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MIGS Update: New Pathways in Hysterectomy Surgery, ERAS, and Endometriosis and Chronic Pelvic Pain Research

January 7, 2019

The Center for Minimally Invasive Gynecologic Surgery (MIGS) at UPMC Magee-Womens Hospital, led by director Ted Lee, MD, and assistant director Suketu Mansuria, MD, is home to one of the largest and busiest gynecologic minimally invasive surgery programs in the country. Innovative research to advance the discipline — breaking new ground for the treatment of many common gynecologic conditions — is a hallmark of the program.

With colleagues Richard Guido, MD, Nicole Donnellan, MD, and Noah Rindos, MD, the fellowship trained surgeons of the MIGS division perform more than 1,000 surgical cases each year. As a tertiary care center, the MIGS surgeons at UPMC Magee see some of the most complex cases, and patients are often referred here because of their expertise in performing these highly complicated cases laparoscopically. “Over the last several years, we’ve had a focus onimplementing new clinical pathways designed to improve patient outcomes and patient satisfaction. This has transformed various aspects of the program. Part of this has involved our adoption of enhanced recovery after surgery (ERAS) protocols for our hysterectomy patients, while another off-shoot has been our development of a same-day discharge pathway that is beginning to show some impressive results,” says Dr. Mansuria.

A New Path Forward With Results

Minimally invasive hysterectomy typically affords less postsurgical pain, a faster recovery, and fewer complications than traditional open procedures. A goal of the MIGS division in recent years has been to increase the percentage of laparoscopic, robotic, or vaginal procedures. “Our desire was to reduce the number of abdominal hysterectomies and do it across the entire UPMC system, not just in our practice at UPMC Magee,” says Dr. Mansuria. To effect change on a systemwide level, physicians had to be engaged and become partners in care. “We wanted physicians to be involved in the decision-making process to truly see that this approach is better for all of our patients.”

Dr. Mansuria and colleagues put together a team to analyze UPMC patient data, comparing outcomes from minimally invasive hysterectomies to those done as open procedures. Using evidencebased recommendations from the American College of Obstetricians and Gynecologists (ACOG) and internal UPMC data, a pathway was developed that would offer guidance and recommendations to the surgeon as to the best route for performing the hysterectomy. Questions about the size of the uterus, comorbidities, and other factors are used to develop the recommendation. “At this point, it’s still up to the physician to decide whether they want to follow those recommendations, but the pathway helps identify good candidates for a minimally invasive hysterectomy,” says Dr. Mansuria. For those clinicians who do not feel comfortable doing surgery minimally invasively, the pathway assists with referral of the patient to a specialist.

The pathway was implemented in 2012 across the then 14 hospitals within the UPMC system. Data from the implementation was compared from 2012 to 2014. “In a caseload of well over 6,000 hysterectomies system-wide, we saw a 39 percent reduction in abdominal hysterectomies with an equivalent increase in minimally invasive hysterectomies,” indicates Dr. Mansuria. Beyond just a reduction in open surgical cases, data was collected and analyzed to report on postsurgical complications. “We are not only doing more minimally invasive hysterectomies, but we also are improving patient care,” says Dr. Mansuria. Length of stay has significantly decreased, and there also have been significant reductions in surgical site infections, readmissions, and blood transfusions.

ERAS Is Changing the Nature of Surgery Across Disciplines

ERAS protocols are becoming more prevalent across the entire range of surgical disciplines and practices. Dr. Mansuria and colleagues implemented a protocol that borrows some of the principles and practices of ERAS and applied it to their minimally invasive surgical cases. “We felt that a lot of what ERAS was built upon for large, open surgeries — things like better pain control and decreased nausea and vomiting after surgery — were applicable to our minimally invasive cases,” says Dr. Mansuria. Working with colleagues in anesthesia, nursing, and other areas, the Center developed its own version of ERAS for minimally invasive cases and launched the protocol in August 2016.

The ERAS protocol for minimally invasive hysterectomy uses a multimodal analgesia approach. It combines nonsteroidal medications, acetaminophen, and limited amounts of narcotics. “Working in conjunction with our anesthesia partners, we’ve been able to significantly reduce the amount of opioids we use by adopting what’s called TIVA, or total intravenous anesthesia. We’ve seen a significant reduction in the amount of opioids administered intra-operatively. Even though we are giving a significantly smaller amount of opioids intraoperatively, pain scores are unchanged and remain very low,” says Dr. Mansuria. These new findings from the pathway are currently being finalized for publication in the near future.

Same-Day Discharges — A Growing Trend

An offshoot of the MIGS pathway for hysterectomies has been a secondary component designed to increase the number of sameday discharges for hysterectomy. Traditionally, minimally invasive hysterectomy patients would have an overnight stay in the hospital at UPMC Magee. However, now, with the pathways and ERAS protocols in place, this is changing in a dramatic way. “Discharging patients the same day has a number of benefits. We’ve seen lower rates of infection, and the risks of deep vein thrombosis and pulmonary embolism are also lower. At the same time, patient satisfaction has remained very high,” says Dr. Mansuria. This work has also shown that the rates of complications, ED visits, and readmissions have not risen. “In a few short years, we’ve gone from every minimally invasive hysterectomy requiring an overnight stay to nearly 85 percent of patients being discharged the same day. This includes hysterectomy in our cancer patients, as well as those with a complicated pelvic reconstruction, severe endometriosis, and large fibroids. This is great news for everyone involved, and we’ll be publishing our findings on the pathway in the near future,” says Dr. Mansuria.

Improving the Diagnosis and Management of Endometriosis and Chronic Pelvic Pain Patients

Chronic pelvic pain can be a difficult complaint to accurately diagnose. “It can go far beyond endometriosis as the culprit,” explains Dr. Donnellan, “which is one of the reasons there is such a large time lag from the appearance of symptoms to accurate diagnosis for these patients if they have endometriosis. There are a lot of factors involved, but as a field, we have to develop new tools and understandings to cut down significantly on the diagnostic odyssey many of these patients currently face.”

This patient population is a high utilization cohort, one in which UPMC as a whole is actively investigating new models of care to not only increase the value of care provided to the patient but also to reduce costs at the same time. “We currently have a work group established to develop an endometriosis and chronic pelvic pain center of excellence that will attack the issue from multiple angles with respect to creating a multidisciplinary patient care approach,” says Dr. Donnellan. This collaborative effort brings together physicians from gynecology, psychiatry, urology, anesthesia, neurology, and physical medicine and rehabilitation to work together to address the complexities of caring for patients experiencing pelvic pain in a manner that will improve the overall value of care while at the same time addressing associated costs and high utilization of this patient population.

Translational Research to Improve the Diagnosis of Endometriosis

The MIGS division at UPMC Magee provides superb surgical care for endometriosis and is continuing to evolve with respect to how surgeries are performed. “At the same time, we are evolving to dramatically improve the health care experience for those patients with chronic pelvic pain who are struggling with its consequences by looking for better diagnostic tools with a greater emphasis on whole-person care, and specifically whole-woman care.”

There are several promising lines of investigation currently open at UPMC Magee looking into ways to accurately diagnose endometriosis without the need to do confirmatory surgery. One group of investigators is currently looking at microRNAs (miRNAs) and the development of a laboratory panel that could be used to detect the presence of endometriosis. “Work is still ongoing to optimize this approach before we can move to testing in a clinical trial,” says Dr. Donnellan.

Other investigators are collaborating with Dr. Donnellan and the MIGS division to explore potential biomarkers. “David Peters, PhD, from our department, is developing the concept of detecting endometrial markers in the blood that are shed during the menstrual cycle. This work may be able to identify and chart new molecular markers of the menstrual cycle that could be indicative of an endometriotic state. This is exciting work because no one has yet been able to devise a nonsurgical way to accurately confirm the presence of endometriosis,” says Dr. Donnellan.

For Further Reading

Sanei-Moghaddam A, Ma T, Goughnour SL, Edwards RP, Lounder PJ, Ismail N, Comerci JT, Mansuria SM, Linkov F. Changes in Hysterectomy Trends After the Implementation of a Clinical Pathway. Obstet Gynecol. 2016; 127(1): 139-47.

Linkov F, Sanei-Moghaddam A, Edwards RP, Lounder PJ, Ismail N, Goughnour SL, Kang C, Mansuria SM, Comerci JT. Implementation of Hysterectomy Pathway: Impact on Complications. Womens Health Issues. 2017; (4): 493-498.

Sanei-Moghaddam A, Goughnour S, Edwards R, Comerci J, Kelley J, Donnellan N, Linkov F, Mansuria S. Hysterectomy Pathway as the Global Engine of Practice Change: Implications for Value in Care. Cent Asian J Glob Health. 2017; 6(1): 299.