2026 Southeastern Residency Conference

Evaluation of Postoperative Outcomes and the Impact of an Enhanced Recovery Pathway in Patients Who Have Undergone a Laparotomy Procedure

Mackenzie Winter Waters, Melissa Bagwell, Leborah Cole Lee, Courtney Reliford, Kayla Brown

Abstract
Purpose: Utilization of an enhanced recovery pathway (ERP) perioperatively has shown benefit in reducing postoperative symptoms, complications, length of stay, and readmission rates, but it is not widely utilized at our institution. The purpose of this study was to supplement current literature regarding the clinical impact of an ERP on patient outcomes following surgical procedures by retrospectively assessing patients’ postsurgical outcomes as it relates to ERP utilization compared to those who received standard of care. The hypothesis of this study is that implementation of an ERP would result in a reduction in opioid consumption and a decrease in postoperative complications.

Methods: This single-center, retrospective chart review was approved by the Institutional Review Board at East Alabama Medical Center (EAMC) and evaluated the impact of an ERP after the following elective open laparotomy surgical procedures: gynecologic-oncologic, colorectal, and/or hysterectomy. The primary outcome was total morphine milliequivalents (MME) utilized during inpatient hospitalization stay (IHS). Secondary outcomes included average pain scales, adverse drug events related to narcotics, prescribed narcotic(s) on discharge, incidence of postoperative ileus, incidence of acute kidney injury, adherence to the ERP postoperative analgesic medication regimen (> 75% scheduled doses received), average daily dose of narcotics (in MME) and non-narcotic medications (in mg) used for pain management, length of IHS, 30- and 90-day hospital readmission, and 90-day mortality. Patients were identified using the electronic medical record and assessed for the following inclusion criteria: ≥19 years of age and hospitalized for previously defined elective surgical procedures between May 1, 2024, and May 31, 2025. Exclusion criteria included pregnancy, prisoners, males, length of IHS <24 hours, patients admitted with a bowel obstruction or ileus prior to surgery, and patients who received a patient-controlled analgesia pump for pain management. Criteria were assessed to obtain at least 50 patients in the ERP group and 50 patients in the non-ERP group. Data analysis was conducted using a Chi-square, Fisher’s exact test, Student’s t-test, or Mann-Whitney U test dependent on data type and distribution. All statistical analyses were performed in IBM SPSS Statistics version 30.0.0.0 (IBM Corp., 2024).

Results: There were 1,582 patients screened for inclusion, with 50 patients in each group meeting inclusion criteria. Patients within the ERP group used a lower amount of total MME compared to the non-ERP group (median 766.3 versus 935, P = 0.046). The ERP group had a lower average daily MME utilization (median 242.5 versus 316.7, P = 0.005), lower average pain scales (median 3.4 versus 5.5 (on a 10-point scale), P < 0.001), and a higher average daily utilization of APAP in mg (median 2066.7 versus 1175, P < 0.001). Differences in narcotics prescribed at discharge showed statistical significance (P < 0.001), and post-HOC analysis was performed with the adjusted P value for significance set at < 0.008. Oxycodone was prescribed more frequently in the ERP group (68% versus 28%; P < 0.001) and oxycodone-APAP prescribed more frequently in the non-ERP group (50% versus 10%; P < 0.001). All other secondary outcomes did not show statistical significance.

Conclusion: Utilization of an ERP perioperatively resulted in clinically and statistically significant reductions in narcotic utilization and average pain scales throughout hospitalization. One strength is this study included evaluation of pain outcomes in invasive surgical procedures, which are associated with higher pain scores and longer length of inpatient hospital stay compared to non-invasive surgeries. One limitation of this study was that men were excluded due to the nature of procedures that utilized an ERP. In the future, our organization plans to expand the use of an ERP to other surgical areas, including colorectal surgeries and cesarean deliveries.