Open Journal of Obstetrics and Gynecology, 2011, 1, 139-143
doi:10.4236/ojog.2011.13026 Published Online September 2011 ( OJOG
Published Online September 2011 in SciRes.
Assessing outcomes after fast track surgical management of
corpus cancer
Jonathan Carter1,2*, Shannon Philp1,2
1Sydney Gynaecological Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, Australia;
2The University of Sydney, Sydney, Australia.
E-mail: *
Received 12 June 2011; revised 15 July 2011; accepted 22 July 2011.
Objective: The aim of the study was to audit the out-
comes of patients with corpus cancer managed with a
fast track surgery (FTS) program. Design: Clinical
audit of outcomes after laparotomy for corpus cancer
and managed by FTS principles. Setting: Tertiary
hospital, University based subspecialty gynaecological
oncology practice. Population or Sample: Consecutive
patients with uterine corpus cancer. There were no
exclusions. Methods: Three year audit of FTS Data-
base. Main Outcome Measures: Ability to tolerate
early oral feeding (EOF), length of stay (LOS), peri-
operative complication rate and readmission rate.
Results: Sixy six patients were operated upon whose
median age was 59.5 years. Forty six (70%) had stage
I disease, 7 (11%) stage II, 9 (14%) stage III and 4
(6%) had stage IV disease. Twenty seven (41%) had
lymph node sampling performed. Median operating
time was 2. 5 hour s. Mean BMI was 30 kg/m2 (Range:
18 - 47). Fifty patients (76%) were classified as over-
weight or obese. Twenty four patients (36%) had a
“non-zero” performance status. Mean intraoperative
EBL was 227 ml. Median LOS was 3.0 days. There
were 3 (5%) intraoperative complications. There were
no intraoperative ureteric, bowel or vascular injuries.
Postoperatively, 13 (20%) patients experienced a total
of 24 adverse events. Only 2 (3%) patients experi-
enced complications greater than grade 2. Conclusion:
This audit shows that in an unselected group of pati-
ents undergoing laparotomy as management for their
uterine malignancy and managed by a FTS protocol,
overall excellent results can be achieved.
Keywords: Fast Track Surgery; Clinical Audit; Corpus
Endometrial cancer is the most common gynaecological
cancer affecting women, and with an increasing inci-
dence, a safe, cost effective and tolerated management is
important [1]. Treatment remains removal of the uterus
and adnexa, and this can be accomplished via laparotomy,
vaginally, totally laparoscopic, laparoscopically assisted
or robotically. Surgical staging to define the extent of
disease may be added to hysterectomy, however the ra-
tionale for this and data on survival impact is often de-
bated [2].
Fast track surgery programs are not new, nor are they
complicated. They were first described by Kehlet in
Denmark in 2002 and the principles have been adopted
by most surgical specialities worldwide [3,4]. FTS pro-
grams incorporate a number of elements and are not just
clinical pathways. Many of these elements are already
practiced by surgeons, but few embrace the entirety to
gain the maximum benefits for their patients. By mini-
mising stress and maintaining normal physiology as
much as possible, the catabolic stresses of surgery and
anaesthesia can be minimised, optimising patient out-
comes and as a consequence reducing length of stay
Clinical audit is one of the fundamental principles of
clinical governance, the process by which clinicians im-
prove the quality of the care they provide. It provides
powerful information to the consumer (patient) and
health care provider (Hospital, Government) as to the
outcomes really achieved in a real life scenario.
A clinical audit was undertaken of all patients referred
to a single gynaecological oncologist with a diagnosis of
uterine corpus malignancy and who subsequently under-
went surgical management via laparotomy and managed
with a FTS program. The aim of the audit was to docu-
ment outcomes of patients managed with FTS and lapa-
rotomy and to provide a reference for subsequent clinical
This audit reports the experience of 3 full years of pa-
J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 139-143
tients referred to a single gynaecological oncologist, for
the surgical management of cancer of the uterine corpus
managed by a FTS program. The audit includes all pa-
tients taken to the operating room for the calendar years
2008, 2009 and 2010 who underwent a laparotomy.
There were no exclusions and no exceptions. Data was
collected in a real time fashion on the author’s personal
database and analysis undertaken in a retrospective fash-
Our FTS program has been previously described, and
involves preoperative patient counselling regarding the
program by both surgeon and nurse, informing the pa-
tient of their anticipated LOS and the criteria for dis-
charge. Patients are advised that once these criteria are
met, discharge would occur. Narcotic analgesia is limited
and adequate analgesia provided by a combination of
intraoperative paracoxib and transverse abdominis plane
(TAP) block [5,6]. Mechanical bowel preparations are
not routine, fluid balance optimised to retain as close to
normal intravascular volume and unnecessary tissue
trauma is avoided by good surgical technique. Strict at-
tention to haemostasis is important and drains are
avoided. Postoperatively meloxicam is prescribed for 3
days with regular paracetamol. Oral liquids are allowed
on the night of surgery and light diet on post op day 1
with rapid progression thereafter. Movicol or Coloxyl
with Senna is commen ced routinely on post op day 1 and
continued post discharge. All patients receive periopera-
tive Clexane which is continued until discharge. Selected
high risk patients are offered extended Clexane prophy-
laxis. Intraoperatively mechanical sequential compres-
sion devices are employed and all patients have knee
high TED stockings fitted and worn postoperatively for
at least 1 month. Patients are mobilised day 1 post sur-
gery and catheters and IV fluids are also removed on day
1 whenever possible. Patients are given an incentive spi-
rometer or “Triflow” and encouraged to use the device 6
times per hour. Criteria for discharge include the patient
adequately mobilising without assistance, to lerating early
oral feeding, managing their pain and discomfort with
oral analgesia and having adequate home supervision.
Post discharge patients receive a follow up phone call
from our Clinical Nurse Consultant (CNC) within 3 days
of discharge.
Data collected relate to patient characteristics, hospi-
talisation and post-hospitalisation. The following patient
characteristics were collected: age, weight, height, body
mass index (BMI), medical insurance status, and perfor-
mance status. Hospitalisation details included the proce-
dure performed, type of incision (transverse or midline),
operating time, complexity of surgery (simple vs. com-
plex), intraoperative estimated blood loss (EBL), whe-
ther a transfusion was required, the preop erative Hb , post
operative Hb and the Hb change, whether the patient
tolerated early oral feeding (EOF) and if the patient re-
ceived COX Inhibitors. All inpatient complications were
collected, including modified Royal Australian and New
Zealand College of Obstetricians and Gynaecologists
(RANZCOG) Quality Indicators (Table 1). Date of ad-
mission and date of discharge were used to calculate
length of stay (LOS). Post hospitalisation admissions and
complications were also recorded. All patients were re-
viewed 2 - 4 weeks p ost discharge.
Ethics approval was granted to allow review and pre-
sentation of the data as a clinical audit. Statistical analy-
sis included descriptive statistics, t-test and ANOVA for
nominal variables and chi-squared test for categorical
Over the 3 year audit period, 66 patients were operated
upon whose median age was 59.5 years (Range: 35.1 -
86 years). Forty six (70%) had stage I disease, 7 (11%)
stage II, 9 (14%) stage III and 4 (6%) had stage IV dis-
ease. Twenty seven (41%) had lymph node sampling
Table 1. Quality indicators collected by the Sydney gynaeco-
logical oncology group
Transfusion > 2 Units
LOS more than 7 days
Anastomotic Leak
Return to operating room
Post-operative Renal Im pa irment
Perioperative Cardiac Event
Perioperative Respiratory E ven t
Death from Treatment Complications
Hospital Readmission
Nosocomial Infection
Death within 30 days of surgery
Undiagnosed Cancer
Unplanned admission to ICU
Wound Dehiscence
Vascular Injury
Bowel Injury
Febrile Morbidity
Ureteric Injury
Bladder Injury
Nerve Injury
Treatment Refusal
Laparoscopy converted to lap arotomy
Haematoma post surgical dischar ge
Missed electrolyte abnorm a lity
opyright © 2011 SciRes. OJOG
J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 139-143 141
performed. Median and mean operating time was 2.5 and
2.3 hours respectively (Range: 1 - 5 hours). Sixteen (24%)
patients were classified as normal BMI and 50 (76%) as
overweight and obese (25 overweight and 25 obese).
Median and mean BMI were 28 kg/m2 and 30 kg/m2 re-
spectively (Range: 18 - 47).
Forty two patients (64%) had a “0” Performance
Status (PS), 20 (30%) had PS 1 and 4 (6%) had a PS of 2.
In total, 24 (36%) had “non-zero” performance status.
Median preoperative Hb was 129, dropping to 119
Mean intraoperative EBL was 227 ml (95% CI: 189 -
266) with a median EBL of 188ml (Range: 10 ml - 900
ml). There were no intra or postoperative blood transfu-
Median and mean LOS was 3.0 and 3.7 days respec-
tively (Range: 2 - 16 days) with 10 (15%) patients dis-
charged on or before post operative day 2 and an addi-
tional 7 (2%) patients were deemed suitable for discharge
on day 2 but for social reasons were unable to be dis-
charged. Thirty eight (58%) patients were discharged on
day 3. T hree pa t i en t s (5%) had LOS greater than 7 days.
COX 2 inhibitors were prescribed to 58 (88%) and 62
(94%) were able to successfully complete EOF and FTS
There were 3 (5%) intraoperative complications/ad-
verse events. Two were episodes of bradycardia related
to parietal peritoneum stimulation both settling and al-
lowing surgery to proceed. There was 1 intraoperative
bladder injury in a patient who underwent an exentera-
tive procedure, being a Jehovah’s Witness, having pre-
viously undergone an abdomino-perineal resection and
pelvic irradiation for colon cancer, presenting with se-
rous corpus cancer and her uterus fixed to the sacrum.
The bladder was morbidly fixed to the uterus as a con-
sequence of her previous irradiation and the bladder in-
advertently entered during dissection and repaired in 2
layers without sequelae. There was no intraoperative
ureteric, bowel or vascular injuries.
Postoperatively, 13 patents (20%) experienced a total
of 24 complications/adverse events based upon our KPI’s.
There were 6 (9%) hospital readmissions, 5 (8%) wou nd
infections, 3 patients (5%) whose LOS was greater than
7 days, 2 patients (3%) had an unplanned ICU admission,
2 developed an ileus (3%), 2 patients (3%) unplanned
return to theatres, 2 patients (3%) with electrolyte dis-
turbance and 1 each of the following were reported:
haemorrhage from ureteric stents and femoral neuro-
praxia as outlined in Table 2.
One patient (Patient 3) accounted for 5 of 23 (22%)
complications. Only 2 patients (patient 3 and patient 10)
experienced complications greater than grade 2. Patient 3
was a 61 year old, obese Jehovah’s Witness described
above with a past history of abdo mino-perineal r esection
and pelvic irradiation for colon cancer. She was diag-
nosed with a serous corpus cancer and her uterus was
fixed onto the sacrum as a consequence of previous treat-
ments. Intraoperativ ely ureteric stents were inserted. Post
operative bleeding from ureteric stents required her re-
turn to the operating room by the Urology team for re-
moval of ureteric stents, and monitoring in ICU an d sub-
sequent readmission to hospital for management of an
electrolyte disturbance. Patient 10 was a 60 year old
morbidly obese woman who underwent repair of an inci-
sional hernia by general surgical colleagues at the same
time as her uterine cancer surgery. She underwent exten-
sive soft tissue mobilisation an d was readmitted 3 weeks
after surgery with a wound infection that required de-
bridement in the operating room and VAC dressing
Patients commonly ask their surgeon “have you done this
before?” and “am I going to be OK?” The answer to
these questions are not derived from published RCTs,
rather they are derived from clinical audit of personal
Clinical audit is one of the fundamental principles of
clinical governance, the process by which clinicians im-
prove the quality of the care they provide. The process
involves regularly collecting and measuring activity and
outcomes, and analysing and comparing these outcomes
with current or “recognised standards”, together with a
rigorous peer review process. It makes clinicians ac-
countable to the public, by constantly monitoring and
maintaining high standards, being transparent and ac-
countable for those standards, identifying problems and
addressing them and to constantly improve on those
standards to improve overall quality of care. It is what
the public expect [7]. The key feature of audit is that it
involves reviewing actual and all surgical performance
outcomes. In lay terms, the purpose of audit is to confirm
that your outcomes are, what you say or think they are
[8]. It has been shown quite clearly from cardiac surgery
that structured data collection, analysis, and feedback to
clinicians improves the qu ality of outcomes [9].
Our study provides the first real base-line or “recog-
nised standard” on laparotomy patients managed by FTS
for the surgical management of uterine cancer.
In this audit, all patients with a diagnosis of uterine
corpus malignancy and managed by a FTS program were
included. During the study period there were no patients
who underwent laparo scopy and as such this audit repre-
sents extensive experience of fast track surgical care in
patients with uterine malignancy managed by laparotomy
and thus serves as a “recognised standard”.
opyright © 2011 SciRes. OJOG
J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 139-143
Copyright © 2011 SciRes.
Table 2. Intraoperative and postoperative quality indicators.
Pt Age LOS PS BMI Grade Complication/Adverse
Event Comment
Intraoperative Complications
1 80 13 1 40 2 Bradycardia Elderly obese woman, developed bradycardia during packing.
Surgery continued. ICU monitoring. Developed post opera-
tive ileus, UTI, wound infection, resulting in increased LOS
2 66 6 0 26 2 Bradycardia Bradycardia settled spontaneously. Surgery continued.
3 61 16 0 30 1 Bladder injury
Jehovah’s Witness with past history of abdomino-perineal
resection and pelvic irradiation for colon cancer. Uterus fixed
on sacrum. Intraoperative bladder injury. R epaired in 2 layers,
no sequelae
Postoperative Complications
1 80 13 1 40 2
ICU Admission
Wound infection
LOS >7 days
Elderly obese woman, developed bradycardia during packing.
Surgery continued. ICU monitoring. Developed post opera-
tive ileus, wound infection, resulting in increased LOS
3 61 16 0 30 3
Return to theatre
ICU Admission
LOS >7days
Hospital readmission
Jehovah’s Witness with past history of abdomino-perineal
resection and pelvic irradiation for colon cancer. Uterus fixed
on sacrum. Ureteric stents inserted. Post operative bleeding
from ureteric stents requiring return to OR by Urology team
for removal of stents. Monitoring in ICU. Subsequent read-
mission to hospital for management of electrolyte disturbance
4 58 3 0 38 2 Wound infection Diagnosed 4 weeks post op. Treated with oral antibiotics by
5 57 3 0 29 2 Wound infection Wound haematoma/infection treated with oral antibiotics by
GP. No sequelae
6 43 4 0 23 1 Hospital readmission Constipation. Readmitted but no specific management
7 61 3 0 25 1 Hospital readmission
Unable to void after catheter removal. Readmitted 1 week
post op for successful trial of void
8 61 3 0 40 1 Hospital readmission Resuture vaginal vault
9 46 2 0 29 2 Hospital readmission
Wound infection Readmitted with wound infection, conservatively managed
with IV antibio t i c s a n d VAC dressing
10 60 6 1 43 3 Hospi t a l r e a dmission
Wound Infection
Return to theatre
Readmission with wound infection 3 weeks after extensive
wound mobilization for repair of incisional hernia in obese
patient. Return to theatre for wound debridement and VAC
11 59 2 1 17 1 Other Femoral neuropraxia, settled prior to discharge
12 61 3 1 28 1 Electrolyte Raised creatinine. Settled prior to discharge
13 68 10 2 34 2 Electrolyte
LOS >7 days
Preexisting CRF, post operative electrolyte disturbance, and
ileus settling with conservative management. Length of stay
10 days
CRF: Chronic renal failure; VAC: Vacuum assisted closure; ICU: Intensive care unit; LOS: Length of stay; UTI: Urinary tract infec tion; GP: Genera l prac titioner.
The extended experience confirms our earlier work
that the majority of patients can complete a FTS program,
with minimal morbidity and a low incidence of readmis-
sion and as a consequence, a shorter hospital stays [5].
In a health care and financial environment where
monetary constraints are ever increasing and medical
technology is becoming more complex and expensive,
clinicians and hospital administrators need to have access
to audit data to confirm whether inve stment in expensive
technology provides an enhanced outcome. It is note-
worthy that the LOS and outcomes in the audit patients
reported in this article were not too dissimilar to those
reported in recent RCTs comparing laparotomy and lapa-
roscopy [10-13].
This audit provides a baseline data set for a large
group of patients with uterine corpus cancer operated
upon with laparotomy and managed by FTS. It allows for
subsequent data to be compared against and as such is a
J. Carter et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 139-143 143
powerful tool for the gynaecological oncologist embark-
ing upon surgery for cancer of the uterine corpus.
The authors acknowledge financial support from The Chris O’Brien
Lifehouse at RPA.
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