Hysterectomy is one of the major gynecologic procedures and the second most common surgery in women after cesarean section (1), which could be performed via different methods, including abdominal, vaginal, and laparoscopic hysterectomy (2-5). Although routine abdominal hysterectomy (RAH) is still the most frequently performed procedure and the only available technique for enlarged uteri (6), there are some challenges associated with it and the pre-, peri-, and post-operative measurements (7-9). On the other hand, surgery and anesthesia generally have negative impacts on human physiology and cause unpleasant feelings in patients (10-13).
Fast-track surgery is a multi-modal strategy that reduces the hormonal response to surgery-induced stress and improves post-operative recovery without a need for re-hospitalization (14-18). This approach prevents and reduces post-operative pain, nausea and vomiting, paralytic ileus, weakness, and fatigue, and relies on the following principles: to inform the patient about the process of surgery, safe painless recovery with minimum doses of opioids, minimal invasive surgery, improved management of post-surgery pain and nausea, reduced fasting time before surgery and rapid feeding after surgery, early walking after surgery, and intravenous fluid therapy during surgery, avoiding the insertion of nasogastric tube and drain, administration of topical anesthetics to control pain, and thromboembolism prophylaxis (19-23).
This strategy is rarely investigated in gynecologic surgeries (19, 24, 25) and in particular there is no report of such practice from Iran. This study was designed to compare the results of FTH with those of RAH in Kowsar Training Hospital, Qazvin, Iran.

 

Study Design and Setting

This prospective randomized case-control pilot study was carried out on 82 patients between 30-60 years old, eligible for hysterectomy, who had attended the Obstetrical and Gynecological Clinic at Kowsar Training Hospital in Qazvin, Iran.
The patients were randomly divided into two equal groups of 41 members. Data collection was carried out through completion of a questionnaire specifically designed for this study. Patients' demographic and clinical information including age, gravidity, history of other diseases and abdominal surgery, degree of pain based on VAS at 3, 6, 12, and 24 hours post-operation, tolerance to normal diet, administered painkiller dose, postoperative nausea and vomiting, duration of hospital stay, time of first gas passing, and readmission were recorded.

Severity of Nausea and Vomiting

The severity of nausea was rated in three categories and marked as no nausea, mild nausea without vomiting and need for antiemetic agent, and severe nausea and vomiting in need of antiemetic therapy which was treated with ondansetron 4 mg, intravenously injected, when necessary. The presence of nausea and vomiting were recorded 3, 6, 12, and 24 hours post-operation in the study checklist.
Severity of Pain and First Gas Passage
To analyze the degree of pain more accurately based on VAS, 3 categories were considered as below:

• Slight pain: scored as 0, 1, 2, and 3

• Moderate pain: scored as 4, 5, and 6

• Severe pain: scored as 7, 8, 9, and 10

The degree of pain was recorded 3, 6, 12, and 24 hours post-operation in the study checklist. Moreover, the time of first passage of gas was questioned and noted.

Post-operative Complications

Post-operative complications including severe bleeding, need for blood transfusion, need for reoperation for any reason associated with hysterectomy, deep vein thrombosis (DVT) and pulmonary embolism, rehospitalization, urinary tract infection, Foley catheter remaining in place at discharge, wound complications including bleeding and infection, vaginal cuff bleeding and infection, and severe prolonged post-operative ileus were also recorded.

Discharging the Patient

The women who could walk and tolerate normal diet, had easy urination, manageable pain with oral painkillers, no fever, and no signs of intestinal obstruction were ready to be discharged. If a patient did not feel well enough to be discharged for any reason, the cause for inability to discharge was recorded. The patients were reexamined for the presence of any complication one week after discharge during suture removal.

Treatments on the Patients

Treatments on FTH Group:

• Following admission, the patients did not require fasting and could drink two glasses of filtered sweet fluid 2 hours pre-operation.

• Fluid therapy was limited to 500 mL ringer solution within an hour prior to surgery.

• The patients received 100 mg diclofenac suppository immediately before surgery.

• Antiemetic prophylaxis was achieved by intravenous injection of 8 mg betamethasone following induction of anesthesia.

• Once the patient was transferred to the ward, 100 mL lactated ringer’s solution was given until the permission for oral nutrition.

• The painkiller was 100 mg diclofenac rectal suppository (every 8 hours) and in cases of more severe pain, ketorolac was administered. Preferably, no opioid was used.

• Patients were encouraged to move and walk 6 hours post-operation.

• The patients were allowed to drink at least 6 hours after surgery if tolerated.

• Foley catheter was immediately removed following mobilization.

Treatments on RAH Group:

• Patients were required to keep fasting for 12 hours before the surgery.

• hydration was unlimited and based on the decision made by the anesthesiologist in charge.

• Fluid replacement therapy during surgery was equal to the volume of fluid loss.

• After operation, the volume of fluid replacement therapy was unlimited (3 L 1:3 and 2:3 per 24 hours).

• Patients were allowed to walk and eat filtered liquid foods 24 hours post-surgery.

• Foley catheter was left until the next morning.

General Treatments

• Antibiotic prophylaxis was performed for all patients according to the hospital routine guidelines.

• Anticoagulant prophylaxis was given according to the hospital protocols.

• Foley catheter was inserted before surgery.

• General anesthesia was induced by intravenous injection of propofol 1-2 mg/kg and fentanyl 1-2 µg/kg followed by tracheal intubation facilitated by intravenous injection of atracurium 5 mg/kg and continued by propofol perfusion 100-120 µg/kg/min.

• According to the decision made by the anesthesiologist, the administration of atracurium and fentanyl was repeated.

• Ephedrine 5-10 mg was also injected when systolic pressure showed 30% reduction compared to the baseline pressure.

• The anesthesia methods used for both groups were almost similar except for the application of fentanyl for the FTH group, which was only injected at time of anesthesia induction and was not repeated during the surgery if possible.

• Hysterectomy was performed according to the hospital routine guidelines.

• Diclofenac rectal suppository (100 mg) was re-administered at the end of surgery.

• Hemodynamic status of patients in both groups was monitored according to the routine protocols used in the ward.

Ethical Statement

This study was approved by the Ethics Committee of Qazvin University of Medical Sciences (Code: IR.QUMS.REC.1395.318) at 20.08.2018 and performed after submission of written signed informed consent form by each patient.
 

Statistical Analysis

Data were analyzed using SPSS^® software, version 24. Qualitative variables were presented as frequency tables and frequency percents and those of quantitative variables were calculated as mean ± standard deviation. Statistical tests included Fisher's exact test, Chi square test, and independent t-test. P-value equal to 0.05 was considered as statistically significant.