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O THE EDITORS: I read with interest “A clinical pathway forostoperative management and early patient discharge: does itork in gynecologic oncology?” but I find the data impossible

o interpret without defined inclusion and exclusion criteriand without explanation of how the pathway was implementedn cases necessitating hospital stays of � 2 days.1 I cannot be-ieve that a patient who goes to the intensive care unit intubatedfter a 10-hour debulking is drinking tea the next morning.ure, ovarian cancer diagnoses and radical surgeries are asso-iated with longer hospital stays, but they also comprise theart of a gynecologic oncologist’s practice that makes it differ-nt from a general gynecologist’s practice, and cookie cutteranagement does not apply. Had the authors narrowed their

nclusion criteria to, say, endometrial cancer cases and ex-luded, say, patients going to the intensive care unit and thosendergoing exenterations or any procedure taking longer thanhours, this pathway might be applicable to the treatment of

uch patients. However, as presented, it is a stretch to say thisathway “works” in gynecologic oncology. f

tephanie V. Blank, MDepartment of Obstetrics and Gynecologyivision of Gynecologic Oncologyew York University School of Medicine

60 East 34th St.ew York, NY 10016

tephanie.blank@med.nyu.edu

EFERENCE. Chase DM, Lopez S, Nguyen C, Pugmire GA, Monk BJ. A clinicalathway for postoperative management and early patient discharge:oes it work in gynecologic oncology? Am J Obstet Gynecol008;199:541.e1-7.

2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2008.12.047

EPLY

hank you for your interest in the evidence-based treatment of theostoperative gynecologic oncology patient.1 For the demo-raphic information on the patients who were included in thistudy, please refer to the rest of the article at www.ajog.org. Astated in the text, this study was a retrospective cohort of 880 con-

ecutive patients who were treated by the same 2 surgeons. In this ©

pisiotomy use has changed

o demonstrate this premise.

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ase series, there were 422 patients (48%) with a postoperativeiagnosis of a gynecologic malignancy, with two-thirds of theseaving endometrial cancer. Importantly, 123 women were foundo have ovarian carcinoma and were treated with radical and/ortagingprocedures. In thosepatientswithmalignancy, themedianength of stay was 2 days (range, 2-52 days); however, older pa-ients, patients with ovarian cancer, and patients with higher body

ass index and estimated blood loss did have longer hospital staysP � .01). For example, patients with ovarian cancer were dis-harged on average postoperative day 3 (range, 2-52 days).

In regards to your hypothetical patient with ovarian cancer whoas intubated in the intensive care unit after a 10-hour debulking

urgery, there appears to be nothing that would prevent her fromesuming a diet, receiving oral pain medications, ambulating, andiscontinuing her Foley catheter after extubation on the first post-perative day. However, we agree that the protracted nature of herurgery is a risk factor for ileus. Clearly, postoperative manage-

ent algorithms must be individualized; however, there is no ev-dence that the absence of flatus and bowel movements shouldrevent early feeding.2 To suggest that an algorithm impliescookie cutter” medicine is to suggest that incorporating evidencento clinical medicine is not reasonable. Our data were presentedimply to help create rational evidence-based algorithms that

ight serve to guide a physician’s practice. f

ana M. Chase, MDradley J. Monk, MDivision of Gynecologic Oncologyhao Family Comprehensive Cancer Centerniversity of California Irvine, Medical Center

01 The City Dr, Building 56, Room 262range, CA 92868jmonk@uci.edu

EFERENCES. Chase DM, Lopez S, Nguyen C, Pugmire GA, Monk BJ. A clinicalathway for postoperative management and early patient discharge:oes it work in gynecologic oncology? Am J Obstet Gynecol008;199:541.e1-7.. Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed

traditional) oral fluids and food for reducing complications after majorbdominal gynaecologic surgery. Cochrane Database Syst Rev007;4:CD004508.

2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2008.12.048

O THE EDITORS: I was interested to read the recent edito-ial “Synthesize evidence and they will change?”1 by Johnhorp. Although I agree with the main premise of the “build itnd they will come” hypothesis of evidence-based medicine, Io not agree with Dr Thorp’s use of episiotomy as an example

Dr Thorp states that “Despite this evidence, the US practiceof routine use of episiotomy] did not change. . .” On the con-rary, the practice of episiotomy in the United States hashanged markedly over time. For example, in a study that ex-mined national episiotomy practice, the use per 100 vaginal

eliveries decreased from 65.3% in 1979 to 38.6% in 1997.2

JULY 2009 American Journal of Obstetrics & Gynecology e17