Perioperative care pathway in Gynaecological Oncology:A Prospective Audit of current practice in a tertiary care hospital

Our study results showed that minimally invasive surgeries areassociated with decreased length of the stay in the hospital after the surgery.Median day of discharge of day in open surgery was 5  and with theminimally invasive surgeries (MIS) was 4 Andthere was no difference in postop morbidity. We found statisticallysignificant correlation between patients who underwent bowel preparation vs nobowel preaperation with decrease in Clavien Dindo grading in patients in whombowel preparation was not done. Majority of patients in current audit hadprolonged fasting (>6hours) In our study 46.5% patients received onlysingle antiemetic agent. Our nurse patient ratio is quite poor in recoveryroom and surgeons are uncomfortable to send patients to recovery area withoutNGT but happy to remove it by 10-12 hours after surgery and thus almost 95.7 %patients had their NGT removed within 24 hours post-surgery. 5% patients whohad NGT retained after 24 hours had significantly higher hospital length ofstay (LOS) (median 5 days vs 7.5 days). Probably these patients had someproblem like prolonged ileus or complicated bowel resections which increasedhospital LOS rather than delayed removal of NGT. In our audit 29.6 %patients did not get drains and 8.9 % of patients drain was removed within 24hours. Patients who had surgical drains for >24 hours had increased hospitalLOS.

32% of our patients had urinary catheter in place for more than 24hours. And we found that early removal of urinary catheter had a statistically significantassociation with decreased post-operative morbidity outcomes as well as reducedreadmissions and less hospital LOS. Ourstudy showed that our surgeons were quite comfortable starting liquids orallywithin 24 hours but reluctant to give solids. We found that early oral fluiddiet significantly decreased postoperative length of stay from 5 [2] to 3.5[1]and decreased the post-operative complications as per Clavien Dindo grading.Ourstudy showed that our surgeons were quite comfortable starting liquids orallywithin 24 hours but reluctant to give solids. We found that early oral fluiddiet significantly decreased postoperative length of stay from 5 [2] to 3.5[1]and decreased the post-operative complications as per Clavien Dindo grading.

What our study results show is ourcompliance to ERAS bundles is exteremely poor. Most of the elements where wefound good compliance are part of standard practice for many years and notnecessarily as part of ERAS bundles. Elements like preoperative antibiotic, avoidanceof night sedation, multimodal analgesia are decided by anaesthetist and haveexcellent compliance. However other elements especially where surgeons aremajor decision makers, compliance rate is still very poor and probably reflectlack of awareness and unwillingness to adopt change. With proper education andinstitution of protocols, it is possible to improve compliance andpostoperative outcomes