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Abstract
Background and Objective: Hysterectomy is one of the most common surgical procedures women will undergo in their lifetime. Several factors affect surgical outcomes. It has been suggested that high-volume surgeons favorably affect outcomes and hospital cost. The objective is to determine the impact of individual surgeon volume on total hospital costs for hysterectomy. Methods: This is a retrospective cohort of women undergoing hysterectomy for benign indications from 2011 to 2013 at 10 hospitals within the University of Pittsburgh Medical Center System. Cases that included concomitant procedures were excluded. Costs by surgeon volume were analyzed by tertile group and with linear regression. Results: We studied 5,961 hysterectomies performed by 257 surgeons: 41.5% laparoscopic, 27.9% abdominal, 18.3% vaginal, and 12.3% robotic. Surgeons performed 1–542 cases (median = 4, IQR = 1–24). Surgeons were separated into equal tertiles by case volume: low (1–2 cases; median total cost, $4,349.02; 95% confidence interval [CI] [$3,903.54–$4,845.34]), medium (3–15 cases; median total cost, $2,807.90; 95% CI [$2,693.71–$2,926.93]) and high (>15 cases, median total cost $2,935.12, 95% CI [$2,916.31–$2,981.91]). ANOVA analysis showed a significant decrease (P < .001) in cost from low-to-medium– and low-to-high–volume surgeons. Linear regression showed a significant linear relationship (P < .001), with a $1.15 cost reduction per case with each additional hysterectomy. Thus, if a surgeon performed 100 cases, costs were $115 less per case (100 × $1.15), for a total savings of $11,500.00 (100 × $115). Conclusion: Overall, in our models, costs decreased as surgeon volume increased. Low-volume surgeons had significantly higher costs than both medium- and high-volume surgeons.
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Affiliation(s)
- Jonathan P Shepherd
- Department of Obstetrics and Gynecology, St Francis Hospital and Medical Center, Hartford, Connecticut, USA
| | - Charelle M Carter-Brooks
- Department of Obstetrics, Gynecology and Reproductive Sciences of the University of Pittsburgh, Magee Women's Hospital, Pittsburgh, Pennsylvania, USA
| | - Kelly L Kantartzis
- Department of Obstetrics, Gynecology and Reproductive Sciences of the University of Pittsburgh, Magee Women's Hospital, Pittsburgh, Pennsylvania, USA
| | - Ted Lee
- Department of Obstetrics, Gynecology and Reproductive Sciences of the University of Pittsburgh, Magee Women's Hospital, Pittsburgh, Pennsylvania, USA
| | - Michael J Bonidie
- Department of Obstetrics, Gynecology and Reproductive Sciences of the University of Pittsburgh, Magee Women's Hospital, Pittsburgh, Pennsylvania, USA
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Nolfi AL, Brown BN, Liang R, Palcsey SL, Bonidie MJ, Abramowitch SD, Moalli PA. Host response to synthetic mesh in women with mesh complications. Am J Obstet Gynecol 2016; 215:206.e1-8. [PMID: 27094962 DOI: 10.1016/j.ajog.2016.04.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/31/2016] [Accepted: 04/08/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Despite good anatomic and functional outcomes, urogynecologic polypropylene meshes that are used to treat pelvic organ prolapse and stress urinary incontinence are associated with significant complications, most commonly mesh exposure and pain. Few studies have been performed that specifically focus on the host response to urogynecologic meshes. The macrophage has long been known to be the key cell type that mediates the foreign body response. Conceptually, macrophages that respond to a foreign body can be dichotomized broadly into M1 proinflammatory and M2 proremodeling subtypes. A prolonged M1 response is thought to result in chronic inflammation and the formation of foreign body giant cells with potential for ongoing tissue damage and destruction. Although a limited M2 predominant response is favorable for tissue integration and ingrowth, excessive M2 activity can lead to accelerated fibrillar matrix deposition and result in fibrosis and encapsulation of the mesh. OBJECTIVE The purpose of this study was to define and compare the macrophage response in patients who undergo mesh excision surgery for the indication of pain vs a mesh exposure. STUDY DESIGN Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Womens Hospital were offered enrollment. Twenty-seven mesh-vagina complexes that were removed for the primary complaint of a mesh exposure (n = 15) vs pain in the absence of an exposure (n = 12) were compared with 30 full-thickness vaginal biopsy specimens from women who underwent benign gynecologic surgery without mesh. Macrophage M1 proinflammatory vs M2 proremodeling phenotypes were examined via immunofluorescent labeling for cell surface markers CD86 (M1) vs CD206 (M2) and M1 vs M2 cytokines via enzyme-linked immunosorbent assay. The amount of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) proteolytic enzymes were quantified by zymography and substrate degradation assays, as an indication of tissue matrix degradation. Statistics were performed with the use of 1-way analysis of variance with appropriate post hoc tests, t-tests, and Fisher's Exact test. RESULTS Twenty-seven mesh-vaginal tissue complexes were excised from 27 different women with mesh complications: 15 incontinence mid urethral slings and 12 prolapse meshes. On histologic examination, macrophages surrounded each mesh fiber in both groups, with predominance of the M1 subtype. M1 and M2 cytokines/chemokines, MMP-9 (pro- and active), and MMP-2 (active) were increased significantly in mesh-vagina explants, as compared with vagina without mesh. Mesh explants that were removed for exposure had 88.4% higher pro-MMP-9 (P = .035) than those removed for pain. A positive correlation was observed between the profibrotic cytokine interleukin-10 and the percentage of M2 cells (r = 0.697; P = .037) in the pain group. CONCLUSION In women with complications, mesh induces a proinflammatory response that persists years after implantation. The increase in MMP-9 in mesh explants that were removed for exposure indicates degradation; the positive association between interleukin-10 and M2 macrophages in mesh explants that are removed for pain is consistent with fibrosis.
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Affiliation(s)
- Alexis L Nolfi
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bryan N Brown
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rui Liang
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stacy L Palcsey
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA
| | - Michael J Bonidie
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Pamela A Moalli
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
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Abstract
Background and Objective: The costs to perform a hysterectomy are widely variable. Our objective was to determine hysterectomy costs by route and whether traditionally open surgeons lower costs when performing laparoscopy versus robotics. Methods: Hysterectomy costs including subcategories were collected from 2011 to 2013. Costs were skewed, so 2 statistical transformations were performed. Costs were compared by surgeon classification (open, laparoscopic, or robotic) and surgery route. Results: A total of 4,871 hysterectomies were performed: 34.2% open, 50.7% laparoscopic, and 15.1% robotic. Laparoscopic hysterectomy had the lowest total costs (P < .001). By cost subcategory, laparoscopic hysterectomy was lower than robotic hysterectomy in 6 and higher in 1. When performing robotic hysterectomy, open and robotic surgeon costs were similar. With laparoscopic hysterectomy, open surgeons had higher costs than laparoscopic surgeons for 1 of 2 statistical transformations (P = .007). Open surgeons had lower costs performing laparoscopic hysterectomy than robotic hysterectomy with robotic maintenance and depreciation included (P < .001) but similar costs if these variables were excluded. Conclusion: Although laparoscopic hysterectomy had lowest costs overall, robotics may be no more costly than laparoscopic hysterectomy when performed by surgeons who predominantly perform open hysterectomy.
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Affiliation(s)
- Jonathan P Shepherd
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kelly L Kantartzis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ki Hoon Ahn
- Korea University Medical Center, Seoul, South Korea
| | - Michael J Bonidie
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Zhang F, Bonidie MJ, Ventrelli SM, Furlan A. Intraovarian oxidized cellulose (Surgicel) mimicking acute ovarian pathology after recent pelvic surgery. Radiol Case Rep 2015; 10:39-41. [PMID: 26649116 PMCID: PMC4661478 DOI: 10.1016/j.radcr.2015.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/20/2015] [Indexed: 12/03/2022] Open
Abstract
Oxidized regenerated cellulose (Ethicon Surgicel) is often used during surgery to achieve hemostasis. The appearance of Surgicel on postoperative computed tomography (CT) may be mistaken for abscess. Meanwhile, the literature regarding its ultrasound appearance remains scant. We report the CT and sonographic appearances of Surgicel in the right ovary of a 21-year-old woman presenting to the emergency department with pelvic pain 7 days after ovarian cystectomy. The patient was discharged home with only supportive measures, and follow-up ultrasound obtained 26 days later demonstrated resolution of the sonographic abnormality. This case stresses the importance of familiarity with common imaging appearances of topical hemostatic agents and the need to correlate radiologic findings with the patient's clinical condition and prior operative reports to identify patients suitable for conservative management.
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Affiliation(s)
- Feng Zhang
- Department of Radiology, University of Pittsburgh Medical Center, Radiology Suite 201 East Wing, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Michael J Bonidie
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, 300 Halket Street #5600, Pittsburgh, PA, 15213, USA
| | - Stephen M Ventrelli
- Department of Radiology, University of Pittsburgh Medical Center, Radiology Suite 201 East Wing, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Alessandro Furlan
- Department of Radiology, University of Pittsburgh Medical Center, Radiology Suite 201 East Wing, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
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Abstract
OBJECTIVE We sought to determine the incidence of unsuspected injury to the lower urinary tract as detected by intraoperative cystoscopy when the Burch procedure is performed. STUDY DESIGN We reviewed the records of 181 women who underwent pelvic surgery, which included a Burch retropubic urethropexy for genuine stress urinary incontinence, between Jan 1, 1998, and Dec 31, 1999. All patients underwent intraoperative cystoscopy at the completion of the Burch procedure after the administration of intravenous indigo carmine dye. RESULTS There were 6 (3.3%) injuries to the lower urinary tract. Five of the injuries were cystotomies that had been recognized during operation. One obstructed left ureter was detected by cystoscopy and relieved by the release of left paravaginal repair sutures. No unsuspected injuries that were detected by cystoscopy were attributable to the Burch procedure. CONCLUSIONS The lower urinary tract injury rate was 3.3%. All but one injury was recognized before cystoscopy. The one injury was attributed to concomitant paravaginal repair and not to the Burch procedure.
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Affiliation(s)
- E J Gill
- Division of Urogynecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynecology, Medical College of Virginia at Virginia Commonwealth University, Richmond, VA, USA
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Tweardy DJ, Sasaki M, Cardamone JJ, McCoy JP, Bonidie MJ, Signorella AP. Production of laminin B2 chain protein and messenger RNA by a murine neutrophil precursor cell line, 32Dc13. Blood 1990; 76:1398-404. [PMID: 1698480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Laminin is a heterotrimeric glycoprotein that plays a central role in promoting neutrophil chemotaxis, motility, and attachment to basement membrane. Rabbit peritoneal exudate neutrophils stain positively for laminin, which is presumed to be of exogenous origin and bound to laminin receptors on the cell surface. We examined 32Dc13 cells, a murine neutrophil precursor cell line, by immunoprecipitation. Northern blot analysis, flow cytometry, and electron microscopy for the endogenous production of laminin. Our results demonstrate that 32Dc13 cells endogenously produce a laminin B2 chain protein and messenger RNA (mRNA) without producing any detectable A or B1 chain protein or mRNA. The B2 chain protein was not secreted by the cells; rather it could be detected on the cell surface after treatment of cells with neuraminidase. These findings suggest the possibility of a novel role for the laminin B2 chain in myeloid development and function.
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Affiliation(s)
- D J Tweardy
- Department of Medicine, University of Pittsburgh School of Medicine, PA
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