Effect of length of surgery on the incidence of venous thromboembolism after benign hysterectomy

Operative Time and Accrual of Postoperative Complications in Minimally Invasive Versus Open Myomectomy

STUDY OBJECTIVE

To compare the prevalence and accrual of 30-day postoperative complications by operative time for open myomectomy (OM) and minimally invasive myomectomy (MIM).

DESIGN

Retrospective cohort study SETTING: Hospitals participating in the National Surgical Quality Improvement Program database from January 2015 to December 2021.

PATIENTS

Female patients aged ≥18 years undergoing OM or MIM.

INTERVENTIONS

Patients were categorized into OM and MIM cohorts. Covariates associated with operative time and composite complications were identified using general linear model and chi-square or Fisher's exact test as appropriate. Adjusted spline regression was performed as a test of linearity between operative time and composite complications. Adjusted risk ratios of 30-day postoperative individual, minor, major, and composite complications by 60-minute operative time increments were estimated using Poisson regression with robust error variance.

MEASUREMENTS AND MAIN RESULTS

Of 27 728 patients, 11 071 underwent MIM and 16 657 underwent OM. Mean operative times (SD) were 164.6 (82.0) for MIM and 129.2 (67.0) for OM. Raw composite complication rates were 5.5% for MIM and 15.8% for OM. Adjusted spline regression demonstrated linearity between operative time and relative risk of composite postoperative complications for both MIM and OM. MIM had higher adjusted relative risk (aRR, 95% CI) compared to OM of blood transfusion (1.55, 1.45-1.64 versus 1.29, 1.25-1.34), overall minor complications (1.13, 1.03-1.23 versus 1.01, 0.92-1.10), and overall major complications (1.43, 1.35-1.51 versus 1.27, 1.12-1.32). Operative time had greater impact on risk of composite complications for MIM than OM, reaching aRR 2.0 at 296 minutes versus 461 minutes for OM.

CONCLUSION

OM has a higher overall rate of composite, minor, and major complications compared to MIM. While operative time is independently and linearly associated with postoperative complications with myomectomy regardless of approach, optimizing surgical efficiency for MIM may be more critical than for OM.

Machine learning models for prediction of postoperative venous thromboembolism in gynecological malignant tumor patients

AIM

To identify risk factors that associated with the occurrence of venous thromboembolism (VTE) within 30 days after hysterectomy among gynecological malignant tumor patients, and to explore the value of machine learning (ML) models in VTE occurrence prediction.

METHODS

A total of 1087 patients between January 2019 and January 2022 with gynecological malignant tumors were included in this single-center retrospective study and were randomly divided into the training dataset (n = 870) and the test dataset (n = 217). Univariate logistic regression analysis was used to identify risk factors that associated with the occurrence of postoperative VTE in the training dataset. Machine learning models (including decision tree (DT) model and logistic regression (LR) model) to predict the occurrence of postoperative VTE were constructed and internally validated.

RESULTS

The incidence of developing 30-day postoperative VTE was 6.0% (65/1087). Age, previous VTE, length of stay (LOS), tumor stage, operative time, surgical approach, lymphadenectomy (LND), intraoperative blood transfusion and gynecologic Caprini (G-Caprini) score were identified as risk factors for developing postoperative VTE in gynecological malignant tumor patients (p < 0.05). The AUCs of LR model and DT model for predicting VTE were 0.722 and 0.950, respectively.

CONCLUSION

The ML models, especially the DT model, constructed in our study had excellent prediction value and shed light upon its further application in clinic practice.

Venous Thromboembolism After Abdominal and Minimally Invasive Large Specimen Hysterectomy

STUDY OBJECTIVE

To investigate the incidence of venous thromboembolism (VTE) in patients undergoing large specimen hysterectomy for benign indications. To evaluate the impact of route of surgery and operative time in the development of VTE in this population.

DESIGN

Retrospective cohort study (Canadian Task Force Classification II2) of targeted hysterectomy data prospectively collected from the American College of Surgeons National Surgical Quality Improvement Program involving over 500 hospitals across the United States.

SETTING

National Surgical Quality Improvement Program Database.

PATIENTS

Women aged 18 years or older undergoing hysterectomy for benign indications between 2014 and 2019. Patients were further classified into 4 groups according to uterine weight: <100 g, 100-249 g, 250 g-499 g, and specimens ≥500 g.

INTERVENTIONS

Current Procedural Terminology codes were used to identify cases. Variables including age, ethnicity, body mass index, smoking status, diabetes, hypertension, blood transfusion, and American Society of Anesthesiologists classification system scores were collected. Cases were stratified by route of surgery, operative time, and uterine weight.

MEASUREMENTS AND MAIN RESULTS

A total of 122,418 hysterectomies occurring between 2014 and 2019 were included in our study, of which 28,407 (23.2%) patients underwent abdominal, 75,490 (61.7%) laparoscopic, and 18,521 (15.1%) vaginal hysterectomy. The overall rate of VTE in patients with large specimen hysterectomies (≥500 g) was 0.64%. After multivariable adjustment, there was no significant difference in the odds of VTE between uterine weight groups. Only 30% of the surgeries with uterine weight above 500 g were performed with minimally invasive surgical routes. Patients who underwent minimally invasive hysterectomy had lower odds of VTE via laparoscopic (adjusted odds ratio [aOR] 0.62; confidence interval [CI]: 0.48-0.81) and vaginal (aOR 0.46; CI: 0.31-0.69) routes compared to laparotomy. Prolonged operative time (>120 min) was associated with increased odds of VTE (aOR 1.86; CI:1.51-2.29).

CONCLUSION

The occurrence of VTE after a benign large specimen hysterectomy is rare. The odds of VTE is higher with longer operative times and lower with minimally invasive approaches, even for markedly enlarged uteri.

Trends in Same-Day Discharge Rate After Minimally Invasive Sacrocolpopexy and Propensity Score-Matched Analysis of Postoperative Complication Rates Using the National Surgical Quality Improvement Program Database

OBJECTIVE

The primary aim of this study was to review trends in the same-day discharge (SDD) rate after minimally invasive sacrocolpopexy (MISCP). The secondary aim was to compare the composite 30-day postoperative complication rates between propensity score-matched SDD and admitted cohorts.

METHODS

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2019. Patients who underwent MISCP were identified by Current Procedural Terminology codes. Concurrent hysterectomy, anterior or posterior repairs, rectopexy, and midurethral sling were also identified. Multivariable logistic regression and propensity score matching were performed.

RESULTS

A total of 12,762 MISCP patients were captured: 3,968 underwent MISCP only, 4,065 underwent MISCP with total laparoscopic hysterectomy, 734 underwent MISCP with laparoscopically assisted vaginal hysterectomy, and 3,995 underwent MISCP with laparoscopic supracervical hysterectomy. Overall, the SDD rate was 16.3%, with an increase from 12.3% in 2015 to 23.1% in 2019. Multivariable logistic regression showed that admitted patients were more likely to be older, to be of Black race, have an American Society of Anesthesiologists classification of 3 or 4, have hypertension requiring medication, have longer operative time, and have undergone concurrent anterior or posterior repair, rectopexy, or sling. After propensity score matching, the composite postoperative complication rates were similar between the 2 cohorts (5.7% vs 6.4%, P = 0.818). However, superficial surgical site infection was more likely in the SDD cohort (adjusted odds ratio, 2.3; P < 0.001) and blood transfusion in the admitted cohort (adjusted odds ratio, 11.9; P = 0.0.34).

CONCLUSIONS

The rate of SDD after MISCP seems to be increasing. Composite postoperative complication rates are similar between SDD and admitted cohorts.