Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery

Eleftheria Kalogera, Gregg Nelson, Jessica Liu, Q Lina Hu, Clifford Y Ko, Elizabeth Wick, Sean C Dowdy

The Agency for Healthcare Research and Quality (AHRQ), in partnership with the American College of Surgeons (ACS) and the Armstrong Institute (AI) at Johns Hopkins, developed the Safety Program for Improving Surgical Care and Recovery (ISCR), which integrates principles of implementation science into adoption of enhanced recovery pathways (ERP) and promotes evidence-based perioperative care. The objective of this study is to review the ERPs literature in gynecologic surgery (GS) and provide the framework for ISCR pathway for GS. We searched PubMed and Cochrane Central Register of Controlled Trials databases from 1990 to October 2017. Studies were included in hierarchical and chronological order: meta-analyses, systematic reviews, randomized controlled trials, interventional and observational studies. ERP components relevant to GS were identified through review of existing pathways. A PubMed search for each component was performed in GS and expanded to include colorectal surgery as needed in order to have sufficient evidence to support or deter a process. This review focuses on surgical components; anesthesiology components are reported separately in a companion article in the anesthesiology literature. Fifteen surgical components were identified: patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization, early postoperative feeding, early IV fluid discontinuation, early removal of urinary catheters, use of laxatives, chewing gum, peripheral mu antagonists, surgical site infection reduction bundle, glucose management, pre- and postoperative venous thromboembolism prophylaxis. In addition, 14 components previously identified in the colorectal ISCR pathway review were included in the final pathway. Evidence and existing guidelines support 29 protocol elements for the AHRQ Safety Program for ISCR in GS.