(53) Implementation of an Enhanced Recovery After Surgery Pathway in Adolescent Patients Undergoing Laparoscopic Evaluation of Endometriosis

Background: In July 2023, a multi-disciplinary team from a tertiary children’s hospital implemented an enhanced recovery after surgery (ERAS) pathway to standardize care and improve the perioperative experience for adolescents undergoing diagnostic laparoscopy for endometriosis. Pathway components include pre-operative gynecologic and anesthesia visits, intraoperative multimodal analgesia, and postoperative management (Fig 1 & 2). This study aimed to (1) assess perioperative compliance to the Endometriosis ERAS pathway, and (2) evaluate patient metrics as indicators for pathway efficacy pre- and post- pathway implementation.

Methods: This was an IRB approved, single-site study of patients aged 12-20 undergoing laparoscopy for endometriosis. Data was collected from 6/2022-6/2023 (pre-ERAS) and 8/2023- 8/2024 (post-ERAS). To assess pathway compliance (aim 1) the rates of preoperative prescription, referral placement, day of surgery preoperative medication, preoperative carbohydrate loading, intraoperative anesthesia bundle, and postoperative prescriptions were measured. Post Anesthesia Care Unit (PACU) length of stay, discharge pain score, and patient concerns (ER visit, phone call/message, or readmissions) were interpreted as surrogate metrics for pathway efficacy (aim 2) and were analyzed pre and post intervention using independent t-tests and Chi squared/Fisher’s exact tests. All data analysis was performed using SPSS.

Results: 53 patients were included (20 pre and 33 post-ERAS). Mean age was 16.6 years (SD 1.7). Compliance was as follows: 81% preoperative prescriptions, 45% pain management referrals, 33% physical/occupational therapy, 76% day of surgery preoperative medications, 39% preoperative carbohydrate load, 87% intraoperative bundle compliance, and 61% postoperative prescriptions. PACU length of stay, discharge pain scores, and patient concerns were not significantly different pre vs post ERAS.

Conclusions: The Endometriosis ERAS pathway was a multidisciplinary team effort and has overall high compliance but leaves room for improvement in some facets (particularly specialty referrals and preoperative carbohydrate loading). While our data does not show improved patient metrics in the pre vs post pathway group, this is likely reflective of our efforts to emulate this pathway in the year leading up to implementation. Future directions include: analyzing a pre-ERAS group more remote from the pathway start date, revisiting the multidisciplinary team to see what barriers exist to improve compliance, and eliciting qualitative feedback from patients about their perspective.