Assessing outcomes after fast track surgical management of corpus cancer

doi:10.4236/ojog.2011.13026

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Open Journal of Obstetrics and Gynecology, 2011, 1, 139-143

doi:10.4236/ojog.2011.13026 Published Online September 2011 (http://www.SciRP.org/journal/ojog/ OJOG

Published Online September 2011 in SciRes. http://www.scirp.org/journal/OJOG

Assessing outcomes after fast track surgical management of

corpus cancer

Jonathan Carter1,2*, Shannon Philp1,2

1Sydney Gynaecological Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia;

2The University of Sydney, Sydney, Australia.

E-mail: *[email protected]

Received 12 June 2011; revised 15 July 2011; accepted 22 July 2011.

ABSTRACT

Objective: The aim of the study was to audit the out-

comes of patients with corpus cancer managed with a

fast track surgery (FTS) program. Design: Clinical

audit of outcomes after laparotomy for corpus cancer

and managed by FTS principles. Setting: Tertiary

hospital, University based subspecialty gynaecological

oncology practice. Population or Sample: Consecutive

patients with uterine corpus cancer. There were no

exclusions. Methods: Three year audit of FTS Data-

base. Main Outcome Measures: Ability to tolerate

early oral feeding (EOF), length of stay (LOS), peri-

operative complication rate and readmission rate.

Results: Sixy six patients were operated upon whose

median age was 59.5 years. Forty six (70%) had stage

I disease, 7 (11%) stage II, 9 (14%) stage III and 4

(6%) had stage IV disease. Twenty seven (41%) had

lymph node sampling performed. Median operating

time was 2. 5 hour s. Mean BMI was 30 kg/m2 (Range:

18 - 47). Fifty patients (76%) were classified as over-

weight or obese. Twenty four patients (36%) had a

“non-zero” performance status. Mean intraoperative

EBL was 227 ml. Median LOS was 3.0 days. There

were 3 (5%) intraoperative complications. There were

no intraoperative ureteric, bowel or vascular injuries.

Postoperatively, 13 (20%) patients experienced a total

of 24 adverse events. Only 2 (3%) patients experi-

enced complications greater than grade 2. Conclusion:

This audit shows that in an unselected group of pati-

ents undergoing laparotomy as management for their

uterine malignancy and managed by a FTS protocol,

overall excellent results can be achieved.

Keywords: Fast Track Surgery; Clinical Audit; Corpus

Cancer

1. INTRODUCTION

Endometrial cancer is the most common gynaecological

cancer affecting women, and with an increasing inci-

dence, a safe, cost effective and tolerated management is

important [1]. Treatment remains removal of the uterus

and adnexa, and this can be accomplished via laparotomy,

vaginally, totally laparoscopic, laparoscopically assisted

or robotically. Surgical staging to define the extent of

disease may be added to hysterectomy, however the ra-

tionale for this and data on survival impact is often de-

bated [2].

Fast track surgery programs are not new, nor are they

complicated. They were first described by Kehlet in

Denmark in 2002 and the principles have been adopted

by most surgical specialities worldwide [3,4]. FTS pro-

grams incorporate a number of elements and are not just

clinical pathways. Many of these elements are already

practiced by surgeons, but few embrace the entirety to

gain the maximum benefits for their patients. By mini-

mising stress and maintaining normal physiology as

much as possible, the catabolic stresses of surgery and

anaesthesia can be minimised, optimising patient out-

comes and as a consequence reducing length of stay

(LOS).

Clinical audit is one of the fundamental principles of

clinical governance, the process by which clinicians im-

prove the quality of the care they provide. It provides

powerful information to the consumer (patient) and

health care provider (Hospital, Government) as to the

outcomes really achieved in a real life scenario.

A clinical audit was undertaken of all patients referred

to a single gynaecological oncologist with a diagnosis of

uterine corpus malignancy and who subsequently under-

went surgical management via laparotomy and managed

with a FTS program. The aim of the audit was to docu-

ment outcomes of patients managed with FTS and lapa-

rotomy and to provide a reference for subsequent clinical

audits.

2. METHODS

This audit reports the experience of 3 full years of pa-

J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 139-143

140

tients referred to a single gynaecological oncologist, for

the surgical management of cancer of the uterine corpus

managed by a FTS program. The audit includes all pa-

tients taken to the operating room for the calendar years

2008, 2009 and 2010 who underwent a laparotomy.

There were no exclusions and no exceptions. Data was

collected in a real time fashion on the author’s personal

database and analysis undertaken in a retrospective fash-

ion.

Our FTS program has been previously described, and

involves preoperative patient counselling regarding the

program by both surgeon and nurse, informing the pa-

tient of their anticipated LOS and the criteria for dis-

charge. Patients are advised that once these criteria are

met, discharge would occur. Narcotic analgesia is limited

and adequate analgesia provided by a combination of

intraoperative paracoxib and transverse abdominis plane

(TAP) block [5,6]. Mechanical bowel preparations are

not routine, fluid balance optimised to retain as close to

normal intravascular volume and unnecessary tissue

trauma is avoided by good surgical technique. Strict at-

tention to haemostasis is important and drains are

avoided. Postoperatively meloxicam is prescribed for 3

days with regular paracetamol. Oral liquids are allowed

on the night of surgery and light diet on post op day 1

with rapid progression thereafter. Movicol or Coloxyl

with Senna is commen ced routinely on post op day 1 and

continued post discharge. All patients receive periopera-

tive Clexane which is continued until discharge. Selected

high risk patients are offered extended Clexane prophy-

laxis. Intraoperatively mechanical sequential compres-

sion devices are employed and all patients have knee

high TED stockings fitted and worn postoperatively for

at least 1 month. Patients are mobilised day 1 post sur-

gery and catheters and IV fluids are also removed on day

1 whenever possible. Patients are given an incentive spi-

rometer or “Triflow” and encouraged to use the device 6

times per hour. Criteria for discharge include the patient

adequately mobilising without assistance, to lerating early

oral feeding, managing their pain and discomfort with

oral analgesia and having adequate home supervision.

Post discharge patients receive a follow up phone call

from our Clinical Nurse Consultant (CNC) within 3 days

of discharge.

Data collected relate to patient characteristics, hospi-

talisation and post-hospitalisation. The following patient

characteristics were collected: age, weight, height, body

mass index (BMI), medical insurance status, and perfor-

mance status. Hospitalisation details included the proce-

dure performed, type of incision (transverse or midline),

operating time, complexity of surgery (simple vs. com-

plex), intraoperative estimated blood loss (EBL), whe-

ther a transfusion was required, the preop erative Hb , post

operative Hb and the Hb change, whether the patient

tolerated early oral feeding (EOF) and if the patient re-

ceived COX Inhibitors. All inpatient complications were

collected, including modified Royal Australian and New

Zealand College of Obstetricians and Gynaecologists

(RANZCOG) Quality Indicators (Table 1). Date of ad-

mission and date of discharge were used to calculate

length of stay (LOS). Post hospitalisation admissions and

complications were also recorded. All patients were re-

viewed 2 - 4 weeks p ost discharge.

Ethics approval was granted to allow review and pre-

sentation of the data as a clinical audit. Statistical analy-

sis included descriptive statistics, t-test and ANOVA for

nominal variables and chi-squared test for categorical

data.

3. RESULTS

Over the 3 year audit period, 66 patients were operated

upon whose median age was 59.5 years (Range: 35.1 -

86 years). Forty six (70%) had stage I disease, 7 (11%)

stage II, 9 (14%) stage III and 4 (6%) had stage IV dis-

ease. Twenty seven (41%) had lymph node sampling

Table 1. Quality indicators collected by the Sydney gynaeco-

logical oncology group

Transfusion > 2 Units

LOS more than 7 days

DVT or PE

Anastomotic Leak

Return to operating room

Post-operative Renal Im pa irment

Perioperative Cardiac Event

Perioperative Respiratory E ven t

Death from Treatment Complications

Hospital Readmission

Nosocomial Infection

Death within 30 days of surgery

Undiagnosed Cancer

Unplanned admission to ICU

Wound Dehiscence

Vascular Injury

Bowel Injury

Febrile Morbidity

Ureteric Injury

Bladder Injury

Nerve Injury

Treatment Refusal

Laparoscopy converted to lap arotomy

Haematoma post surgical dischar ge

Missed electrolyte abnorm a lity

J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 139-143 141

performed. Median and mean operating time was 2.5 and

2.3 hours respectively (Range: 1 - 5 hours). Sixteen (24%)

patients were classified as normal BMI and 50 (76%) as

overweight and obese (25 overweight and 25 obese).

Median and mean BMI were 28 kg/m2 and 30 kg/m2 re-

spectively (Range: 18 - 47).

Forty two patients (64%) had a “0” Performance

Status (PS), 20 (30%) had PS 1 and 4 (6%) had a PS of 2.

In total, 24 (36%) had “non-zero” performance status.

Median preoperative Hb was 129, dropping to 119

postoperatively.

Mean intraoperative EBL was 227 ml (95% CI: 189 -

266) with a median EBL of 188ml (Range: 10 ml - 900

ml). There were no intra or postoperative blood transfu-

sions.

Median and mean LOS was 3.0 and 3.7 days respec-

tively (Range: 2 - 16 days) with 10 (15%) patients dis-

charged on or before post operative day 2 and an addi-

tional 7 (2%) patients were deemed suitable for discharge

on day 2 but for social reasons were unable to be dis-

charged. Thirty eight (58%) patients were discharged on

day 3. T hree pa t i en t s (5%) had LOS greater than 7 days.

COX 2 inhibitors were prescribed to 58 (88%) and 62

(94%) were able to successfully complete EOF and FTS

protocol.

There were 3 (5%) intraoperative complications/ad-

verse events. Two were episodes of bradycardia related

to parietal peritoneum stimulation both settling and al-

lowing surgery to proceed. There was 1 intraoperative

bladder injury in a patient who underwent an exentera-

tive procedure, being a Jehovah’s Witness, having pre-

viously undergone an abdomino-perineal resection and

pelvic irradiation for colon cancer, presenting with se-

rous corpus cancer and her uterus fixed to the sacrum.

The bladder was morbidly fixed to the uterus as a con-

sequence of her previous irradiation and the bladder in-

advertently entered during dissection and repaired in 2

layers without sequelae. There was no intraoperative

ureteric, bowel or vascular injuries.

Postoperatively, 13 patents (20%) experienced a total

of 24 complications/adverse events based upon our KPI’s.

There were 6 (9%) hospital readmissions, 5 (8%) wou nd

infections, 3 patients (5%) whose LOS was greater than

7 days, 2 patients (3%) had an unplanned ICU admission,

2 developed an ileus (3%), 2 patients (3%) unplanned

return to theatres, 2 patients (3%) with electrolyte dis-

turbance and 1 each of the following were reported:

haemorrhage from ureteric stents and femoral neuro-

praxia as outlined in Table 2.

One patient (Patient 3) accounted for 5 of 23 (22%)

complications. Only 2 patients (patient 3 and patient 10)

experienced complications greater than grade 2. Patient 3

was a 61 year old, obese Jehovah’s Witness described

above with a past history of abdo mino-perineal r esection

and pelvic irradiation for colon cancer. She was diag-

nosed with a serous corpus cancer and her uterus was

fixed onto the sacrum as a consequence of previous treat-

ments. Intraoperativ ely ureteric stents were inserted. Post

operative bleeding from ureteric stents required her re-

turn to the operating room by the Urology team for re-

moval of ureteric stents, and monitoring in ICU an d sub-

sequent readmission to hospital for management of an

electrolyte disturbance. Patient 10 was a 60 year old

morbidly obese woman who underwent repair of an inci-

sional hernia by general surgical colleagues at the same

time as her uterine cancer surgery. She underwent exten-

sive soft tissue mobilisation an d was readmitted 3 weeks

after surgery with a wound infection that required de-

bridement in the operating room and VAC dressing

placement.

4. DISCUSSION

Patients commonly ask their surgeon “have you done this

before?” and “am I going to be OK?” The answer to

these questions are not derived from published RCTs,

rather they are derived from clinical audit of personal

experience.

Clinical audit is one of the fundamental principles of

clinical governance, the process by which clinicians im-

prove the quality of the care they provide. The process

involves regularly collecting and measuring activity and

outcomes, and analysing and comparing these outcomes

with current or “recognised standards”, together with a

rigorous peer review process. It makes clinicians ac-

countable to the public, by constantly monitoring and

maintaining high standards, being transparent and ac-

countable for those standards, identifying problems and

addressing them and to constantly improve on those

standards to improve overall quality of care. It is what

the public expect [7]. The key feature of audit is that it

involves reviewing actual and all surgical performance

outcomes. In lay terms, the purpose of audit is to confirm

that your outcomes are, what you say or think they are

[8]. It has been shown quite clearly from cardiac surgery

that structured data collection, analysis, and feedback to

clinicians improves the qu ality of outcomes [9].

Our study provides the first real base-line or “recog-

nised standard” on laparotomy patients managed by FTS

for the surgical management of uterine cancer.

In this audit, all patients with a diagnosis of uterine

corpus malignancy and managed by a FTS program were

included. During the study period there were no patients

who underwent laparo scopy and as such this audit repre-

sents extensive experience of fast track surgical care in

patients with uterine malignancy managed by laparotomy

and thus serves as a “recognised standard”.

J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 139-143

142

OJOG

Table 2. Intraoperative and postoperative quality indicators.

Pt Age LOS PS BMI Grade Complication/Adverse

Event Comment

Intraoperative Complications

1 80 13 1 40 2 Bradycardia Elderly obese woman, developed bradycardia during packing.

Surgery continued. ICU monitoring. Developed post opera-

tive ileus, UTI, wound infection, resulting in increased LOS

2 66 6 0 26 2 Bradycardia Bradycardia settled spontaneously. Surgery continued.

3 61 16 0 30 1 Bladder injury

Jehovah’s Witness with past history of abdomino-perineal

resection and pelvic irradiation for colon cancer. Uterus fixed

on sacrum. Intraoperative bladder injury. R epaired in 2 layers,

no sequelae

Postoperative Complications

1 80 13 1 40 2

ICU Admission

Ileus

Wound infection

LOS >7 days

Elderly obese woman, developed bradycardia during packing.

Surgery continued. ICU monitoring. Developed post opera-

tive ileus, wound infection, resulting in increased LOS

3 61 16 0 30 3

Haematuria/haemorrhage

Return to theatre

ICU Admission

LOS >7days

Hospital readmission

Jehovah’s Witness with past history of abdomino-perineal

resection and pelvic irradiation for colon cancer. Uterus fixed

on sacrum. Ureteric stents inserted. Post operative bleeding

from ureteric stents requiring return to OR by Urology team

for removal of stents. Monitoring in ICU. Subsequent read-

mission to hospital for management of electrolyte disturbance

4 58 3 0 38 2 Wound infection Diagnosed 4 weeks post op. Treated with oral antibiotics by

5 57 3 0 29 2 Wound infection Wound haematoma/infection treated with oral antibiotics by

GP. No sequelae

6 43 4 0 23 1 Hospital readmission Constipation. Readmitted but no specific management

7 61 3 0 25 1 Hospital readmission

Unable to void after catheter removal. Readmitted 1 week

post op for successful trial of void

8 61 3 0 40 1 Hospital readmission Resuture vaginal vault

9 46 2 0 29 2 Hospital readmission

Wound infection Readmitted with wound infection, conservatively managed

with IV antibio t i c s a n d VAC dressing

10 60 6 1 43 3 Hospi t a l r e a dmission

Wound Infection

Return to theatre

Readmission with wound infection 3 weeks after extensive

wound mobilization for repair of incisional hernia in obese

patient. Return to theatre for wound debridement and VAC

dressing

11 59 2 1 17 1 Other Femoral neuropraxia, settled prior to discharge

12 61 3 1 28 1 Electrolyte Raised creatinine. Settled prior to discharge

13 68 10 2 34 2 Electrolyte

Ileus

LOS >7 days

Preexisting CRF, post operative electrolyte disturbance, and

ileus settling with conservative management. Length of stay

10 days

CRF: Chronic renal failure; VAC: Vacuum assisted closure; ICU: Intensive care unit; LOS: Length of stay; UTI: Urinary tract infec tion; GP: Genera l prac titioner.

The extended experience confirms our earlier work

that the majority of patients can complete a FTS program,

with minimal morbidity and a low incidence of readmis-

sion and as a consequence, a shorter hospital stays [5].

In a health care and financial environment where

monetary constraints are ever increasing and medical

technology is becoming more complex and expensive,

clinicians and hospital administrators need to have access

to audit data to confirm whether inve stment in expensive

technology provides an enhanced outcome. It is note-

worthy that the LOS and outcomes in the audit patients

reported in this article were not too dissimilar to those

reported in recent RCTs comparing laparotomy and lapa-

roscopy [10-13].

This audit provides a baseline data set for a large

group of patients with uterine corpus cancer operated

upon with laparotomy and managed by FTS. It allows for

subsequent data to be compared against and as such is a

J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 139-143 143

powerful tool for the gynaecological oncologist embark-

ing upon surgery for cancer of the uterine corpus.

5. ACKNOWLEDGEMENTS

The authors acknowledge financial support from The Chris O’Brien

Lifehouse at RPA.

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