Intestinal obstruction from a forgotten artery forceps: a case report

A 43-year-old multiparous patient p2+0 all alive who had abdominal hysterectomy secondary to ruptured uterus 2 1/2 years prior to presentation, was seen with acute (surgical) abdomen. An artery forceps was seen on plain abdominal X-ray and subsequent laparotomy revealed gangrenous ileum. The entire length of the ileum was involved, including the ileocecal valve and part of the cecum. The patient had limited right hemicolectomy and anastomosis of the distal part of the jejunum with the proximal section of the transverse colon. The post-operative period was uneventful and she was discharged to outpatient clinic 2 weeks post operatively.

Hysterectomy: benefits of clinical performance indicators in the evaluation of healthcare facilities

PURPOSE

The aim of our study was to verify, by applying clinical performance indicators, the quality of healthcare given to hysterectomy patients and the benefits on their adoption in healthcare facilities.

METHODS

The different surgical approaches and indications for surgery were evaluated in 534 patients analysing postoperative short-term complications and triggered clinical performance indicators (CPIs).

RESULTS

Surgery was performed by the abdominal (80.9%) and vaginal route (19.1%). Postoperative complication rate was 13.5% and CPIs were triggered 108 times overall: 42 in benign conditions (10.3%) and 30 in malignancy (23.4%) (p = 0.001). In patients operated on for benign conditions the different approaches, abdominal or vaginal, showed differences in postoperative period (p = 0.4). In 10.9% of malignant and in 2.9% of benign conditions hospital stay was triggered (p = 0.001). Vaginal surgery showed a shorter average stay than laparotomy (p = 0.001).

CONCLUSION

The use of CPIs may determine a refinement of clinical performance with positive effects on health, patient satisfaction, postoperative morbidity hospitalisation and healthcare cost savings.

Quality of care for women undergoing a hysterectomy: effects of insurance and race/ethnicity

OBJECTIVE

We assessed the quality of hospital care for women who underwent a hysterectomy to compare Medicaid-covered women with privately insured women and minority women with White women.

METHODS

We evaluated medical decisions, inpatient care, quality of inpatient care, and outcomes.

RESULTS

Quality of hospital care was equivalent for Medicaid-covered women compared with privately insured women and for non-Hispanic Black women compared with White women. Medicaid-covered women (40%) and Black women (68%) were more likely to have a complication compared with privately insured women and White women, respectively.

CONCLUSIONS

Increased complications after hysterectomy may result in increased economic burdens to Medicaid. Further studies of the racial/ethnic and sociodemographic issues are needed so that disparities may be adequately addressed.

Clinical opinion: guidelines for hysterectomy

OBJECTIVE

Abdominal hysterectomy remains the predominant method of uterine removal in the United States, despite evidence that vaginal hysterectomy offers advantages in regard to operative time, complication rates, return to normal activities, and overall cost of treatment.

STUDY DESIGN

The predominance of the abdominal approach may be based on factors other than clinical considerations that include resident training, use of obsolete or limited guidelines, a perception rather than a confirmation that pathologic conditions exist that may suggest contraindications to the vaginal approach, misconceptions regarding the cost and safety of vaginal hysterectomy, and increased third-party reimbursement for the abdominal procedure.

RESULTS

Evidence-based practice guidelines that were developed by the Society of Pelvic Reconstructive Surgeons and were adopted by the National Guidelines Clearinghouse have demonstrated that, in a number of studies that span several years, a dramatic shift toward the vaginal approach occurred when the guidelines were applied prospectively.

CONCLUSION

The guidelines demonstrate that transvaginal hysterectomy is both feasible and optimal for many patients who long have been considered inappropriate candidates for vaginal hysterectomy. This clinical opinion attempts to address the reasons for the predominant use of the abdominal approach.

Consequences of inadvertent, suboptimal primary surgery in carcinoma of the uterine cervix

OBJECTIVES

Invasive cervical cancer that is discovered only after simple hysterectomy remains a problem. Little is known about the best management of this group since there are no relevant outcome studies. This study aimed to quantify the benefits of guideline-based treatment by comparing outcome data in patients treated by inappropriate simple hysterectomy and adjuvant radiotherapy with data in patients treated with primary radical surgery, radiotherapy, or radiochemotherapy.

METHODS

Records of 288 patients who had undergone radical hysterectomy with pelvic lymphadenectomy or simple hysterectomy were extracted and divided into three groups-radical hysterectomy alone (n = 89), radical hysterectomy and adjuvant radiotherapy (n = 119), and simple hysterectomy with adjuvant radiotherapy (n = 80). Disease-free and overall survival were calculated using Kaplan-Meier analyses.

RESULTS

There was a trend towards better overall survival in the radical hysterectomy group. Disease-free survival was significantly better in patients treated by radical hysterectomy, followed by simple hysterectomy plus radiotherapy, and then radical hysterectomy plus radiotherapy (P(log rank DFS) < 0.002). When the two radical surgery groups were combined and compared with the suboptimally treated group, no significant differences were seen for overall survival.

CONCLUSION

Postoperative radiotherapy is a good treatment for patients with cervical cancer who have undergone suboptimal simple hysterectomy. Appropriate selection criteria for further surgery remain to be defined.

Ovarian cancer surgery in Maryland: volume-based access to care

PURPOSE

To characterize the patterns of primary surgical care for ovarian cancer in a statewide population according to annual surgeon and hospital case volume.

METHODS

The Maryland hospital discharge database was accessed for annual surgeon and hospital ovarian cancer case volume for the time intervals: 1990-1992, 1993-1995, 1996-98, and 1999-2000. Annual surgeon case volume was categorized as low (</=4), intermediate (5-9), or high (>/=10). Annual hospital case volume was categorized as low (</=9), intermediate (10-19), or high (>/=20). Logistic regression models were used to evaluate for significant trends in case volume distribution over time and factors associated with access to high-volume care.

RESULTS

Overall, 2417 cases were performed by 531 surgeons at 49 hospitals. The distribution according to annual surgeon case volume was low (56.3%), intermediate (9.2%), and high (34.5%). Between 1993 and 2000, there was no significant increase in the proportion of cases performed by high-volume surgeons (OR = 1.03, 95% CI = 0.81-1.33, P = 0.79). Access to high-volume surgeons was positively associated with care at high-volume hospitals and negatively associated with residence >/=50 miles from a high-volume hospital. The overall hospital volume case distribution was low (49.6%), intermediate (27.6%), and high (22.8%). There was a statistically significant decrease in access to high-volume hospitals between 1990 and 1998 (OR = 0.39, 95% CI = 0.30-0.50, P < 0.0001).

CONCLUSION

A large proportion of primary ovarian cancer surgeries are performed by low-volume surgeons at low-volume hospitals. In light of positive volume-outcomes data for malignancies treated with technically complex operative procedures, increased efforts to concentrate the surgical care of women with ovarian cancer are warranted. Condensed abstract. A large proportion of primary ovarian cancer surgeries are performed by low-volume surgeons at low-volume hospitals. In light of positive volume-outcomes data for malignancies treated with technically complex operative procedures, increased efforts to concentrate the surgical care of women with ovarian cancer are warranted.

Reliability of clinical guideline development using mail-only versus in-person expert panels

BACKGROUND

Clinical practice guidelines quickly become outdated. One reason they might not be updated as often as needed is the expense of collecting expert judgment regarding the evidence. The RAND-UCLA Appropriateness Method is one commonly used method for collecting expert opinion. We tested whether a less expensive, mail-only process could substitute for the standard in-person process normally used.

METHODS

We performed a 4-way replication of the appropriateness panel process for coronary revascularization and hysterectomy, conducting 3 panels using the conventional in-person method and 1 panel entirely by mail. All indications were classified as inappropriate or not (to evaluate overuse), and coronary revascularization indications were classified as necessary or not (to evaluate underuse). Kappa statistics were calculated for the comparison in ratings from the 2 methods.

RESULTS

Agreement beyond chance between the 2 panel methods ranged from moderate to substantial. The kappa statistic to detect overuse was 0.57 for coronary revascularization and 0.70 for hysterectomy. The kappa statistic to detect coronary revascularization underuse was 0.76. There were no cases in which coronary revascularization was considered inappropriate by 1 method, but necessary or appropriate by the other. Three of 636 (0.5%) hysterectomy cases were categorized as inappropriate by 1 method but appropriate by the other.

CONCLUSIONS

The reproducibility of the overuse and underuse assessments from the mail-only compared with the conventional in-person conduct of expert panels in this application was similar to the underlying reproducibility of the process. This suggests a potential role for updating guidelines using an expert judgment process conducted entirely through the mail.

[Obstetrical hysterectomy]

OBJECTIVE

Obstetrical hysterectomy still remains life saving operation. The aim of study was to determinate the frequency, indications and complications after the operation in the hospital in Zielona Góra, Poland.

MATERIALS AND METHODS

A retrospective review based on hospital data of 36 patients undergoing obstetrical hysterectomy over the period of 11 years was undertaken.

RESULTS

The incidence of obstetrical hysterectomy during 1990-2001 et the Department of Obstetrics and Gynaecology in the district hospital in Zielona Góra was 1: 593 deliveries. Post partum hysterectomy occurred in 0.021% of normal deliveries and 1.03% of cesarean sections. The most common indications were placenta increta and placenta accreta /61.1%/, followed by uterine atony /13.8%/ and rupture of the uterus /11.1%. The most frequent complications were shock and lesion of the urinary bladder/both 5.6%/. The maternal mortality was 2.8%.

CONCLUSIONS

1. The most common indications for the obstetrical hysterectomy are: placenta's pathologies; uterine atony and rupture of the uterus. 2. Obstetrical hysterectomy is connected with high risk of complications and maternal mortality.

[Evaluation of the advantages of laparoscopic procedures for hysterectomy]

OBJECTIVE

The objective of this publication was the analysis of 102 laparoscopic hysterectomy. The results were discussed in comparison with traditional laparotomy.

MATERIAL AND METHODS

There was the analysis of 102 hysterectomy by the means of laparoscopy done in 2000-2002. Following parameters were evaluated: duration of the operation, blood loss, complication, the day of introducing enteral nutrition and duration of hospitalization.

RESULTS

It was observed, that laparoscopic operation took more time than laparotomy (average time: 96.4 min vs 62.37 min). Blood loss was similar in both procedures. Comparing the changes of hemoglobin concentration in serum before and after the procedures it was observed average change 1.75 g% for laparoscopy and 1.71 g% for laparotomy. Time introducing enteral nutrition and duration of hospitalization was shorter for laparoscopic procedures. 87.25% of patients was able to eat in next day after laparoscopic operation. Average amount of days of hospitalization after laparoscopic procedures was 3.75 days, after laparotomy 6.44 days. The infections were the most common postoperative complications. The infections were more common in laparotomy group.

CONCLUSIONS

The new method causes: shortened time of hospitalization, quicker introducing of general diet, avoiding the large wound of abdominal segments, small amount of complications.

Radiofrequency bipolar coagulation for radical hysterectomy: technique, feasibility and complications

This study describes the surgical technique and intra- and postoperative complications associated with the use of a radiofrequency bipolar coagulator in a series of 18 Piver type III-IV radical hysterectomies performed in cervical cancer patients. Preliminary vessel-by-vessel dissection of the lateral parametria was possible in 17 out of 18 (94%) cases, and a direct application of a radiofrequency bipolar coagulation instrument was performed to coagulate the posterior and anterior parametrial tissues in all cases. We were able to easily coagulate isolated vessels up to 5 mm of maximal diameter. In no case were clamps or hemoclips necessary to complete hemostasis. We did not observe any parametrial vessel damage or heat-related injury of the surrounding normal tissue. The median size of the parametria removed was 44 mm (range 31-58) and nodes were detected in 15 cases (83%). Median operative time and estimated blood loss for the whole procedure including systematic pelvic and aortic lymphadenectomy was 250 min (range 200-410) and 550 ml (range 400-2500), respectively. Median follow-up time was 9 months (range 5-13). No complications specifically related to the use of radiofrequency coagulation were found. In conclusion the radio-frequency coagulation with this instrument appears to be a safe technique that is particularly useful in reducing blood loss and operative time without affecting radicality in patients undergoing radical hysterectomy.

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is to identify problems associated with the quality of hysterectomy care accessed by members of SEWA (Self-Employed Women's Association), an Indian CBHI scheme, and discuss mechanisms that would optimize quality of care. Data on hysterectomy care were collected through a review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA's members varied from potentially dangerous to excellent. Dangerous conditions included operating theatres without separate hand-washing facilities or proper lighting, the absence of qualified nursing staff, performing hysterectomy on demand, removing both ovaries without consulting or notifying the patient, and failing to send the excised organs for histopathology, even when signs were suggestive of disease. Women paid substantial amounts of money, even for poor and potentially dangerous care. In order to improve the quality of care for its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocations; (3) contract with providers giving a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better quality care and contract directly with them.

Patient accept questionnaires integrated in clinical routine: a study by the Swedish National Register for Gynecological Surgery

BACKGROUND

In 1996, the Swedish National Register for Gynecological Surgery started to collect pre- and postoperative information on patients using questionnaires given out as part of routine medical care. The information is used in providing clinical care to the patient and for quality assessment.

AIMS

To evaluate patients' acceptance of questionnaires as a means of collecting information, and to investigate whether the questionnaire is a suitable tool for follow-up of patients.

METHODS

In 1998, evaluations of the ordinary questionnaires were done by an evaluation questionnaire mailed to 80 patients who had been recently hysterectomized. The results were triangulated with results from the register's database and data from interviews with physicians and secretaries.

RESULTS

The majority of the patients appreciated the questionnaires. Patients did not report any major problems in filling in the questionnaires. Most problems were due to administrative errors of the departments. Up to 36% of the patients missed the scheduled follow-up visit 2 months after the operation. Two out of four departments regarded the follow-up visit necessary and requested by the patients. Out of 1226 patients followed up postoperatively by questionnaire, 75% stated that they did not need any medical care. Among physicians, some distrust of questionnaires was noted.

CONCLUSIONS

The patients in this study preoperatively, and for short- and long-term follow-up, accepted the questionnaire as an instrument of data collection. Questionnaires provide a more complete collection of post-treatment information than follow-up visits do. A large number of unnecessary follow-up visits can be avoided through use of a questionnaire.

SOGC clinical guidelines. Hysterectomy

OBJECTIVE

To identify the indications for hysterectomy, preoperative assessment, and available alternatives required prior to hysterectomy. Patient self-reported outcomes of hysterectomy have revealed high levels of patient satisfaction. These may be maximized by careful preoperative assessment and discussion of other treatment choices. In most cases hysterectomy is performed to relieve symptoms and improve quality of life. The patient's preference regarding treatment alternatives must be considered carefully.

OPTIONS

The areas of clinical practice considered in formulating this guideline are preoperative assessment including alternative treatments, choice of method for hysterectomy, and evaluation of risks and benefits. The risk-to-benefit ratio must be examined individually by the woman and her health practitioners.

OUTCOMES

Optimizing the decision-making process of women and their caregivers in proceeding with a hysterectomy having considered the disease process, and available alternative treatments and options, and having reviewed the risks and anticipated benefits.

EVIDENCE

Using Medline, PubMed, and the Cochrane Database, English language articles were reviewed from 1996 to 2001 as well as the review published in the 1996 SOGC guidelines. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS, AND COSTS

Hysterectomy is the treatment of choice for certain gynaecologic conditions. The predicted advantages must be carefully weighed against the possible risks of the surgery and other treatment alternatives. In the properly selected patient, the result from the surgery should be an improvement in the quality of life. The cost of the surgery to the health care system and to the patient must be interpreted in the context of the cost of untreated conditions. The approach selected for the hysterectomy will impact on the cost of the surgery.

RECOMMENDATIONS

Benign Disease 1. Leiomyomas: For symptomatic fibroids, hysterectomy provides a permanent solution to menorrhagia and the pressure symptoms related to an enlarged uterus. (I-A) 2. Abnormal uterine bleeding: Endometrial lesions must be excluded and medical alternatives should be considered as a first line of therapy. (III-B) 3. Endometriosis: Hysterectomy is often indicated in the presence of severe symptoms with failure of other treatments and when fertility is no longer desired. (1-B) 4. Pelvic relaxation: A surgical solution usually includes vaginal hysterectomy, but must include pelvic supporting procedures. (II-B) 5. Pelvic pain: A multidisciplinary approach is recommended, as there is little evidence that hysterectomy will cure chronic pelvic pain. When the pain is confined to dysmenorrhea or associated with significant pelvic disease, hysterectomy may offer relief. (II-C) Preinvasive Disease 1. Hysterectomy is usually indicated for endometrial hyperplasia with atypia. (I-A) 2. Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy. (I-B) 3. Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix when invasive disease has been excluded. (I-B) Invasive Disease 1. Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube carcinoma. (I-A) Acute Conditions 1. Hysterectomy is indicated for intractable postpartum hemorrhage when conservative therapy has failed to control bleeding. (II-B) 2. Tubo-ovarian abscesses that are ruptured or do not respond to antibiotics may be treated with hysterectomy and bilateral salpingo-oophorectomy in selected cases. (I-C) 3. Hysterectomy may be required for cases of acute menorrhagia refractory to medical or conservative surgical treatment. (II-C) Other Indications 1. Consultation with an oncologist or geneticist is recommended when considering hysterectomy and prophylactic oophorectomy for a familial history of ovarian cancer. (III-C) Surgical Approach 1. The vaginal route shoe should be considered as a first choice for all benign indications. The laparoscopic approach should be considered when it reduces the need for a laparotomy. (III-B) VALIDATION: Medline searches were performed in preparing this guideline with input from experts in their field across Canada. The guideline was reviewed and accepted by SOGC Council and Executive.

SPONSOR

The Society of Obstetricians and Gynaecologists of Canada.

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is: (1) to identify problems associated with the quality of hysterectomy care accessed by members of SEWA, an Indian CBHI scheme; and (2) to discuss mechanisms that might be put in place by SEWA, and CBHI schemes more generally, to optimize quality of health care. Data on the structure and process of hysterectomy care were collected primarily through review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA's members varies tremendously, from potentially dangerous to excellent. Seemingly dangerous aspects of structure include: operating theatres without separate hand-washing facilities or proper lighting; and the absence of qualified nursing staff. Dangerous aspects of process include: performing hysterectomy on demand; removing both ovaries without consulting or notifying the patient; and failing to send the excised organs for histopathology, even when symptoms and signs are suggestive of disease. Women pay substantial amounts of money even for care of poor, and potentially dangerous, quality. In order to improve the quality of hospital care accessed by its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate cases where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocation decisions; (3) select, and contract with, providers who provide a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better-quality care and contract directly with them.

Transfusion rate associated with hysterectomy for benign disease

The transfusion rate associated with hysterectomy for benign disease is an indirect indicator of haemorrhage. It is used in quality assurance activities and is one measure of standard of care. This retrospective study was conducted to determine the transfusion rate for these operations in a tertiary referral hospital. In addition, it was considered that the information could be used in deciding the need for a routine preoperative group and save policy (G and S). The Blood Bank records of all women undergoing hysterectomy for benign disease from 1993-1998 were examined and the number of women transfused was recorded. A total of 1220 hysterectomies were performed. Of women having vaginal hysterectomies only 0.38% required transfusion compared with 2.18% for abdominal hysterectomies. These data suggest that there is no need for a strict policy of preoperative G and S for all patients. In addition, this information can be used as a benchmark when reviewing morbidity associated with hysterectomy and in particular when various methods of hysterectomy are compared.

[Removal or conservation of ovaries during hysterectomy for benign lesions]

At the time of hysterectomy, the aging ovary presents a dilemma. We conducted a prospective study to assess the feasibility of systematic oophorectomy in women 50 years or older and a retrospective study of hysterectomy history in patients who developed cancer of the ovary. Our finding and data in the literature point out the requirement for careful assessment of two aspects of the problem, one technical (feasibility of adnexectomy) and the other functional (ovary function and risk of cancer on the retained ovary).