Fast-track hysterectomy: a randomised, controlled study

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Abstract

Objective

To investigate if intrathecally administered morphine combined with a low-dose mode of total intravenous anaesthesia (TIVA) accelerates recovery after abdominal surgery as compared, to patient-controlled analgesia (PCA) combined with anaesthesia, based on volatile anaesthetics.

Study design

Fifty-three patients who were hysterectomised abdominally were randomised to TIVA or PCA. Their per- and post-operative course was strictly monitored and their pain score was evaluated with a visual analogue scale at repeated time intervals.

Results

Patients with TIVA had a significantly shorter stay on the post-operative ward, 180 (105–330) min, compared with the PCA group, 237 (120–1140) min (p < 0.01). The start of peroral fluid also differed significantly between groups, 4 h (2–6) for TIVA versus 5 h (2–24) for the PCA group (p < 0.01). The removal of the indwelling catheter took place significantly earlier in the TIVA group, 9 h (5–23) versus 22 h (17–24) in the PCA group (p < 0.0001). There was significantly less post-operative nausea in the TIVA group compared with the PCA group on the first post-operative day (p < 0.01). The length of stay was shorter, 2 days (1–3) compared with 3 days (1–6) for the TIVA group versus PCA (p < 0.001). There was no difference in complications between groups. One patient in each group was re-admitted to hospital because of a vaginal cuff infection.

Conclusion

The TIVA per- and post-operative care was an advantage over PCA in most respects.

Introduction

Conventional open abdominal hysterectomy is still a commonly performed operation, especially when the uterus is greatly enlarged and when there are endometriosis and adhesions intra-abdominally. Limiting factors for early recovery and discharge after abdominal hysterectomy are nausea, pain, bowel paralysis and other organ dysfunction. In Sweden, the trend is to remove most ordinary and moderately oversized uteri with a vaginal hysterectomy or sometimes with a laparoscopic operation [1]. There is, however, a point at which uterine volume limits vaginal and laparoscopic operations as they are too time consuming [2]. For such oversized uteri, open hysterectomy is still the standard operation. Both vaginal and laparoscopic hysterectomy are a better choice for the patient because of a more rapid recovery and minimum requirements for post-operative hospitalisation as compared to conventional abdominal hysterectomy [3].

In the mid-1990s, Professor Kehlet introduced fast-track colorectal surgery in Denmark. He was able to show that, with improved pre-, peri- and post-operative care, including regimens with new anaesthetic and analgesic techniques (e.g. epidural analgesia and non-opioid multi-modal analgesia), the patient had a shorter recovery and an earlier discharge [4]. Most importantly, the patient had a better post-operative period with less pain and nausea, which facilitated early fluid intake and rapid mobilisation. The use of fast-track colorectal surgery is supported by randomised, controlled studies [5]. To begin with, the fast-track setting was slowly implemented in other surgical disciplines. In gynaecological surgery, Möller et al. in 2001 showed that it was possible to shorten the hospital stay after open hysterectomy and make the post-operative period more like that after LAVH [6]. There are also indications that it is possible in a fast-track setting to reduce the time in hospital after different types of vaginal surgery, including vaginal hysterectomy [7].

Our aim with this study was to perform a randomised study in which we compared two groups of women undergoing abdominal hysterectomy. One group of women was treated in the standardised way with patient-controlled analgesia (PCA) combined with anaesthesia based on volatile anaesthetics, while the other group was treated with intrathecal morphine combined with a low-dose mode of total intravenous anaesthesia (TIVA) in a fast-track setting with the emphasis on information, treatment of nausea and pain, early fluid and food intake and swift mobilisation.

Section snippets

Material and methods

This study comprises 53 patients who were hysterectomised abdominally in 2004–2005. The patients were prospectively randomised into two groups using the closed-envelope technique. Twenty-seven women were allocated to the TIVA group, while 26 were put in the PCA group. The exclusion criteria were major medical illness, concomitant surgical procedures (except salpingo-oophorectomy), malignancy, unwillingness to participate and language problems, i.e. they did not understand Swedish. At the first

Clinical characteristics

There were no differences between the TIVA group and the PCA group regarding demographic characteristics (Table 1).

Per-operative data

The data from the operation, including estimated blood loss and operating time, did not differ. In both groups, the indication for hysterectomy was mainly bleeding disorders or pain according to myomata uteri. As most uteruses of low to moderate size were removed transvaginally, those in the studied groups were mostly oversized. There was no weight difference between groups, TIVA

Comments

At our clinic, most normal and moderately oversized uteri are removed transvaginally. Oversized uteri with myomata are left for the abdominal approach and they sometimes also require a midline incision. Our data illustrate that it is possible to reduce the hospital stay after these operations. Back in 2000, the mean hospital stay after this operation at our clinic was 4.6 days. Now, in a fast-track setting, the patient can be discharged after 2 days. A short hospital stay was possible in a

Conclusion

The fast-track setting is useful as it can be used at most clinics. Using standard surgical equipment, the patient can be handled by ordinary surgeons, anaesthesiologists and nurses. This new multi-modal approach is an effective tool for diminishing PONV and helping the patient to be rapidly mobilised.

Conflicts of interest

Author and co-authors had no conflicts of interest.

Acknowledgement

The FoU-unit Fyrbodal.

References (20)

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