decreased insulin resistance.

CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov Identifier no NCT02291406.

Place, publisher, year, edition, pages
Elsevier, 2016
Keyword
Hysterectomy, Inflammatory response, Insulin resistance, Robotic-assisted hysterectomy
National Category
Obstetrics, Gynecology and Reproductive Medicine
Research subject
Obstetrics and Gynaecology
Identifiers
urn:nbn:se:oru:diva-58062 (URN)10.1016/j.clnu.2016.12.015 (DOI)28043722 (PubMedID)
Note

Funding Agencies:

Research Committee of Örebro County Council

Nyckelfonden

Stiftelsen Gynekologisk Onkologi

Lisa och Göran Grönbergs Stiftelse

Available from: 2017-06-16 Created: 2017-06-16 Last updated: 2017-10-18Bibliographically approved
4. Female sex hormones in relation to insulin resistance after hysterectomy
Open this publication in new window or tab >>Female sex hormones in relation to insulin resistance after hysterectomy
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-59437 (URN)
Available from: 2017-09-01 Created: 2017-09-01 Last updated: 2017-10-18Bibliographically approved

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