Clinimetric properties of 3 instruments measuring postoperative recovery in a gynecologic surgical population

Same-day discharge after laparoscopic hysterectomy for benign/premalignant disease: A multicentre randomised controlled trial

OBJECTIVE

To evaluate whether physical function and quality of life was influenced by discharge on the same-day after a total laparoscopic hysterectomy.

DESIGN

Multicentre non-inferiority randomised controlled trial.

SETTING

Five teaching hospitals and two university hospitals in the Netherlands.

POPULATION

Patients undergoing laparoscopic hysterectomy for benign or premalignant disease.

METHODS

Following informed consent, participants were allocated 1:1 either to same-day discharge (SDD) or next-day discharge (NDD).

MAIN OUTCOME MEASURES

The primary outcome was physical function at 7 days after surgery measured by the Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function short Form 10A. Secondary outcomes were physical function and quality of life at 1 and 3 days and 6 weeks after surgery measured with PROMIS short Form 10A and the EuroQol questionnaire (EQ-5D-5L).

RESULTS

Two hundred and five patients were included of whom 105 were allocated to SDD and 100 to NDD. Physical function 7 days after surgery was 35.95 in the SDD group and 35.63 in the control group (mean difference 0.32; 95% CI [0.07-0.57]). As the upper limit of the 95% CI does not exceed the non-inferiority margin of 4 points, non-inferiority of SDD could be demonstrated. No difference in physical function nor quality of life on Days 1 and 3 and 6 weeks could be found.

CONCLUSION

This research demonstrates same-day discharge after laparoscopic hysterectomy is non-inferior to next day discharge in physical function 7 days after surgery.

Procedural sedation and analgesia versus general anesthesia for hysteroscopic myomectomy (PROSECCO trial): A multicenter randomized controlled trial

BACKGROUND

Hysteroscopic resection is the first-choice treatment for symptomatic type 0 and 1 fibroids. Traditionally, this was performed under general anesthesia. Over the last decade, surgical procedures are increasingly being performed in an outpatient setting under procedural sedation and analgesia. However, studies evaluating safety and effectiveness of hysteroscopic myomectomy under procedural sedation are lacking. This study aims to investigate whether hysteroscopic myomectomy under procedural sedation and analgesia with propofol is noninferior to hysteroscopic myomectomy under general anesthesia.

METHODS AND FINDINGS

This was a multicenter, randomized controlled noninferiority trial conducted in 14 university and teaching hospitals in the Netherlands between 2016 and 2021. Inclusion criteria were age ≥18 years, maximum number of 3 type 0 or 1 fibroids, maximum fibroid diameter 3.5 cm, American Society of Anesthesiologists class 1 or 2, and having sufficient knowledge of the Dutch or English language. Women with clotting disorders or with severe anemia (Hb < 5.0 mmol/L) were excluded. Women were randomized using block randomization with variable block sizes of 2, 4, and 6, between hysteroscopic myomectomy under procedural sedation and analgesia (PSA) with propofol or under general anesthesia (GA). Primary outcome was the percentage of complete resections, assessed on transvaginal ultrasonography 6 weeks postoperatively by a sonographer blinded for the treatment arm and surgical outcome. Secondary outcomes were the surgeon's judgment of completeness of procedure, menstrual blood loss, uterine fibroid related and general quality of life, pain, recovery, hospitalization, complications, and surgical reinterventions. Follow-up period was 1 year. The risk difference between both treatment arms was estimated, and a Farrington-Manning test was used to determine the p-value for noninferiority (noninferiority margin 7.5% of incomplete resections). Data were analyzed according to the intention-to-treat principle, including a per-protocol analysis for the primary outcome. A total of 209 women participated in the study and underwent hysteroscopic myomectomy with PSA (n = 106) or GA (n = 103). Mean age was 45.1 [SD 6.4] years in the PSA group versus 45.0 [7.7] years in the GA group. For 98/106 women in the PSA group and 89/103 women in the GA group, data were available for analysis of the primary outcome. Hysteroscopic resection was complete in 86/98 women (87.8%) in the PSA group and 79/89 women (88.8%) in the GA group (risk difference -1.01%; 95% confidence interval (CI) -10.36 to 8.34; noninferiority, P = 0.09). No serious anesthesiologic complications occurred, and conversion from PSA to GA was not required. During the follow-up period, 15 serious adverse events occurred (overnight admissions). All were unrelated to the intervention studied. Main limitations were the choice of primary outcome and the fact that our study proved to be underpowered.

CONCLUSIONS

Noninferiority of PSA for completeness of resection was not shown, though there were no significant differences in clinical outcomes and quality of life. In this study, hysteroscopic myomectomy for type 0 and 1 fibroids with PSA compared to GA was safe and led to shorter hospitalization. These results can be used for counseling patients by gynecologists and anesthesiologists. Based on these findings, we suggest that hysteroscopic myomectomies can be performed under PSA in an outpatient setting.

TRIAL REGISTRATION

The study was registered prospectively in the Dutch Trial Register (NTR 5357; registration date: 11 August 2015; Date of initial participant enrollment: 18 February 2016).

A Content Framework of a Novel Patient-Reported Outcome Measure for Detecting Early Adverse Events After Major Abdominal Surgery

BACKGROUND

Systematic health monitoring with patient-reported outcome instruments may predict post-discharge complications after major surgery. The objective of this study was to conceptualize a novel patient-reported outcome instrument for detecting early adverse events within two weeks of discharge after major emergency abdominal surgery and colorectal cancer surgery.

METHODS

This study was conducted in two phases. (1) An exhaustive health concept pool was generated using systematic content analysis of existing patient-reported outcome measures (N = 31) and semi-structured interviews of readmitted patients (N = 49) and health professionals (N = 10). Concepts were categorized into three major domains: 'Symptoms,' 'functional status,' and 'general health perception.' We calculated the frequency of each health concept as the proportion of patients, who experienced the respective concept prior to readmission. (2) Colorectal cancer surgeons (N = 13) and emergency general surgeons (N = 12) rated the relevance of each health concept (1 = irrelevant, 5 = very relevant) in the context of detecting post-discharge adverse events. We selected concepts with either a high mean relevance score (≥ 4) or a combination of moderate mean relevance score and high patient-reported frequency (≥ 3 and ≥ 20% or ≥ 2.5 and ≥ 50%, respectively).

RESULTS

Content analysis of existing items with additions from patients and experts resulted in 58 health concepts, of which the majority were distinct symptoms (N = 40). The selection procedure resulted in 29 patient-reported health concepts relevant for detecting adverse events after discharge.

CONCLUSION

The outlined framework provides content validity for future patient-reported outcome instruments detecting adverse events in the early post-discharge period after major emergency abdominal surgery and colorectal cancer surgery.

Personalised electronic health programme for recovery after major abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial

BACKGROUND

Despite the adoption of minimally invasive techniques, recovery after abdominal surgery takes a long time. Electronic health (eHealth) modalities can provide guidance to patients, facilitating early return to normal activities. We aimed to assess the impact of a personalised eHealth programme on patients' return to normal activities after major abdominal surgery.

METHODS

This single-blind, randomised, placebo-controlled trial was done at 11 teaching hospitals in the Netherlands. Eligible participants were aged 18-75 years who underwent a laparoscopic or open colectomy or hysterectomy. An independent researcher randomly allocated participants (in a 1:1 ratio) to either the intervention or control group by use of computer-based randomisation lists, with stratification by sex, type of surgery, and hospital. Participants in the intervention group had access to a perioperative, personalised eHealth programme consisting of both standard face-to-face care and eHealth, that comprised interactive tools offering goal attainment and a personalised outcome measurement, which managed recovery expectations and provided postoperative guidance tailored to each patient. Patients were provided with an activity tracker and had access to a website and mobile app with an electronic consultation (eConsult) functionality. The control group received standard care and access to a placebo website containing recovery advice provided by the hospital. The primary outcome was the number of days between surgery and personalised return to normal activities, assessed with Kaplan-Meier curves. Intention-to-treat and per-protocol analyses were done with a Cox regression model. This trial is registered with the Netherlands National Trial Register (NTR5686).

FINDINGS

Between Feb 11, 2016, and Aug 9, 2017, 355 participants were randomly assigned to the intervention (n=178) or control (n=177) groups. 342 participants were included in the intention-to-treat analysis. The median time until return to normal activities was 52 days (IQR 33-111) in the intervention group, and 65 days (39-152) in the control group (adjusted hazard ratio 1·30 [95% CI 1·03-1·64]; p=0·027). The frequency of postoperative complications did not differ between groups.

INTERPRETATION

This eHealth programme, delivering personalised care based on goal attainment scaling, enabled patients to return to their normal activities 13 days earlier than those who received standard care.

FUNDING

ZonMw.

Short-term recovery after NovaSure® endometrial ablation: a prospective cohort study

Background

Endometrial ablation is a frequently performed treatment for heavy menstrual bleeding, but detailed information about recovery to help inform patients is lacking.

Objective

To gain more insight into the short-term recovery after NovaSure® endometrial ablation, with the goal of improving preprocedural counselling.

Materials and Methods

A total of 61 women who underwent endometrial ablation between March 2019 and November 2021 in a teaching hospital in the Netherlands were included in this prospective cohort study.

Main outcome measures

Short-term recovery was investigated through questionnaires in the first week after the procedure. The primary outcome was the Recovery Index (RI-10). Secondary outcomes included health-related quality of life (EQ-5D-5L), pain intensity, use of analgesics, nausea, vaginal discharge, capability of performing activities (domestic chores, sports, work), self-rated health (EQ-VAS) and the feeling of full recovery.

Results

A total of 33 women underwent the procedure under local anaesthesia and 28 women under procedural sedation. The RI-10 increased in the first week; median scores on day one, two and seven were 34 (IQR 28.5-41.5), 38.5 (IQR 31-47), and 42 (IQR 37.5-48), respectively. The median time for full recovery was five days. However, 23% of all women were not fully recovered within seven days. Women needed a median time of two days for returning to their work and 5.5 days for sporting activities. There were no differences in recovery between both anaesthesia techniques.

Conclusions

Women undergoing endometrial ablation can be informed that most will fully recover within the first week of the procedure and that there is no difference in expected recovery time according to whether the procedure is undertaken with local anaesthesia or conscious sedation.

What is New?

The short-term recovery after endometrial ablation has been mapped in this trial. This information can be used in counselling women with heavy menstrual bleeding.

Effects of Video-Based Patient Education and Consultation on Unplanned Health Care Utilization and Early Recovery After Coronary Artery Bypass Surgery (IMPROV-ED): Randomized Controlled Trial

BACKGROUND

Health care utilization after coronary artery bypass graft (CABG) surgery is high and is partly of an unplanned nature. eHealth applications have been proposed to reduce care consumption, which involve and assist patients in their recovery. In this way, health care expenses could be reduced and quality of care could be improved.

OBJECTIVE

The aim of this study was to evaluate if an eHealth program can reduce unplanned health care utilization and improve mental and physical health in the first 6 weeks after CABG surgery.

METHODS

A single-blind randomized controlled trial was performed, in which patients scheduled for nonacute CABG surgery were included from a single center in the Netherlands between February 2020 and October 2021. Participants in the intervention group had, alongside standard care, access to an eHealth program consisting of online education videos and video consultations developed in conjunction with the Dutch Heart Foundation. The control group received standard care. The primary outcome was the volume and costs of a composite of unplanned health care utilization, including emergency department visits, outpatient clinic visits, rehospitalization, patient-initiated telephone consultations, and visits to a general practitioner, measured using the Medical Technology Assessment Medical Consumption Questionnaire. Patient-reported anxiety and recovery were also assessed. Intention-to-treat and "users-only" analyses were used.

RESULTS

During the study period, 280 patients were enrolled and randomly allocated at a 1:1 ratio to the intervention or control group. The intention-to-treat analysis consisted of 136 and 135 patients in the intervention and control group, respectively. At 6 weeks, the primary endpoint had occurred in 43 of 136 (31.6%) patients in the intervention group and in 61 of 135 (45.2%) patients in the control group (hazard ratio 0.56, 95% CI 0.34-0.92). Recovery was faster in the intervention group, whereas anxiety was similar between study groups. "Users-only" analysis yielded similar results.

CONCLUSIONS

An eHealth strategy comprising educational videos and video consultations can reduce unplanned health care utilization and can aid in faster patient-reported recovery in patients following CABG surgery.

TRIAL REGISTRATION

Netherlands Trial Registry NL8510; https://trialsearch.who.int/Trial2.aspx?TrialID=NL8510.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1007/s12471-020-01508-9.

A Qualitative Assessment of Factors That Children, Parents, and Clinicians Prioritize in the Setting of Elective Anesthesia and Surgery

BACKGROUND

Assessing the postoperative recovery of pediatric patients is challenging as there is no validated comprehensive patient-centered recovery assessment tool for this population. A qualitative investigative approach with in-depth stakeholder interviews can provide insight into the recovery process and inform the development of a comprehensive patient-centered postoperative assessment tool for children.

METHODS

We conducted open-ended, semistructured interviews with children 6-12 years old undergoing elective surgery (n = 35), their parents (n = 37), and clinicians (n = 23) who commonly care for this population (nurses, anesthesiologists, and surgeons). A codebook was developed and analyzed using NVivo 12 Plus. The codebook was iteratively developed using a qualitative content analysis approach with modifications made throughout to refine codes. We report the results of this thematic analysis of patient, parent, and clinician transcripts.

RESULTS

Postoperative recovery priorities/concerns overlapped and also diverged across the 3 groups. Topics prioritized by children included mobility and self-care, as well as access to a strong social support network following surgery. The majority of children reported feeling anxious about the surgery and separating from their parents, as well as sadness about their inability to participate in activities while recovering. Although children highly valued familial support during recovery, there was variable awareness of the impact of surgery on family members and support network. In contrast, parents focused on the importance of clear and open communication among themselves and the health care team and being equipped with appropriate knowledge and resources on discharge. The immediate repercussions of the child's surgery, such as pain, confusion, and nausea, appeared to be a primary focus of both parents and clinicians when describing recovery. Clinicians had a comprehensive awareness of the possible psychological impacts of surgery in children, while parents reported varying degrees of awareness or concern regarding longer-term or more latent impacts of surgery and anesthesia (eg, anxiety and depression). Prior experience with pediatric surgery emerged as a distinguishing characteristic for parents and clinicians as parents without prior experience expressed less understanding of or comfort with managing a child's recovery following surgery.

CONCLUSIONS

A patient-centered qualitative investigative approach yielded insights regarding the importance of various aspects of recovery in pediatric patients, their parents, and members of the health care team. Specifically, this investigation highlighted the importance of clear communication providing anticipatory guidance for families presenting for elective surgery in an effort to optimize patient recovery. This information will be used in the development of a patient-centered recovery assessment tool.

IMPROV-ED trial: eHealth programme for faster recovery and reduced healthcare utilisation after CABG

Background

After coronary artery bypass grafting (CABG), healthcare utilisation is high and is partly unplanned. eHealth applications have been proposed to reduce healthcare consumption and to enable patients to get actively involved in their recovery. This way, healthcare expenses can be reduced and the quality of care can be improved.

Objectives

We aim to evaluate whether the use of an eHealth programme can reduce unplanned healthcare utilisation and improve mental and physical health in the first 6 weeks after discharge in patients who underwent CABG. In addition, patient satisfaction and use of the eHealth programme will be evaluated.

Methods

For this single-centre randomised controlled trial, at least 280 patients referred for CABG will be included at the preoperative outpatient clinic and randomised to an intervention or control group. The intervention group will have access to an eHealth programme, which consists of online educational videos developed by the Dutch Heart Foundation and postoperative video consultations with a physician. The control group will receive standard care and will not have access to the eHealth programme. The primary endpoint is healthcare utilisation; other endpoints include anxiety, duration of recovery, quality of life and patient satisfaction. Participants will complete several questionnaires at 6 time points during the study.

Results

Patient enrolment started in February 2020 and completion of the follow-up period is expected in August 2021.

Conclusion

This randomised trial was initiated to test the hypothesis that patients who are partaking in our eHealth programme use less unplanned care and experience a better quality of life, less anxiety and a faster recovery than controls.

Factors Influencing Postoperative Recovery and Time Off Work of Patients with Benign Indications for Surgery - Results of a Prospective Study

Objectives The study aimed to answer a number of questions: Which medical, psychological and sociodemographic factors affect the recovery of women after gynecological surgery for benign indications? Does patients' health-related quality of life improve after surgical intervention? How long are patients signed off work postoperatively? How do patients assess their own capacity to work? Method Study population: All women between the ages of 18 and 67 years who underwent gynecological surgery for benign indications at the Charité Campus Virchow Clinic over a 7-month period were consecutively enrolled in the study. Four standardized patient surveys (the first survey [T0] was carried out in hospital, T1 at 1 week, T2 at 6 weeks and T3 at 7 - 8 months after discharge by telephone interview) were carried out using evaluated questionnaires to record patients' recovery (Recovery Index), quality of life (RAND-36), satisfaction, complications, sociodemographic information and time off work with a medical sick note. Relevant medical and demographic data were also collected. Statistical analysis was carried out using univariate statistical tests for descriptive analysis and complex multifactorial statistical procedures to record observations over time. Results A total of 182 patients were included in this study (participation rate: 70%). Relevant prior operations (p = 0.01), in-hospital (p = 0.004) and postoperative complications (p < 0.001), preoperative psychological wellbeing (p = 0.01), physical functioning (p = 0.005) and postoperative anxiety (p = 0,006) had a significant impact on recovery (Recovery Index) and changed significantly over time (p < 0.001). The invasiveness of the surgery or sociodemographic parameters (including migration background) had no significant effect. Health-related quality of life (measured with the RAND-36 questionnaire) also improved postoperatively. More invasive surgical interventions were associated with longer sick leave times and, to a certain extent, with a poorer evaluation of patients' capacity to work. Conclusion Recovery after gynecological surgery is a multifactorial process. This survey of a patient population identified psychological and physical factors which influence recovery but did not find significant sociodemographic parameters affecting recovery. Irrespective of these findings, gynecological surgery for benign indications resulted in an improvement in health-related quality of life. Prospective studies need to investigate whether psychological interventions could reduce preoperative fear and thereby improve postoperative recovery.

Anesthetics' role in postoperative urinary retention after pelvic organ prolapse surgery with concomitant midurethral slings: a randomized clinical trial

INTRODUCTION AND HYPOTHESIS

Spinal anesthesia can be a potential risk factor for postoperative urinary retention (POUR). Our objective was to compare POUR rates for outpatient vaginal pelvic floor surgeries when using spinal versus general anesthesia. Our hypothesis was that spinal anesthesia would have higher POUR rates compared with general anesthesia.

METHODS

This was a randomized clinical trial on subjects undergoing outpatient pelvic organ prolapse (POP) surgery with a concomitant midurethral sling (MUS). Subjects were discharged home the same day as surgery. Subjects were excluded if they had a preoperative post-void residual > 150 ml, they were < 40 years of age, surgery was < 1 h, or they had contraindications to spinal or general anesthesia. A standardized voiding trial was performed. The primary aim was to compare POUR rates between anesthesia groups. A power analysis estimated 28 subjects were required per group to detect a 37% difference with 80% power and an alpha of 0.05.

RESULTS

The trial was registered at ClinicalTrials.gov on July 15, 2015. Sixty-one subjects were enrolled between June 22, 2015, and December 31, 2017. Three were excluded, leaving 29 in each group. Groups were similar in demographics. For the primary outcome, there was a 14.3% difference in POUR rates between spinal and general anesthesia, which did not reach statistical significance based on our power calculation (p = 0.2516).

CONCLUSIONS

Based on this study, there is not an increased rate of POUR with the use of spinal anesthesia for POP surgery with MUS. However, since there was a trend toward higher rates of POUR in the spinal group, it is possible that a larger powered study design would be able to detect a statistically significant difference between the groups. Based on these findings, if surgical patients would benefit from spinal anesthesia, the risk of urinary retention should not be considered a reason to not utilize this form of anesthesia.

CLINICAL TRIAL REGISTRATION

Does spinal anesthesia for prolapse surgery with concomitant sling lead to an increase in urinary retention compared to general anesthesia? https://clinicaltrials.gov/ct2/show/NCT02547155?term=laura+martin&rank=3 (NCT02547155).

The (cost) effectiveness of procedural sedation and analgesia versus general anaesthesia for hysteroscopic myomectomy, a multicentre randomised controlled trial: PROSECCO trial, a study protocol

BACKGROUND

In women with abnormal uterine bleeding, fibroids are a frequent finding. In case of heavy menstrual bleeding and presence of submucosal type 0-1 fibroids, hysteroscopic resection is the treatment of first choice, as removal of these fibroids is highly effective. Hysteroscopic myomectomy is currently usually performed in the operating theatre. A considerable reduction in costs and a higher patient satisfaction are expected when procedural sedation and analgesia with propofol (PSA) in an outpatient setting is applied. However, both safety and effectiveness - including the necessity for re-intervention due to incomplete resection - have not yet been evaluated.

METHODS

This study is a multicentre randomised controlled trial with a non-inferiority design and will be performed in the Netherlands. Women > 18 years with a maximum of 3 symptomatic type 0 or 1 submucosal fibroids with a maximum diameter of 3.5 cm are eligible to participate in the trial. After informed consent, 205 women will be randomised to either hysteroscopic myomectomy using procedural sedation and analgesia with propofol in an outpatient setting or hysteroscopic myomectomy using general anaesthesia in a clinical setting in the operating theatre. Primary outcome will be the percentage of complete resections, based on transvaginal ultrasonography 6 weeks postoperatively. Secondary outcomes are cost effectiveness, menstrual blood loss (Pictorial blood assessment chart), quality of life, pain, return to daily activities/work, hospitalization, (post) operative complications and re-interventions. Women will be followed up to one year after hysteroscopic myomectomy.

DISCUSSION

This study may demonstrate comparable effectiveness of hysteroscopic myomectomy under procedural sedation and analgesia versus general anaesthesia in a safe and patient friendly environment, whilst achieving a significant cost reduction.

TRIAL REGISTRATION

Dutch trial register, number NTR5357 . Registered 11th of August 2015.

Construct Validity and Responsiveness of the Abdominal Surgery Impact Scale in the Context of Recovery After Colorectal Surgery

BACKGROUND

The Abdominal Surgery Impact Scale is a patient-reported outcome measure that evaluates quality of life after abdominal surgery. Evidence supporting its measurement properties is limited.

OBJECTIVE

This study aimed to contribute evidence for the construct validity and responsiveness of the Abdominal Surgery Impact Scale as a measure of recovery after colorectal surgery in the context of an enhanced recovery pathway.

DESIGN

This is an observational validation study designed according to the Consensus-based Standards for the Selection of Health Measurement Instruments checklist.

SETTING

This study was conducted at a university-affiliated tertiary hospital.

PATIENTS

Included were 100 consecutive patients undergoing colorectal surgery (mean age, 65; 57% male).

INTERVENTION

There were no interventions.

MAIN OUTCOME MEASURES

Construct validity was assessed at 2 days and 2 and 4 weeks after surgery by testing the hypotheses that Abdominal Surgery Impact Scale scores were higher 1) in patients without vs with postoperative complications, 2) with higher preoperative physical status vs lower, 3) without vs with postoperative stoma, 4) in men vs women, 5) with shorter time to readiness for discharge (≤4 days) vs longer, and 6) with shorter length of stay (≤4 days) vs longer. To test responsiveness, we hypothesized that scores would be higher 1) preoperatively vs 2 days postoperatively, 2) at 2 weeks vs 2 days postoperatively, and 3) at 4 weeks vs 2 weeks postoperatively.

RESULTS

The data supported 3 of the 6 hypotheses (hypotheses 1, 5, and 6) tested for construct validity at all time points. Two of the 3 hypotheses tested for responsiveness (hypotheses 1 and 2) were supported.

LIMITATIONS

This study was limited by the risk of selection bias due to the use of secondary data from a randomized controlled trial.

CONCLUSIONS

The Abdominal Surgery Impact Scale was responsive to the expected trajectory of recovery up to 2 weeks after surgery, but did not discriminate between all groups expected to have different recovery trajectories. There remains a need for the development of recovery-specific, patient-reported outcome measures with adequate measurement properties. See Video Abstract at http://links.lww.com/DCR/A814.

Effects of deep vs moderate neuromuscular block on the quality of recovery after robotic gastrectomy

BACKGROUND

It remains unclear whether deep neuromuscular blockade results in better postoperative recovery than does moderate neuromuscular blockade. Therefore, in this study, we aimed to compare the effects of deep neuromuscular blockade and moderate neuromuscular blockade on the quality of postoperative recovery in patients undergoing robotic gastrectomy.

METHODS

In this prospective, double-blind, single-center randomized controlled superiority trial with two parallel groups, 56 adult patients (19-80 years) scheduled for elective robotic gastrectomy were randomly assigned to a moderate neuromuscular blockade group or a deep neuromuscular blockade group in a 1:1 ratio. In the deep and moderate neuromuscular blockade groups, the infusion rate for rocuronium was adjusted to maintain a post-tetanic count of 1-2 or a train-of-four count of 1-2, respectively. The primary outcome was the Quality of Recovery-40 (QoR-40) score on postoperative day 1. Secondary outcomes included the QoR-40 score on postoperative day 2, intraoperative hemodynamic data, intraoperative respiratory data, visual analog scale score for pain, postoperative incidences of nausea and vomiting, postoperative rescue analgesic use, and postoperative rescue antiemetic use.

RESULTS

The postoperative QoR-40 score was similar between the two groups on postoperative days 1 and 2. Moreover, the two groups showed no differences in intraoperative hemodynamic and respiratory data or postoperative pain, nausea and vomiting, and rescue medication use.

CONCLUSION

Our findings suggest that the quality of recovery after robotic gastrectomy is similar for deep and moderate neuromuscular blockade. Therefore, deep neuromuscular blockade during robotic gastrectomy may be unnecessary, at least in patients with normal body mass index.

Electronic Health Program to Empower Patients in Returning to Normal Activities After General Surgical and Gynecological Procedures: Intervention Mapping as a Useful Method for Further Development

Background

Support for guiding and monitoring postoperative recovery and resumption of activities is usually not provided to patients after discharge from the hospital. Therefore, a perioperative electronic health (eHealth) intervention (“ikherstel” intervention or “I recover” intervention) was developed to empower gynecological patients during the perioperative period. This eHealth intervention requires a need for further development for patients who will undergo various types of general surgical and gynecological procedures.

Objective

This study aimed to further develop the “ikherstel” eHealth intervention using Intervention Mapping (IM) to fit a broader patient population.

Methods

The IM protocol was used to guide further development of the “ikherstel” intervention. First, patients’ needs were identified using (1) the information of a process evaluation of the earlier performed “ikherstel” study, (2) a review of the literature, (3) a survey study, and (4) focus group discussions (FGDs) among stakeholders. Next, program outcomes and change objectives were defined. Third, behavior change theories and practical tools were selected for the intervention program. Finally, an implementation and evaluation plan was developed.

Results

The outcome for an eHealth intervention tool for patients recovering from abdominal general surgical and gynecological procedures was redefined as “achieving earlier recovery including return to normal activities and work.” The Attitude-Social Influence-Self-Efficacy model was used as a theoretical framework to transform personal and external determinants into change objectives of personal behavior. The knowledge gathered by needs assessment and using the theoretical framework in the preparatory steps of the IM protocol resulted in additional tools. A mobile app, an activity tracker, and an electronic consultation (eConsult) will be incorporated in the further developed eHealth intervention. This intervention will be evaluated in a multicenter, single-blinded randomized controlled trial with 18 departments in 11 participating hospitals in the Netherlands.

Conclusions

The intervention is extended to patients undergoing general surgical procedures and for malignant indications. New intervention tools such as a mobile app, an activity tracker, and an eConsult were developed.

Trial Registration

Netherlands Trial Registry NTR5686; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5686 

Personalised perioperative care by e-health after intermediate-grade abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial

BACKGROUND

Instructing and guiding patients after surgery is essential for successful recovery. However, the time that health-care professionals can spend with their patients postoperatively has been reduced because of efficiency-driven, shortened hospital stays. We evaluated the effect of a personalised e-health-care programme on return to normal activities after surgery.

METHODS

A multicentre, single-blind, randomised controlled trial was done at seven teaching hospitals in the Netherlands. Patients aged 18-75 years who were scheduled for laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication were recruited. An independent researcher randomly allocated participants to either the intervention or control group using computer-based randomisation lists, with stratification by sex, type of surgery, and hospital. Participants in the intervention group had access to a perioperative, personalised, e-health-care programme, which managed recovery expectations and provided postoperative guidance tailored to the patient. The control group received usual care and access to a placebo website containing standard general recovery advice. Participants were unaware of the study hypothesis and were asked to complete questionnaires at five timepoints during the 6-month period after surgery. The primary outcome was time between surgery and return to normal activities, measured using personalised patient-reported outcome measures. Intention-to-treat and per-protocol analyses were done. This trial is registered in the Netherlands National Trial Register, number NTR4699.

FINDINGS

Between Aug 24, 2015, and Aug 12, 2016, 344 participants were enrolled and randomly allocated to either the intervention (n=173) or control (n=171) group. 14 participants (4%) were lost to follow-up, with 330 participants included in the primary outcome analysis. Median time until return to normal activities was 21 days (95% CI 17-25) in the intervention group and 26 days (20-32) in the control group (hazard ratio 1·38, 95% CI 1·09-1·73; p=0·007). Complications did not differ between groups.

INTERPRETATION

A personalised e-health intervention after abdominal surgery speeds up the return to normal activities compared with usual care. Implementation of this e-health programme is recommended in patients undergoing intermediate-grade abdominal, gynaecological, or general surgical procedures.

FUNDING

ZonMw.

Quality of Recovery After Low-Pressure Laparoscopic Donor Nephrectomy Facilitated by Deep Neuromuscular Blockade: A Randomized Controlled Study

Background

The use of low intra-abdominal pressure (<10 mmHg) reduces postoperative pain scores after laparoscopic surgery.

Objective

To investigate whether low-pressure pneumoperitoneum with deep neuromuscular blockade improves the quality of recovery after laparoscopic donor nephrectomy (LDN).

Design, setting and participants

In a single-center randomized controlled trial, 64 live kidney donors were randomly assigned to 6 or 12 mmHg insufflation pressure. A deep neuromuscular block was used in both groups. Surgical conditions were rated by the five-point Leiden-surgical rating scale (L-SRS), ranging from 5 (optimal) to 1 (extremely poor) conditions. If the L-SRS was insufficient, the pressure was increased stepwise.

Main outcome measure

The primary outcome measure was the overall score on the quality of recovery-40 (QOR-40) questionnaire at postoperative day 1.

Results

The difference in the QOR-40 scores on day 1 between the low- and standard-pressure group was not significant (p = .06). Also the overall pain scores and analgesic consumption did not differ. Eight procedures (24%), initially started with low pressure, were converted to a standard pressure (≥10 mmHg). A L-SRS score of 5 was significantly more prevalent in the standard pressure as compared to the low-pressure group at 30 min after insufflation (p < .01).

Conclusions

Low-pressure pneumoperitoneum facilitated by deep neuromuscular blockade during LDN does not reduce postoperative pain scores nor improve the quality of recovery in the early postoperative phase. The question whether the use of deep neuromuscular blockade during laparoscopic surgery reduces postoperative pain scores independent of the intra-abdominal pressure should be pursued in future studies.

Trial registration

The trial was registered at clinicaltrial.gov before the start of the trial (NCT02146417).

Using PROMIS for measuring recovery after abdominal surgery: a pilot study

BACKGROUND

To assess the construct validity and responsiveness of the PROMIS Physical Function v1.2 short form 8b (PROMIS-PF), and the PROMIS Ability to Participate in Social Roles and Activities v2.0 short form 8a (PROMIS-APS) in postoperative recovery.

METHODS

An observational pilot study was conducted in which 30 patients participated, undergoing various forms of abdominal surgery. Patients completed the PROMIS-PF and PROMIS-APS, the Short Form 36 Health Survey (SF-36) and the World Health Organization Disability Assessment Schedule 2.0 (WHODAS) at several time points before and after surgery. The construct validity and responsiveness of the two PROMIS short forms were evaluated by testing pre-defined hypotheses and were considered adequate when at least 75% of the data was consistent with the hypotheses. Construct validity was evaluated by calculating Spearman correlations and the responsiveness by calculating effect sizes.

RESULTS

6/7 (85.7%) of the results were consistent with the hypotheses supporting the construct validity of the PROMIS-PF. For the PROMIS-APS this was the case in 7/15 (46.7%) of the results. For the PROMIS-PF, 6/7 (85.7%) of the results were consistent with the hypotheses, supporting responsiveness. Regarding the responsiveness of the PROMIS-APS, only 7 out of 13 (53.8%) of these results were consistent with the hypotheses.

CONCLUSIONS

This study supported the construct validity and the responsiveness of the PROMIS-PF v1.2 short form 8b for measuring recovery in abdominal surgery. Considering the major advantages of PROMIS, we recommend the use of the PROMIS-PF in abdominal surgery.

Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation

OBJECTIVE

To evaluate the implementation and effectiveness of an internet-based perioperative care programme for patients following gynaecological surgery for benign disease.

DESIGN

Stepped-wedge cluster randomised controlled trial.

SETTING

Secondary care, nine hospitals in the Netherlands, 2011-2014.

PARTICIPANTS

433 employed women aged 18-65 years scheduled for hysterectomy and/or laparoscopic adnexal surgery.

INTERVENTIONS

An internet-based care programme was sequentially rolled out using a multifaceted implementation strategy. Depending on the implementation phase of their hospital, patients were allocated to usual care (n=206) or the care programme (n=227). The care programme included an e-health intervention equipping patients with tailored personalised convalescence advice.

MAIN OUTCOME MEASURES

The primary outcome was duration until full sustainable return to work (RTW). The degree of implementation of the care programme was evaluated at the level of the patient, healthcare provider and organisation by indicators measuring internet-based actions by patients and providers.

RESULTS

Median time until RTW was 49 days (IQR 27-76) in the intervention group and 62 days (42-85) in the control group. A piecewise Cox model was fitted to take into account non-proportionality of hazards. In the first 85 days after surgery, patients receiving the intervention returned to work faster than patients in the control group (HR 2.66, 95% CI 1.88 to 3.77), but this effect was reversed in the small group of patients that did not reach RTW within this period (0.28, 0.17 to 0.46). Indicators showed that the implementation of the care programme was most successful at the level of the patient (82.8%) and professional (81.7%).

CONCLUSIONS

Implementation of an internet-based care programme has a large potential to lead to accelerated recovery and improved RTW rates following different types of gynaecological surgeries.

TRIAL REGISTRATION NUMBER

NTR2933; Results.

Cost-effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: economic evaluation alongside a stepped-wedge cluster-randomised trial

OBJECTIVES

To evaluate the cost-effectiveness and cost-utility of an internet-based perioperative care programme compared with usual care for gynaecological patients.

DESIGN

Economic evaluation from a societal perspective alongside a stepped-wedge cluster-randomised controlled trial with 12 months of follow-up.

SETTING

Secondary care, nine hospitals in the Netherlands, 2011-2014.

PARTICIPANTS

433 employed women aged 18-65 years scheduled for a hysterectomy and/or laparoscopic adnexal surgery.

INTERVENTION

The intervention comprised an internet-based care programme aimed at improving convalescence and preventing delayed return to work (RTW) following gynaecological surgery and was sequentially rolled out. Depending on the implementation phase of their hospital, patients were allocated to usual care (n=206) or to the intervention (n=227).

MAIN OUTCOME MEASURES

The primary outcome was duration until full sustainable RTW. Secondary outcomes were quality-adjusted life years (QALYs), health-related quality of life and recovery.

RESULTS

At 12 months, there were no statistically significant differences in total societal costs (€-647; 95% CI €-2116 to €753) and duration until RTW (-4.1; 95% CI -10.8 to 2.6) between groups. The incremental cost-effectiveness ratio (ICER) for RTW was 56; each day earlier RTW in the intervention group was associated with cost savings of €56 compared with usual care. The probability of the intervention being cost-effective was 0.79 at a willingness-to-pay (WTP) of €0 per day earlier RTW, which increased to 0.97 at a WTP of €76 per day earlier RTW. The difference in QALYs gained over 12 months between the groups was clinically irrelevant resulting in a low probability of cost-effectiveness for QALYs.

CONCLUSIONS

Considering that on average the costs of a day of sickness absence are €230, the care programme is considered cost-effective in comparison with usual care for duration until sustainable RTW after gynaecological surgery for benign disease. Future research should indicate whether widespread implementation of this care programme has the potential to reduce societal costs associated with gynaecological surgery.

TRIAL REGISTRATION NUMBER

NTR2933; Results.

Laparoscopic sacrocolpopexy versus vaginal sacrospinous fixation for vaginal vault prolapse, a randomized controlled trial: SALTO-2 trial, study protocol

BACKGROUND

Hysterectomy is one of the most performed surgical procedures during lifetime. Almost 10 % of women who have had a hysterectomy because of prolapse symptoms, will visit a gynaecologist for a surgical correction of a vaginal vault prolapse thereafter. Vaginal vault prolapse can be corrected by many different surgical procedures. A Cochrane review comparing abdominal sacrocolpopexy to vaginal sacrospinous fixation considered the open abdominal procedure as the treatment of first choice for prolapse of the vaginal vault, although operation time and hospital stay is longer. Literature also shows that hospital stay and blood loss are less after a laparoscopic sacrocolpopexy compared to the abdominal technique. To date, it is unclear which of these techniques leads to the best operative result and the highest patient satisfaction. Prospective trials comparing vaginal sacrospinous fixation and laparoscopic sacrocolpopexy are lacking. The aim of this randomized trial is to compare the disease specific quality of life of the vaginal sacrospinous fixation and laparoscopic sacrocolpopexy as the treatment of vaginal vault prolapse.

METHODS

We will perform a multicentre prospective randomized controlled trial. Women with a post-hysterectomy symptomatic, POP-Q stage ≥2, vaginal vault prolapse will be included. Participants will be randomized to the vaginal sacrospinous fixation group or the laparoscopic sacrocolpopexy group. Primary outcome is disease specific quality of life at 12 months follow-up. Secondary outcome will be the effect of the surgical treatment on prolapse related symptoms, sexual functioning, procedure related morbidity, hospital stay, post-operative recovery, anatomical results using the POP-Q classification after one and 5 years follow-up, type and number of re-interventions, costs and cost-effectiveness. Analysis will be performed according to the intention to treat principle and not as a per protocol analysis. With a power of 90% and a level of 0.05, the calculated sample size necessary is 96 patients. Taking into account 10% attrition, a number of 106 patients (53 in each arm) will be included.

DISCUSSION

The SALTO-2 trial is a randomized controlled multicentre trial to evaluate whether the laparoscopic sacrocolpopexy or vaginal sacrospinous fixation is the first-choice surgical treatment in patients with a stage ≥2 vault prolapse.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR3977 ; Registered 28 April 2013.

Assessing pre- and postoperative activity levels with an accelerometer: a proof of concept study

Background

Postoperative recovery after abdominal surgery is measured mostly based on subjective or self-reported data. In this article we aim to evaluate whether recovery of daily physical activity levels can be measured postoperatively with the use of an accelerometer.

Methods

In this multicenter, observational pilot study, 30 patients undergoing laparoscopic abdominal surgery (hysterectomy, adnexal surgery, cholecystectomy and hernia inguinal surgery) were included. Patients were instructed to wear an Actigraph wGT3X-BT accelerometer during one week before surgery (baseline) and during the first, third and fifth week after surgery. Wear time, steps taken and physical activity intensity levels (sedentary, light, moderate and vigorous) were measured. Patients were blinded for the accelerometer outcomes. Additionally, an activity diary comprising patients’ self-reported time of being recovered and a list of 18 activities, in which the dates of resumption of these 18 activities were recorded after surgery, was completed by the patient.

Results

Five patients were excluded from analyses because of technical problems with the accelerometer (n = 1) and protocol non-adherence (n = 4). Light, moderate, vigorous, combined moderate and vigorous intensity physical activity (MVPA), and step counts showed a clear recovery curve after surgery. Patients who underwent minor surgery reached their baseline step count and MVPA three weeks after surgery. Patients who underwent intermediate surgery had not yet reached their baseline step count during the last measuring week (five weeks after surgery). The results of the activity diaries showed a fair agreement with the accelerometer results (Cohens Kappa range: 0.273-0.391). Wearing the accelerometer was well tolerated and not regarded as being burdensome by the patients.

Conclusions

The accelerometer appeared to be a feasible way to measure recovery of postoperative physical activity levels in this study and was well tolerated by the patients. The agreement with self-reported physical recovery times was fair.

Electronic supplementary material

The online version of this article (doi:10.1186/s12893-017-0223-0) contains supplementary material, which is available to authorized users.

Substitution of Usual Perioperative Care by eHealth to Enhance Postoperative Recovery in Patients Undergoing General Surgical or Gynecological Procedures: Study Protocol of a Randomized Controlled Trial

Background

Due to the strong reduction in the length of hospital stays in the last decade, the period of in-hospital postoperative care is limited. After discharge from the hospital, guidance and monitoring on recovery and resumption of (work) activities are usually not provided. As a consequence, return to normal activities and work after surgery is hampered, leading to a lower quality of life and higher costs due to productivity loss and increased health care consumption.

Objective

With this study we aim to evaluate whether an eHealth care program can improve perioperative health care in patients undergoing commonly applied abdominal surgical procedures, leading to accelerated recovery and to a reduction in costs in comparison to usual care.

Methods

This is a multicenter randomized, single-blinded, controlled trial. At least 308 patients between 18 and 75 years old who are on the waiting list for a laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication will be included. Patients will be randomized to an intervention or control group. The intervention group will have access to an innovative, perioperative eHealth care program. This intervention program consists of a website, mobile phone app, and activity tracker. It aims to improve patient self-management and empowerment by providing guidance to patients in the weeks before and after surgery. The control group will receive usual care and will have access to a nonintervention (standard) website consisting of the digital information brochure about the surgical procedure being performed. Patients are asked to complete questionnaires at 5 moments during the first 6 months after surgery. The primary outcome measure is time to return to normal activities based on a patient-specific set of 8 activities selected from the Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning item bank version 1.2. Secondary outcomes include social participation, self-rated health, duration of return to work, physical activity, length of recovery, pain intensity, and patient satisfaction. In addition, an economic evaluation alongside this randomized controlled trial will be performed from the societal and health care perspective. All statistical analyses will be conducted according to the intention-to-treat principle.

Results

The enrollment of patients started in September 2015. The follow-up period will be completed in February 2017. Data cleaning and analyses have not begun as of the time this article was submitted.

Conclusions

We hypothesize that patients receiving the intervention program will resume their normal activities sooner than patients in the control group and costs will be lower.

ClinicalTrial

Netherlands Trial Registry NTC4699; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4699 (Archived by WebCite at http://www.webcitation.org/6mcCBZmwy)

Evaluation of the Swedish Web-Version of Quality of Recovery (SwQoR): Secondary Step in the Development of a Mobile Phone App to Measure Postoperative Recovery

BACKGROUND

The majority of all surgeries are performed on an outpatient basis (day surgery). The Recovery Assessment by Phone Points (RAPP) app is an app for the Swedish Web-version of Quality of Recovery (SwQoR), developed to assess and follow-up on postoperative recovery after day surgery.

OBJECTIVES

The objectives of this study are (1) to estimate the extent to which the paper and app versions of the SwQoR provide equivalent values; (2) to contribute evidence as to the feasibility and acceptability of a mobile phone Web-based app for measuring postoperative recovery after day surgery and enabling contact with a nurse; and (3) to contribute evidence as to the content validity of the SwQoR.

METHODS

Equivalence between the paper and app versions of the SwQoR was measured using a randomized crossover design, in which participants used both the paper and app version. Feasibility and acceptability was evaluated by a questionnaire containing 16 questions regarding the value of the app for follow-up care after day surgery. Content validity evaluation was based on responses by day surgery patients and the staff of the day surgery department.

RESULTS

A total of 69 participants completed the evaluation of equivalence between the paper and app versions of the SwQoR. The intraclass correlation coefficient (ICC) for the SwQoR was .89 (95% CI 0.83-0.93) and .13 to .90 for the items. Of the participants, 63 continued testing the app after discharge and completed the follow-up questionnaire. The median score was 69 (inter-quartile range, IQR 66-73), indicating a positive attitude toward using an app for follow-up after day surgery. A total of 18 patients and 12 staff members participated in the content validity evaluation. The item-level content validity index (I-CVI) for the staff group was in the 0.64 to 1.0 range, with a scale-level content validity index (S-CVI) of 0.88. For the patient group, I-CVI was in the range 0.30 to 0.92 and S-CVI was 0.67. The content validity evaluation of the SwQoR, together with three new items, led to a reduction from 34 to 24 items.

CONCLUSIONS

Day surgery patients had positive attitudes toward using the app for follow-up after surgery, and stated a preference for using the app again if they were admitted for a future day surgery procedure. Equivalence between the app and paper version of the SwQoR was found, but at the item level, the ICC was less than .7 for 9 items. In the content validity evaluation of the SwQoR, staff found more items relevant than the patients, and no items found relevant by either staff or patients were excluded when revising the SwQoR.

Validação da versão brasileira do questionário Quality of Recovery - 40 Items

Resumo Objetivo Validar, entre pacientes submetidos à prostatectomia radical, a versão brasileira do questionário Quality of Recovery-40 Item (QoR-40). Métodos Estudo metodológico realizado com 224 pacientes submetidos à prostatectomia radical, sendo 24 para análise semântica e 200 para as propriedades psicométricas, considerando validades de constructo e discriminante, fidedignidade e responsividade. Resultados A análise semântica resultou em alterações na redação de três itens. Na validade de constructo convergente, as correlações entre o QoR-40 e os domínios das escalas de qualidade de vida e visual analógica de recuperação cirúrgica foram moderadas. A validade de constructo discriminante constatou diferenças estatisticamente significativas entre pacientes com o diagnóstico de enfermagem Recuperação cirúrgica retardada e com incontinência urinária. Quanto à fidedignidade, valores de alfa de Cronbach foram satisfatórios. A responsividade demonstrou que o questionário obteve adequada capacidade em identificar mudanças no decorrer do tempo. Conclusão O questionário brasileiro possui adequadas validade, fidedignidade e responsividade.

Comparison of the effectiveness of low pressure pneumoperitoneum with profound muscle relaxation during laparoscopic donor nephrectomy to optimize the quality of recovery during the early post-operative phase: study protocol for a randomized controlled clinical trial

BACKGROUND

Since technique modifications of laparoscopic donor nephrectomy, e.g. retroperitoneoscopic donor nephrectomy or hand-assistance, have not shown significant benefit regarding safety or improvement of recovery, further research should focus on improving postoperative recovery. The use of low pressure pneumoperitoneum has shown to significantly reduce postoperative pain after laparoscopy. To facilitate the use of low pressure pneumoperitoneum, deep neuromuscular block will be used.

METHODS/DESIGN

This trial is a phase IV, single center, double-blind, randomized controlled clinical trial in which 64 patients will be randomized to: low pressure pneumoperitoneum (6 mmHg) and deep neuromuscular block or normal pressure pneumoperitoneum (12 mmHg) and deep neuromuscular block. Deep neuromuscular block is defined as post tetanic count < 5. Primary outcome measurement will be Quality of Recovery-40 questionnaire (overall score) on day 1.

DISCUSSION

This study is the first randomized study to assess the combination of low pressure pneumoperitoneum in combination with deep neuromuscular block from a patients' perspective. The study findings may also be applicable for other laparoscopic procedures.

TRIAL REGISTRATION

The trial was registered at trials.gov (NCT02146417) in July 2014.

Sacrospinous hysteropexy versus vaginal hysterectomy with suspension of the uterosacral ligaments in women with uterine prolapse stage 2 or higher: multicentre randomised non-inferiority trial

OBJECTIVE

To investigate whether uterus preserving vaginal sacrospinous hysteropexy is non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments in the surgical treatment of uterine prolapse.

DESIGN

Multicentre randomised controlled non-blinded non-inferiority trial.

SETTING

4 non-university teaching hospitals, the Netherlands.

PARTICIPANTS

208 healthy women with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery.

INTERVENTIONS

Treatment with sacrospinous hysteropexy or vaginal hysterectomy with suspension of the uterosacral ligaments. The predefined non-inferiority margin was an increase in surgical failure rate of 7%.

MAIN OUTCOME MEASURES

Primary outcome was recurrent prolapse stage 2 or higher of the uterus or vaginal vault (apical compartment) evaluated by the pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse at 12 months' follow-up. Secondary outcomes were overall anatomical recurrences, including recurrent anterior compartment (bladder) and/or posterior compartment (bowel) prolapse, functional outcome, complications, hospital stay, postoperative recovery, and sexual functioning.

RESULTS

Sacrospinous hysteropexy was non-inferior for anatomical recurrence of the apical compartment with bothersome bulge symptoms or repeat surgery (n=0, 0%) compared with vaginal hysterectomy with suspension of the uterosacral ligaments (n=4, 4.0%, difference -3.9%, 95% confidence interval for difference -8.6% to 0.7%). At 12 months, overall anatomical recurrences, functional outcome, quality of life, complications, hospital stay, measures on postoperative recovery, and sexual functioning did not differ between the two groups. Five serious adverse events were reported during hospital stay. None was considered to be related to the type of surgery.

CONCLUSIONS

Uterus preservation by sacrospinous hysteropexy was non-inferior to vaginal hysterectomy with suspension of the uterosacral ligaments for surgical failure of the apical compartment at 12 months' follow-up.

TRIAL REGISTRATION

trialregister.nl NTR1866.

Hysteropexy in the treatment of uterine prolapse stage 2 or higher: a multicenter randomized controlled non-inferiority trial comparing laparoscopic sacrohysteropexy with vaginal sacrospinous hysteropexy (LAVA-trial, study protocol)

BACKGROUND

Pelvic organ prolapse is a common health problem: the lifetime risk of undergoing surgery for pelvic organ prolapse by the age of 85 years is 19%. Pelvic organ prolapse has significant negative effects on a woman's quality of life. Worldwide, vaginal hysterectomy is the leading treatment method for patients with symptomatic uterovaginal prolapse. Several studies have shown that vaginal sacrospinous hysteropexy and laparoscopic sacrohysteropexy are safe and effective alternatives in treating uterine descent. To date, it is unclear which of these techniques leads to the best operative result and the highest patient satisfaction. Therefore, we conducted the LAVA trial.

METHODS

The LAVA trial is a randomized controlled multicenter non-inferiority trial. The study compares laparoscopic sacrohysteropexy with vaginal sacrospinous hysteropexy in women with uterine prolapse stage 2 or higher. The primary outcome of this study is surgical success of the apical compartment at 1 and 5 years follow-up. Secondary outcomes are subjective improvement on urogenital symptoms and quality of life (assessed by disease-specific and general quality of life questionnaires), complications following surgery, hospital stay, post-operative recovery, sexual functioning and costs-effectiveness. Evaluation will take place pre-operatively, and 6 weeks, 6 months, 12 months and annually till 60 months after surgery. Validated questionnaires will be used.Analysis will be performed according to the intention to treat principle. Based on comparable recurrence rates of 3% and a non-inferiority margin of 10%, 62 patients are needed in each arm to prove the hypothesis with a 95% confidence interval.

DISCUSSION

The LAVA trial is a randomized controlled multicenter non-inferiority trial that will provide evidence whether the efficacy of laparoscopic sacrohysteropexy is non-inferior to vaginal sacrospinous hysteropexy in women with symptomatic uterine prolapse stage 2 or higher.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR4029.

The cost effectiveness of a tailored, web-based care program to enhance postoperative recovery in gynecologic patients in comparison with usual care: protocol of a stepped wedge cluster randomized controlled trial

Background

The length of recovery after benign gynecological surgery and return to work frequently exceeds the period that is recommended or expected by specialists. A prolonged recovery is associated with a poorer quality of life. In addition, costs due to prolonged sick leave following gynecological surgery cause a significant financial burden on society.

Objective

The objective of our study was to present the protocol of a stepped wedge cluster randomized controlled trial to evaluate the cost effectiveness of a new care program for patients undergoing hysterectomy and/or adnexal surgery for benign disease, compared to the usual care.

Methods

The care program under study, designed to improve convalescence and to prevent delayed return to work, targets two levels. At the hospital level, guidelines will be distributed among clinical staff in order to stimulate evidence-based patient education. At the patient level, additional perioperative guidance is provided by means of an eHealth intervention, equipping patients with tailored convalescence advice, and an occupational intervention is available for those patients at risk of prolonged sick leave. Due to the stepped wedge design of the trial, the care program will be sequentially rolled out among the 9 participating hospitals, from which the patients are recruited. Eligible for this study are employed women, 18-65 years of age, who are scheduled for hysterectomy and/or laparoscopic adnexal surgery. The primary outcome is full sustainable return to work. The secondary outcomes include general recovery, quality of life, self-efficacy, coping, and pain. The data will be collected by means of self-reported electronic questionnaires before surgery and at 2, 6, 12, 26, and 52 weeks after surgery. Sick leave and cost data are measured by monthly sick leave calendars, and cost diaries during the 12 month follow-up period. The economic evaluation will be performed from the societal perspective. All statistical analyses will be conducted according to the intention-to-treat principle.

Results

The enrollment of the patients started October 2011. The follow-up period will be completed in August 2014. Data cleaning or analysis has not begun as of this article’s submission.

Conclusions

We hypothesize the care program to be effective by means of improving convalescence and reducing costs associated with productivity losses following gynecological surgery. The results of this study will enable health care policy makers to decide about future implementation of this care program on a broad scale.

Trial Registration

Netherlands Trial Register: NTR2933; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2933 (Archived by WebCite at http://www.webcitation.org/6Q7exPG84).

A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: results of a multicentre randomised trial

OBJECTIVE

To evaluate the effectiveness of an eHealth intervention on recovery and return to work, after gynaecological surgery.

DESIGN

Randomised multicentre trial that ran from March 2010 until September 2011.

SETTING

Secondary care in seven general and university hospitals in The Netherlands.

POPULATION

A cohort of 215 women (aged 18-65 years) who had a hysterectomy and/or laparoscopic adnexal surgery for a benign indication.

METHODS

The women were randomly assigned to the intervention group (n = 110) or the control group (n = 105). The intervention group received an eHealth programme that provided personalised tailor-made pre- and postoperative instructions on the resumption of daily activities, including work, and tools to improve self-empowerment and to identify recovery problems. The control group was provided with access to a control website.

MAIN OUTCOME MEASURES

The primary outcome was the duration of sick leave until a full sustainable return to work. Secondary outcome measures were quality of life, general recovery, and pain intensity.

RESULTS

In intention-to-treat analysis the eHealth intervention was effective on time to return to work (hazard ratio 1.43; 95% confidence interval 1.003-2.040; P = 0.048). The median duration of sick leave until a full sustainable return to work was 39 days (interquartile range 20-67 days) in the intervention group and 48 days (interquartile range 21-69 days) in the control group. After 26 weeks pain intensity was lower (visual analogue scale, cumulative odds ratio 1.84; 95% confidence interval 1.04-3.25; P = 0.035) and quality of life was higher (Rand-36 health survey, between-group difference 30, 95% confidence interval 4-57; P = 0.024) in the intervention group, compared with the control group.

CONCLUSIONS

The use of the eHealth intervention by women after gynaecological surgery results in a faster return to work, with a higher quality of life and less pain.

Prediction of time to return to work after gynaecological surgery: a prospective cohort study in the Netherlands

OBJECTIVE

To measure the impact of the level of invasiveness of gynaecological procedures on time to full Return to Work (RTW) and to identify the most important preoperative sociodemographic, medical and work-related factors that predict the risk of prolonged sick leave.

DESIGN

Prospective cohort study.

SETTING

Dutch university hospital.

POPULATION

A total of 148 women aged 18-65 years scheduled for gynaecological surgery for benign indications.

METHODS

A questionnaire regarding the surgical procedure as well as perioperative and postoperative complications was completed by the attending resident at baseline and 6 weeks after surgery. All other outcome measures were assessed using self-reported patient questionnaires at baseline and 12 weeks post-surgery. The follow-up period was extended up to 1 year after surgery in women failing to return to work. Surgical procedures were categorised into diagnostic, minor, intermediate and major surgery.

MAIN OUTCOME MEASURES

Time to RTW and important predictors for prolonged sick leave after surgery.

RESULTS

Median time to RTW was 7 days (interquartile range [IQR] 5-14) for diagnostic surgery, 14 days (IQR 9-28) for minor surgery, 60 days (IQR 28-101) for intermediate surgery and 69 days (IQR 56-135) for major surgery. Multivariable analysis showed a strongest predictive value of RTW 1 year after surgery for level of invasiveness of surgery (minor surgery hazard ratio [HR] 0.51, 95% CI 0.32-0.81; intermediate surgery HR 0.20, 95% CI 0.12-0.34; major surgery HR 0.09, 95% CI 0.06-0.16), RTW expectations before surgery (HR 0.55, 95% CI 0.36-0.84), and preoperative functional status (HR 1.09, 95% CI 1.04-1.13). A prediction model regarding the probability of prolonged sick leave at 6 weeks was developed, with a sensitivity of 89% and a specificity of 86%.

CONCLUSIONS

RTW often takes a long time, especially after intermediate and major surgery. This study reveals important predictors for prolonged sick leave and provides a prediction model for the risk of sick leave extending 6 weeks after benign gynaecological surgery in the Netherlands.

Measurement of quality of recovery using the QoR-40: a quantitative systematic review

BACKGROUND

Several rating scales have been developed to measure quality of recovery after surgery and anaesthesia, but the most extensively used is the QoR-40, a 40-item questionnaire that provides a global score and subscores across five dimensions: patient support, comfort, emotions, physical independence, and pain. It has been evaluated in a variety of settings, but its overall psychometric properties (validity, reliability, ease of use, and interpretation) and clinical utility are uncertain.

METHODS

We undertook a quantitative systematic review of studies evaluating psychometric properties of the QoR-40. Data were combined in meta-analyses using random effects models. This resulted in a total sample of 3459 patients from 17 studies originating in nine countries.

RESULTS

We confirmed content, construct, and convergent [pooled r=0.58, 95% confidence interval (CI): 0.51-0.65] validity. Reliability was confirmed by excellent intraclass correlation (pooled α=0.91, 95% CI: 0.88-0.93), test-retest reliability (pooled r=0.90, 95% CI: 0.86-0.92), and inter-rater reliability (intraclass correlation=0.86). The clinical utility of the QoR-40 instrument was supported by high patient recruitment into evaluation studies (97%), and an excellent completion and return rate (97%). The mean time to complete the QoR-40 was 5.1 (95% CI: 4.4-5.7) min.

CONCLUSIONS

The QoR-40 is a widely used and extensively validated measure of quality of recovery. The QoR-40 is a suitable measure of postoperative quality of recovery in a range of clinical and research situations.

Effectiveness of a multidisciplinary care program on recovery and return to work of patients after gynaecological surgery; design of a randomized controlled trial

BACKGROUND

Return to work after gynaecological surgery takes much longer than expected, irrespective of the level of invasiveness. In order to empower patients in recovery and return to work, a multidisciplinary care program consisting of an e-health intervention and integrated care management including participatory workplace intervention was developed.

METHODS/DESIGN

We designed a randomized controlled trial to assess the effect of the multidisciplinary care program on full sustainable return to work in patients after gynaecological surgery, compared to usual clinical care. Two hundred twelve women (18-65 years old) undergoing hysterectomy and/or laparoscopic adnexal surgery on benign indication in one of the 7 participating (university) hospitals in the Netherlands are expected to take part in this study at baseline. The primary outcome measure is sick leave duration until full sustainable return to work and is measured by a monthly calendar of sickness absence during 26 weeks after surgery. Secondary outcome measures are the effect of the care program on general recovery, quality of life, pain intensity and complications, and are assessed using questionnaires at baseline, 2, 6, 12 and 26 weeks after surgery.

DISCUSSION

The discrepancy between expected physical recovery and actual return to work after gynaecological surgery contributes to the relevance of this study. There is strong evidence that long periods of sick leave can result in work disability, poorer general health and increased risk of mental health problems. We expect that this multidisciplinary care program will improve peri-operative care, contribute to a faster return to work of patients after gynaecological surgery and, as a consequence, will reduce societal costs considerably.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR2087.

Clinimetrics: the science of clinical measurements

'Clinimetrics' is the term introduced by Alvan R. Feinstein in the early 1980s to indicate a domain concerned with indexes, rating scales and other expressions that are used to describe or measure symptoms, physical signs and other clinical phenomena. Clinimetrics has a set of rules that govern the structure of indexes, the choice of component variables, the evaluation of consistency, validity and responsiveness. This review illustrates how clinimetrics may help expanding the narrow range of information that is currently used in clinical science. It will focus on characteristics and types of clinimetric indexes and their current use. The clinimetric perspective provides an intellectual home for clinical judgment, whose implementation is likely to improve outcomes both in clinical research and practice.

The Postoperative Recovery Profile (PRP) - a multidimensional questionnaire for evaluation of recovery profiles

AIMS AND OBJECTIVES

The previously developed Postoperative Recovery Profile (PRP) questionnaire is intended for self-assessment of general recovery after surgery. The aim of this study was to further evaluate the questionnaire regarding the construct validity and ability to discriminate recovery profiles between groups. Furthermore, the item variables of greatest importance during the progress of recovery were investigated.

METHODS

Post-operative recovery was assessed during the period from discharge to 12 months after lower abdominal and orthopaedic surgery. Construct validity was evaluated by comparing the assessments from the PRP questionnaire and a global recovery scale. Recovery profiles of the diagnose groups were displayed by the cumulative proportion recovered participants over time. The importance of item variables was investigated by ranking ordering.

RESULTS

A total of 158 patients were included. Support was given for good construct validity. The result showed that 7.6% of all possible pairs were disordered when comparing the assessments from the PRP questionnaire and the global recovery scale. Twelve months after discharge the PRP assessments discriminated significantly the recovery profiles of the abdominal and orthopaedic groups. The variable pain was one of the top five most important issues at each follow-up occasion in both study groups. The importance of the item variables was thereby emphasized.

CONCLUSIONS

The PRP questionnaire allows for evaluation of the progress of post-operative recovery, and can be useful to assess patient-reported recovery after surgical treatment both on individual and group levels. Knowledge about recovery profiles can assist clinicians in determining the critical time points for measuring change.

Total laparoscopic hysterectomy versus total abdominal hysterectomy with bilateral salpingo-oophorectomy for endometrial carcinoma: a randomised controlled trial with 5-year follow-up

This report is on recovery and long-term outcomes in a small-scale randomised controlled trial (RCT) after total laparoscopic hysterectomy versus total abdominal hysterectomy in (potential) endometrial carcinoma patients. An RCT was performed among women with atypical endometrial hyperplasia and endometrial carcinoma scheduled for hysterectomy in a teaching hospital in The Netherlands. Women were randomised to total laparoscopic hysterectomy versus total abdominal hysterectomy both with bilateral salpingo-oophorectomy and were followed until 5 years after the intervention. Patients completed the RAND 36-Item Short Form Health Survey (RAND-36), Quality of Recovery-40 (QoR-40) and Recovery Index-10 (RI-10) until 12 weeks after surgery. Main outcome measure was quality of life and recovery in the first 12 weeks after surgery. A linear mixed model was used for statistical analysis while accounting for baseline values where applicable. Seventeen women were included, of whom 11 allocated to the laparoscopic arm and 6 to the abdominal arm. Laparoscopic hysterectomy performed better on all scales and subscales used in the study. A statistically significant treatment effect, favouring laparoscopic hysterectomy, was found in the total RAND-36 (difference between groups 142 units, 95% confidence interval 46; 236). Clinical follow-up was completed after median 60 months, but this study was too small for conclusions regarding the safety and survival. Laparoscopic hysterectomy results in better postoperative quality of life in the first 12 weeks after surgery when compared with abdominal hysterectomy.

Treatment of uterine prolapse stage 2 or higher: a randomized multicenter trial comparing sacrospinous fixation with vaginal hysterectomy (SAVE U trial)

BACKGROUND

Pelvic organ prolapse is a common health problem, affecting up to 40% of parous women over 50 years old, with significant negative influence on quality of life. Vaginal hysterectomy is currently the leading treatment method for patients with symptomatic uterine prolapse. Several studies have shown that sacrospinous fixation in case of uterine prolapse is a safe and effective alternative to vaginal hysterectomy. However, no large randomized trials with long-term follow-up have been performed to compare efficacy and quality of life between both techniques.The SAVE U trial is designed to compare sacrospinous fixation with vaginal hysterectomy in the treatment of uterine prolapse stage 2 or higher in terms of prolapse recurrence, quality of life, complications, hospital stay, post-operative recovery and sexual functioning.

METHODS/DESIGN

The SAVE U trial is a randomized controlled multi-center non-inferiority trial. The study compares sacrospinous fixation with vaginal hysterectomy in women with uterine prolapse stage 2 or higher. The primary outcome measure is recurrence of uterine prolapse defined as: uterine descent stage 2 or more assessed by pelvic organ prolapse quantification examination and prolapse complaints and/or redo surgery at 12 months follow-up. Secondary outcomes are subjective improvement in quality of life measured by generic (Short Form 36 and Euroqol 5D) and disease-specific (Urogenital Distress Inventory, Defecatory Distress Inventory and Incontinence Impact Questionnaire) quality of life instruments, complications following surgery, hospital stay, post-operative recovery and sexual functioning (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire). Analysis will be performed according to the intention to treat principle. Based on comparable recurrence rates of 3% and considering an upper-limit of 7% to be non-inferior (beta 0.2 and one sided alpha 0.025), 104 patients are needed per group.

DISCUSSION

The SAVE U trial is a randomized multicenter trial that will provide evidence whether the efficacy of sacrospinous fixation is similar to vaginal hysterectomy in women with uterine prolapse stage 2 or higher.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR1866.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

The three approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions depending on the part of the procedure performed laparoscopically.

OBJECTIVES

To assess the most beneficial and least harmful surgical approach to hysterectomy for women with benign gynaecological conditions.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (15 August 2008), CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August 2008), EMBASE (1980 to August 2008), Biological Abstracts (1969 to August 2008), the National Research Register, and relevant citation lists.

SELECTION CRITERIA

Only randomised controlled trials comparing one surgical approach to hysterectomy with another were included.

DATA COLLECTION AND ANALYSIS

Independent selection of trials and data extraction were employed following Cochrane guidelines.

MAIN RESULTS

There were 34 included studies with 4495 women. The benefits of VH versus AH were speedier return to normal activities (mean difference (MD) 9.5 days), fewer febrile episodes or unspecified infections (odds ratio (OR) 0.42), and shorter duration of hospital stay (MD 1.1 days). The benefits of LH versus AH were speedier return to normal activities (MD 13.6 days), lower intraoperative blood loss (MD 45 cc), a smaller drop in haemoglobin (MD 0.55 g/dl), shorter hospital stay (MD 2.0 days), and fewer wound or abdominal wall infections (OR 0.31) at the cost of more urinary tract (bladder or ureter) injuries (OR 2.41) and longer operation time (MD 20.3 minutes). The benefits of LAVH versus TLH were fewer febrile episodes or unspecified infection (OR 3.77) and shorter operation time (MD 25.3 minutes). There was no evidence of benefits of LH versus VH and the operation time (MD 39.3 minutes) as well as substantial bleeding (OR 2.76) were increased in LH. For some important outcomes, the analyses were underpowered to detect important differences or they were simply not reported in trials. Data were absent for many important long-term outcome measures.

AUTHORS' CONCLUSIONS

Because of equal or significantly better outcomes on all parameters, VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH however the length of the surgery increases as the extent of the surgery performed laparoscopically increases. The surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon in light of the relative benefits and hazards.

Can prolonged sick leave after gynecologic surgery be predicted? An observational study in The Netherlands

BACKGROUND

Sick leave frequently has been used as an outcome to evaluate minimal invasive surgery compared with conventional open surgery. However, sick leave is determined not only by the surgical approach. Recently, a postoperative recovery-specific quality-of-life questionnaire, the Recovery Index (RI-10), has been developed and validated. This study investigated the relation of the Recovery Index 10, the RI-6 (a subset of 6 questions), and the type of surgery to sick leave.

METHODS

The study enrolled 46 patients with a paid job scheduled for elective gynecologic surgery, who filled out the RI-10. After 8 weeks, the patients were approached by telephone to give information on their return to work.

RESULTS

Of the 46 patients, 23 (50%) returned to work completely after 8 weeks, 14 (30%) resumed work partly, and 9 (20%) did not resume work at all. In the analysis, the patients who completely returned to work were compared with those who did not return or partially returned. Recovery as expressed in the RI-6 improved with time after surgery. It appeared that the measurement 2 weeks after surgery showed the best discriminative capacity to predict sick leave after 8 weeks, with an area under the curve of 0.88 (confidence interval, 0.74-1.03). The subjective postoperative recovery as expressed by the RI-6 is more closely related to the type of surgery (p = 0.001) sick leave is (p = 0.14).

CONCLUSIONS

The subjective recovery scored by the patient on a questionnaire of six questions is a better outcome than sick leave for evaluating surgical approaches. If administered 2 weeks after surgery, it may predict prolonged sick leave.