A clinical pathway for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for advanced ovarian and primary peritoneal cancers

Objectives.: To evaluate the safety, feasibility, and economic impact of a clinical pathway, including rapid diet advancement, for patients undergoing rectosigmoid colectomy as part of cytoreductive surgery for advanced ovarian and primary peritoneal cancers. Methods.: Between 8/1/98 and 6/30/06, 64 consecutive patients met study inclusion criteria. Using case-control methodology, post-operative management was dictated by a prescribed clinical pathway in 19 patients (Group A) and directed by individual surgeon preference in 45 patients (Group B). Critical elements of the clinical pathway included: rapid diet advancement, early discontinuance of nasogastric suction, criteria-based utilization of parenteral nutrition, selective laboratory testing, and deferring initiation of chemotherapy until after discharge. Results.: Stage IIIC/IV disease was present in 94% of all patients. The median time to flatus was 6 days for both groups (p = 0.95); however, the median time to tolerance of diet was 3 days for Group A and 6 days for Group B (p = 0.013). Compared to Group B, patients in Group A had a significantly shorter median length of hospital stay (7 days vs 10 days, p = 0.014) and lower median 30-day post-operative hospital cost ($19,700 vs $25,110, p = 0.028), with no significant difference in 30-day readmission rate (21% vs 33%, p = 0.379). Clinical pathway-directed management was associated with a median reduction in hospital cost of $5410 per patient. Conclusions.: A critical pathway incorporating rapid diet advancement for patients undergoing primary cytoreductive surgery with rectosigmoid colectomy for ovarian and primary peritoneal cancers is feasible, safe, and associated with a significant reduction in length of hospital stay and hospital-related costs.