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Same-day discharge is feasible and safe in patients undergoing minimally invasive staging for gynecologic malignancies

Published:August 14, 2014DOI:https://doi.org/10.1016/j.ajog.2014.08.010

      Objective

      The objective of the study was to evaluate the feasibility and safety of same-day discharge of patients undergoing minimally invasive comprehensive surgical staging for endometrial and cervical cancer.

      Study Design

      We performed a retrospective review of consecutive patients from January 2008 to December 2011 undergoing comprehensive staging for endometrial or cervical cancer by traditional laparoscopy or robotic-assisted laparoscopy and intended for same-day discharge. Patients accomplishing same-day discharge were compared with those who required admission. Clinical and demographic data, perioperative outcomes, and postoperative patient contacts within 6 weeks were collected. Multivariate logistic regression modeling was used to determine factors associated with admission and unscheduled patient contacts within 2 weeks of surgery.

      Results

      A total of 141 patients were identified. One hundred eighteen patients (83.7%) underwent same-day discharge and 23 (16.3%) required overnight admission. The variables that significantly predicted overnight admission were severe pain in the postanesthesia care unit (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.74–26.6; P = .006), delayed ability to tolerate oral intake (OR, 9.3; 95% CI, 2.25–38.6, P = .002), traditional laparoscopic vs robotic-assisted surgical approach (OR, 9.05; 95% CI, 2.34–35.1; P = .001), and surgery start time at 2:00 pm or later (OR, 36.8; 95% CI, 6.19–219.3; P < .0001). There was no difference in the readmission rate between patients undergoing same-day discharge compared with overnight admission (11% vs 17%, P = .48). No variables significantly predicted unscheduled patient contact within 2 weeks of surgery at P < .01.

      Conclusion

      Same-day discharge for patients undergoing laparoscopic or robotic-assisted laparoscopic staging for endometrial or cervical cancer is feasible and safe. There are low complication rates and few readmissions or unscheduled patient contacts within 2 weeks of surgery.

      Key words

      Minimally invasive surgical (MIS) techniques for the treatment and staging of gynecological malignancies have become widely adopted. MIS has been associated with improved perioperative outcomes, including decreased blood loss and transfusion rates, less postoperative pain, faster recovery, and shorter hospital stays.
      • Nezhat F.R.
      • Datta M.S.
      • Liu C.
      • Chuang L.
      • Zakashansky K.
      Robotic radical hysterectomy versus total laparoscopic radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer.
      • Soliman P.T.
      • Frumovitz M.
      • Sun C.C.
      • et al.
      Radical hysterectomy: a comparison of surgical approaches after adoption of robotic surgery in gynecologic oncology.
      • Tinelli R.
      • Malzoni M.
      • Cosentino F.
      • et al.
      Robotics versus laparoscopic radical hysterectomy with lymphadenectomy in patients with early cervical cancer: a multicenter study.
      The only prospective randomized trial in gynecological oncology, the GOG-LAP 2 trial, also showed equivalent clinical outcomes between patients undergoing surgical staging for endometrial cancer via laparoscopy compared with laparotomy.
      • Walker J.L.
      • Piedmonte M.R.
      • Spirtos N.M.
      • et al.
      Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2.
      Robotic-assisted laparoscopy has been widely adopted since the Food and Drug Administration approved the first surgical robot in 2005. By 2010, robotic hysterectomy accounted for 9.5% of hysterectomies across the country, and 22% of hysterectomies in hospitals with a robotic platform.
      • Wright J.D.
      • Ananth C.V.
      • Lewin S.N.
      • et al.
      Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease.
      The utilization of MIS for surgical staging for both endometrial cancer and cervical cancer has increased to approximately 30%.
      • Wright J.D.
      • Herzog T.J.
      • Neugut A.I.
      • et al.
      Comparative effectiveness of minimally invasive and abdominal radical hysterectomy for cervical cancer.
      • Yu X.
      • Lum D.
      • Kiet T.K.
      • et al.
      Utilization of and charges for robotic versus laparoscopic versus open surgery for endometrial cancer.
      In hospitals with robotic platforms, up to 98% of endometrial cancer staging is now being performed via a robotic assisted approach.
      • Lau S.
      • Vaknin Z.
      • Ramana-Kumar A.V.
      • Halliday D.
      • Franco E.L.
      • Gotlieb W.H.
      Outcomes and cost comparisons after introducing a robotics program for endometrial cancer surgery.
      For patients undergoing MIS for gynecological malignancies, most studies report average hospital stays of 1 day after surgery.
      • Wright J.D.
      • Herzog T.J.
      • Neugut A.I.
      • et al.
      Comparative effectiveness of minimally invasive and abdominal radical hysterectomy for cervical cancer.
      • Yu X.
      • Lum D.
      • Kiet T.K.
      • et al.
      Utilization of and charges for robotic versus laparoscopic versus open surgery for endometrial cancer.
      • Wright J.D.
      • Burke W.M.
      • Wilde E.T.
      • et al.
      Comparative effectiveness of robotic versus laparoscopic hysterectomy for endometrial cancer.
      Patients are commonly kept in the hospital following MIS for pain and nausea control, prolonged bladder catheterization, and observation for surgical complications. However, it is plausible that patients undergoing MIS for gynecological malignancies could in fact be discharged home the same day of surgery if certain criteria are met, given that many studies describe decreased pain, nausea, and surgical complications using MIS methods.
      • Nezhat F.R.
      • Datta M.S.
      • Liu C.
      • Chuang L.
      • Zakashansky K.
      Robotic radical hysterectomy versus total laparoscopic radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer.
      • Soliman P.T.
      • Frumovitz M.
      • Sun C.C.
      • et al.
      Radical hysterectomy: a comparison of surgical approaches after adoption of robotic surgery in gynecologic oncology.
      • Tinelli R.
      • Malzoni M.
      • Cosentino F.
      • et al.
      Robotics versus laparoscopic radical hysterectomy with lymphadenectomy in patients with early cervical cancer: a multicenter study.
      Same-day discharge is common for cardiac, cholecystectomy, and orthopedic patients after minimally invasive procedures.
      • Gien L.T.
      • Kupets R.
      • Covens A.
      Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology.
      • Hoekstra A.V.
      • Jairam-Thodla A.
      • Rademaker A.
      • et al.
      The impact of robotics on practice management of endometrial cancer: transitioning from traditional surgery.
      Several studies have reported success with same-day discharge of patients undergoing laparoscopic hysterectomy for benign gynecological conditions.
      Robotic-assisted minimally invasive surgery for gynecologic and urologic oncology: an evidence-based analysis.
      • Cardenas-Goicoechea J.
      • Adams S.
      • Bhat S.B.
      • Randall T.C.
      Surgical outcomes of robotic-assisted surgical staging for endometrial cancer are equivalent to traditional laparoscopic staging at a minimally invasive surgical center.
      • Jacoby V.L.
      • Autry A.
      • Jacobson G.
      • Domush R.
      • Nakagawa S.
      • Jacoby A.
      Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches.
      Furthermore, Gien et al
      • Gien L.T.
      • Kupets R.
      • Covens A.
      Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology.
      evaluated same-day discharge for patients undergoing laparoscopic surgery for a range of gynecological cancers and found that 48.5% successfully underwent same-day discharge and 5% were readmitted within 3 weeks after surgery.
      To our knowledge, assessment of the feasibility of same-day discharge for robotic procedures in gynecology oncology patients undergoing complete staging has not yet been published. We sought to evaluate the feasibility of same-day discharge for a consecutive group of women undergoing surgical staging for endometrial or cervical cancer by traditional laparoscopy or robotic-assisted laparoscopy. We also sought to identify variables associated with surgical admission as well as complication, readmission, and provider contact rates associated with same-day discharge.

      Materials and Methods

      After obtaining institutional review board approval from Kaiser Permanente, we performed a retrospective review of consecutive patients undergoing minimally invasive surgical staging for endometrial or cervical cancer between January 2008 and December 2011 at the West Los Angeles or Los Angeles Medical Center. Investigators abstracted data from each patient’s electronic medical record (EMR), specifically from notes from outpatient clinic, admission, anesthesia, and the postanesthesia care unit (PACU) as well as from the operative and pathology reports.
      Investigators abstracted data regarding clinical and demographic information, perioperative data, and postoperative contacts, including emergency room visits, readmissions, and unscheduled office visits, e-mails, and phone calls within 6 weeks of surgery. Patients were excluded if they had known metastatic disease, were intended for overnight admission, or were converted to laparotomy at the time of the procedure.

      Surgical procedure

      All patients with endometrial or cervical cancer who underwent comprehensive surgical staging with either a robotic-assisted or traditional laparoscopic technique were included in the analysis. All endometrial cancer patients underwent total hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, and bilateral paraaortic lymphadenectomy to the level of the inferior mesenteric artery.
      For cervical cancers, the procedure included cystoscopy with bilateral ureteral stent placement, radical hysterectomy, bilateral pelvic lymphadenectomy, and ureteral stent removal; bilateral salpingo-oophorectomy was performed in a subset of patients. All cervical cancer patients were discharged to home with a Foley catheter in place. Robotic procedures were performed using the Model S Da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA) at the West Los Angeles campus. Traditional laparoscopic procedures were performed at either of the Kaiser Permanente campuses. Two faculty surgeons were the primary surgeons for all of the procedures with gynecological oncology fellows assisting.
      All patients received prophylactic cefazolin, or appropriate alternatives, prior to skin incision to prevent wound infections. All patients also received dexamethasone and ondansetron to prevent nausea and vomiting. Anesthetic management was not specifically mandated, but in general, patients were given a benzodiazepine prior to surgery, sevoflurane and fentanyl intraoperatively, and ketorolac and local anesthesia with 0.5% Marcaine at the conclusion of the procedure. An orogastric tube was placed after intubation. In addition, sequential compression devices were placed on the lower extremities of all patients during and after surgery to prevent deep venous thrombosis.
      Patients who were discharged home before midnight on the same day as their surgery were categorized as having same-day discharge. The midnight demarcation was chosen based on the fact that Kaiser Permanente, as well as Medicare, tracks hospital days from midnight to midnight. During the study period, patients were discharged the same day if they met standard Kaiser Southern California PACU discharge criteria: normal vital signs, adequate oxygenation, able to ambulate independently, adequate pain control with oral medications, able to tolerate oral intake, and able to void postoperatively. The exception was for cervical cancer patients, all of whom were discharged with a Foley catheter in place.

      Predictors of overnight stay

      Multiple perioperative variables were assessed as possible predictors of overnight stay, including characteristics of the patient, tumor, and surgery. Operative time was defined as time from examination under anesthesia to the completion of skin closure; thus, the operative time for the robotic cases encompassed docking, console, and undocking time. Intraoperative complications included damage to organs, nerves, or vasculature. Anesthesia parameters included PACU pain scores; usage of antiemetics, nonsteroidal antiinflammatory drugs, and narcotics; status of catheter discontinuation; time to void; and time to oral intake. To facilitate a comparison, narcotic doses were converted to morphine intravenous equivalent doses using standardized tables.

      eOpioid: opioids and opiates calculator: SentientWare; 2009. Available at: https://itunes.apple.com/us/app/eopioid-opioids-opiates-calculator/id329470252?mt=8. Accessed Jan. 22, 2013.

      Outcome measures

      Postoperative complications and unscheduled contacts with health care providers were compared between patients undergoing same-day discharge and those requiring overnight admission. Postoperative complications included thromboembolic events, lymphedema, vaginal cuff complications, fistulas, femoral nerve neuropathy, bowel obstruction, non–wound-related infections (eg, pneumonia or sepsis), acute renal failure, requirement of blood transfusion, and intensive care unit admission.
      The first postoperative appointment with the surgeon for gynecological oncology patients was scheduled 1 week after surgery. Data were collected regarding readmissions, emergency room visits without readmission, unscheduled office visits, and any verbal contacts (telephone or e-mail) within 6 weeks after surgery.

      Statistics

      Stata11 software (StataCorp LP, College Station, TX) was utilized to perform the statistical analysis. Descriptive statistics were used to analyze baseline characteristics. Categorical data were analyzed using a Fisher exact test, and nonparametric data were analyzed using the Mann–Whitney U test. A 2-tailed value of P < .01 was considered statistically significant.
      To assess the combined effects of multiple variables in a manner that controls for multiple chances to find differences without assuming independence of dependent variables, a multivariate logistic regression model with backward elimination was used to identify predictive factors for same-day discharge. A second model was developed, also through backward elimination, to identify factors associated with unscheduled postoperative contacts. Unscheduled postoperative contacts was defined to include any hospital readmission, any emergency room visit without readmission, and any office visit other than those routinely scheduled; this included all patients with a postoperative complication. A value of P < .05 was required for inclusion in the final model. Given the original assessment of multiple variables, P < .01 was designated as statistically significant in the final multivariate models.
      • Gelman A.
      • Hill J.
      • Yajima M.
      Why we (usually) don't have to worry about multiple comparisons.

      Results

      Study population and patient characteristics

      One hundred fifty-three consecutive patients with endometrial and cervical cancer were scheduled for comprehensive surgical staging via a minimally invasive method with a planned same-day discharge during the study period. Twelve patients (7.8%) were converted to laparotomy during the MIS procedure. All patients who were converted to laparotomy were excluded; thus, 141 patients met eligibility criteria and were included in the analysis. One hundred eighteen patients (83.7%) underwent same-day discharge and 23 patients (16.3%) required overnight admission. There were no significant statistical differences in demographic or clinical characteristics between the same-day and overnight groups (Table 1).
      Table 1Patient and cancer characteristics
      CharacteristicSame-day discharge (n = 118)Overnight stay (n = 23)P value
      Age, y, median (range)60 (19–84)61 (36–78).97
      BMI, median (range)26 (16–48)27 (21–48).23
      Hypertension, n (%)> .999
       Yes44 (37)9 (39)
       No74 (63)14 (61)
      Diabetes, n (%)
       Yes17 (14)4 (17).75
       No101 (86)19 (83)
      Cardiovascular disease, n (%).69
       Yes10 (8)1 (4)
       No108 (92)22 (96)
      Lung disease, n (%).70
       Yes11 (9)3 (13)
       No107 (91)20 (87)
      Smoking, n (%).11
       Yes8 (7)4 (7)
       No110 (93)19 (83)
      Prior abdominal surgery, n (%).48
       Yes48 (41)7 (30)
       No70 (59)16 (70)
      Stage, n (%).77
       I96 (81)18 (78)
       II or greater22 (19)5 (22)
      Cancer type, n (%).77
       Endometrial96 (81)20 (87)
       Cervical22 (19)3 (13)
      BMI, body mass index.
      Penner. Same day DC safety. Am J Obstet Gynecol 2015.

      Perioperative variables

      Examining operative variables, same-day discharge was associated with robotic-assisted laparoscopy (vs traditional laparoscopy) and surgery initiation before 2:00 pm (P < .01; Table 2). With regard to postoperative variables, same-day discharge was associated with lower pain scores in the PACU, lower narcotic requirements, ability to void if the Foley catheter was discontinued, and shorter median time to oral intake (all P < .01). Lower estimated blood loss (P = .03) and shorter median time to void approached significance in predicting same-day discharge (P = .01).
      Table 2Perioperative variables
      VariableSame-day dischargeOvernight stayP value
      Mode of surgery, n (%).001
       Laparoscopic20 (62.5)12 (37.5)
       Robotic98 (89.9)11 (10.1)
      Surgery start time, n (%).005
       Before 2:00 pm109 (87.2)16 (12.8)
       After 2:00 pm9 (56.2)7 (43.8)
      Operative time, cut to close, min, median (range)146 (91–253)170 (93–403).11
      Uterine weight, g, median (range)123.5 (39–885)104 (32–1332).38
      EBL, mL, median (range)50 (10–400)50 (10–950).03
      Pelvic nodes, median (range)13 (0–38)9 (0–25).04
      Paraaortic nodes, median (range)
      Total n = 116; endometrial cancer only; cervical cancer patients did not have paraaortic nodes removed.
      8 (0–28)6 (0–15).14
      Intraoperative complication(s), n (%).51
       Yes3 (2.5)1 (4.4)
       No115 (97.5)22 (95.6)
      Narcotics (morphine equivalents), n (%).004
       <125 mg98 (89)12 (11)
       ≥125 mg20 (62.5)11 (37.5)
      Antiemetics, n (%).71
       <4106 (84.1)20 (15.8)
       ≥412 (80)3 (20)
      PACU pain score, n (%).002
       Mild (0-2)51 (86.4)8 (13.6)
       Moderate (3-6)40 (95.2)2 (4.8)
       Severe (7-10)27 (67.5)13 (32.5)
      Void status, n (%)< .0001
       Foley removed, able to void93 (87.7)13 (12.3)
       Foley removed, unable to void3 (30)7 (70)
       Foley left in place (cervical cancer)22 (88)3 (12)
      Time to void, min, median (range)222.5 (39–529)385 (48–676).01
      Time to PO intake, min, median (range)235.5 (13–523)316 (108–943).009
      PACU stay, min, median (range)225 (113–569)200 (109–685).34
      EBL, estimated blood loss; PACU, post anesthesia care unit; PO, per orem.
      Penner. Same day DC safety. Am J Obstet Gynecol 2015.
      a Total n = 116; endometrial cancer only; cervical cancer patients did not have paraaortic nodes removed.

      Multivariate model to predict same-day discharge

      A multivariate logistic regression model was then constructed via backward elimination to identify the factors that were predictive of same-day discharge (Table 3 and Figure 1). Surgery start time at 2:00 pm or later, severe pain (pain score of 7 of ≥10), laparoscopic (vs robotic) approach, and more than 6 hours to oral intake were all significantly associated with an increased likelihood of an overnight stay (P < .01, Figure 1, A). Surgery start at 2:00 pm or later had the strongest impact, with an odds ratio (OR) of 36.8 (P < .0001) for an overnight stay. An inability to void after catheter removal approached significance in predicting increased likelihood of an overnight stay (P = .012). Once controlling for these variables in a multivariate analysis, there were no other factors significantly associated with an overnight stay.
      Table 3Predictive factors for overnight stay
      VariableORSEzP > |z|95% CI lower bound95% CI upper bound
      Lsc (vs robotic)9.056.253.19.0012.3435.10
      Surgery start time 2:00 pm or later36.8033.53.96< .00016.19219.3
      Severe pain in PACU6.814.742.76.0061.7426.60
      Time to oral intake longer than 6 h9.316.753.08.0022.2538.60
      Unable to void (if Foley removed)9.708.752.52.0121.6656.80
      CI, confidence interval; Lsc, laparoscopic; OR, odds ratio; PACU, postanesthesia care unit.
      Penner. Same day DC safety. Am J Obstet Gynecol 2015.
      Figure thumbnail gr1
      Figure 1Predictive factors for overnight stay
      A multivariate model of factors that predict the need for overnight admission (P < .05 required for inclusion; P < .01 required for statistical significance).
      Penner. Same day DC safety. Am J Obstet Gynecol 2015.

      Postoperative outcomes and contacts

      Postoperative complications

      Within the same-day discharge group, 5.9% of patients developed a postoperative complication within 1 week, compared with 8.7% in the overnight group (P = NS; Figure 2, A). There was no difference in the overall frequency or type of complications 2 weeks postoperatively between the same-day and overnight admission groups (12.7% vs 8.7%, P = NS, Table 4).
      Figure thumbnail gr2
      Figure 2Postoperative contacts
      A, Postoperative contacts: any patient contact within 7 days postoperatively. B, Postoperative contacts: any patient contact within 14 days postoperatively. Breakdown of postoperative patient contacts was based on the duration since surgery. No statistical differences are seen between the 2 groups (all results P > .05).
      Penner. Same day DC safety. Am J Obstet Gynecol 2015.
      Table 4Complications within 2 weeks (n = 141)
      VariableSame-day discharge, n, % (n = 118)Overnight stay, n, % (n = 23)P value
      Pelvic abscess or vaginal cuff cellulitis4 (3.4)0 (0)> .999
      Hematoma1 (0.8)0 (0)> .999
      Venous thromboembolism1 (0.8)0 (0)> .999
      Fistula1 (0.8)0 (0)> .999
      Pneumonia1 (0.8)0 (0)> .999
      Neuropathy/nerve palsy2 (1.7)1 (4.3).416
      Wound infection5 (4.2)1 (4.3)> .999
      Lymphedema1 (0.8)0 (0)> .999
      Death1 (0.8)0 (0)> .999
      Any complication15 (12.7)2 (8.7).739
      There were 19 complications in 17 patients.
      Penner. Same Day DC safety. Am J Obstet Gynecol 2015.

      Readmissions

      Seventeen patients in the entire cohort (12%) were readmitted to the hospital within 6 weeks; 1 patient was admitted within 7 postoperative days and 2 others were admitted within 14 postoperative days. There was no difference in readmission rates between the same-day discharge and overnight groups at 1, 2, or 6 weeks. Reasons for readmission included pelvic abscess, vaginal cuff dehiscence, hematoma, and venous thromboembolism (Figure 2, A and B). Causes for readmission in any time frame were also not significantly different between the 2 groups (Table 5).
      Table 5Readmission (within 6 weeks) (n = 141)
      IndicationSame-day discharge, % (n) (n = 118)Overnight stay, % (n) (n = 23)P value
      Pelvic abscess5.1% (6)4.3% (1)> .999
      Vaginal cuff dehiscence1.7% (2)4.3% (1).416
      Hematoma1.7% (2)0.0% (0)> .999
      Venous thromboembolism0.8% (1)4.3% (1).301
      Fistula0.8% (1)0.0% (0)> .999
      Pain1.7% (2)0.0% (0)> .999
      Pneumonia0.8% (1)0.0% (0)> .999
      Ureteral re-implantation0.8% (1)0.0% (0)> .999
      Vaginal bleeding0.8% (1)4.3% (1).301
      Any readmission11.0% (13)17.4% (4).481
      Total readmissions 17 patients.
      Penner. Same day DC safety. Am J Obstet Gynecol 2015.

      Emergency room visits, unscheduled office visits, and verbal contacts

      There was no significant difference between the same-day group or overnight group by postoperative day 7 or 14 in terms of emergency room visits without admission to the hospital (day 7, P = NS; day 14, P = NS; Figure 2, A and B, respectively). With regard to unscheduled office visits, more patients in the overnight group had an unscheduled office visit within 7 and 14 postoperative days, although the difference was not statistically significant (Figure 2, A and B). There were no significant differences between the same-day discharge and overnight admission groups in terms of verbal contact (either face to face, by phone, or by e-mail) within 7 or 14 postoperative days (Figure 2, A and B).

      Multivariate model to predict contact within 14 days postoperatively

      A multivariate logistic regression was performed, and variables eliminated via backward elimination to identify the factors that were predictive of unscheduled contact with a medical provider within 14 days postoperatively (Table 6 and Figure 3). Again, unscheduled contact included any hospital readmission, any emergency room visit without readmission, any office visit other than those already scheduled, and/or any complication. The only factor that met the criteria for inclusion in the multivariate model assessing unscheduled contact within 14 days was a history of smoking within the last 10 years (OR, 4.92; P = .03); however, this failed to meet our predetermined threshold for significance. In a multivariate analysis, there was no difference in postoperative contacts within 14 days between the same-day discharge and overnight admission groups or by any clinical risk factor.
      Table 6Multivariate analysis for unscheduled contacts
      VariableORSEzP > |z|95% CI lower bound95% CI upper bound
      Age1.010.02520.30.7660.9591.06
      Cardiovascular disease0.1700.219−1.37.1700.0142.13
      Lung disease3.001.911.72.0860.85610.50
      Diabetes1.300.9420.36.7190.3135.38
      Hypertension0.9640.528−0.07.9460.3292.82
      Smoked within last 10 y4.923.652.14.0321.15021.10
      Cervical cancer (vs endometrial)3.022.141.56.1190.75312.10
      Surgery start time 2:00 pm0.9030.670−0.14.8910.2113.87
      Surgery duration ≥180 min0.7890.446−0.42.6750.2612.39
      Overnight stay0.8500.549−0.25.8010.2393.02
      CI, confidence interval; OR, odds ratio.
      Penner. Same day DC safety. Am J Obstet Gynecol 2015.
      Figure thumbnail gr3
      Figure 3Odds ratios for unscheduled postoperative contacts
      Multivariate model to identify the predictors of unplanned patient contact following discharge. Only a current smoking history reached criteria for inclusion (P < .05); no variable was significantly associated with postoperative contacts (P < .01).
      Penner. Same day DC safety. Am J Obstet Gynecol 2015.

      Comment

      Recent literature supports the safety of same-day discharge after minimally invasive cardiac and orthopedic surgeries as well as after routine minimally invasive cholecystectomy or hysterectomy.
      • Gien L.T.
      • Kupets R.
      • Covens A.
      Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology.
      • Hoekstra A.V.
      • Jairam-Thodla A.
      • Rademaker A.
      • et al.
      The impact of robotics on practice management of endometrial cancer: transitioning from traditional surgery.
      However, a much smaller body of literature is available regarding the feasibility of same-day discharge after comprehensive minimally invasive gynecological oncology procedures. To our knowledge this is the first study restricted to only those patients who had complex, comprehensive gynecological oncology staging for endometrial and cervical malignancy via both traditional laparoscopic and robotic-assisted approaches.
      We found no significant difference in complication or readmission rates whether subjects were discharged to home on the day of surgery or admitted overnight. Additionally, we are able to show that same-day discharge does not result in a significant change in the contacts between the patient and the health care system.
      In examining the factors associated with overnight stay in patients planned for same-day discharge, age, body mass index, or medical comorbidities were not predictive. Rather, the primary factors leading to an overnight stay were laparoscopic vs robotic approach (OR, 9.05; P = .001), surgery starting after 2:00 pm (OR, 36.8; P < .0001), delay in ability to tolerate oral intake (OR, 9.31; P = .002), and severe pain (pain score of 7 of ≥10) in PACU (OR, 6.81; P = .006). Differences in admission between the laparoscopic and robotic groups may be explained by a more consistent set of staff involved with the robotic patients who were trained in the practice of same-day discharge.
      Interestingly, none of the factors predictive of overnight stay was associated with an increase in unscheduled postoperative contacts (complications, readmissions, emergency room visits, or unscheduled office visits). In addition, in both bivariate and multivariate analyses, neither overnight stay nor same-day discharge were found to be predictive of any form of unscheduled postoperative contacts. As with an overnight stay, age, medical comorbidities, and surgical features were not associated with a significant difference in unscheduled postoperative contacts.
      The perioperative outcomes in this study reinforce data from other published studies of the safety and feasibility of same-day discharge for patients after gynecological surgery, whether for benign conditions or cancer. For a simple hysterectomy in benign conditions, same-day discharge rates range from 52% to 92% and complication rates vary from 3.6% to 7.5%.
      • Morrison Jr., J.E.
      • Jacobs V.R.
      Outpatient laparoscopic hysterectomy in a rural ambulatory surgery center.
      • Perron-Burdick M.
      • Yamamoto M.
      • Zaritsky E.
      Same-day discharge after laparoscopic hysterectomy.
      • Thiel J.
      • Gamelin A.
      Outpatient total laparoscopic hysterectomy.
      Gien et al
      • Gien L.T.
      • Kupets R.
      • Covens A.
      Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology.
      were the first to show that same-day discharge for gynecological oncology patients treated with traditional laparoscopy is feasible. Less than 5% of patients were readmitted to the hospital within 3 weeks after surgery. The likelihood of readmission increased with age, duration of surgery, and surgeries that started after 1:00 pm.
      In contrast, our analysis revealed a readmission rate of 2.5% at 2 weeks, and we did not find an association between age, duration of surgery, or late surgery start time (here, after 2:00 pm) with the likelihood of readmission. Although we did follow up patients for contacts and complications through the conventional 6 week postoperative window, we elected to focus on the data regarding patient contacts only in the first 2 weeks after surgery. We do not believe that the timing of discharge would have an impact on postoperative contacts outside the initial 2 week window.
      One of the strengths of our study is that the Kaiser Permanente system has implemented a robust EMR. Thus, the patients’ clinical information is accurate and consistent throughout follow-up. Another strength is that the data from this study would be generalizable to a patient population that is similarly diverse as that of Kaiser Permanente Southern California. As opposed to other studies showing 40-50% lower use of minimally invasive techniques in minority populations, 41% of our study population was nonwhite.
      • Jacoby V.L.
      • Autry A.
      • Jacobson G.
      • Domush R.
      • Nakagawa S.
      • Jacoby A.
      Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches.
      The focus on patient safety is another strength of this study. A primary deterrent to same-day discharge in many settings is a clinician’s hesitance about a possible untoward event in the immediate postoperative period. To address that issue, we were able to leverage the comprehensive EMR at Kaiser Permanente to track all unplanned patient contacts, not just readmissions. Thus, the model presented includes same-day discharge (vs overnight stay) as well as clinical risk factors found in the literature to be associated with readmission or often presented as prohibitive of same-day discharge because of the risk of short-term complication.
      • Walsh C.A.
      • Walsh S.R.
      • Tang T.Y.
      • Slack M.
      Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis.
      The major limitation of this study is the retrospective study design, which may introduce selection bias because surgeons may select patients for robotic-assisted or traditional laparoscopy based on surgical complexity. We tried to overcome this limitation by including all patients within the defined time period. We were able to limit the influence of the surgeon on this bias because all surgical cases were performed by the same operating surgeons (A.E.A. and S.E.L.). Furthermore, Kaiser Permanente Southern California has clear postoperative recovery protocols that were in use at both facilities during the study period.
      Although this study’s results offer preliminary support for same-day discharge with patient populations similar to those served by the Kaiser Permanente Southern California system, long-term randomized trials that evaluate both direct and indirect costs (like time away from work and disability) and long-term clinical and quality-of-life outcomes are still needed to confirm the feasibility, safety, and generalizability of same day discharge for patients undergoing surgical staging for gynecological cancers.
      This study confirms that same-day discharge for robotic-assisted or traditional laparoscopic comprehensive gynecological cancer staging procedures is safe and feasible. Factors that predict same-day discharge include severe pain in the PACU, laparoscopic vs robotic-assisted procedure, delayed time to oral intake, and surgery start time at 2:00 pm or later. Few patients had unscheduled visits to medical providers during the immediate postoperative period, and same-day discharge was not associated with an increase in unscheduled postoperative contacts. These results have led to an adoption of same-day discharge across other surgical specialties at our facility without jeopardizing patient safety.

      Acknowledgments

      We are grateful to Ms Jane Neff Rollins, MSPH, for medical writing assistance. Author contributions including the following: K.R.P., N.D.F., L.B., A.E.A., and S.E.L. were responsible for the conception and design; K.R.P., L.B., N.D.F. were responsible for the collection and assembly of the data; K.R.P. performed the data analysis and interpretation; K.R.P., N.D.F., A.E.A., and S.E.L. wrote the manuscript; and all authors had final approval of the manuscript.

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