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P015: AN ENHANCED RECOVERY PROTOCOL IMPROVES OUTCOMES FOR PATIENTS UNDERGOING COMPLEX ABDOMINAL WALL RECONSTRUCTION
Todd R Smolinsky, MD; Jameson G Wiener, MD; Sellers Boudreau, MD; Britney P Corey, MD; Daniel I Chu, MD; Abhishek D Parmar, MD; University of Alabama at Birmingham
Introduction: Enhanced recovery protocols (ERP) have the potential to streamline care and improve short-term outcomes for surgical patients. However, for patients undergoing complex abdominal wall reconstruction (AWR), little literature exists on the effectiveness of these protocols.
Methods: We reviewed our institutional experience with complex AWR over a 2-year period (January 2018-January 2020). We identified patients undergoing complex abdominal wall reconstruction who were compliant with four out of eleven critical elements of our ERP (preoperative regional nerve block, regular diet postoperative day 1, foley removal postoperative day 1, and postoperative multimodal analgesic use). These compliant patients (N=48) were compared to patients who did not meet these criteria (N=89). The primary outcome of interest was hospital length of stay while secondary outcomes included inpatient complications, inpatient narcotic usage, readmissions, and pain medication needs at postoperative follow-up.
Results: We identified 137 patients during the study period. The majority of the patients were female (61.3%), white (75.9%), ASA 3 (70.8%), and nonsmokers (91.2%) with an average BMI of 31.8 + 4.8. Average hernia widths and lengths were 7.1 (+ 2.8) and 11.0 (+4.4), respectively. 61.3% of the operations were performed minimally invasively and included retrorectus (51.8%) and transversus abdominus release (48.2%). The average length of stay for the overall cohort was 3.65 days (+ 3.8 days). Morbidity and mortality rates were 22.6% and 0.7%. Only 18.3% of patients were compliant with all 11 elements of our ERP. ERP and non-ERP patients had similar ASA statuses (p=0.69), sex (p=0.56), BMIs (p=0.19), smoking statuses (p=0.9), operative times (p=0.8), estimated blood loss (0.3), and hernia lengths and widths (p= 0.7 and 0.3). ERP patients were more likely to have a diagnosis of hypertension (68.8% vs. 42.7%, p<0.01) and anticoagulation use (47.9% vs. 19.2%, p=0.0004), and to have undergone HgbA1c testing preoperatively (89.6% vs. 33.7%, p=0.0001). ERP patients were more likely to undergo a minimally invasive approach to AWR (91.7% vs. 44.9%, p<0.01). ERP patients had a significantly lower average length of stay (2.0 days vs. 4.5 days, p<0.01), were less likely to have a complication (12.5% vs. 28.1%, p=0.04), and required fewer morphine equivalents (p=0.02). While non-significant, ERP patients had trends towards lower rates of readmissions (4.2% vs. 13.5%, p=0.08) and pain medication needs at follow-up (10.4% vs. 21.6%, p=0.1).
Conclusion: Patients undergoing complex abdominal wall reconstruction within an ERP pathway experience fewer complications, decreased postoperative length of stay, and require less narcotics during their hospitalization compared to their non-ERP counterparts. The novel evidence provided by this study indicates that ERP pathways are effective in patients undergoing complex abdominal wall reconstruction and can provide benefits for both patients and hospitals.
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