Predictors of 30-day morbidity after hysterectomy for benign disease

Prognostic impact of intraoperative rupture in early-stage epithelial ovarian cancer: an ancillary study of GORILLA-3002

OBJECTIVE

To evaluate whether intraoperative rupture affects oncological outcomes in patients with early-stage epithelial ovarian cancer (EOC).

METHODS

A multicenter retrospective study was conducted on patients with early-stage EOC based on surgical and final pathological reports between 2007 and 2021. Oncologic outcomes were compared between the unruptured group (International Federation of Gynaecology and Obstetrics [FIGO] stage IA/IB) and ruptured group (FIGO stage IC1). The primary endpoint was progression-free survival (PFS). Propensity score matching (PSM) was performed to adjust for the imbalance in prognostic factors between the groups.

RESULTS

Overall, 197 (58.3 %) patients comprised the unruptured group (FIGO stage IA/IB), and 141 (41.7 %) were in the intraoperatively ruptured group (FIGO stage IC1). No significant difference in the 5-year PFS was observed between the two groups before PSM (92.65 % vs. 92.80 %, P = 0.93). After PSM, the 5-year PFS showed a noticeable decrease in the ruptured group compared to the unruptured group, although this difference showed borderline statistical significance (96.90 % vs. 89.82 %, P = 0.061). This trend was particularly discernible in cases with aggressive tumor characteristics; intraoperative rupture remained an independent prognostic factor for shorter PFS in patients with high-grade histology (adjusted hazard ratio = 14.4, 95 % confidence interval = 2.8-74.1).

CONCLUSIONS

Although not statistically significant, intraoperative rupture may negatively affect PFS in these patients after PSM. Therefore, rupture during surgery should be avoided as it can cause upstaging and unnecessary chemotherapy.

Prognostic impact of erythropoietin-stimulating agent use during front-line chemotherapy in patients with ovarian cancer: A Korean multicenter cohort study

OBJECTIVE

To evaluate whether treatment with erythropoiesis-stimulating agents (ESAs) for chemotherapy-induced anemia affects progression-free survival (PFS) in patients receiving front-line chemotherapy following surgery for ovarian cancer (OC).

METHODS

We retrospectively reviewed all consecutive patients who received front-line chemotherapy after surgery between 2013 and 2019 at six institutions. The patients were divided according to the use of ESAs during front-line chemotherapy. The primary endpoint was PFS. The secondary endpoint was the occurrence of thromboembolism. Propensity score matching (PSM) analysis was used to compare survival between matched cohorts.

RESULTS

Overall, 2147 patients (433 receiving ESA and 1714 for no-ESA) were identified, with a median follow-up of 44.0 months. The ESA group showed a significantly higher proportion of stage III/IV disease (81.8% vs 61.1%; P < 0.001) and postoperative gross residual disease (32.3% vs 21.2%; P < 0.001) than the no-ESA group. In the multivariable Cox regression analysis, the use of ESAs did not affect PFS (adjusted hazard ratio, 1.03; 95% confidence interval [CI]: 0.89-1.20; P = 0.661). The incidence of thromboembolism was 10.2% in the ESA group and 4.6% in the no-ESA group (adjusted odds ratio, 6.58; 95% CI: 3.26-13.28; P < 0.001). When comparing the well-matched cohorts after PSM, PFS did not differ between the ESA (median PFS 23.5 months) and no-ESA groups (median PFS 22.2 months) (P = 0.540, log-rank test).

CONCLUSIONS

The use of ESAs during front-line chemotherapy did not negatively affect PFS in patients with OC after surgery but increased the risk of thromboembolism.

Impact of resident participation on surgical outcomes in laparoscopically assisted vaginal hysterectomy

OBJECTIVE

To compare surgical outcomes in patients with benign diseases who underwent laparoscopically assisted vaginal hysterectomy (LAVH) to determine the association between surgical outcomes and resident participation in the gynecologic field.

METHODS

A single-center retrospective study was conducted of patients diagnosed with benign gynecologic diseases who underwent LAVH between January 2010 and December 2015. Clinicopathologic characteristics and surgical outcomes were compared between the resident involvement and non-involvement groups. The primary endpoint was the 30-day postoperative morbidity. Observers were propensity matched for 17 covariates for resident involvement or non-involvement.

RESULTS

Of the 683 patients involved in the study, 165 underwent LAVH with resident involvement and 518 underwent surgery without resident involvement. After propensity score matching (157 observations), 30-day postoperative morbidity occurred in 6 (3.8%) and 4 (2.5%) patients in the resident involvement and non-involvement groups, respectively (P = 0.501). The length of hospital stay differed significantly between the two groups: 5 days in the resident involvement group and 4 days in the non-involvement group (P < 0.001). On multivariate analysis, Charlson Comorbidity Index >2 (odds ratio [OR] 8.01, 95% confidence interval [CI] 2.68-23.96; P < 0.001), operative time (OR 1.02, 95% CI 1.01-1.03; P < 0.001), and estimated blood loss (OR 1.00, 95% CI 1.00-1.00; P < 0.001) were significantly associated with 30-day morbidity, but resident involvement was not statistically significant.

CONCLUSION

There was no significant difference in the 30-day morbidity rate when residents participated in LAVH. These findings suggest that resident participation in LAVH may be a viable approach to ensure both residency education and patient safety.

Risk of Reintervention or Postoperative Bleeding after Laparoscopy for Benign Gynecological Disease: A Clinical Prediction Model

OBJECTIVE

The objective of the study was to develop a clinically applicable prediction tool to early seek for postoperative major complications after laparoscopic surgery for benign pathologies.

DESIGN

Retrospective analysis of prospectively collected data was performed.

SETTING

The study was conducted at Tertiary Care University Hospital.

PARTICIPANTS

The participants of this study were reproductive-aged women undergoing laparoscopy for benign conditions.

METHODS

Anamnestic, intraoperative, and postoperative characteristics from January 2019 to December 2021 were retrospectively reviewed. Patients with postoperative complications (reintervention or postoperative bleeding) were matched in a 1:2 ratio with women with same surgical indications without complications. Cases and controls were matched for preoperative hemoglobin, hematocrit, weight, height, body mass index, age, and blood volume. A prediction model was created by inserting multiple independent modifying factors through logistic regression. The receiver operating characteristic (ROC) curve was used to evaluate the predictive accuracy of the model, and the Hosmer-Lemeshow (H-L) test was carried out to evaluate the goodness-of-fit, and a calibration curve was drawn to confirm the predictive performance. A nomogram was depicted to visualize the prediction model.

RESULTS

Thirty-nine complicated procedures were matched with 78 uncomplicated controls. According to the multivariate logistic regression analysis findings, the prediction model was developed using C-reactive protein (CRP), intraoperative blood loss, and 24 h postoperative urinary volume, therefore a nomogram was generated. The area under the ROC curve of the prediction model was 0.879, depicting good accuracy, the sensitivity was 60.00%, while specificity reached 93.59%. The H-L test (χ2 = 4.45, p = 0.931) and the calibration curve indicated a good goodness-of-fit and prediction stability.

LIMITATIONS

The retrospective design, moderate sensitivity, and study population limit the generalization of the findings, requiring additional research.

CONCLUSIONS

This prediction model based on CRP, intraoperative blood loss, and 24 h postoperative urinary volume might be a potentially useful tool for predicting reintervention and postoperative bleeding in patients undergoing planned gynecological laparoscopy.

Advanced gynecologic surgery in women with Parkinson's disease

OBJECTIVE

To assess the effect of Parkinson's disease (PD) on perioperative outcomes following gynecologic surgery.

BACKGROUND

Gynecological complaints are common among women with PD but under-reported, under-diagnosed and under-treated, in part due to surgical hesitancy. Non-surgical management options are not always acceptable to patients. Advanced gynecologic surgeries are effective for symptom management. Hesitancy toward elective surgery in PD stems from concern regarding perioperative risks.

METHODS

This retrospective cohort study derived data by querying the Nationwide Inpatient Sample (NIS) database between 2012 and 2016 to identify women who underwent advanced gynecologic surgery. Non-parametric Mann-Whitney U and Fisher exact tests were used to compare quantitative and categorical variables respectively. Age and Charlson Comorbidity Index values were used to create matched cohorts.

RESULTS

526 (0.1%) women with and 404,758 without a diagnosis of PD underwent gynecological surgery. Median age of patients with PD (70 years vs 44 years, p < 0.001) and median comorbid conditions (4 vs 0, p < 0.001) were higher compared to counterparts. Median length of stay (LOS) was longer in PD group (3 days vs 2 days, p < 0.001) with lower rates of routine discharge (58% vs 92%, p = 0.001). Groups were comparable in post-operative mortality (0.8% vs 0.3%, p = 0.076). After matching, there was no difference in LOS (p = 0.346) or mortality (0.8% vs 1.5%, p = 0.385) and PD group was more likely to be discharged to skilled nursing facilities.

CONCLUSION

PD does not worsen perioperative outcomes following gynecologic surgery. Neurologists may use this information to provide reassurance to women with PD undergoing such procedures.

Mesenteric traction syndrome - Incidence, impact, and treatment: A systematic scoping review of the literature

BACKGROUND

Mesenteric traction syndrome (MTS) is commonly seen during major abdominal surgery and is characterised by facial flushing, hypotension, and tachycardia 15 min into surgery. MTS also impacts the postoperative course, as severe MTS has been associated with increased postoperative morbidity. However, despite MTS being common and severe MTS causing increased postoperative morbidity, the gaps in the literature are not clearly defined. We aimed to examine the diagnostic criteria, incidence, intraoperative and postoperative impact, and potential preventative measures of MTS while highlighting potential gaps in the literature.

METHODS

We followed the Prisma guidelines and performed a systematic literature search. We included only human studies examining MTS. All hits were screened for title and abstract, followed by a full-text review by at least two authors for determining eligibility for inclusion. Data were extracted and risk of bias was assessed by two independent reviewers.

RESULTS

A total of 37 studies, comprising 1102 patients were included in the review. The combined incidence of MTS during open abdominal surgery was found to be 76%, with 35% developing severe MTS. It was found that the development of MTS was associated with marked haemodynamic changes. It was also found that several different subjective diagnostic criteria exist and that severe MTS was associated with increased postoperative morbidity. Furthermore, several preventative measures for protecting against MTS have been examined, but only on the incidence of MTS and not on the postoperative course.

CONCLUSION

MTS occurs in 76% of patients undergoing major abdominal surgery and is associated with deleterious haemodynamic effects, which are more pronounced in patients developing severe MTS. Severe MTS is also associated with a worse postoperative outcome. However, gaps are still present in the current literature on MTS.

Severe mesenteric traction syndrome is associated with increased systemic inflammatory response, endothelial dysfunction, and major postoperative morbidity

This study aimed to determine if mesenteric traction syndrome (MTS) triggers increased systemic inflammation and endothelial cell dysfunction. Patients developing severe MTS had pronounced early IL6 elevations followed by endothelial cell damage. Furthermore, these processes were associated with increased postoperative morbidity.

OBJECTIVE

To determine whether mesenteric traction syndrome (MTS) leads to increased systemic inflammation and dysfunction of the glycocalyx and endothelial cell and whether this correlates with the degree of postoperative morbidity.

INTRODUCTION

Severe MTS is associated with increased postoperative morbidity following major gastrointestinal surgery, but the pathophysiological mechanism has not been previously explored. Systemic inflammatory response and impaired glycocalyx and endothelial cells may be responsible for the development of symptoms.

METHODS

The study analyzed prospectively collected data from two cohorts (n = 67). The severity of the MTS response was graded intraoperatively and blood samples for PGI₂, catecholamines, IL6, and endothelial biomarkers obtained at predefined time points.

RESULTS

Patients undergoing either esophagectomy (n = 45) or gastrectomy (n = 22) were included. Surgery led to significantly increased plasma concentrations of all biomarkers. Yet, patients who developed severe MTS had higher baseline epinephrine levels (p < 0.05) and higher levels of PGI₂ (p < 0.05), Syndecan-1 (p < 0.001), and sVEGFR1 (p < 0.001). Peak values of IL6, Syndecan-1, sVEGFR1, and sTM all correlated to peak PGI₂. Lastly, patients with high postoperative morbidity had higher baseline epinephrine (p = 0.009) and developed higher plasma IL6 (p = 0.007) and sTM (p = 0.022).

CONCLUSION

The development of severe MTS during upper gastrointestinal surgery is associated with preoperative elevated plasma epinephrine and further a more pronounced proinflammatory response and damage to the vascular endothelium. The increased postoperative morbidity seen in patients with severe MTS may thus, in part, be explained by an inherent susceptibility towards an inappropriate secretion of PGI₂, which leads to an increased surgical stress response and endothelial damage. These findings must be confirmed in a new prospective cohort.

Outcomes of Total Laparoscopic Hysterectomy: A Single-Surgeon Experience of Initial 50 Cases

Introduction

In this study, we reported a single surgeon experience of total laparoscopic hysterectomy (TLH) in terms of intraoperative and early postoperative outcomes and complications. In addition, we compared our results with published literature for a reevaluation of complications and outcomes.

Material and methods

This present prospective study was conducted on 50 patients who underwent TLH due to benign causes. Patients diagnosed with abnormal uterine bleeding (AUB), uterine fibroids, and post-menopausal bleeding (PMB) were included in this analysis. Patients were discharged after 24 hours of surgery if there were considered fit for discharge. The patients' age, co-morbidities, size of the uterus, additional procedure along with TLH, and postoperative complications were collected and analyzed. The follow-up period was three months, done on the tenth day after surgery, the thirtieth day, and then at three months.

Results

The mean age of our patients was 46.42±5.01 years. The major indication of hysterectomy was fibroids diagnosed in 27 (54.0%) patients and AUB in 18 (36.0%) patients. Out of 50, 10 (20.0%) patients had a previous cesarean section, and 4 (8.0%) had a bilateral tubal ligation (BTL). Mean surgery duration was 124.26±44.74 minutes. Mean hospital stay was 2.18±0.39 days. Total complications occurred in five (10.0%) patients, ureteric injury in one (2.0%) patient, port-site infections in 2 (4.0%), and vault infections in 2 (4.0%) patients.

Conclusion

TLH is a safe procedure and can be performed with minimal complications in patients with benign uterine etiology.

5,926 hysterectomies: complications described by Clavien-Dindo classification

Hysterectomy is the most common major gynaecological surgery. Due to its high volume, the analysis of its results is relevant. The objective of this study was to describe intraoperative complications and reoperations, for both benign and malignant causes, using the Clavien-Dindo classification (approved by local ethics committee, number 100220). Between 2000 and 2019, 5926 elective hysterectomies were performed, of which 90.2% were for benign aetiology and 9.8% for malignant causes. The abdominal route was 52.7%, vaginal 40.1% and laparoscopic 7.2%. Intraoperative complications and reoperations (grade III Clavien-Dindo) were 4% and 2.1%, respectively. Oncological surgery had significantly more intraoperative complications (10% vs. 3.4%) and reoperations (3.6% vs. 1.9%) than benign procedures. Noteworthy, intraoperative complications required a new operation in only 3.4% for malignant and 2.8% for benign surgery. Our data showed the relevance of detecting and rectifying intraoperative complications during surgery, which consequently leads to a lower reoperation rate, minimising postoperative morbidity and mortality for patients.Impact StatementWhat is already known on this subject? The surgical complications of hysterectomy, both intraoperative and postoperative, are extensively described. However, this information is not well systematised, in which elective and emergency surgery are mixed. In addition to the above, there are few documents comparing the results of hysterectomies due to benign versus malignant causes.What the results of this study add? Using the Clavien-Dindo classification, this study adds an organised description of intraoperative complications and reoperations of hysterectomy in the context of elective surgery. In addition, it provides information on the comparison between surgery for benign versus malignant causes, as well as information on intraoperative complications requiring a new operation.What the implications are of these findings for clinical practice and/or further research? These findings provide clear and orderly data about the risks of elective hysterectomy and showed the relevance of detecting and rectifying intraoperative complications during the procedure. This is useful for specialists to preoperatively identify the risks for each hysterectomy group and provide their patients with more detailed information during informed consent.