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Fast track abdominal hysterectomy: On the mode of anesthesia, postoperative recovery and health economics
Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Hysterectomy is the most common major gynecological operation in the Western World and approximately 5000 benign hysterectomies are performed in Sweden every year. Consequently it is a surgical procedure that affects many women. The procedure comprises challenges concerning perioperative health care, perceived postoperative symptoms, quality of life aspects and health economics. The concept of fast track is a multimodal strategy to reduce hormonal surgical stress response and achieve an enhanced postoperative recovery and is today considered to be evidence based in relation to colorectal surgery. Spinal anesthesia, as an important part of fast track, provides benefits of extended effect on analgesia and reduced postoperative morbidity. It is reasonable to believe that employing the strategies of fast track including spinal anesthesia could also provide substantial benefits for women requiring surgical removal of the uterus.

Aims: To determine whether duration of hospital stay, presence and intensity of postoperative symptoms, duration of sick leave and cost-effectiveness differ between women undergoing benign fast track abdominal hysterectomy in spinal anesthesia with intrathecal morphine (SA) and in standard general anesthesia (GA).

Material & Methods: 180 women participated in this open randomized multicenter study with five participating hospitals in the southeast region of Sweden. One hundred and sixty two completed the study; 82 women were randomized to SA and 80 to GA. A fast track model comprising premedication without sedatives, intravenous fluid regulation, analgesics based on non-opioids, pre-emptive antiemetic therapy, early enteral nutrition and mobilization and standard criteria for discharge were used. End points were duration of hospital stay, use of analgesics, perceived postoperative symptoms, occurrence of postoperative complications, duration of sick leave and health economic evaluations.

Results: Duration of hospital stay did not differ between the two modes of anesthesia. Vomiting and pruritus occurred significantly more often after SA. Complication rates did not differ between groups. Women with SA experienced less overall discomfort and had a reduced need for opioids postoperatively. Abdominal pain, drowsiness and fatigue occurred less often and with lower intensity among the women in the SA group. Health related quality of life improved faster and the duration of sick leave was shorter in women after SA. Total costs (hospital costs plus costs for productivity loss) were lower for the SA group. Within the first 29 days after hysterectomy the women in the SA group gained more QALYs than women in the GA group.

Conclusions: The duration of hospitalisation after fast track abdominal hysterectomy was less than 50 hours and mode of anesthesia did not influence this. SA displayed considerable advantages regarding postoperative symptoms and recovery. SA was considered cost-effective in comparison with GA due to lower total costs and more QALYs gained. Our study indicates that SA should be recommended as the first choice of anesthesia in benign abdominal hysterectomy.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2011. , 75 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1251
Keyword [en]
Abdominal hysterectomy; Cost-effectiveness; Fast track; General anesthesia; Health economy; Intrathecal morphine; Postoperative recovery Postoperative symptoms Randomized study; Spinal anesthesia; Quality of Life
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-70469ISBN: 978-91-7393-107-6 (print)OAI: oai:DiVA.org:liu-70469DiVA: diva2:439816
Public defence
2011-10-07, Berzeliussalen, Ingång 65, Campus US, Linköpings Universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2011-09-09 Created: 2011-09-09 Last updated: 2011-09-12Bibliographically approved
List of papers
1. The impact of mode of anaesthesia on postoperative recovery from fast-track abdominal hysterectomy: a randomised clinical trial
Open this publication in new window or tab >>The impact of mode of anaesthesia on postoperative recovery from fast-track abdominal hysterectomy: a randomised clinical trial
2011 (English)In: BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY, ISSN 1470-0328, Vol. 118, no 3, 299-308 p.Article in journal (Refereed) Published
Abstract [en]

Objective To determine whether the duration of hospital stay after abdominal hysterectomy in a fast-track setting differed between women operated under general anaesthesia or in spinal anaesthesia with intrathecal morphine. Design An open randomised controlled multicentre study. Setting Five hospitals in the south-east of Sweden. Population One hundred and eighty women scheduled for benign hysterectomy were randomised: 162 completed the study, 82 were allocated to spinal anaesthesia and 80 were allocated to general anaesthesia. Methods Fast-track model comprising no use of sedatives for premedication, pre-emptive anti-emetic therapy, intravenous fluid restriction, analgesics based on non-opioids, early enteral nutrition and mobilisation, and standard criteria for discharge. Spinal anaesthesia with 20 mg hyperbaric bupivacaine and 0.2 mg morphine. General anaesthesia with propofol, fentanyl and rocuronium, and with continuous propofol and ventilation with oxygen-in-air for maintenance of anaesthesia. Main outcome measures Hospital stay, consumption of analgesics, vomiting, pruritus and bowel function recovery. Results Median hospitalisation did not differ significantly between women who had hysterectomy with spinal or general anaesthesia (46 and 50 hours, respectively). Spinal anaesthesia was associated with a significantly lower use of opioids and a faster recovery of bowel function, although vomiting and pruritus were more prevalent. Conclusions In a fast-track model the duration of hospitalisation after abdominal hysterectomy was andlt; 50 hours, independent of the mode of anaesthesia. Spinal anaesthesia reduced the need for postoperative morphine compared with general anaesthesia. In order to improve patient recovery after gynaecological surgery further studies based on fast-track programmes are needed.

Place, publisher, year, edition, pages
Blackwell Publishing Ltd., 2011
Keyword
Fast-track, general anaesthesia, hysterectomy, intrathecal morphine, randomised study, spinal anaesthesia
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-66315 (URN)10.1111/j.1471-0528.2010.02697.x (DOI)000286148300006 ()
Note

This is the authors’ version of the following article: Ninnie Borendal Wodlin, Lena Nilsson and Preben Kjölhede, The impact of mode of anaesthesia on postoperative recovery from fast-track abdominal hysterectomy: a randomised clinical trial, 2011, BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY, (118), 3, 299-308. which has been published in final form at: http://dx.doi.org/10.1111/j.1471-0528.2010.02697.x Copyright: Blackwell Publishing Ltd. http://eu.wiley.com/WileyCDA/Brand/id-35.html

Available from: 2011-03-11 Created: 2011-03-11 Last updated: 2015-06-08
2. Mode of anesthesia and postoperative symptoms following abdominal hysterectomy in a fast-track setting
Open this publication in new window or tab >>Mode of anesthesia and postoperative symptoms following abdominal hysterectomy in a fast-track setting
2011 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 4, 369-379 p.Article in journal (Refereed) Published
Abstract [en]

Objective. To determine whether postoperative symptoms differ between women who undergo abdominal benign hysterectomy in a fast-track model under general anesthesia or spinal anesthesia with intrathecal morphine. Design. Secondary analysis from a randomized, open, multicenter study. Setting. Five hospitals in south-east Sweden. Population. One-hundred and eighty women scheduled for benign hysterectomy were randomized; 162 completed the study; 82 were allocated to spinal and 80 to general anesthesia. Methods. The Swedish Postoperative Symptoms Questionnaire, completed daily for 1 week and thereafter once a week until 5 weeks postoperatively. Main Outcome Measures. Occurrence, intensity and duration of postoperative symptoms. Results. Women who had hysterectomy under spinal anesthesia with intrathecal morphine experienced significantly less discomfort postoperatively compared with those who had the operation under general anesthesia. Spinal anesthesia reduced the need for opioids postoperatively. The most common symptoms were pain, nausea and vomiting, itching, drowsiness and fatigue. Abdominal pain, drowsiness and fatigue occurred significantly less often and with lower intensity among the spinal anesthesia group. Although postoperative nausea and vomiting was reported equally in the two groups, vomiting episodes were reported significantly more often during the first day after surgery in the spinal anesthesia group. Spinal anesthesia was associated with a higher prevalence of postoperative itching. Conclusions. Spinal anesthesia with intrathecal morphine carries advantages regarding postoperative symptoms and recovery following fast-track abdominal hysterectomy.

Place, publisher, year, edition, pages
Informa Healthcare, 2011
Keyword
Abdominal hysterectomy, anesthesia, fast track, postoperative symptoms, randomized study
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67978 (URN)10.1111/j.1600-0412.2010.01059.x (DOI)000289515500013 ()
Note

Original Publication: Ninnie Borendal Wodlin, Lena Nilsson, Kristofer Arestedt and Preben Kjölhede, Mode of anesthesia and postoperative symptoms following abdominal hysterectomy in a fast-track setting, 2011, ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA, (90), 4, 369-379. http://dx.doi.org/10.1111/j.1600-0412.2010.01059.x Copyright: Informa Healthcare http://informahealthcare.com/

Available from: 2011-05-04 Created: 2011-05-04 Last updated: 2017-12-11
3. Health-related quality of life and postoperative recovery in fast-track hysterectomy
Open this publication in new window or tab >>Health-related quality of life and postoperative recovery in fast-track hysterectomy
2011 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 90, no 4, 362-368 p.Article in journal (Refereed) Published
Abstract [en]

Objective. To determine whether health-related quality of life (HRQoL) and postoperative recovery of women who undergo abdominal hysterectomy in a fast-track program under general anesthesia (GA) differ from women who receive spinal anesthesia with intrathecal morphine (SA). Design. Secondary analysis from an open randomized controlled multicenter study. Setting. Five hospitals in south-east Sweden. Population. One hundred and eighty women admitted for abdominal hysterectomy for benign disease were randomized; 162 completed the study, 80 with GA and 82 with SA. Methods. The HRQoL was measured preoperatively using the EuroQoL EQ-5D and the Short-Form-36 health survey (SF-36) questionnaires. The EQ-5D was used daily for 1 week; thereafter, once weekly for 4 weeks and again 6 months after operation. The SF-36 was completed at 5 weeks and 6 months. Dates of commencing and ending sick leave were registered. Main Outcome Measures. Changes in HRQoL; duration of sick leave. Results. The HRQoL improved significantly faster in women after SA than after GA. Sick leave was significantly shorter after SA than after GA (median 22.5 vs. 28 days). Recovery of HRQoL and duration of sick leave were negatively influenced by postoperative complications. In particular, the mental component of HRQoL was negatively affected by minor complications, even 6 months after the operation. Conclusions. Spinal anesthesia with intrathecal morphine provided substantial advantages in fast-track abdominal hysterectomy for benign gynecological disorders by providing faster recovery and shorter sick leave compared with general anesthesia.

Place, publisher, year, edition, pages
Informa Healthcare, 2011
Keyword
Abdominal hysterectomy, anesthesia, fast-track program, quality of life, randomized study
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67977 (URN)10.1111/j.1600-0412.2010.01058.x (DOI)000289515500012 ()
Note

Original Publication: Ninnie Borendal Wodlin, Lena Nilsson and Preben Kjölhede, Health-related quality of life and postoperative recovery in fast-track hysterectomy, 2011, ACTA OBSTETRICIA ET GYNECOLOGICA SCANDINAVICA, (90), 4, 362-368. http://dx.doi.org/10.1111/j.1600-0412.2010.01058.x Copyright: Informa Healthcare http://informahealthcare.com/

Available from: 2011-05-04 Created: 2011-05-04 Last updated: 2017-12-11
4. Cost-effectiveness of general anesthesia versus spinal anesthesia in fast track abdominal benign hysterectomy
Open this publication in new window or tab >>Cost-effectiveness of general anesthesia versus spinal anesthesia in fast track abdominal benign hysterectomy
2011 (English)In: American Journal of Obstetrics and Gynecology, ISSN 0002-9378, E-ISSN 1097-6868, Vol. 205, no 4, 043- p.Article in journal (Refereed) Published
Abstract [en]

Objective: The study objective was to compare total costs for hospital stay and postoperative recovery for two groups of women who underwent fast track abdominal benign hysterectomy, one group under general anesthesia, the other under spinal anesthesia. Costs were evaluated in relation to health related quality of life.

Study Design: Costs of treatment using data from a randomized multicenter study at five hospitals in Sweden were analyzed retrospectively. Of 180 women scheduled for benign abdominal hysterectomy; 162 were randomized for the study, 80 allocated to general anesthesia and 82 to spinal anesthesia.

Results: Total costs (hospital costs plus costs reduced productivity costs) were lower for the spinal anesthesia group. Women who had spinal anesthesia had a faster recovery measured by health related quality of life and QALYs gained in postoperative month one.

Conclusion: Use of spinal anesthesia for fast track benign abdominal hysterectomy was more cost-effective than general anesthesia.

Place, publisher, year, edition, pages
Elsevier, 2011
Keyword
Cost-effectiveness; Fast track hysterectomy; General anesthesia; Health economy; Spinal anesthesia
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-70468 (URN)10.1016/j.ajog.2011.05.043 (DOI)000296084600022 ()
Note

Funding agencies|Medical Research Council of South East Sweden||Linkoping University||County Council of Ostergotland||multicenter study group||

Available from: 2011-09-09 Created: 2011-09-09 Last updated: 2017-12-08Bibliographically approved

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