Systematic assessment of surgical complications in 438 cases of vaginal native tissue repair for pelvic organ prolapse adopting Clavien–Dindo classification

Infection and the evaluation of biomarkers in obstetrics and gynecology patients with infectious disease: a retrospective observational study from clinical pharmacists’ consultation experience

Background

The use of empirical anti-infective medication calls for the identification of common pathogens and accurate infectious biomarkers. However, clinical pharmacists’ anti-infective experience in the field of obstetrics and gynaecology is rare in the literature. This study aimed to retrospectively analyze the correlation between the anti-infective effectiveness after 7 days of antibiotic treatment and infectious biomarkers, according to clinical pharmacists’ consultation cases of gynecological and obstetric infections.

Methods

In this retrospective study, clinical pharmacists’ anti-infective consultation experiences applied by physicians from January 1, 2018, to December 31, 2020, were included. The exclusion criteria were as follows: (1) the patient died or left the hospital before undergoing an effectiveness evaluation after the consultation; (2) treatment was discontinued due to adverse reactions related to antibiotics; (3) the patient did not undergo an effectiveness evaluation within 3 or 7 days after application of the clinical pharmacist’s treatment plan; and (4) the physician did not adopt the clinical pharmacist’s suggestions. The registered information included patient characteristics, pathological bacteria, anti-infective medication and changes in infection indices before and after treatment. Statistical analysis of temperature, white blood cells (WBCs), C-reactive protein (CRP), procalcitonin (PCT) and WBCs in urine after 3 days and 7 days of anti-infective treatment, compared with before anti-infective treatment, was performed by the chi-square test. A t test was conducted to further study WBC count and CRP. A receiver operating characteristic curve verified the sensitivity and specificity of WBC count, CRP and PCT.

Results

A total of 265 cases were included. The CRP levels of patients 3 d and 7 d after antibiotic treatment were significantly lower than before antibiotic treatment (P < 0.05, P < 0.01), while the WBC count showed a downward trend after 3 days and a significant decrease after 7 days (P < 0.01). The areas under the curve (AUCs) for prognosis on the 7th day for WBC count, CRP and PCT were 0.90, 0.75 and 0.522, respectively. The AUC for WBC count combined with CRP was 0.90, which was higher than that for the biomarkers tested separately, especially compared to PCT. The most common gynecological infections were surgical site infection (SSI), urinary tract infection and fever of unknown origin, and the most common pathogens were E. coli and E. faecalis in Gram-negative and Gram-positive samples, respectively. Pharmacists’ recommended treatment plans included carbapenems and β-lactam antibiotics.

Conclusions

Our dual-center study indicates that the combination of WBC count and CRP can improve diagnostic accuracy and treatment efficiency, and PCT alone is insensitive to gynecological infections, according to clinical pharmacists’ experience.

Efficacy and safety of surgery in renal carcinoma patients 75 years and older: a retrospective analysis

Objective

To investigate the efficacy and complications of surgical treatment in patients with renal cell carcinoma aged ≥ 75 years.

Methods

From January 2009 to May 2019, we assessed 166 patients aged 75 years and older, who either had radical nephrectomy (RN) or partial nephrectomy (PN) as treatments for diagnosed renal cell carcinoma. Patients were divided into one group of patients aged 75–79 years and the second group of patients ≥ 80 years. The complications and survival were compared between the two groups.

Results

All 166 patients were successfully operated on. Differences between the two groups were statistically significant in intraoperative and postoperative complications and Clavien–Dindo score of ≥ 1 (P = 0.02, P < 0.001, P = 0.001). Univariate analysis revealed no significant correlation between a Clavien–Dindo score ≥ 1 versus gender, body mass index (BMI), lack of symptoms, KPS, baseline GFR, postoperative GFR, tumor size, tumor location, surgical method, and transfusion or no transfusion (ALL P > 0.05). Multifactor analysis showed that age ≥ 80 years, partial nephrectomy, and operation time were independent predictors of a Clavien–Dindo score ≥ 1. No significant difference was found in OS between the two groups, (P < 0.0001), and no significant difference in CSS (P = 0.056). There was no significant difference in OS and CSS between the RN and PN groups (P = 0.143, P = 0.281, respectively).

Conclusions

According to our findings, the overall safety of surgical therapy for elderly patients with renal cell carcinoma is adequate. PN should be carefully examined, especially over the age of 80. To select suitable patients based on an assessment of the tumor's complexity and patients' physical condition, such as age, underlying diseases and other conditions, technical feasibility, balance of benefits and a case-by-case.

Complications of Pelvic Organ Prolapse Surgery in the 2015 Finnish Pelvic Organ Prolapse Surgery Survey Study

OBJECTIVE

To describe the major complications of pelvic organ prolapse (POP) surgery in Finland.

METHODS

The Finnish Pelvic Organ Prolapse Surgery Survey 2015 study is a prospective cohort of POP surgeries performed in Finland in 2015. Perioperative, postoperative, and late complications during 1 year of follow-up were compared among native tissue repair, transvaginal mesh, and abdominal mesh surgery. Major complications were assessed using the Clavien-Dindo grading system. Predictive factors for major complications were studied with logistic regression analysis.

RESULTS

Within 1 year after POP surgery, 396 (11.2%) of 3,515 women had at least one complication: 10.9% after native tissue, 11.7% after transvaginal mesh, and 13.5% after abdominal mesh repair. The majority of complications occurred within 2 months after surgery and postoperative infection (4.3%) and bleeding or hematoma (2.6%) were the most frequent. The incidence of organ injuries was low. Mesh-augmented surgery was associated with significantly higher rates of bladder and bowel injuries than native tissue surgery. Complication-related reoperations occurred significantly more often after abdominal mesh repair than native tissue surgery (5.2% vs 1.8%, P=.001). Mesh-related complications were diagnosed more often after transvaginal mesh repair. The overall rate of major complications (Clavien-Dindo grades III-V) was 3.3%. Abdominal mesh surgery was associated with the highest rate of major adverse events (8.8% vs native tissue repair 2.6% and transvaginal mesh 4.9%). The incidence of Clavien-Dindo grade IV or V complications was rare (less than 0.6%). Mesh surgery (transvaginal mesh adjusted odds ratio [aOR] 2.23, 95% CI 1.31-3.80, and abdominal mesh aOR 3.02, 95% CI 1.67-5.46), longer operating time (aOR 2.84, 95% CI 1.78-4.53), prior POP surgery (aOR 1.68, 95% CI 1.00-2.81) and difficult surgery (aOR 2.75, 95% CI 1.63-4.62) were associated with an increased risk for occurrence of major complications.

CONCLUSION

Serious adverse events were rare regardless of the operative approach. However, mesh-augmented surgery was associated with higher risk for major complications.

Clavien-Dindo classification for grading complications after total pharyngolaryngectomy and free jejunum transfer

Background

The frequency of postoperative complications is used as an indicator of surgical quality; however, comparison of outcomes is hampered by a lack of agreement on the definition of complications and their severity. A standard grading system for surgical complications is necessary to improve the quality of clinical research and reporting in head and neck reconstruction.

Methods

The aim of this study was to compare postoperative morbidity after microvascular head and neck reconstruction between patients with versus without a history of prior radiation therapy (RT) by using the Clavien–Dindo classification. A group of 274 patients was divided into two cohorts based on the history of prior RT: the RT group included 79 patients and the non-RT group included 195 patients. Postoperative (30-day) complications were compared between the groups with a nonstandardized evaluation system and the Clavien–Dindo classification.

Results

The grades of complications according to the Clavien–Dindo classification were significantly higher in the RT group than in the non-RT group. The frequency of postoperative complications did not differ significantly between the groups according to the nonstandardized evaluation system.

Conclusions

The Clavien–Dindo classification could serve as a useful, highly objective tool for grading operative morbidity after microvascular head and neck reconstruction when comparing similar defects and methods of reconstruction. Widespread use of the Clavien–Dindo classification system would allow adequate comparisons of surgical outcomes among different surgeons, centers, and therapies.

LeFort colpocleisis for recurrent pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The causes of recurrence of pelvic organ prolapse (POP) are sufficiently understood. However, few studies are available evaluating reoperation for recurrence of POP. This study evaluates the efficacy and safety of LeFort colpocleisis for recurrent POP.

METHODS

We reviewed data from patients with recurrent POP who underwent LerFort colpocleisis at a center between March 2012 and April 2017. Quality of life was assessed using the Pelvic Floor Distress Inventory Questionnaire (PFDI-20) scores. The Patient Global Impression of Improvement scale (PGI-I) was used to assess self-perceived success and subjective measures of satisfaction. The Clavien-Dindo classification (CD) was used to assess the safety of the procedure. Chi-square and paired t-tests were used to compare the same patients before and after treatment in the follow-up.

RESULTS

Twenty-six patients with recurrent POP after previous prolapse surgery underwent LeFort colpocleisis. Most of these patients had at least one comorbidity. The mean age (years) was 71.8 (7.3). The mean time to recurrent POP was 5.602 (3.643) years. There were no intraoperative bladder lesions or rectal lesions. At mean follow-up of 33.1 months, all patients had no recurrence (< stage 2), significant resolution of awareness of prolapse (P < 0.05), and significantly improved satisfaction on PGI-I after surgery. Minor complications were classified as CD II level in four cases (15.4%).

CONCLUSION

This study suggests that LeFort colpocleisis is feasible and safe for recurrent POP, especially in older women with comorbidities.

Maternal Complications following Open Fetal Myelomeningocele Repair at the Zurich Center for Fetal Diagnosis and Therapy

INTRODUCTION

Despite undoubtable benefits of open fetal myelomeningocele (fMMC) repair, there are considerable maternal risks. The aim of this study was to evaluate and systematically categorize maternal complications after open fMMC repair.

METHODS

We analyzed data of 40 fMMC repairs performed at the Zurich Center for Fetal Diagnosis and Therapy. Maternal complications were classified according to a 5-level grading system based on a classification of surgical complications proposed by Clavien and Dindo.

RESULTS

We observed no grade 5 complication (death of a patient). Five (12.5%) women demonstrated severe grade 4 complications: 1 case of uterine rupture in a nullipara at 36 gestational weeks (GW), a third-degree atrioventricular block which needed short mechanical resuscitation, a bilateral lung embolism requiring intensive care unit (ICU) management due to low-output syndrome, and chorioamnionitis and urosepsis both requiring ICU management at 31 GW. Twenty-six (65%) women had minor (grade 1-3) complications.

CONCLUSIONS

Only one grade 4 complication (uterine rupture, 2.5%) was a clear-cut direct consequence of fetal surgery. The other four grade 4 complications (10%) occurred in the context of, but cannot unequivocally be attributed to, fetal surgery, since they may occur also in other circumstances. The classification system used is a tenable step towards stringent documentation of maternal complications.

LAVH superior to TVH when concomitant salpingo-oophorectomy is intended in prolapse hysterectomy: a comparative cohort study

PURPOSE

This comparative cohort study evaluated the influence of surgical route for prolapse hysterectomy (vaginal or laparoscopically assisted) on the achievement of intended elective salpingo-oophorectomy, which was a procedural goal planned with the patient before primary vaginal native-tissue prolapse surgery.

METHODS

Consecutive patients who underwent total vaginal hysterectomy (TVH; n = 163) or laparoscopically assisted vaginal hysterectomy (LAVH; n = 144) and vaginal native-tissue repair for pelvic organ prolapse at Jena University Hospital were enrolled.

RESULTS

Peri- and postoperative parameters, including Clavien-Dindo (CD) classification of surgical complications, were compared between groups using Student's t test, Fisher's exact test, and multivariable regression. Patient characteristics were similar, except that grade IV prolapse was more common in the LAVH group (p < 0.001). The following parameters differed between the TVH and LAVH groups: concomitant salpingectomy (1.2% vs. 34%) and salpingo-oophorectomy (45% vs. 66%), non-performance of intended salpingo-oophorectomy (36% vs. 0% OR 0.006, 95% CI < 0.001-0.083), adhesiolysis (0% vs. 44%), CD II-III complications (51% vs. 14.6% p < 0.001), operating time (153 ± 61 vs. 142 ± 27 min), and postoperative in-patient days (9.02 ± 4.9 vs. 4.99 ± 0.96; all p < 0.001).

CONCLUSIONS

LAVH enabled the safe performance of planned concomitant salpingo-oophorectomy in all cases. To achieve the procedural goal in such cases, laparoscopic assistance in prolapse hysterectomy should be considered.

Gynaecological Prolapse Surgery in Very Old Female Patients: A Case-Control Study on Co-Morbidity and Surgical Complications

BACKGROUND

The aim of this study is to compare very elderly female patients with a younger control group after prolapse surgery with regard to co-morbidity and complications.

METHOD

In a case-control design, the consecutive data of patients after prolapse surgery at the age of over 80 years and those of a control group were analysed by means of the Clavien-Dindo (CD) classification of surgical complications, the Charlson Comorbidity Index and the Cumulative Illness Rating Scale Geriatrics (CIRS-G). Statistics: Student's t, Fisher's exact and Mann-Whitney U tests.

RESULTS

The analysis comprised n = 57 vs. n = 60 operations. In the very elderly patients there was often a grade IV prolapse (p < 0.001), apical fixations were more frequent (p < 0.001), but the operating times were not different. In the very elderly patients 21 % CD II+III complications were observed, in the control group 6.6 % (p = 0.031). No CD IV and V complications occurred in either group, the duration of inpatient stay amounted to 5 (± 1) vs. 4.1 (± 0.8; p < 0.001) days, the very elderly patients needed an inpatient follow-up more frequently (p < 0.001). The co-morbidities of the very elderly patients differed from those of the control group in number (median 2.0 vs. 1.5; p < 0.001), in CIRS-G (4.1 ± 2.2 vs. 2.4 ± 1.7; p < 0.01) and in Charlson Index (1.6 ± 1.6 vs. 0.5 ± 0.7; p < 0.001).

CONCLUSIONS

A prolapse in very elderly women can be safely managed by surgery. In no case did the complications require intensive care treatment nor were they life-threatening, but they did lead to a longer duration of hospital stay and more frequently to further treatment geriatric or inpatient internal medicine facilities.

Systematic classification of uterine cervical elongation in patients with pelvic organ prolapse

OBJECTIVE

To define and classify cervical elongation, to compare uterine measurements after prolapse hysterectomy with a non-prolapse control group, and to associate stage of prolapse and degree of cervical elongation.

STUDY DESIGN

This was a single-centre retrospective case-control study conducted at the University Hospital, Urogynaecological Unit, with a certified urogynaecological surgeon. Data were collected from patients with and without pelvic organ prolapse (POP) who underwent laparoscopically assisted vaginal hysterectomy. Post-hysterectomy uterine cervical elongation was examined using the corpus/cervix ratio (CCR), calculated from measurements taken on photographs. Cervical elongation was classified as physiological (grade 0, CCR>1.5) grade I (CCR>1 and ≤1.5) grade II (CCR>0.5 and ≤1), and grade III (CCR≤0.5).

RESULTS

Cervical elongation was detected in 288/295 (97.6%) patients in the prolapse group (grade I, 44/288 [15.2%]; grade II, 212 [73.6%]; grade III, 32 [11.1%]). Mean CCR was greater among those with stage II/III than among those with stage IV prolapse (1.0±0.4 vs. 0.8±0.2; p<0.001). Grades of cervical elongation and prolapse stages were associated (p<0.001). Grade I cervical elongation was detected in 26/69 (37.6%), grade II in 5/69, and grade III in 0/69 patients of the control group. Cervical elongation was found more often in the prolapse group compared to the control group (p<0.001). Mean total uterine length did not differ between the prolapse and control groups (8.0±1.6 vs. 8.2±1.3cm), but mean calculated cervical length was greater in the prolapse group than in the control group (4.4±1.1 vs. 3.1+0.8cm; p<0.001).

CONCLUSIONS

Uterine cervical elongation is found in patients undergoing hysterectomy for pelvic organ prolapse. Cervical elongation grades and prolapse stages are correlated. Defining uterine cervical elongation based on corpus/cervix ratio with grades I-III could be a valuable basic tool for further research.

Bilateral minimal tension sacrospinous fixation in pelvic organ prolapse: an observational study

OBJECTIVE

To evaluate the safety and the subjective and objective outcomes of bilateral minimal tension sacrospinous fixation for pelvic organ prolapse.

STUDY DESIGN

This was a single-centre observational study conducted at the University Hospital, Urogynaecological Unit, with a certified urogynaecological surgeon. A cohort of 110 patients receiving modified bilateral sacrospinous fixation following a diagnosis of grade II-IV pelvic organ prolapse and defects of three pelvic compartments. Non-absorbable sutures were placed on each side of the sacrospinous ligament. The main aim was to achieve a minimal tension situation by intentionally leaving suture bridges on both sides of the suspension. The post-surgical follow-up period was 14±7 months. The three characteristics of cure in functional surgery - anatomy, function, and subjective patient's judgement - were evaluated in this study. Primary outcomes were anatomic, functional, and subjective cures, that were measured pre- and postoperatively using the POP-Q system values, a validated pelvic quality-of-life questionnaire (P-QoL/D), and interviews regarding expectations, goal-setting, goal achievement, and satisfaction. Secondary outcome measures included data on surgical complications. Data analysis was performed with descriptive statistics, Wilcoxon tests, and Mann-Whitney U-tests.

RESULTS

A total of 110 patients underwent anterior and posterior colporrhaphy and minimal tension bilateral sacrospinous fixation. An objective anatomic cure was reported for 94.5% of patients, and significant improvement of all prolapse symptoms was observed following surgery (p<0.001). Full or partial fulfilment of the criteria for a subjective cure was demonstrated in 96% of the patients. Only 5.5% of the patients experienced postoperative urinary tract infections. No other complications requiring medical or surgical interventions were reported.

CONCLUSION

Bilateral minimal tension sacrospinous fixation was associated with low morbidity, as well as excellent anatomic, functional, and subjective results at follow-up.